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Kaniecki T, Hughes M, McMahan Z. Managing gastrointestinal manifestations in systemic sclerosis, a mechanistic approach. Expert Rev Clin Immunol 2024; 20:603-622. [PMID: 38406978 PMCID: PMC11098704 DOI: 10.1080/1744666x.2024.2320205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/14/2024] [Indexed: 02/27/2024]
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a connective tissue disease with heterogeneous presentation. Gastrointestinal (GI) complications of SSc are characterized by esophageal reflux, abnormal motility, and microbiome dysbiosis, which impact patient quality of life and mortality. Preventative therapeutics are lacking, with management primarily aimed at symptomatic control. AREAS COVERED A broad literature review was conducted through electronic databases and references from key articles. We summarize the physiology of gastric acid production and GI motility to provide context for existing therapies, detail the current understanding of SSc-GI disease, and review GI medications studied in SSc. Finally, we explore new therapeutic options. We propose a management strategy that integrates data on drug efficacy with knowledge of disease pathophysiology, aiming to optimize future therapeutic targets. EXPERT OPINION SSc-GI complications remain a challenge for patients, clinicians, and investigators alike. Management presently focuses on treating symptoms and minimizing mucosal damage. Little evidence exists to suggest immunosuppressive therapy halts progression of GI involvement or reverses damage, leaving many unanswered questions about the optimal clinical approach. Further research focused on identifying patients at risk for GI progression, and the underlying mechanism(s) that drive disease will provide opportunities to prevent long-term damage, and significantly improve patient quality of life.
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Affiliation(s)
- Timothy Kaniecki
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael Hughes
- Department of Rheumatology, Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Salford, US
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Zsuzsanna McMahan
- Division of Rheumatology, UTHealth Houston McGovern Medical School, Houston, TX
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2
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Vitton V, Barthet M, Granel B, Gonzalez JM. Refractory GERD and systemic sclerosis: The end of a dead end? Clin Res Hepatol Gastroenterol 2023; 47:102140. [PMID: 37187259 DOI: 10.1016/j.clinre.2023.102140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Véronique Vitton
- Service de Gastroentérologie, Hôpital NORD, Assistance Publique - Hôpitaux de Marseille, Aix-Marseille Université, France.
| | - Marc Barthet
- Service de Gastroentérologie, Hôpital NORD, Assistance Publique - Hôpitaux de Marseille, Aix-Marseille Université, France
| | - Brigitte Granel
- Service de médecine interne, Hôpital NORD, Assistance Publique - Hôpitaux de Marseille, Aix-Marseille Université, France
| | - Jean-Michel Gonzalez
- Service de Gastroentérologie, Hôpital NORD, Assistance Publique - Hôpitaux de Marseille, Aix-Marseille Université, France
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3
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Abstract
The gastrointestinal tract is the second largest organ system in the body and is often affected by connective tissue disorders. Scleroderma is the classic rheumatologic disease affecting the esophagus; more than 90% of patients with scleroderma have esophageal involvement. This article highlights esophageal manifestations of scleroderma, focusing on pathogenesis, clinical presentation, diagnostic considerations, and treatment options. In addition, this article briefly reviews the esophageal manifestations of other key connective tissue disorders, including mixed connective tissue disease, myositis, Sjogren syndrome, systemic lupus erythematosus, fibromyalgia, and Ehlers-Danlos syndrome.
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Affiliation(s)
- Nitin K Ahuja
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 3400 Civic Center Boulevard 7 South Pavilion, Philadelphia, PA 19104, USA
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 430 Broadway Street, Pavilion C, 3rd Floor, C-343, Redwood City, CA 94063-6341, USA.
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4
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Hii A, Liu DS, Kholmurodova F, Irvine T, Bright T, Watson DI, Thompson SK. Partial Fundoplication is Effective Treatment for Female Patients with Gastroesophageal Reflux and Scleroderma: A Multicenter Comparative Cohort Study. World J Surg 2021; 46:147-153. [PMID: 34590163 DOI: 10.1007/s00268-021-06326-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with scleroderma often suffer from dysphagia and gastroesophageal reflux disease (GERD). Partial fundoplication is a validated anti-reflux procedure for GERD but may worsen dysphagia in scleroderma patients. Its utility in these patients is unknown. Here, we evaluate the efficacy and acceptability of partial fundoplication for the treatment of medically refractory GERD in patients with scleroderma. METHODS Analysis of a prospectively maintained database of patients who underwent fundoplication across 14 hospitals between 1991 and 2019. Perioperative outcomes, reintervention rates, heartburn, dysphagia, and patient satisfaction were assessed at 3 months, 1- and 3-years post-surgery. RESULTS A total of 17 patients with scleroderma were propensity score matched to 526 non-scleroderma controls. All underwent a partial fundoplication. Perioperative outcomes including complication rate, length of stay, and need for reoperation were similar between the two groups. Compared to baseline, both groups reported significantly improved heartburn at 3 months, 1- and 3-years following partial fundoplication. Surgery was equally effective at controlling heartburn across all follow-up timepoints in patients with or without scleroderma. Dysphagia to solids was more common in patients with scleroderma than controls at 3-months post-surgery, but was not significantly different to controls at 1- and 3-year follow-up. Satisfaction scores were high and comparable between both groups across all postoperative timepoints, with 100% of patients with scleroderma reporting that their initial choice to undergo surgery was correct. CONCLUSIONS Partial fundoplication controls reflux and is associated with a transient period of dysphagia to solids in patients with scleroderma. This approach is safe, effective and acceptable for patients with scleroderma and medically refractory GERD.
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Affiliation(s)
- Amanda Hii
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, 5042, Australia
| | - David S Liu
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, 5042, Australia. .,Department of Surgery, Austin Hospital, Heidelberg, VIC, 3084, Australia.
| | - Feruza Kholmurodova
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, 5042, Australia
| | - Tanya Irvine
- Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, 5042, Australia
| | - Tim Bright
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, 5042, Australia.,Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, 5042, Australia
| | - David I Watson
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, 5042, Australia.,Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, 5042, Australia
| | - Sarah K Thompson
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, 5042, Australia.,Discipline of Surgery, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, 5042, Australia
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Voulgaris TA, Karamanolis GP. Esophageal manifestation in patients with scleroderma. World J Clin Cases 2021; 9:5408-5419. [PMID: 34307594 PMCID: PMC8281422 DOI: 10.12998/wjcc.v9.i20.5408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/22/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023] Open
Abstract
The esophagus is the most commonly affected part of the gastrointestinal system in patients with systemic sclerosis (SSc). Esophageal involvement may lead to a significant reduction in patient quality of life. The exact pathophysiology is complex and not yet fully elucidated. Ultimately, esophageal smooth muscle becomes atrophied and replaced by fibrous tissue leading to severe motility disturbance of the distal esophagus. Symptoms are mainly attributed to gastroesophageal reflux disease and to esophageal dysmotility. Compelling evidence has correlated esophageal involvement to the severity of pulmonary disease. No formed guidelines exist about the diagnostic modalities used to assess esophageal disease in patients with SSc, though upper gastrointestinal endoscopy is the first and most important modality used as it can reveal alterations commonly observed in patients with SSc. Further exploration can be made by high resolution manometry and pH-impedance study. Proton pump inhibitors remain the mainstay of treatment, while prokinetic agents are commonly used as add-on therapy in patients with symptoms attributed to gastroesophageal reflux disease not responding to standard therapy as well as to motility disturbances. Gastroesophageal reflux disease symptoms in patients with SSc are frequently difficult to manage, and new therapeutic modalities are emerging. The role of surgical treatment is restricted and should only be preserved for resistant cases.
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Affiliation(s)
- Theodoros A Voulgaris
- Department of Gastroenterology and Hepatology, Laiko General Hospital, National and Kapodistian University of Athens, Athens 11527, Greece
| | - Georgios P Karamanolis
- Department of Gastroenterology and Hepatology, Laiko General Hospital, National and Kapodistian University of Athens, Athens 11527, Greece
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Yodice M, Mignucci A, Shah V, Ashley C, Tadros M. Preoperative physiological esophageal assessment for anti-reflux surgery: A guide for surgeons on high-resolution manometry and pH testing. World J Gastroenterol 2021; 27:1751-1769. [PMID: 33967555 PMCID: PMC8072189 DOI: 10.3748/wjg.v27.i16.1751] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/18/2021] [Accepted: 03/25/2021] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is one of the most commonly encountered digestive diseases in the world, with the prevalence continuing to increase. Many patients are successfully treated with lifestyle modifications and proton pump inhibitor therapy, but a subset of patients require more aggressive intervention for control of their symptoms. Surgical treatment with fundoplication is a viable option for patients with GERD, as it attempts to improve the integrity of the lower esophageal sphincter (LES). While surgery can be as effective as medical treatment, it can also be associated with side effects such as dysphagia, bloating, and abdominal pain. Therefore, a thorough pre-operative assessment is crucial to select appropriate surgical candidates. Newer technologies are becoming increasingly available to help clinicians identify patients with true LES dysfunction, such as pH-impedance studies and high-resolution manometry (HRM). Pre-operative evaluation should be aimed at confirming the diagnosis of GERD, ruling out any major motility disorders, and selecting appropriate surgical candidates. HRM and pH testing are key tests to consider for patients with GERD like symptoms, and the addition of provocative measures such as straight leg raises and multiple rapid swallows to HRM protocol can assess the presence of underlying hiatal hernias and to test a patient’s peristaltic reserve prior to surgery.
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Affiliation(s)
- Michael Yodice
- Department of Gastroenterology, Albany Medical College, Albany, NY 12208, United States
| | - Alexandra Mignucci
- Department of Gastroenterology, Albany Medical College, Albany, NY 12208, United States
| | - Virali Shah
- Department of Gastroenterology, Albany Medical College, Albany, NY 12208, United States
| | - Christopher Ashley
- Section of Gastroenterology, Stratton VA Medical Center, Albany, NY 12208, United States
| | - Micheal Tadros
- Department of Gastroenterology, Albany Medical Center, Schenectady, NY 12309, United States
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7
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Kaniecki T, Abdi T, McMahan ZH. A practical approach to the evaluation and management of gastrointestinal symptoms in patients with systemic sclerosis. Best Pract Res Clin Rheumatol 2021; 35:101666. [PMID: 33676855 DOI: 10.1016/j.berh.2021.101666] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The gastrointestinal (GI) tract is the most commonly affected internal organ system in systemic sclerosis (SSc). SSc may lead to impaired function in any region of the GI tract, from the esophagus to the anorectum, which causes significant morbidity as well as mortality in patient subsets. Given the low prevalence of SSc in the community, many rheumatologists may not have a systematic framework for diagnosing or treating the GI complaints in this disease. These practice recommendations aim to summarize and consolidate the current guidelines from the fields of gastroenterology and rheumatology and establish a symptom-based framework for diagnosis and management based on available evidence in the literature. Subject areas that are in need of additional research are also identified.
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Affiliation(s)
- Timothy Kaniecki
- The Johns Hopkins Hospital, Department of Internal Medicine, USA
| | - Tsion Abdi
- Johns Hopkins University, Division of Gastroenterology, USA
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Surgical treatment of recalcitrant gastroesophageal reflux disease in patients with systemic sclerosis: a systematic review. Langenbecks Arch Surg 2021; 406:1353-1361. [PMID: 33611653 PMCID: PMC8370958 DOI: 10.1007/s00423-021-02118-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/03/2021] [Indexed: 12/16/2022]
Abstract
Introduction Gastroesophageal reflux disease (GERD) is frequently seen in patients with systemic sclerosis (SSc). Long-standing GERD may cause esophagitis, long-segment strictures, and Barrett’s esophagus and may worsen pre-existing pulmonary fibrosis with an increased risk of end-stage lung disease. Surgical treatment of recalcitrant GERD remains controversial. The purpose of this systematic review was to summarize the current data on surgical treatment of recalcitrant GERD in SSc patients. Materials and methods A systematic literature review according to PRISMA and MOOSE guidelines. PubMed, EMBASE, and Web of Science databases were consulted. Results A total of 101 patients were included from 7 studies. The age ranged from 34 to 61 years and the majority were females (73.5%). Commonly reported symptoms were heartburn (92%), regurgitation (77%), and dysphagia (74%). Concurrent pulmonary disease was diagnosed in 58% of patients. Overall, 63 patients (62.4%) underwent open fundoplication, 17 (16.8%) laparoscopic fundoplication, 15 (14.9%) Roux en-Y gastric bypass (RYGB), and 6 (5.9%) esophagectomy. The postoperative follow-up ranged from 12 to 65 months. Recurrent symptoms were described in up to 70% and 30% of patients undergoing fundoplication and RYGB, respectively. Various symptoms were reported postoperatively depending on the type of surgical procedures, anatomy of the valve, need for esophageal lengthening, and follow-up. Conclusions The treatment of recalcitrant GERD in SSc patients is challenging. Esophagectomy should be reserved to selected patients. Minimally invasive RYGB appears feasible and safe with promising preliminary short-term results. Current evidence is scarce while a definitive indication about the most appropriate surgical treatment is lacking. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-021-02118-8.
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Loganathan P, Gajendran M, Davis B, McCallum R. Efficacy and Safety of Robotic Dor Fundoplication on Severe Gastroesophageal Reflux Disease in Patients With Scleroderma. J Investig Med High Impact Case Rep 2021; 9:23247096211051211. [PMID: 34654321 PMCID: PMC8521723 DOI: 10.1177/23247096211051211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/19/2021] [Accepted: 09/16/2021] [Indexed: 12/02/2022] Open
Abstract
Systemic sclerosis (SSc) is a disease that affects the gastrointestinal tract resulting in its atrophy and fibrosis of smooth muscles. Approximately 80% of SSc patients develop both gastroesophageal reflux disease (GERD) and dysphagia. The nocturnal GERD can cause regurgitation and aspiration, which can further aggravate the pulmonary fibrosis from SSc. Also, their dysphagia is further worsened by performing standard Nissen fundoplication. Therefore, we aimed to investigate whether Dor fundoplication (a 180° anterior wrap) can reduce nocturnal heartburn and regurgitation without worsening dysphagia in patients with SSc and severe GERD. Five SSc patients with drug-refractory severe GERD underwent a Dor fundoplication procedure with a median follow-up of 2 years (range: 1-5 years). In all 5 patients, the preoperative high-resolution manometry showed significant impairment of esophageal motility. Patients were interviewed postoperatively to assess for nocturnal and diurnal GERD symptoms, treatment response, the status of dysphagia, and adverse effects of surgery. The average age of 5 patients was 50 years and all were females. Four of the 5 patients (80%) reported 90% improvement in both diurnal and nocturnal GERD symptoms since surgery, with no nocturnal reflux, heartburn, or regurgitation, and reports to sleep at night without requiring any more pillows or wedges. About 50% of patients reported a decrease in their proton pump inhibitor dosage after surgery compared to before surgery. No surgical complication was reported and specifically, no worsening of dysphagia. The Dor fundoplication performed for refractory GERD in SSc patients substantially decreases heartburn and regurgitation, primarily nocturnal, without affecting dysphagia, thus improving the quality of life.
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Affiliation(s)
| | - Mahesh Gajendran
- Texas Tech University Health Sciences Center El Paso, Texas
- UT Health San Antonio, TX, USA
| | - Brian Davis
- Texas Tech University Health Sciences Center El Paso, Texas
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10
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Laparoscopic Fundoplication Is Effective Treatment for Patients with Gastroesophageal Reflux and Absent Esophageal Contractility. J Gastrointest Surg 2021; 25:2192-2200. [PMID: 33904061 PMCID: PMC8484087 DOI: 10.1007/s11605-021-05006-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/31/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anti-reflux surgery in the setting of preoperative esophageal dysmotility is contentious due to fear of persistent long-term dysphagia, particularly in individuals with an aperistaltic esophagus (absent esophageal contractility). This study determined the long-term postoperative outcomes following fundoplication in patients with absent esophageal contractility versus normal motility. METHODS A prospective database was used to identify all (40) patients with absent esophageal contractility who subsequently underwent fundoplication (36 anterior partial, 4 Nissen). Cases were propensity matched based on age, gender, and fundoplication type with another 708 patients who all had normal motility. Groups were assessed using prospective symptom assessment questionnaires to assess heartburn, dysphagia for solids and liquids, regurgitation, and satisfaction with surgery, and outcomes were compared. RESULTS Across follow-up to 10 years, no significant differences were found between the two groups for any of the assessed postoperative symptoms. Multivariate analysis found that patients with absent contractility had worse preoperative dysphagia (adjusted mean difference 1.09, p = 0.048), but postoperatively there were no significant differences in dysphagia scores at 5- and 10-year follow-up. No differences in overall patient satisfaction were identified across the follow-up period. CONCLUSION Laparoscopic partial fundoplication in patients with absent esophageal contractility achieves acceptable symptom control without significantly worse dysphagia compared with patients with normal contractility. Patients with absent contractility should still be considered for surgery.
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11
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Akiyama J, Sumida J, Nakagawa K, Masamune A, Issariyakulkarn N, Patcharatrakul T, Shetler K, Kuribayashi S, Uraoka T, Triadafilopoulos G. New developments in esophageal function testing and esophageal manifestations of connective tissue disorders. Ann N Y Acad Sci 2020; 1481:170-181. [DOI: 10.1111/nyas.14424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/25/2020] [Accepted: 06/09/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Junichi Akiyama
- Division of Gastroenterology and Hepatology National Center for Global Health and Medicine Tokyo Japan
| | - Junko Sumida
- Division of Gastroenterology and Hepatology National Center for Global Health and Medicine Tokyo Japan
| | - Kenichiro Nakagawa
- Division of Gastroenterology Tohoku University Graduate School of Medicine Sendai Japan
| | - Atsushi Masamune
- Division of Gastroenterology Tohoku University Graduate School of Medicine Sendai Japan
| | - Navapan Issariyakulkarn
- Division of Gastroenterology King Chulalongkorn Memorial Hospital Thai Red Cross Society Bangkok Thailand
| | - Tanisa Patcharatrakul
- Division of Gastroenterology King Chulalongkorn Memorial Hospital Thai Red Cross Society Bangkok Thailand
- Center of Excellence in Neurogastroenterology and Motility, Department of Medicine, Faculty of Medicine Chulalongkorn University Bangkok Thailand
| | - Katerina Shetler
- Department of Gastroenterology Palo Alto Medical Foundation Mountain View California
| | - Shiko Kuribayashi
- Department of Gastroenterology and Hepatology Gunma University Graduate School of Medicine Maebashi Japan
| | - Toshio Uraoka
- Department of Gastroenterology and Hepatology Gunma University Graduate School of Medicine Maebashi Japan
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology Stanford University School of Medicine Stanford California
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12
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Pauwels A, Boecxstaens V, Andrews CN, Attwood SE, Berrisford R, Bisschops R, Boeckxstaens GE, Bor S, Bredenoord AJ, Cicala M, Corsetti M, Fornari F, Gyawali CP, Hatlebakk J, Johnson SB, Lerut T, Lundell L, Mattioli S, Miwa H, Nafteux P, Omari T, Pandolfino J, Penagini R, Rice TW, Roelandt P, Rommel N, Savarino V, Sifrim D, Suzuki H, Tutuian R, Vanuytsel T, Vela MF, Watson DI, Zerbib F, Tack J. How to select patients for antireflux surgery? The ICARUS guidelines (international consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for antireflux surgery). Gut 2019; 68:1928-1941. [PMID: 31375601 DOI: 10.1136/gutjnl-2019-318260] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 05/28/2019] [Accepted: 05/29/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Antireflux surgery can be proposed in patients with GORD, especially when proton pump inhibitor (PPI) use leads to incomplete symptom improvement. However, to date, international consensus guidelines on the clinical criteria and additional technical examinations used in patient selection for antireflux surgery are lacking. We aimed at generating key recommendations in the selection of patients for antireflux surgery. DESIGN We included 35 international experts (gastroenterologists, surgeons and physiologists) in a Delphi process and developed 37 statements that were revised by the Consensus Group, to start the Delphi process. Three voting rounds followed where each statement was presented with the evidence summary. The panel indicated the degree of agreement for the statement. When 80% of the Consensus Group agreed (A+/A) with a statement, this was defined as consensus. All votes were mutually anonymous. RESULTS Patients with heartburn with a satisfactory response to PPIs, patients with a hiatal hernia (HH), patients with oesophagitis Los Angeles (LA) grade B or higher and patients with Barrett's oesophagus are good candidates for antireflux surgery. An endoscopy prior to antireflux surgery is mandatory and a barium swallow should be performed in patients with suspicion of a HH or short oesophagus. Oesophageal manometry is mandatory to rule out major motility disorders. Finally, oesophageal pH (±impedance) monitoring of PPI is mandatory to select patients for antireflux surgery, if endoscopy is negative for unequivocal reflux oesophagitis. CONCLUSION With the ICARUS guidelines, we generated key recommendations for selection of patients for antireflux surgery.
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Affiliation(s)
- Ans Pauwels
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Veerle Boecxstaens
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Department of Surgical Oncology, Oncological and Vascular Access Surgery, Leuven, Belgium.,Department of Oncology, KU Leuven, Leuven, Belgium
| | | | | | - Richard Berrisford
- Peninsula Oesophago-gastric Surgery Unit, Derriford Hospital, Plymouth, Plymouth, UK
| | - Raf Bisschops
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Guy E Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Serhat Bor
- Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Albert J Bredenoord
- Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - Michele Cicala
- Digestive Diseases, Universita Campus Bio Medico, Roma, Italy
| | - Maura Corsetti
- Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - Fernando Fornari
- Programa de Pós-Graduação: Ciências em Gastroenterologia e Hepatologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Chandra Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jan Hatlebakk
- Gastroenterology, Haukeland Sykehus, University of Bergen, Bergen, Norway
| | - Scott B Johnson
- Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, USA
| | - Toni Lerut
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Lars Lundell
- Department of Surgery, Karolinska, Stockholm, Sweden
| | - Sandro Mattioli
- Department of Medical and Surgical Sciences, Universita degli Studi di Bologna, Bologna, Emilia-Romagna, Italy
| | - Hiroto Miwa
- Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Taher Omari
- Department of Gastroenterology, Flinders University, Adelaide, Australia
| | - John Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Roberto Penagini
- Department of Pathophysiology and Transplantation, Ospedale Maggiore Policlinico, Milano, Lombardia, Italy
| | - Thomas W Rice
- Thoracic Surgery, Emeritus Staff Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, USA
| | - Philip Roelandt
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Nathalie Rommel
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Neurosciences, KU Leuven, Leuven, Belgium
| | - Vincenzo Savarino
- Internal Medicine and Medical Specialties, Universita di Genoa, Genoa, Italy
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University London, London, UK
| | - Hidekazu Suzuki
- Gastroenterology and Hepatology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Radu Tutuian
- Gastroenteroloy, Tiefenauspital Bern, Bern, Switzerland
| | - Tim Vanuytsel
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
| | | | - David I Watson
- Department of Surgery, Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia
| | - Frank Zerbib
- Department of Gastroenterology, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - Jan Tack
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
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Perez Rivera CJ, Kadamani Abiyomaa A, González-Orozco A, Ocampo MA, Caicedo I, Mosquera MS. Total gastrectomy in systemic scleroderma when anti-reflux surgery is not viable: A case report. Int J Surg Case Rep 2019; 62:103-107. [PMID: 31491675 PMCID: PMC6731380 DOI: 10.1016/j.ijscr.2019.08.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 08/07/2019] [Accepted: 08/09/2019] [Indexed: 11/29/2022] Open
Abstract
Systemic scleroderma in severe cases, such as gastroesophageal reflux disease, a lung transplant cannot be performed. Although gastroesophageal reflux disease can be medically treated, a poor response will warrant an anti-reflux surgery. We propose an open gastrectomy with roux-en-Y anastomosis as an alternative to the Nissen fundoplication. The decision to provide a surgical intervention must be individualized.
Introduction Systemic scleroderma is an autoimmune disease that can affect the respiratory system and the gastrointestinal tract. When diffuse lung disease and pulmonary hypertension develop, a lung transplant is usually considered as treatment. This option, however, is not feasible in the presence of concomitant gastroesophageal reflux disease. In this case, medical therapy is initially warranted. If this fails, surgical approach may be considered in order for the patient to be a lung transplant candidate. Case presentation A 56-year-old female, with previous history of intestinal pneumonitis, mild pulmonary hypertension and gastroesophageal reflux secondary to systemic scleroderma, is considered for lung transplant. Initially, due to persistent gastroesophageal reflux, a transplant was not a viable. This was corrected with an open gastrectomy with roux-en-Y anastomosis. Follow-up one week later revealed normal anatomy, adequate esophageal-jejunal anastomosis, and adequate contrast medium transit via esophagogram. Additionally, there was no evidence of contrast medium reflux indicating a resolved gastroesophageal reflux disease. This led to the patient becoming a candidate for lung transplant. Discussion We suggest an open gastrectomy with roux-en-Y anastomosis as an alternative to the Nissen fundoplication for patients with connective tissue disease that develop terminal pulmonary consequences and require a lung transplant.
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Affiliation(s)
| | | | | | | | - Isabella Caicedo
- Fundación Cardioinfantil - Instituto de Cardiología, Bogotá, Colombia.
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Bakhos CT, Petrov RV, Parkman HP, Malik Z, Abbas AE. Role and safety of fundoplication in esophageal disease and dysmotility syndromes. J Thorac Dis 2019; 11:S1610-S1617. [PMID: 31489228 DOI: 10.21037/jtd.2019.06.62] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Gastroesophageal reflux disease (GERD) is quite prevalent worldwide, especially in the western hemisphere. The pathophysiology of GERD is complex, involving an incompetent esophagogastric junction (EGJ) as an anti-reflux barrier, as well as other co-morbid conditions such as gastroparesis, hiatal herniation or hyper acid secretion. Esophageal dysmotility is also frequently encountered in GERD, further contributing to the disease in the form of fragmented peristalsis, ineffective esophageal motility (IEM) or the more severe aperistalsis. The latter is quite common in systemic connective tissue disorders such as scleroderma. The main stay treatment of GERD is pharmacologic with proton pump inhibitors (PPI), with surgical fundoplication offered to patients who are not responsive to medications or would like to discontinue them for medical or other reasons. The presence of esophageal dysmotility that can worsen or create dysphagia can potentially influence the choice of fundoplication (partial or complete), or whether it is even possible. Most of the existing literature demonstrates that fundoplication may be safe in the setting of ineffective or weak peristalsis, and that post-operative dysphagia cannot be reliably predicted by pre-operative manometry parameters. In cases of complete aperistalsis (scleroderma-like esophagus), partial fundoplication can be offered in select patients who exhibit prominent reflux symptoms after a comprehensive multidisciplinary evaluation. Roux-en-Y gastric bypass is an alternative to fundoplication in patients with this extreme form of esophageal dysmotility, after careful consideration of the nutritional status.
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Affiliation(s)
- Charles T Bakhos
- Department of Thoracic Medicine and Surgery, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Roman V Petrov
- Department of Thoracic Medicine and Surgery, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Henry P Parkman
- Department of Medicine, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Zubair Malik
- Department of Medicine, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Abbas E Abbas
- Department of Thoracic Medicine and Surgery, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
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15
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Asano Y, Jinnin M, Kawaguchi Y, Kuwana M, Goto D, Sato S, Takehara K, Hatano M, Fujimoto M, Mugii N, Ihn H. Diagnostic criteria, severity classification and guidelines of systemic sclerosis. J Dermatol 2018; 45:633-691. [PMID: 29687465 DOI: 10.1111/1346-8138.14162] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/06/2017] [Indexed: 01/17/2023]
Abstract
Several effective drugs have been identified for the treatment of systemic sclerosis (SSc). However, in advanced cases, not only their effectiveness is reduced but they may be also harmful due to their side-effects. Therefore, early diagnosis and early treatment is most important for the treatment of SSc. We established diagnostic criteria for SSc in 2003 and early diagnostic criteria for SSc in 2011, for the purpose of developing evaluation of each organ in SSc. Moreover, in November 2013, the American College of Rheumatology and the European Rheumatology Association jointly developed new diagnostic criteria for increasing their sensitivity and specificity, so we revised our diagnostic criteria and severity classification of SSc. Furthermore, we have revised the clinical guideline based on the newest evidence. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of SSc.
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Affiliation(s)
- Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masatoshi Jinnin
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Woman's Medical University, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Daisuke Goto
- Department of Rheumatology, Faculty of Medicine, Univertity of Tsukuba, Ibaraki, Japan
| | - Shinichi Sato
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Takehara
- Department of Molecular Pathology of Skin, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Masaru Hatano
- Graduate School of Medicine Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoki Mugii
- Section of Rehabilitation, Kanazawa University Hospital, Ishikawa, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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16
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Denaxas K, Ladas SD, Karamanolis GP. Evaluation and management of esophageal manifestations in systemic sclerosis. Ann Gastroenterol 2018; 31:165-170. [PMID: 29507463 PMCID: PMC5825946 DOI: 10.20524/aog.2018.0228] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 10/28/2018] [Indexed: 12/12/2022] Open
Abstract
Systemic sclerosis (SSc) is a multisystemic autoimmune connective tissue disorder; in the gastrointestinal tract, the esophagus is the most commonly affected organ. Symptoms of esophageal disease are due to gastroesophageal reflux disease (GERD) and esophageal motor dysfunction. Since the development of high-resolution manometry (HRM), this method has been preferred for the study of SSc patients with esophageal involvement. Using HRM, classic scleroderma esophagus, defined as absent or ineffective peristalsis of the distal esophagus in combination with a hypotensive lower esophageal sphincter, was found in as many as 55% of SSc patients. Endoscopy is the appropriate test for evaluating dysphagia and identifying evidence and possible complications of GERD. In the therapeutic area, treatment ranges from general supportive measures to the administration of drugs such as proton pump inhibitors and/or prokinetics. However, as many SSc patients do not respond to existing therapies, there is an urgent need for new therapeutic modalities. Buspirone, a 5-hydroxytryptamine 1A receptor agonist, could be a putative therapeutic option, as it was found to exert a significant beneficial effect in SSc patients with esophageal involvement. This review summarizes our knowledge concerning the evaluation and management of esophageal manifestations in SSc patients, including emerging therapeutic modalities.
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Affiliation(s)
- Konstantinos Denaxas
- Academic Department of Gastroenterology, National and Kapodistrian University of Athens, “Laikon” General Hospital, Athens, Greece
| | - Spyros D. Ladas
- Academic Department of Gastroenterology, National and Kapodistrian University of Athens, “Laikon” General Hospital, Athens, Greece
| | - George P. Karamanolis
- Academic Department of Gastroenterology, National and Kapodistrian University of Athens, “Laikon” General Hospital, Athens, Greece
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17
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Surgical management of gastroesophageal reflux disease in patients with systemic sclerosis. Surg Endosc 2018; 32:3855-3860. [PMID: 29435755 DOI: 10.1007/s00464-018-6115-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 02/07/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Systemic sclerosis (scleroderma) is frequently associated with both gastroesophageal reflux disease (GERD) and simultaneous esophageal dysmotility. Anti-reflux procedures in this patient population must account for the existing physiology of each patient and likely disease progression. We aim to compare perioperative and intermediate outcomes of fundoplication versus gastric bypass for the treatment of GERD. METHODS After IRB approval, patients with systemic sclerosis undergoing fundoplication or gastric bypass for the treatment of GERD from 2004 to 2016 were identified. Demographics, perioperative data, immediate complications, and symptom improvement were retrieved and analyzed. RESULTS Fourteen patients with systemic sclerosis underwent surgical treatment of GERD during the defined study period. Average body mass index was 26 kg/m2. Seven fundoplications (2 Nissens, 4 Toupets, and 1 Dor) and 7 Roux-en-Y gastric bypasses (RYGB) were performed. No 30-day mortality was observed in either group. Median follow-up was 97 months for the fundoplication group (range 28-204 months), and 19 months for the RYGB group (range 1-164 months). Preoperatively, dysphagia, heartburn, and regurgitation were present in 71% (n = 10), 86% (n = 12), and 64% (n = 9) of patients, respectively. Eleven patients had pH study prior to surgical intervention, and 91% of them had abnormal acid exposure. Esophagitis was evident in 85% (n = 11) of patients during preoperative upper endoscopy, and two patients had Barrett's esophagus. Impaired esophageal motility was present in all RYGB patients and 71% of fundoplication patients. Of the patients who had assessment of their GERD symptoms at follow-up, all five patients in the RYGB group and only 3 (50%) patients in the fundoplication group reported symptom improvement or resolution. CONCLUSIONS Laparoscopic RYGB as an anti-reflux procedure is safe and may provide an alternative to fundoplication in the treatment of GERD for systemic sclerosis patients with esophageal dysmotility.
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18
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Andrade A, Folstein MK, Davis BR. Case report of robotic dor fundoplication for scleroderma esophagus with aperistalsis on manometry. Int J Surg Case Rep 2017. [PMID: 28645009 PMCID: PMC5480277 DOI: 10.1016/j.ijscr.2017.06.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Scleroderma commonly affects the esophagus. Tailored therapy is crucial for successful management of scleroderma esophagus. Robotic Dor Fundoplication is an effective option for patients with scleroderma esophagus.
Scleroderma is a systemic disease of collagen deposition resulting in fibrosis of small arteries and arterioles. It commonly affects the skin, lungs, and gastrointestinal tract. The most common site of GI tract involvement is the esophagus. We present the case report of a 44 year old female with scleroderma esophagus and severe reflux which was successfully treated with robotic dor fundoplication. Because of the wide variety of symptoms with which this problem can present, a tailored approach taking into consideration the patient’s symptomatology and findings during diagnostic work-up was implemented with good results. The patient exhibited complete resolution of symptoms at short term follow up. Robotic dor fundoplication is an effective option for patients with scleroderma esophagus and no evidence of hiatal hernia or esophageal shortening.
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Affiliation(s)
- Alonso Andrade
- Department of Surgery, Texas Tech University Health Sciences Center, El Paso, TX, United States.
| | - Matthew K Folstein
- Department of Surgery, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Brian R Davis
- Department of Surgery, Texas Tech University Health Sciences Center, El Paso, TX, United States
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Minimally Invasive Fundoplication Is Safe and Effective in Patients With Severe Esophageal Hypomotility. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017; 11:396-399. [PMID: 27922988 DOI: 10.1097/imi.0000000000000318] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Fundoplication is used to treat refractory gastroesophageal reflux disease (GERD). A subset of patients has coexisting esophageal dysmotility, including aperistalsis or hypoperistalsis. These patients may be at increased risk of dysphagia after fundoplication. To evaluate the outcomes of minimally invasive fundoplication (MIF) in patients with GERD and esophageal hypomotility. METHODS Retrospective review of all patients who underwent MIF and had severe esophageal hypomotility from January 2003 to June 2013. Patients underwent both pH testing and high-resolution esophageal manometry before surgery, in addition to symptom assessment before and after surgery. Severe esophageal hypomotility was defined as mean distal amplitude of contraction of less than 30 mm Hg and liquid bolus clearance of less than 50%. RESULTS Thirty-four patients with GERD and esophageal hypomotility were included. By manometry, 38% had scleroderma-like esophagus and the other 62% had ineffective peristalsis. Ten patients (29%) had systemic scleroderma. Fundoplications performed (34 laparoscopically and 4 robotically) included Toupet (30), Dor (2), and Nissen (2). All patients tolerated oral feeding at a median of 1 day. One patient required surgical revision at 4 months postoperatively. Mean follow-up was 36 weeks, at which time 41% were asymptomatic and 56% had reduced symptoms. Persistent dysphagia was noted in four patients (11.7%) and was successfully treated with endoscopic dilation. CONCLUSIONS Minimally invasive fundoplication is both safe and effective in treating patients with severe GERD and concomitant esophageal hypomotility. Those with postoperative dysphagia are successfully managed by endoscopic treatments.
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20
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Goldberg MB, Abbas AES, Smith MS, Parkman HP, Schey R, Dempsey DT. Minimally Invasive Fundoplication is Safe and Effective in Patients with Severe Esophageal Hypomotility. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael B. Goldberg
- Department of Surgery, Temple University Hospital, Lewis Katz School of Medicine, Philadelphia, PA USA
| | - Abbas El-Sayed Abbas
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Lewis Katz School of Medicine, Philadelphia, PA USA
| | - Michael S. Smith
- Section of Gastroenterology, Department of Medicine, Temple University Hospital, Lewis Katz School of Medicine, Philadelphia, PA USA
| | - Henry P. Parkman
- Section of Gastroenterology, Department of Medicine, Temple University Hospital, Lewis Katz School of Medicine, Philadelphia, PA USA
| | - Ron Schey
- Section of Gastroenterology, Department of Medicine, Temple University Hospital, Lewis Katz School of Medicine, Philadelphia, PA USA
| | - Daniel T. Dempsey
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA USA
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21
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Thompson JS, Langenfeld SJ, Hewlett A, Chiruvella A, Crawford C, Armijo P, Oleynikov D. Surgical treatment of gastrointestinal motility disorders. Curr Probl Surg 2016; 53:503-549. [PMID: 27765162 DOI: 10.1067/j.cpsurg.2016.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 08/22/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Jon S Thompson
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE.
| | - Sean J Langenfeld
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Alexander Hewlett
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | | | | | | | - Dmitry Oleynikov
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
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22
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Esophageal Surgeries in Systemic sclerosis (SSc) - A Systematic Review of the Literature. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2016. [DOI: 10.5301/jsrd.5000199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectives In some patients with systemic sclerosis (SSc), esophageal symptoms can be severe enough to warrant surgical intervention; however, no single procedure seems to predominate because there exists no published rationale for the choice of a particular procedure. We did a systematic literature review of all published trials involving patients with SSc requiring esophageal surgery and compared their relative outcomes and complications. Methods All articles (excluding review articles) describing esophageal surgeries in SSc patients published between 1965 and November 2015 were reviewed. A minimum of 12 weeks’ follow-up was also needed for inclusion. Primary outcome measures were improvement of patient- and/or physician-described reduction in heartburn, reflux or dysphagia. Complications related and unrelated to the procedure were also evaluated. Results Ten articles satisfied selection criteria. A total of 119 patients, all ≥18 years of age, were included from the 10 articles selected Excluding the 1-2 patient case reports, favorable responses were seen in 30%-81% of patients. Complications were varied and differed from series to series Conclusions The efficacy of the procedure and the specific surgical approach to use remains based on anecdotal data. There is clearly a need for careful, controlled studies in uniform groups of SSc patients before being able to rationally recommend esophageal surgery for dysphagia/heartburn in SSc.
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23
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Advances in the evaluation and management of esophageal disease of systemic sclerosis. Curr Rheumatol Rep 2015; 17:475. [PMID: 25475597 DOI: 10.1007/s11926-014-0475-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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24
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Budev MM, Yun JJ. Medical complications after lung transplantation. CURRENT PULMONOLOGY REPORTS 2015. [DOI: 10.1007/s13665-015-0115-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
The diagnosis of esophageal motility disorders has been greatly enhanced with the development of high-resolution esophageal manometry studies and the Chicago Classification. Both hypomotility disorders and hypercontractility disorders of the esophagus have new diagnostic criteria. For the foregut surgeon, new diagnostic criteria for esophageal motility disorders have implications for decision-making during fundoplication and may expand the role of surgical therapy for esophageal achalasia by clarifying diagnostic criteria.
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Affiliation(s)
- Steven P Bowers
- Mayo Clinic Florida, Department of Surgery, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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26
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Nagaraja V, McMahan ZH, Getzug T, Khanna D. Management of gastrointestinal involvement in scleroderma. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2015; 1:82-105. [PMID: 26005632 DOI: 10.1007/s40674-014-0005-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gastrointestinal tract (GIT) commonly affects patients with systemic sclerosis (SSc). The GI involvement is quite heterogeneous varying from asymptomatic disease to significant dysmotility causing complications like malabsorption, weight loss and severe malnutrition. This review focuses on the management of GI involvement in SSc and has been categorized based on the segment of GIT involved. A brief discussion on the role of patient reported outcome measures in SSc-GI involvement has also been incorporated.
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Affiliation(s)
- Vivek Nagaraja
- Division of Rheumatology, University of Toledo, Toledo, Ohio
| | | | - Terri Getzug
- Division of Rheumatology, University of Toledo, Toledo, Ohio
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan
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Abstract
Gastrointestinal involvement (GI) is increasingly recognized as a major cause of both morbidity and mortality in systemic sclerosis (SSc). GI complications are common, second only to skin involvement, and affect up to 90% of patients. Although treatment modalities have changed little for upper gut symptoms such as GI reflux, there are emerging treatment modalities for the common lower gut symptoms (constipation and fecal incontinence), which will be reviewed. The important link between reflux and interstitial lung disease in SSc is also addressed. The aim of this review is to help the clinician understand and manage GI symptoms in SSc.
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Affiliation(s)
- Shamaila Butt
- Gastrointestinal Physiology unit, University College Hospital, London, UK.
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Abstract
OPINION STATEMENT Progressive systemic sclerosis (PSS) or scleroderma is characterized by fibrosis of the skin and visceral organs. Gastrointestinal disease occurs in up to 90% of patients, with the esophagus being the most commonly affected organ. Heartburn, dysphagia, and regurgitation occur in most patients. Esophageal manometry aids in diagnosing PSS. Endoscopy rules out complications, such as Barrett's esophagus, Candida esophagitis, and cancer. Lifestyle modifications should be implemented, including avoidance of alcohol, nicotine, and NSAIDs. Proton pump inhibitor therapy should be instituted, although it is unclear whether the dose should be adjusted according to symptoms or to 24-hour pH monitoring. Prokinetic agents are useful in the early stages of PSS when gastrointestinal musculature is still intact. Metoclopramide improves reflux, lower esophageal sphincter pressure, and gastric emptying but has an inconsistent effect on esophageal peristalsis. A decision on when to perform antireflux surgery, if at all, is controversial. Esophageal disease in PSS is a common and difficult-to-treat problem.
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29
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Reoperative antireflux surgery for dysphagia. Surg Endosc 2010; 25:1160-7. [PMID: 21052726 DOI: 10.1007/s00464-010-1333-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Accepted: 08/17/2010] [Indexed: 12/30/2022]
Abstract
BACKGROUND Troublesome dysphagia is a common indication for redo antireflux surgery (Re-ARS). This study is aimed to analyze the efficacy of Re-ARS in resolving dysphagia and to identify risk factors for persistent or new-onset dysphagia after Re-ARS. METHODS A prospectively maintained database was retrospectively reviewed to identify patients after Re-ARS. Dysphagia severity was graded on a scale of 0 to 3 before and after Re-ARS based on responses to a standardized questionnaire. Patients reporting grade 2 or 3 symptoms were considered to have significant dysphagia. Satisfaction was graded using a 10-point analog scale. RESULTS Between December 2003 and July 2008, 106 patients underwent Re-ARS. Significant preoperative dysphagia was reported by 54 patients, and impaired esophageal motility was noted in 31 patients. Remedial surgery included redo fundoplication (n = 87), Collis gastroplasty with redo fundoplication (n = 16), and takedown of the fundoplication or hiatal closure alone (n = 3). At least 1 year follow-up period (mean 21.8 months) was available for 92 patients. For patients with significant preoperative dysphagia (n = 46), the mean symptom score declined from 2.35 to 0.78 (p < 0.0001). Persistent dysphagia was reported by 13 patients and new-onset dysphagia by 4 patients. No patients reported grade 3 dysphagia after Re-ARS. Dilations were used to treat 11 patients. Multivariate logistic regression analysis identified Collis gastroplasty (p = 0.03; adjusted odds ratio [OR], 5.74) and preoperative dysphagia (p = 0.01; adjusted OR, 6.80) as risk factors for significant postoperative dysphagia. The overall satisfaction score was 8.3, but certain subsets had significantly lower satisfaction scores. These subsets included patients with esophageal dysmotility (7.1; p = 0.04), patients who required Collis gastroplasty (7.0; p = 0.09), and patients with esophageal dysmotility who required Collis gastroplasty (5.0; p < 0.01). CONCLUSION Although dysphagia is a common symptom among patients requiring Re-ARS, intervention provides a significant benefit. Patients with preoperative dysphagia, especially those requiring Collis gastroplasty, are at increased risk for persistent dysphagia and decreased satisfaction after Re-ARS.
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30
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Lung atelectasis secondary to massive esophageal dilation in a patient with scleroderma. Can Respir J 2010; 17:e96-8. [PMID: 20808981 DOI: 10.1155/2010/179264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Esophageal dilation is a rare complication of scleroderma and CREST syndrome. A case of atelectasis secondary to right inferior bronchus compression by a massively dilated esophagus is described. The authors are unaware of any previous cases of atelectasis secondary to esophageal dilation in scleroderma.
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Abstract
Scleroderma is a generalized autoimmune disease with variable involvement of the skin and major organs (esophagus, lung, heart and kidney). Scleroderma is essentially a skin disease that frequently involves the digestive system. In scleroderma, the esophagus is the most frequently affected organ of the digestive system, and esophageal dysmotility, reflux and stricture may be observed in the advanced stage. Balloon dilatation and bougienage are generally sufficient in patients developing stricture, and the number of cases in whom resection is performed is very low. In a 20-year-old patient with difficulty in taking even liquid foods, tests revealed sclerodermal involvement of the distal end of the esophagus and stricture. Esophageal resection and gastric replacement were performed. Such systemic diseases as scleroderma, although rare, must be considered in the differential diagnosis of nonmalignant dysphagia, and resection must be borne in mind as a surgical option in cases of advanced stricture.
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Affiliation(s)
- Erdal Yekeler
- Department of Thoracic Surgery, Region Training and Research Hospital, Atatürk University, School of Medicine, Erzurum, Turkey
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Gasper WJ, Sweet MP, Golden JA, Hoopes C, Leard LE, Kleinhenz ME, Hays SR, Patti MG. Lung transplantation in patients with connective tissue disorders and esophageal dysmotility. Dis Esophagus 2008; 21:650-5. [PMID: 18459990 DOI: 10.1111/j.1442-2050.2008.00828.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Lung and esophageal dysfunction are common in patients with connective tissue disease (CTD). Recent reports have suggested a link between pathologic gastroesophageal reflux and bronchiolitis obliterans syndrome (BOS) after lung transplant. Because patients with CTD have a high incidence of esophageal dysmotility and reflux, this group may be at increased risk of allograft dysfunction after lung transplantation. Little is known about antireflux surgery in these patients. Our aims were to describe: (i) the esophageal motility and reflux profile of patients with CTD referred for lung transplantation; and (ii) the safety and outcomes of laparoscopic fundoplication in this group. A retrospective review of 26 patients with CTD referred for lung transplantation between July 2003 and June 2007 at a single center. Esophageal studies included manometry and ambulatory 24-h pH monitoring. Twenty-three patients had esophageal manometry and ambulatory 24-h pH monitoring. Nineteen patients (83%) had pathologic distal reflux and 7 (30%) also had pathologic proximal reflux. Eighteen patients (78%) had impaired or absent peristalsis. Eleven of 26 patients underwent lung transplantation. Ten patients are alive at a median follow-up of 26 months (range 3-45) and one has bronchiolitis obliterans syndrome-1. Six patients had a laparoscopic fundoplication, 1 before transplantation and 5 after. All fundoplication patients are alive at median follow-up of 25 months (range 19-45). In conclusion, esophageal dysmotility and reflux are common in CTD patients referred for lung transplant. For this group, laparoscopic fundoplication is safe in experienced hands.
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Affiliation(s)
- Warren J Gasper
- Department of Surgery, University of California, San Francisco, CA 94143-0790, USA
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Domsic R, Fasanella K, Bielefeldt K. Gastrointestinal manifestations of systemic sclerosis. Dig Dis Sci 2008; 53:1163-74. [PMID: 17934861 DOI: 10.1007/s10620-007-0018-8] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Accepted: 09/07/2007] [Indexed: 12/12/2022]
Abstract
Systemic sclerosis is a chronic disorder of connective tissue that affects the gastrointestinal tract in more than 80% of patients. Changes in neuromuscular function with progressive fibrosis of smooth muscle within the muscularis propria impair normal motor function, which may secondarily alter transit and nutrient absorption. Esophageal manifestations with gastroesophageal reflux and dysphagia are the most common visceral manifestation of the disease, often requiring more intense acid-suppressive medication. Gastric involvement may lead to gastroparesis, which can be found in up to 50% of patients. Severe small bowel disease can present as chronic intestinal pseudo-obstruction with distended loops of small intestine, bacterial overgrowth, impaired absorption and progressive development of nutritional deficiencies. While not studied as extensively, systemic sclerosis often also affects colorectal function resulting in constipation, diarrhea or fecal incontinence. Nutritional support and prokinetics have been used with some success to manage gastric and small or large bowel involvement in patients with systemic sclerosis. Despite advances in management, significant gastrointestinal manifestations of systemic sclerosis still carry a poor prognosis with a five-year mortality exceeding 50%.
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Affiliation(s)
- Robyn Domsic
- Division of Rheumatology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Kent MS, Luketich JD, Irshad K, Awais O, Alvelo-Rivera M, Churilla P, Fernando HC, Landreneau RJ. Comparison of surgical approaches to recalcitrant gastroesophageal reflux disease in the patient with scleroderma. Ann Thorac Surg 2007; 84:1710-5; discussion 1715-6. [PMID: 17954091 DOI: 10.1016/j.athoracsur.2007.06.025] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Revised: 06/01/2007] [Accepted: 06/01/2007] [Indexed: 01/17/2023]
Abstract
BACKGROUND Scleroderma is associated with severe esophageal dysmotility and gastroesophageal reflux disease (GERD). Results after antireflux surgery have been suboptimal due to the profound esophageal dysmotility seen in this disease. We hypothesized that laparoscopic Roux-en-Y gastric bypass (RYGBP) would lead to less dysphagia and better control of GERD symptoms. This report summarizes our initial results of RYGBP compared with other surgical approaches. METHODS A retrospective review identified scleroderma patients who underwent surgical management of GERD from 1995 to 2006. Complications and reinterventions were recorded. Symptom control was assessed by validated questionnaires that measured dysphagia (0 to 5; 0 = no dysphagia), GERD-heartburn-related quality of life index (0 to 45; 0 = best, 45 = worst), and overall quality of life with the Medical Outcomes Study 36-Item Short Form Health Survey. RESULTS Twenty-three scleroderma patients underwent surgical treatment for GERD (fundoplication, n = 10; RYGBP, n = 8; esophagectomy, n = 5). One patient died after esophagectomy and major morbidity occurred in 3 of the remaining 4 patients. No major complications occurred in any patient undergoing either fundoplication or RYGBP. Eighteen patients underwent evaluation by questionnaire at a median of 21 months postoperatively. Decreased dysphagia (0.42 versus 1.86, p = 0.05) and improved control of reflux (GERD-heartburn-related quality of life index score 4 versus 15.6, p = 0.05) were observed in the RYGBP patients compared with those undergoing fundoplication. CONCLUSIONS A high complication rate was seen among patients undergoing esophagectomy. Both reflux control and dysphagia rates were improved in the RYGBP group compared with fundoplication. This finding suggests that RYGBP may be an option for the primary management of scleroderma-associated gastroesophageal reflux.
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Affiliation(s)
- Michael S Kent
- Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15232, USA
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Ntoumazios SK, Voulgari PV, Potsis K, Koutis E, Tsifetaki N, Assimakopoulos DA. Esophageal involvement in scleroderma: gastroesophageal reflux, the common problem. Semin Arthritis Rheum 2006; 36:173-81. [PMID: 17045629 DOI: 10.1016/j.semarthrit.2006.08.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2006] [Revised: 07/17/2006] [Accepted: 08/01/2006] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Systemic sclerosis (SSc) is a multisystem disease characterized by abnormalities of small blood vessels, and fibrosis of the skin and internal organs including gastrointestinal tract. This article reviews the esophageal involvement in SSc, emphasizing the gastroesophageal reflux, which is a common problem in SSc patients. METHODS We conducted a Medline search from 1966 to 2005. The keywords "systemic sclerosis," "esophageal involvement," "gastroesophageal reflux," "esophagitis," and "treatment" were used. RESULTS The gastrointestinal tract is frequently affected in diffuse and limited disease. Although any part of the gastrointestinal tract can be involved, esophageal disease occurs in nearly all patients with SSc. Common esophageal manifestations in SSc include motility abnormalities and gastroesophageal reflux (GER), Barrett's esophagus, adenocarcinoma, infectious esophagitis, and drug-induced esophagitis. Common complications of GER include esophagitis with erosions and bleeding and stricture formation. Extraesophageal manifestations of GER include mouth ulcers, chronic cough, hoarse voice, sore throat, pharyngitis, laryngospasm, asthma, and recurrent pneumonia. Diagnostic procedures used in the investigation of esophageal involvement include barium esophagram, esophageal manometry, 24-hour ambulatory pH, and endoscopy. Treatment of GER in SSc includes behavioral modification and medical therapy, mainly with proton pump inhibitors. Surgical intervention has a limited role in the management of GER in selected SSc patients. CONCLUSIONS Esophageal involvement is frequent in SSc patients. Gastroesophageal reflux may cause high morbidity. Careful examination of the patients reveals gastrointestinal abnormalities even in patients without symptoms. Appropriate treatment of esophageal involvement ameliorates symptoms and prevents complications.
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Affiliation(s)
- Stavros K Ntoumazios
- Department of Otolaryngology, Medical School, University of Ioannina, Ioannina, Greece
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Abstract
Progressive systemic sclerosis (PSS) causes smooth muscle atrophy and fibrosis of the distal two-thirds of the esophagus. Motility studies show reduced-amplitude or absent peristaltic contractions in this region and normal or decreased lower esophageal sphincter pressure. Patients complain of dysphagia, heartburn, and regurgitation due to reflux and dysmotility. Complications include strictures found in 17% to 29% of patients and Barrett esophagus is 0% to 37%. Candida esophagitis is a complication of PSS not seen with non-PSS reflux. Esophageal disease correlates with pulmonary involvement but not with disease in the stomach or intestines. Whether reflux contributes to the pulmonary disease is an open question. Although manometry is the gold standard for diagnosis, cine-esophagram and scintography are only slightly less sensitive and should be considered for following the patients. Symptoms correlate poorly with evidence of esophagitis or abnormal 24-hour pH recordings. As a result, it is unclear which patients should receive acid-reducing or prokinetic medications and which medication to use. Aspiration precautions are important in those with severe esophageal dysmotility. This review of the literature highlights many areas of uncertainty in the diagnosis and treatment of esophageal disease in PSS that can be addressed in clinical studies.
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Affiliation(s)
- Ellen C Ebert
- UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA.
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Lopes LR, Cunha AG, Andreollo NA, Brandalise NA. Tratamento cirúrgico do refluxo gastroesofágico na esclerodermia. Rev Col Bras Cir 2001. [DOI: 10.1590/s0100-69912001000200010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: A esclerodermia é caracterizada pelo aumento fibrótico do tecido conectivo. O envolvimento esofágico atinge 75 a 90% dos pacientes. O receio em se construir uma válvula em um esôfago hipotônico levou às operações de ressecção, que têm morbidade significante. Posteriormente, estudos com técnicas anti-refluxo demonstraram regressão dos sintomas em 69 a 75% dos pacientes. MÉTODO: Sete pacientes femininas (32 a 59 anos, seguimento entre seis e 48 meses) com esclerodermia apresentavam pirose e havia disfagia em seis casos. Quatro pacientes com estenoses necessitaram dilatações. Quatro pacientes foram submetidas à técnica de Nissen modificada e três pacientes à técnica de Lind, por via laparoscópica. Houve uma conversão. RESULTADOS: Todas obtiveram alguma melhora clínica, exceto uma em que houve migração da válvula. Quatro pacientes ficaram com Visick grau I (58%), uma com grau II (14%), uma com grau III (14%) e uma com grau IV (14%). Não houve retardo importante do esvaziamento esofágico à cintilografia, e os exames não demonstraram mais estenoses. CONCLUSÃO: O tratamento cirúrgico anti-refluxo é eficaz em regredir os sintomas da DRGE na esclerodermia, sem comprometer a função esofágica. As ressecções são indicadas para falha do tratamento inicial, pacientes com estenoses graves ou lesões malignas.
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Abstract
A simple, tension-free, in situ gastroplasty was devised in the late 1960s and early 1970s to avoid the recurrences and complications of the Collis and Nissen hiatal hernioplasties. Long-term follow-up has now been completed on 153 patients. For this procedure, the anterior gastric wall is stapled, not cut, and the fundoplication is performed on the cardia and the neoesophagus created by the stapling and is sutured under the diaphragm. A total of 161 patients underwent the stapled, uncut gastroplasty and were followed for up to 24 years. Conditions included reflux in 145, organic stricture in 23, giant hiatal hernia in 14 (with or without obstruction) and collagen esophagus in six. Post-operative tests included subjective symptom evaluation by questionnaire, esophageal manometry and 24-h pH monitoring. Of the total 161 patients, 89 were followed up for 2-10 years and 64 for 1-24 years; seven were lost to follow-up and one died soon after the operation. The stapled, uncut gastroplasty and fundoplication produced 95% excellent and good results (Matthews classification grade I and II). After the procedure, the esophagus was significantly lengthened (from 2.55 +/- 0.96 to 3.2 +/- 0.32 cm; p < 0.001) and sphincter pressure was significantly increased (from 6.35 +/- 3.5 to 27.3 +/- 6.82 mmHg; p < 0.0001). No leakage, bleeding, or 'slipped' recurrence was observed. Only one patient experienced dissolution of the wrap and recurrent symptoms. Aspiration, scleroderma, stricture and short esophagi, post-gastrectomy gastric remnants and hiccups were treated with excellent and good long-term results. The stapled, uncut gastroplasty has universal application with excellent results, not only in typical cases of gastroesophageal reflux, but also in complicated situations such as short esophagus, strictures, or dysperistaltic and aperistaltic esophagus.
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Affiliation(s)
- N J Demos
- University of Medicine and Dentistry of New Jersey, Newark Medical School, Christ Hospital, Jersey City, USA
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Spechler SJ. AGA technical review on treatment of patients with dysphagia caused by benign disorders of the distal esophagus. Gastroenterology 1999; 117:233-54. [PMID: 10381933 DOI: 10.1016/s0016-5085(99)70573-1] [Citation(s) in RCA: 141] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the committee on September 27, 1998.
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Affiliation(s)
- S J Spechler
- Dallas Department of Veterans Affairs Medical Center and University of Texas Southwestern Medical Center Dallas, Texas, USA
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Hunter JG, Trus TL, Branum GD, Waring JP, Wood WC. A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease. Ann Surg 1996; 223:673-85; discussion 685-7. [PMID: 8645041 PMCID: PMC1235211 DOI: 10.1097/00000658-199606000-00006] [Citation(s) in RCA: 328] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The authors examined indications, evaluations, and outcomes after laparoscopic fundoplication in patients with gastroesophageal reflux through this single-institution study. SUMMARY OF BACKGROUND DATA Laparoscopic fundoplication has been performed for less than 5 years, yet the early and intermediate results suggest that this operation is safe and equivalent in efficacy to open techniques of antireflux surgery. METHODS Over a 4-year period, 300 patients underwent laparoscopic Nissen fundoplication (252) or laparoscopic Toupet fundoplication (48) for gastroesophageal reflux refractory to medical therapy or requiring daily therapy with omeprazole or high-dose H2 antagonists. Preoperative evaluation included symptom assessment, esophagogastroduodenoscopy, 24-hour pH evaluation, and esophageal motility study. Physiologic follow-up included 24-hour pH study and esophageal motility study performed 6 weeks and 1 to 3 years after operation. RESULTS The most frequent indication for surgery was the presence of residual typical and atypical gastroesophageal reflux symptoms (64%) despite standard doses of proton pump inhibitors. At preoperative evaluation, 51% of patients had erosive esophagitis, stricture, or Barrett's metaplasia. Ninety-eight percent of patients had an abnormal 24-hour pH study. Seventeen percent had impaired esophageal motility and 2% had aperistalsis. There were four conversions to open fundoplication (adhesions, three; large liver, one). Intraoperative technical difficulties occurred in 19(6%) patients and were dealt with intraoperatively in all but 1 patient (bleeding from enlarged left liver lobe). Minor complications occurred in 6% and major complications in 2%. There was no mortality. Median follow-up was 17 months. One year after operation, heartburn was absent in 93%. Four percent took occasional H2 antagonists, and 3% were back on daily therapy. Atypical reflux symptoms (e.g., asthma, hoarseness, chest pain, or cough) were eliminated or improved in 87% and no better in 13%. Overall patient satisfaction was 97%. Four patients have subsequently undergone laparotomy for repair of gastric perforation (1 year after operation), severe dumping, "slipped" Nissen, and repair of acute paraesophageal herniation. Two patients had laparoscopic revision of herniated fundoplications. Results of follow-up 24-hour pH studies were normal in 91% of patients more than 1 year after operation. In patients with poor esophageal motility, esophageal body pressure improved 1 year after operation in 75% and worsened in 10%. CONCLUSIONS Although long-term efficacy data are lacking, intermediate follow-up shows laparoscopic fundoplication to be safe and effective. A physiologic approach to evaluation and follow-up of patients with gastroesophageal disease allows the surgeon to tailor antireflux surgery to esophageal body function and follow the function of the fundoplication and esophagus after operation.
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Affiliation(s)
- J G Hunter
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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