Fundoplication for laryngopharyngeal reflux disease

The Role of Surgical Intervention in Laryngopharyngeal Reflux Disease

This article covers surgical interventions for laryngopharyngeal reflux disease (LPRD), focusing on upper esophageal sphincter augmentation, fundoplication, and magnetic sphincter augmentation. It discusses indications, procedural details, and an overview of current evidence for surgical management of refractory LPRD.

Overall satisfaction following laparoscopic fundoplication for patients with atypical extraesophageal symptoms: A comparative cohort study

BACKGROUND

Some patients with gastroesophageal reflux (GERD) experience extraesophageal symptoms, which are considered due to laryngopharyngeal reflux (LPR). Most studies evaluating fundoplication for LPR report outcomes from individuals who also have typical esophageal GERD symptoms. Information is limited for patients with LPR but no GERD symptoms. To determine whether LPR patients benefit from fundoplication outcomes were determined for individuals with LPR ± GERD and also those without LPR.

METHODS

Patients undergoing fundoplication from 1997 to 2015 were identified and divided into three symptom groups: LPR only, LPR and GERD, and GERD only. Heartburn, dysphagia, and satisfaction were assessed using 0-10 analog scores and compared at short (1-2 years) and later (5 years) follow-up.

RESULTS

2204 patients underwent fundoplication. 24 patients had LPR only, 130 patients had LPR and GERD, and matched to 1319 patients with GERD only. At 1-2 years follow-up, the LPR only group had lower satisfaction scores than those with GERD symptoms (± concurrent LPR) (7.00 ± 3.49 vs. 8.41 ± 2.42, p = 0.019, and mean ± s.d.). At 1-2 years, 68.1% of the LPR only group had a good outcome (satisfaction score: 7-10) versus 84.6% with LPR and GERD and 84.1% with GERD only.

CONCLUSION

At 1-2 years follow-up, patients with LPR only were less satisfied following fundoplication compared with patients with typical GERD (±LPR). However, some patients with LPR only did benefit and might be considered for surgery if appropriately counseled. Outcomes were similar for patients with LPR and typical GERD and those with only typical symptoms.

Impact of second-generation transoral incisionless fundoplication on atypical GERD symptoms: a systematic review and meta-analysis

BACKGROUND AND AIMS

Transoral incisionless fundoplication (TIF) using the EsophyX device (EndoGastric Solutions, Inc, Redmond, Wash, USA) is a minimally invasive endoscopic fundoplication technique. Our study aimed to assess the efficacy of TIF for atypical GERD symptoms in patients with chronic or refractory GERD.

METHODS

A systematic search of 4 major databases was performed. All original studies assessing atypical GERD using a validated symptom questionnaire (the reflux symptom index [RSI]) were included. The RSI score was assessed before and after TIF at a 6- and 12-month follow-up. Data on technical success rate, adverse events, proton pump inhibitor (PPI) use, and patient satisfaction were also collected. Only TIF procedures currently in practice using the EsophyX device (ie, TIF 2.0) and TIF with concomitant hiatal hernia repair were included in the review.

RESULTS

Ten studies (564 patients) were included. At the 6- and 12- month follow-up, there was a mean reduction of 15.72 (95% confidence interval, 12.15-19.29) and 14.73 (95% confidence interval, 11.74-17.72) points, respectively, in the RSI score post-TIF, with a technical success rate of 99.5% and a pooled adverse event rate of 1%. At both time intervals, more than two-thirds of the patients were satisfied with their health condition and roughly three-fourths of the patients were off daily PPIs.

CONCLUSIONS

Our study shows that TIF using the EsophyX device is safe and effective in reducing atypical GERD symptoms at 6 and 12 months of follow-up. It improves patient-centered outcomes and can be a minimally invasive therapeutic option for patients suffering from atypical GERD symptoms on chronic medical therapy.

The Role of Empirical Treatment with Proton Pump Inhibitor as a Diagnostic Tool in Laryngopharyngeal Reflux

The presentations of laryngopharyngeal reflux (LPR) are diverse and include chronic hoarseness, sensation of foreign body in the throat, sore throat etc. 24 h pH monitoring considered the gold standard of investigation for LPR is costly, cumbersome and not readily available at all centers. Empirical trial of Proton pump inhibitor (PPI) as a diagnostic tool after assessment by Reflux Symptom Index (RSI) and Reflux Findings Score (RFS) is a cheaper, simple and readily available alternative. The objectives of the study were to determine clinical manifestations in patients presenting with LPR and to evaluate the role of empirical treatment with PPI as a diagnostic tool in LPR. 100 patients were divided into experimental group (RSI ≥ 13 and RFS ≥ 7) and control group (RSI < 13 and RFS < 7). Omeprazole trial was given to experimental group and assessed for RSI and RFS at 04 and 08 weeks. Statistical analysis was done within the group and between the groups. (1) The response rate to Omeprazole at 04 and 08 weeks interval (RSI<13 and/or RFS<7) was 60% and 76% respectively. (2) The response to Omeprazole given to the experimental group with RSI≥13 and RFS≥7 was significant at 04 weeks and 08 weeks duration (P<0.0001). RSI and RFS are good clinical tools to assess and diagnose patients with Laryngopharyngeal reflux. Based on the clinical diagnosis an empirical trial of a proton pump inhibitor (PPI) can be given to patients for duration of 02 months resulting in a good response.

Laryngopharyngeal reflux: is laparoscopic fundoplication an effective treatment?

INTRODUCTION

Laryngopharyngeal reflux (LPR) is difficult to diagnose and treat owing to uncertainty relating to the underlying pathology. The initial management of LPR includes lifestyle modifications and oral medications. In patients who have failed to respond to proton pump inhibitor (PPI) therapy, anti-reflux surgery is considered; laparoscopic fundoplication is the surgery of choice. The primary aim of this review is to identify whether fundoplication is effective in improving signs and symptoms of LPR. The secondary aim is to identify whether patients who have had a poor response to PPIs are likely to have symptom improvement with surgery. The objective of the study is to establish the effect of laparoscopic fundoplication on the reflux symptom index score (RSI).

METHODS

PubMed, Embase, Medline and Cochrane databases were used to search according to the PRISMA guidelines. Original articles assessing the efficacy of fundoplication in relieving symptoms of LPR were included. For each study, the efficacy endpoints and safety outcomes were recorded.

FINDINGS

Nine studies from 844 initial records met the inclusion criteria: one prospective case control study, one retrospective case-control study, four prospective case series and three retrospective case series involving 287 fundoplications. All nine studies found fundoplication to be effective in improving symptoms of LPR (p < 0.05).

CONCLUSION

Current evidence suggests laparoscopic fundoplication is an effective treatment for LPR and should be considered if medical management is unsuccessful.

Laparoscopic Toupet Fundoplication for the Treatment of Laryngopharyngeal Reflux: Results at Medium-Term follow-Up

BACKGROUND

The effect of laparoscopic Toupet fundoplication (LTF) for the treatment of laryngopharyngeal reflux (LPR) is unclear. The purpose of this study is to investigate the feasibility and effectiveness of LTF for the treatment of LPR-related symptoms and disease-specific quality of life (QoL) up to 3-year follow-up.

MATERIALS AND METHODS

Observational cohort study (2015-2019). Patients suffering from LPR were included. Preoperative evaluation included esophagogastroduodenoscopy, esophageal manometry and 24-h pH/impedance study. Symptoms and QoL were measured with the reflux symptom index (RSI) and the laryngopharyngeal reflux-health-related quality of life (LPR-HRQL) validate questionnaires at baseline and during follow-up.

RESULTS

Eighty-six patients were included. Twenty-three (27%) patients had pure LPR while 63 (73%) presented with combined LPR/GERD. Cough (89.7%), dyspnea/choking (39.6%) and asthma (25.6%) were the most commonly reported extraesophageal symptoms. The median (interquartile range, IQR) total RSI score before operation and at 3-month, 6-month, 1-year, 2-year and 3-year follow-up was 36.1 (10.3), 9.58 (12.3), 11.8 (10.2), 12.4 (9.6), 12.0 (13.1) and 10.1 (12.0), respectively. The median (IQR) total LPR-HRQL score before operation and at 3-month, 6-month, 1-year, 2-year and 3-year follow-up was 57.4 (22.2), 13.4 (14.9), 15.2 (12.8), 11.4 (10.9) and 11.9 (13.5), respectively. The subscores "voice," "cough," "throat" and "swallow" showed a significant improvement after intervention. Compared to baseline, each per-year follow-up pairwise comparison was significantly improved (p < 0.001).

CONCLUSIONS

LTF seems feasible, effective and promising for the treatment of LPR with improved symptoms and disease-specific patients' quality of life perception up to 3-year follow-up.

Gastroesophageal Reflux Disease - Health-Related Quality of Life Questionnaire: prospective development and validation in Italian

OBJECTIVE

To date, two questionnaires investigating the symptoms of gastroesophageal reflux disease (GERD) (Quality of Life Reflux and Dyspepsia and Reflux Disease Questionnaire) are validated in Italian, but neither of the two questionnaires was correlated with an instrumental examination. The aim of the present study is to improve the GERD-Health Related Quality of Life (HRQL) questionnaire, to evaluate the reliability and validity of its Italian translation, and its sensitivity and specificity.

METHODS

A modified Italian GERD-HRQL (MI-GERD-HRQL) questionnaire was developed adding six questions investigating on regurgitation, for a total of 15 questions. The forward-backward translation process was employed to obtain a definitive from-English-to-Italian version. Data obtained from the questionnaire were compared to upper gastrointestinal endoscopy findings.

RESULTS

The questionnaire was administered twice to 130 Italian-speaking patients by two different and independent raters. Cronbach's α of the first and second questionnaire was 0.944 and 0.942, respectively. Spearman correlation and inter-rater reliability were 0.923 and 0.929, respectively. Sensitivity and specificity were 73.3 and 64%, and 69.5 and 64%, respectively, for the first and second questionnaire.

CONCLUSION

The MI-GERD-HRQL questionnaire proved good consistency, reliability, sensitivity and specificity in the evaluation of typical GERD symptoms.

Anti-reflux surgery for controlling respiratory symptoms of gastro-esophageal reflux disease: A systematic review and meta-analysis

Gastro-esophageal reflux disease (GERD) patients have a higher prevalence of airway symptoms, such as chronic cough, wheezing, and hoarseness. The therapeutic management of patients with these symptoms is controversial. Therefore, this study aims to perform a systematic review and meta-analysis evaluating the efficacy of anti-reflux surgery for controlling respiratory symptoms related to GERD. A systematic review and meta-analysis was performed. Extraction of the data concerning proportions of participants who were not free of respiratory symptoms related to GERD (cough, wheezing, hoarseness) or not substantially improved at follow-ups (failure to cure) was performed. Of the 3,424 initially screened articles, 68 studies were included for systematic review and 61 were included for meta-analysis, with a cumulative sample size of 3,869 patients. Of all the included patients, after anti-reflux surgery, the general symptoms improvement was 80% (95% CI 75.2-84%). The numbers needed to harm (NNH) and the numbers needed to treat (NNT) were 15.21 and 1.23, respectively. Of the included patients, 83.4% (95% CI 78.3-87.5%) patients reported improvement in cough symptoms after surgery. For the wheezing symptom, 71.5% (95% CI 62.9-78.8%) reported improvement after surgery. Moreover, surgery presented better results in improving respiratory symptoms than medical therapy (risk difference: -0.46; 95% CI -0.77, -0.16). Physicians should strongly consider surgical anti-reflux procedures for controlling respiratory symptoms in GERD patients after proper patient selection. Anti-reflux surgery has shown high efficacy in improving respiratory symptoms related to GERD, even when compared to medical therapy.

Linguistic Adaptation, Reliability, and Validation of the Turkish Version of the Reflux Symptom Index

INTRODUCTION

The reflux symptom index (RSI) has been designed to raise the clinical suspicion of laryngopharyngeal reflux (LPR) in patients presenting with ear, nose, and throat symptoms.

OBJECTIVE

To develop a Turkish version of the RSI (Tr-RSI) and to evaluate its internal consistency, reliability, and clinical validity METHODS: The RSI was translated into Turkish. A total of 44 asymptomatic control subjects without LPR and 62 patients with LPR were enrolled into this study. The patients were treated with diet and behavioral modifications combined with 20 mg of rabeprazole twice daily for 3 months. All individuals were asked to fill the Tr-RSI. Participants in the control group were asked to refill the Tr-RSI after 1 week, whereas those in the patient group after treatment. Test-retest reliability, validity, and internal consistency were computed.

RESULTS

The Cronbach's alpha value of Tr-RSI was 0.959, indicating excellent internal consistency. The single-measurement intra-class correlation coefficient absolute agreement was 0.948 (with 95% confidence interval of 0.907-0.971), indicating good test-retest reliability. The Tr-RSI scores for total and each item were significantly higher in the LPR patient group than in the control group (P < 0.001). In the LPR patient group, the posttreatment Tr-RSI scores for each item and total were significantly lower than the pretreatment scores (P < 0.001).

CONCLUSION

The Tr-RSI was successfully created. It can be used with strong internal consistency, high test-retest reliability, and optimal clinical validity.

Duodenogastroesophageal reflux and its effect on extraesophageal tissues: A review

We conducted a literature review to identify elements of duodenogastroesophageal reflux (DGER)—namely pancreatic fluids, hydrochloric acid, pepsin, and bile—as to the effects each has when refluxed to the extraesophageal structures. Further, we wished to acquaint clinicians with the possibilities that, in addition to hydrochloric acid, the other components of DGER are likewise contributing to disease in the extraesophageal areas. Our review included studies that have indicated reflux of the above mentioned components of DGER to the pharynx, larynx, tracheobronchial tree, oral cavity, nasopharynx, nose and sinuses, eustachian tube, and middle ear. Findings demonstrate that injury to the upper aerodigestive tract can occur from a variety of substances secreted from the stomach and duodenum. Treatment for DGER is nonspecific. We conclude that patients with an incomplete response to acid suppression may have significant involvement of pepsin, bile, or both. Future studies are needed to clarify the importance of these elements and to suggest more precise treatments.

Surgical Treatment for Laryngopharyngeal Reflux Disease: A Systematic Review

IMPORTANCE

Laryngopharyngeal reflux (LPR) is a prevalent disease that is usually treated with diet, lifestyle modifications, and proton pump inhibitor therapy. However, nearly 10% to 30% of patients do not achieve adequate acid suppression even with high doses of proton pump inhibitors. For these patients with resistant disease, fundoplication may be recommended but the success rate of fundoplication surgery on laryngopharyngeal symptoms and findings remains uncertain.

OBJECTIVE

To determine whether fundoplication is associated with control of signs and symptoms in patients with LPR.

EVIDENCE REVIEW

A literature search was conducted on PubMed, Cochrane Library, and Scopus according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline to identify studies published between 1990 and 2018 about the efficacy of fundoplication on clinical outcomes of LPR. Three investigators screened publications for eligibility and exclusion based on predetermined criteria. Study design, patient characteristics, diagnostic method, exclusion criteria, treatment characteristics, follow-up, and quality of the outcome assessment were evaluated.

FINDINGS

Of the 266 studies identified, 34 met the inclusion criteria, accounting for 2190 patients with LPR (1270 women and 920 men; mean [SD] age at the time of surgery, 49.3 [6.3] years). A weighted mean of 83.0% of patients (95% CI, 79.7%-86.3%) experienced improvement and a weighted mean of 67.0% of patients (95% CI, 64.1%-69.9%) experienced a disappearance of symptoms, but there is a high level of methodological heterogeneity among studies according to diagnostic method, exclusion criteria, and outcomes used to assess the efficacy of fundoplication. A pH study without impedance study was used in most studies but with various inclusion criteria. According to results of an a priori assessment, the clinical outcomes used were overall poor, excluding many symptoms and findings associated with LPR.

CONCLUSION AND RELEVANCE

The reported studies of fundoplication in LPR disease have important heterogeneity in method of diagnosis, exclusion criteria, symptoms, and signs assessed as therapeutic outcomes; therefore, this systematic review was nonconclusive regarding whether surgery for LPR disease is associated with effective control of sight and symptoms. Otolaryngologists, gastroenterologists, and surgeons must establish a diagnostic criterion standard, clear indications for surgery, and future clinical outcomes to precisely assess the effectiveness of treatment.

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

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

Gastroesophageal Reflux Disease and Aerodigestive Disorders

This relationship between gastroesophageal reflux and airway disorders is complex, possibly bidirectional, and not clearly defined. The tools used to investigate gastroesophageal reflux are mostly informative about involvement of gastroesophageal reflux within the gastrointestinal tract, although they are often utilized to study the relationship between gastroesophageal reflux and airway issues with are suspected to occur in relation to reflux. These modalities often lack specificity for reflux-related airway disorders. Co-incidence of gastroesophageal reflux and airway disorders does not necessarily infer causality. While much of our focus has been on managing acidity, controlling refluxate is an area that has not been traditionally aggressively pursued. Our management approach is based on some of the evidence presented, but also often from a lack of adequate study to provide further guidance.

Outpatient erbium:YAG (2940 nm) laser treatment for snoring: a prospective study on 40 patients

Snoring is a sleep phenomenon due to the partial upper airway obstruction during sleep which causes vibration of the tissues of the rhino-oro-hypopharynx and less frequently the larynx. This study evaluated the use and effectiveness of the erbium:YAG 2940-nm laser as an adjunctive in providing treatment for patients suffering from chronic snoring-related sleep disorders. A prospective study of 40 consecutive patients with snoring and sleep disorders was performed, assessing data before and after three Er:YAG laser treatment sessions. During laser treatment, the pain was almost absent. There were no side effects, except a very mild sore throat in 1 out of 40 patients. The patient's evaluation of satisfaction of the results obtained after the treatments showed that 85% of cases were very satisfied, 5 patients (12.5%) reported being fairly satisfied with the treatment and only 1 subject (2.5%) was not satisfied. Mallampati, Friedman Tongue Position, and degree of O (oropharynx) at nose oropharynx hypopharynx and larynx classification were significantly decreased after the laser sessions. The decrease of Epworth Sleepiness Scale and Visual Analogue Scale for loudness of snoring, waking up during sleep because of snoring, dry mouth on waking, and choking was all statistically significant. The incidence of dreaming during the night also raised significantly; 30/40 (75%) of cases perceived less tightness in their throat and better breathing after treatment. These results were stable at 20 months follow-up (14-24 q) in 72% of cases. Nonsurgical and non-invasive Er:YAG laser treatment demonstrated to be a valid procedure in reducing the loudness of snoring.

Nissen Fundoplication for Laryngopharyngeal Reflux After Patient Selection Using Dual pH, Full Column Impedance Testing

Objectives:

Prior studies demonstrate inconsistent diagnostic strategies for laryngopharyngeal reflux disease (LPR) patients who are offered laparoscopic Nissen fundoplication (Nissen). Superior symptom resolution outcomes are demonstrated in patients with accompanying typical gastroesophageal reflux (GERD) symptoms. This study aims to evaluate the efficacy of selecting patients with LPR complaints for Nissen using full column, dual pH impedance catheters (multichannel intraluminal impedance catheters [MII]).

Methods:

All patients who underwent Nissen for management of LPR symptoms refractory to at least 3 months of twice daily (BID) proton pump inhibitor (PPI) therapy with reflux symptom index (RSI) of 13 or higher and who had demonstrable reflux on MII were included. Pre- and (minimum) 16 week post-Nissen RSI scores as well as LPR-specific complaints were collected.

Results:

Eleven patients met criteria. Nine subjects (5 female, 4 male) had complete data. All 9 (100%) achieved improvement in RSI. The average pre-Nissen RSI was 31.7, and average post-Nissen RSI was 10 ( P < .001). Six (67%) subjects dropped below an RSI of 13. Seven subjects (78%) had resolution of their primary LPR symptom, and 6 (67%) subjects had resolution of all LPR symptoms.

Conclusions:

Patients with LPR who are selected using dual pH and full column impedance are likely to demonstrate improvement in RSI following Nissen.

Reflux and Voice Disorders: Have We Established Causality?

A trend of attributing abnormal voice changes to reflux has gained momentum among medical professionals over the last few decades. Evidence supporting the connection between reflux and voice and the use of anti-reflux medication in patients with dysphonia is conflicting and deserves careful examination. In the current health care environment, it is important that medical decisions be based on science rather than anecdote and practice patterns. The goal of this review is to investigate the evidence linking reflux and voice changes. Specifically, this association will be examined in the context of the Bradford-Hill criteria to determine what evidence exists for a causal relationship between this exposure (reflux) and outcome (voice change).

Laparoscopic antireflux surgery in patients with extra esophageal symptoms related to asthma

Background

Asthma, laryngitis and chronic cough are atypical symptoms of the gastroesophageal reflux disease.

Aim

To analyze the efficacy of laparoscopic surgery in the remission of extra-esophageal symptoms in patients with gastroesophageal reflux, related to asthma.

Methods

Were reviewed the medical records of 400 patients with gastroesophageal reflux disease submitted to laparoscopic Nissen fundoplication from 1994 to 2006, and identified 30 patients with extra-esophageal symptoms related to asthma. The variables considered were: gender, age, gastroesophageal symptoms (heartburn, acid reflux and dysphagia), time of reflux disease, treatment with proton pump inhibitor, use of specific medications, treatment and evolution, number of attacks and degree of esophagitis. Data were subjected to statistical analysis, comparing the pre- and post-surgical findings.

Results

The comparative analysis before surgery (T1) and six months after surgery (T2) showed a significant reduction on heartburn and reflux symptoms. Apart from that, there was a significant difference between the patients with daily crises of asthma (T1 versus T2, 45.83% to 16.67%, p=0.0002) and continuous crises (T1, 41.67% versus T2, 8.33%, p=0.0002).

Conclusion

Laparoscopic Nissen fundoplication was effective in improving symptoms that are typical of reflux disease and clinical manifestations of asthma.

Long-term results of electrical stimulation of the lower esophageal sphincter for treatment of proximal GERD

INTRODUCTION

Electrical stimulation of the lower esophageal sphincter (LES) in gastroesophageal reflux disease (GERD) patients, using EndoStim(®) LES stimulation system (EndoStim BV, the Hague, Netherlands), enhances LES pressure, decrease distal esophageal acid exposure, improves symptoms, and eliminates the need in many patients for daily GERD medications.

AIM

To evaluate, in a post hoc analysis, the effect of LES stimulation on proximal esophageal acid exposure in a subgroup of patients with abnormal proximal esophageal acid exposure.

METHODS

Nineteen patients (median age 54 years; IQR 47-64; men-10) with GERD partially responsive to proton pump inhibitors (PPI), hiatal hernia ≤ 3 cm, esophagitis ≤ LA grade C underwent laparoscopic implantation of the LES stimulator. LES stimulation at 20 Hz, 215 μs, 5-8 m Amp sessions was delivered in 6-12, 30 min sessions each day. Esophageal pH at baseline and after 12-months of LES stimulation was measured 5 and 23 cm above the manometric upper border of LES.

RESULTS

Total, upright and supine values of median (IQR) proximal esophageal pH at baseline were 0.4 (0.1-1.4), 0.6 (0.2-2.3), and 0 (0.0-0.2) %, respectively, and at 12 months on LES-EST were 0 (0-0) % (p = 0.001 total and upright; p = 0.043 supine comparisons). 24-hour distal esophageal acid exposure improved from 10.2 (7.6-11.7) to 3.4 (1.6-7.0) % (p = 0.001). Seven (37%) patients had abnormal (>1.1%) 24-hour proximal acid exposure at baseline; all normalized at 12 months (p = 0.008). In these 7 patients, total, upright, and supine median proximal acid exposure values at baseline were 1.7 (1.3-4.1), 2.9 (1.9-3.7), and 0.3 (0-4.9) %, respectively, and after 12 months of LES-EST were 0 (0-0.0), 0 (0-0.1), and 0 (0-0) % (p = 0.018 total and upright; p = 0.043 supine comparisons). Distal esophageal pH for this group improved from 9.3 (7.8-17.2) at baseline to 3.2 (1.1-3.7) % at 12-months (p = 0.043). There were no GI side effects such as dysphagia, gas-bloat or diarrhea or device or procedure related serious adverse events with LES-EST. There was also a significant improvement in their GERD-HRQL scores.

CONCLUSION

LES-EST is associated with normalization of proximal esophageal pH in patients with GERD and may be useful in treating those with proximal GERD. The LES-EST is safe without typical side effects associated with traditional antireflux surgery.

Laryngopharyngeal reflux and Helicobacter pylori

Laryngopharyngeal reflux (LPR) occurs when gastric contents pass the upper esophageal sphincter, causing symptoms such as hoarseness, sore throat, coughing, excess throat mucus, and globus. The pattern of reflux is different in LPR and gastroesophageal reflux. LPR usually occurs during the daytime in the upright position whereas gastroesophageal reflux disease more often occurs in the supine position at night-time or during sleep. Ambulatory 24-h double pH-probe monitoring is the gold standard diagnostic tool for LPR. Acid suppression with proton pump inhibitor on a long-term basis is the mainstay of treatment. Helicobacter pylori (H. pylori) is found in many sites including laryngeal mucosa and interarytenoid region. In this paper, we aim to present the relationship between LPR and H. pylori and review the current literature.

Globus pharyngeus: a review of its etiology, diagnosis and treatment

Globus is a persistent or intermittent non-painful sensation of a lump or foreign body in the throat. It is a commonly encountered clinical condition that is usually long-lasting, difficult to treat, and has a tendency to recur. Furthermore, due to the uncertain etiology of globus, it remains difficult to establish standard investigation and treatment strategies for affected patients. As a first step for managing globus, careful history taking and nasolaryngoscopy are essential. Given the benign nature of the condition and the recent notion that gastroesophageal reflux disease is a major cause of globus, empirical therapy with a high dose of proton pump inhibitors is reasonable for patients with typical globus. If patients are nonresponsive to this therapy, definitive assessments such as endoscopy, multichannel intraluminal impedance/pH monitoring, and manometry should be considered. Speech and language therapy, anti-depressants, and cognitive-behavioral therapy can be helpful in patients whose symptoms persist despite negative investigations.

Endoscopic management of gastroesophageal reflux disease: a review

Gastroesophageal reflux disease is the most common esophageal disorder encountered in the United States. Gastroesophageal reflux disease symptoms are associated with a negative quality of life and increased healthcare costs and therefore require an effective management strategy. Although proton pump inhibitors remain the primary treatment of gastroesophageal reflux disease, they do not cure the disorder and can leave patients with persistent symptoms despite treatment. Moreover, patients are still at risk of developing such complications as peptic strictures, Barrett's metaplasia, and esophageal cancer. Although laparoscopic Nissen fundoplication has been the conventional alternative treatment for those patients who develop complications of gastroesophageal reflux disease, have intractable symptoms, or wish to discontinue taking proton pump inhibitors, investigators have persisted in developing a number of endoscopic approaches to the treatment of gastroesophageal reflux disease. The present report reviews the history of endoscopic treatments devised for the management of gastroesophageal reflux disease and explores the published data and outcomes associated with the latest approach-endoscopic fundoplication using the EsophyX2 device.

How much pharyngeal exposure is "normal"? Normative data for laryngopharyngeal reflux events using hypopharyngeal multichannel intraluminal impedance (HMII)

BACKGROUND

Laryngopharyngeal reflux (LPR) can cause atypical symptoms, asthma, and pulmonary fibrosis. The aim of this study was to establish the normative data for LPR using hypopharyngeal multichannel intraluminal impedance-pH (HMII).

METHODS

Asymptomatic subjects underwent endoscopy followed by 24-h HMII using a specialized impedance catheter configured to detect LPR before and after a 2-week course of proton pump inhibitors (PPI). Subjects were excluded if they had esophageal pathology or a positive DeMeester score. A cohort of 24 LPR patients who had a complete response to treatment was used for comparison with the normative data.

RESULTS

Forty subjects were enrolled. Thirty-four subjects completed one, and 25 completed both HMII testing periods off and on PPI. There was no difference in the total number of reflux events between off and on PPI [22 (8-32) and 24 (10-28), respectively, p = 0.89]. The 95th percentiles of LPR off and on PPI were 0 and 1, respectively. All patients with treatment responsive LPR had pre-treatment HMII values of LPR greater than the 95th percentile.

CONCLUSION

LPR events are rare in an asymptomatic population. One or more LPR events should be considered abnormal in patients with LPR symptoms regardless of whether there is a positive DeMeester score.

Impact of laparoscopic fundoplication for the treatment of laryngopharyngeal reflux: review of the literature

Laryngopharyngeal reflux (LPR) is part of the so-called extraesophageal manifestations of gastroesophageal reflux disease (GERD). It is presented by unspecific symptoms and signs and is believed to be caused by the reflux of gastric content to the proximal esophagus and larynx. However, evidence considering the role of the antireflux surgery for LPR has failed to demonstrate results comparable to those for GERD. The aim of this paper is to review the current literature regarding the impact of laparoscopic fundoplication for the treatment of LPR.

Endoscopic fundoplication for the treatment of gastroesophageal reflux disease: initial experience

OBJECTIVE

Transoral incisionless fundoplication (TIF) is a promising approach for gastroesophageal reflux disease (GERD) that may decrease morbidity compared with conventional antireflux procedures. We report our initial experience with this minimally invasive approach.

METHODS

Over a 24-month period, 46 patients (mean age, 49 years; 50% female) underwent 48 TIF procedures. All procedures were performed under general anesthesia. Two surgeons participated in all cases; one served as the endoscopist, and the other performed the partial fundoplication. Heartburn severity was measured using the GERD health-related quality of life (GERD-HRQL) instrument (best score = 0, worst score = 45), which includes an additional question assessing overall satisfaction.

RESULTS

Preoperatively, 33 (72%) of 46 patients had small (<3 cm) hiatal hernias, and none had undergone any previous antireflux procedures. Preoperative workup included manometry and barium esophagogram, with pH testing reserved for patients with atypical symptoms or typical symptoms and a lack of response to proton-pump inhibitors. The mean procedure time was 83 minutes (range, 36-180 minutes). The mean procedure time decreased after the first 5 cases from 122 to 78 minutes (P = .001). Mean length of stay was 1.3 days. One patient was readmitted with aspiration pneumonia. Three patients had minor complications (1 had minor bleeding from a suture site and 2 had urinary retention). There were no perioperative deaths. Mean follow-up was 140 days. The mean GERD-HRQL scores improved significantly (23 vs 7; P < .001). There were 22 patients with follow-up greater than 90 days (mean follow-up, 240 days). GERD-HRQL scores remained significantly improved for these patients (23 vs 8; P = .001). Four patients from the entire group (8.6%) had no improvement, in 3 instances due to breakdown of the wrap. Two patients were treated with repeat endoscopic fundoplication and 1 was treated with laparoscopic Nissen fundoplication, and all had a significant improvement in symptoms after reoperation.

CONCLUSIONS

TIF is effective at short-term follow-up and safe for patients with GERD. However, long-term follow-up and randomized trials are required to assess the efficacy and durability of this approach compared with conventional surgical repair.

Long-term outcomes after transoral incisionless fundoplication in patients with GERD and LPR symptoms

Background

A retrospective study evaluated safety, symptom resolution, patient satisfaction, and medication use 1–2 years after transoral incisionless fundoplication (TIF) in patients with gastroesophageal reflux disease (GERD) and/or laryngopharyngeal reflux (LPR) symptoms.

Methods

Thirty-four patients with a confirmed diagnosis of GERD symptoms that were inadequately controlled by antisecretory medications, and who where either dissatisfied with their current therapy or not willing to continue taking medication, underwent TIF using EsophyX at our community-based hospital. Follow-up assessments were completed in 28 patients.

Results

Median age of the study group was 57 (range = 23–77) years, BMI was 25.7 (18.3–36.4) kg/m², and 50% were female. All patients had documented chronic GERD for a median 5 (1–20) years and refractory symptoms to proton pump inhibitors (PPIs). Hiatal hernia was present in 75% (21/28) of patients, and 21% (6/28) had erosive esophagitis (LA grade A or B). TIF was performed following a standardized TIF-2 protocol and resulted in reducing hiatal hernia and restoring the natural anatomy of the gastroesophageal (GE) junction (Hill grade I). There were no postoperative complications. At a median 14-months follow-up, 82% (23/28) of patients were off daily PPIs (64% completely off PPIs), and 68% (19/28) were satisfied with their current health condition compared to 4% before TIF. Median GERD Health-Related Quality of Life scores were significantly reduced to 4 (0–25) from 26 (0–45) before TIF (P < 0.001). Heartburn was eliminated in 65% (17/26) and improved by >50% in 86% (24/28) of patients. Regurgitation was eliminated in 80% (16/20) of patients. Atypical LPR symptoms such as hoarseness, coughing, and throat clearing were eliminated in 63% (17/27) of patients as measured by Reflux Symptom Index scores.

Conclusion

Our results in 28 patients confirm the safety and effectiveness of TIF, documenting symptomatic improvement of GERD and LPR symptoms and clinically significant discontinuation of daily PPIs in 82% of patients.

Traditional reflux parameters and not impedance monitoring predict outcome after fundoplication in extraesophageal reflux

OBJECTIVES/HYPOTHESIS

Fundoplication is considered in patients with refractory extraesophageal reflux symptoms. However, postoperative symptom resolution is inconsistent. This analysis investigates which presenting symptoms and preoperative objective parameters predict postoperative symptom improvement.

STUDY DESIGN

Retrospective cohort study.

METHODS

A total of 237 patients referred for extraesophageal reflux symptoms refractory to medical therapy underwent esophageal function testing. Fundoplication was performed in 27 patients with objective evidence of gastroesophageal reflux disease. Symptomatic improvement was assessed at postoperative intervals. Logistic regression determined which symptoms and objective parameters predicted improvement of the presenting extraesophageal reflux symptom.

RESULTS

Overall, 59% of patients reported at least partial improvement of their presenting extraesophageal symptom after fundoplication. Predictors of symptomatic improvement were the presence of heartburn with or without regurgitation concomitant to their primary presenting symptom (odds ratio [OR], 6.6; 95% confidence interval [CI], 0.97-44.9; P = .05) and pH < 4 more than 12% of a 24-hour period (OR, 10.5; 95% CI, 1.36-81.1; P = .02). Probability of postoperative extraesophageal reflux symptom improvement was 90% if both conditions were present.

CONCLUSIONS

Both heartburn with or without regurgitation and esophageal pH < 4 more than 12% of a 24-hour period predicted postfundoplication resolution of the presenting extraesophageal reflux symptom.

Clinical and pH-metric outcomes of transoral esophagogastric fundoplication for the treatment of gastroesophageal reflux disease

BACKGROUND

Transoral treatment of gastroesophageal reflux disease (GERD) using the EsophyX device enables creation of an esophagogastric fundoplication with potential for better control of reflux than gastrogastric techniques. Efficacy and safety of a rotational/longitudinal esophagogastric transoral incisionless fundoplication (TIF) was evaluated retrospectively using subjective and objective outcomes.

METHODS

Thirty-seven consecutive patients on antisecretory medication and with proven gastroesophageal reflux and limited hiatal hernia underwent TIF for persistent GERD symptoms. Five patients were reoperations for failed laparoscopic fundoplication.

RESULTS

Of the 37 treated patients, 57% were female. The median age was 58 (range=20-81) years and BMI was 25.5 (range=15.9-36.1) kg/m2. Sixty-eight percent indicated GERD-associated cough, asthma, or aspiration as a primary complaint and 32% complained of heartburn or regurgitation. The TIF procedures created tight wraps of 230°-330° extending 3-4 cm above the Z-line. Two complications occurred: one mediastinal abscess treated laparoscopically and one postoperative bleeding requiring transfusion. At 6 (range=3-14) months median follow-up TIF resulted in a significant improvement of both atypical and typical symptoms in 64% and 70-80% of patients, respectively, as indicated by the corresponding GERD health-related quality of life (HRQL) and reflux symptom index (RSI) score reduction by 50% or more compared to baseline on proton pump inhibitors (PPIs). No patient reported problems with dysphagia, bloating, or excess flatulence, and 82% were not taking any PPIs. Reflux characteristics were significantly improved and normalized in 61, 89, and 56% of patients in terms of acid exposure, number of refluxates, and DeMeester scores, respectively. TIF was effective in treating GERD in 75% of patients among whom 54% were in a complete "remission" and 21% were "improved." The remaining 25% were considered failures, and five (13.5%) patients underwent revision.

CONCLUSION

Rotational/longitudinal esophagogastric fundoplication using the EsophyX device significantly improved symptomatic and objective outcomes in over 70% of patients at median 6-month follow-up. Post-fundoplication side effects were not reported after TIF.

Transoral incisionless fundoplication offers high patient satisfaction and relief of therapy-resistant typical and atypical symptoms of GERD in community practice

This retrospective study evaluated clinical outcomes in 124 consecutive gastroesophageal reflux disease (GERD) patients who underwent transoral incisionless fundoplication (TIF) at 2 community hospitals. Out of 123 patients treated successfully, 110 gave consent (74% female, median age 60 [range 21-87] years, body mass index 27.5 [19.0-47.9]). At a median 7-month follow-up (range 5-17), typical and atypical symptom scores were normalized in 75% to 80% of patients, proton pump inhibitors (PPIs) were completely discontinued by 93%, and 83% were satisfied with their current health condition. Endoscopy in 53 patients revealed Hill grade I tight valves in 89% of the cases, reduced hiatal hernia in 33/34 (97%), and healed reflux esophagitis in 25/30 (83%). Based on global analysis, 72% of the patients were in remission, 20% improved symptomatically, and only 8% had ongoing GERD. These results supported the safety and efficacy of TIF as well as encouraged its application as an alternative treatment of GERD refractory to PPIs.

Laparoscopic antireflux surgery in patients with throat symptoms: a word of caution

BACKGROUND

A subset of patients undergoing laparoscopic fundoplication presents with atypical throat symptoms, and the benefit of surgery in these patients is debated. These patients can present with throat symptoms alone or in combination with typical reflux symptoms. We evaluated the clinical outcome in these patients and compared their outcomes with a larger group of patients who did not have throat symptoms before fundoplication.

METHODS

Outcome data for 893 consecutive patients who underwent a laparoscopic fundoplication from January 2002 to June 2008 were collected prospectively and managed on a database. Ninety-three patients with atypical throat symptoms were identified, and divided into subgroups with (n=66) and without (n=27) typical reflux symptoms (heartburn and/or regurgitation), and outcomes were compared with patients (n=800) who didn't have throat symptoms. Symptoms were assessed with analog symptom scores for heartburn and dysphagia, as well as satisfaction with the surgical outcome. Case records for patients with throat symptoms were also reviewed to obtain more detail about specific throat symptoms and their resolution.

RESULTS

Cough was the commonest atypical symptom, followed by sore throat. Heartburn scores improved following surgery in all patient groups. Dysphagia was more common 3 months after surgery in patients without throat symptoms, although there were no differences for dysphagia at later follow-up. Following surgery satisfaction scores were highest in patients with atypical throat symptoms who also had typical reflux symptoms, and the scores were lowest in patients who only had atypical throat symptoms. Nearly twice as many patients who had throat and reflux symptoms reported improvement or resolution of symptoms, compared to patients who only had throat symptoms.

CONCLUSIONS

Fundoplication achieves a good outcome in patients with atypical throat symptoms who also report typical symptoms of reflux. However, surgeons should be cautious about operating on the subgroup of patients with objective evidence of gastroesophageal reflux who describe throat symptoms but do not report heartburn or regurgitation. In this subgroup, expectations of a good outcome should be minimized.

Endoscopic, endoluminal fundoplication for gastroesophageal reflux disease: initial experience and lessons learned

BACKGROUND

Several devices have been developed to create an antireflux barrier endoscopically for the treatment of gastroesophageal reflux disease. All have failed to provide long-term symptom relief, were associated with clinically important complications, or were otherwise removed from the market. A new device, the Esophyx (Endogastric Solutions, Redmond, WA), provides the closest approximation experimentally to a standard Belsy fundoplication. This report describes an initial experience with this device.

METHODS

Patients considered candidates for endoscopic fundoplication include those with symptomatic gastroesophageal reflux disease, a small (<2 cm) hiatal hernia, objective pathologic evidence of gastroesophageal reflux disease, and an absence of other esophageal motility disorders. The procedure was conducted under general anesthesia with a surgeon operating the device and an endoscopist operating the gastroscope. H-fasteners were placed from the esophagus to the gastric cardia with the goal of creating an approximately 270-300° fundoplication approximately 3-4 cm in length. Symptom severity was measured with the GERD-HRQL instrument (best possible score 0, worst possible score 50). The patients were followed-up for complications and symptom improvement.

RESULTS

In all, 26 patients underwent an attempted endoscopic fundoplication. Two patients could not be completed because of the inability to pass the device. Of the 24 patients who underwent endoscopic fundoplication, 20 had the typical symptoms of gastroesophageal reflux disease, 4 had symptoms of laryngopharyngeal reflux, and 4 had recurrent symptoms after a Nissen fundoplication. There was 1 major complication of a gastric mucosal tear that led to bleeding and the need for a blood transfusion. Nineteen (79%) patients reported satisfaction with their symptom relief. Of those dissatisfied, 2 had symptoms of laryngopharyngeal reflux, 1 had functional heartburn, 1 had associated gastroparesis, and 1 had clear failure with gastroesophageal reflux disease. The median GERD-HRQL score improved from 25 (interquartile range, 19.5-28.5) to 5 (interquartile range, 3-9; P = .0004).

CONCLUSION

Endoscopic fundoplication with the Esophyx device is feasible with satisfactory initial results. Endoscopic fundoplication seems to be best suited for patients with small hiatal hernias and mild-to-moderate typical symptoms; however, subsequent trials are needed to assess the long-term effectiveness of the technique.

Lung transplantation, gastroesophageal reflux, and fundoplication

Lung transplantation is an accepted treatment strategy for end-stage lung disease; however, bronchiolitis obliterans syndrome is a major cause of morbidity and mortality. This review explores the role of gastroesophageal reflux disease in bronchiolitis obliterans syndrome and the evidence suggesting the benefits of anti-reflux surgery in improving lung function and survival. There is a high prevalence of gastroesophageal reflux in patients post lung transplantation. This may be due to a high preoperative incidence, vagal damage and immunosuppression. Reflux in these patients is associated with a worse outcome, which may be due to micro-aspiration. Anti-reflux surgery is safe in selected lung transplant recipients; however there has been one report of a postoperative mortality. Evidence is conflicting but may suggest a benefit for patients undergoing anti-reflux surgery in terms of lung function and survival; there are no controlled studies. The precise indications, timing, and choice of fundoplication are yet to be defined, and further studies are required.

[Lung diseases and gastro-oesophageal reflux disease]

Gastro -oesophageal Reflux Disease is a consequence of pathological reflux from stomach to oesophagus. Whenever the refluxed contents extended beyond the oesophagus itself, is called Extraoesophageal Reflux Disease. The author proposes a review about pulmonary disorders and gastroesophageal reflux. Previously, it is evaluated in an abridged way, the concepts of each diseases and after that, in a systematic form, it is discussed the prevalence of gastro -oesophageal reflux in lung diseases, all the mechanisms studies and the impact of gastro -oesophageal treatment on lung disorders. The author concludes that is undeniable the link between Gastro -oesophageal reflux and lung diseases and further reaserch is mandatory in order to corroborate this association.

Reliability and clinical validity of the Italian Reflux Symptom Index

Currently, there is no Italian version of the Reflux Symptom Index (RSI). The aim of this study was to develop an Italian RSI and to evaluate its internal consistency, reliability, and clinical validity. The study design used was a cross-sectional survey study. Eighty patients with a Reflux Finding Score (RFS) >7, and 193 asymptomatic subjects were included in the study. For the RSI reliability analysis, the appositely developed Italian RSI was filled twice, with a week interval, by the 80 patients and 80 control subjects. The test-retest reliability was assessed through the Pearson correlation test, whereas the Cronbach's alpha coefficient was used for internal consistency analysis. For the clinical validity assessment, the scores obtained in the pathological group were compared with the data from the asymptomatic individuals through the Student's t test. Finally, the correlation between RSI and RFS in the 80 patients was assessed. All of the patients filled in the entire questionnaire autonomously. The test-retest reliability in the patients, as well as in the control group, was very high (r>0.90); the internal consistency also showed very high values (alpha=0.99). The mean RSI score in the patients was 21.1+/-6.6, whereas in the control group it was 6.3+/-5.6; the difference was statistically significant (P=0.0001). The mean RFS score in the 80 patients was 9.2+/-2.7 and the correlation between RFS score and RSI score was rather high (r=0.89). The Italian RSI is easily administered, highly reproducible, and exhibits excellent clinical validity.

The diagnosis and management of globus: a perspective from Japan

PURPOSE OF REVIEW

The etiology of globus is multifactorial and its management is controversial. Recent findings in the etiology and diagnosis of globus are discussed, and a subjective opinion on its management is presented.

RECENT FINDINGS

Although there is considerable debate concerning the role of gastroesophageal reflux disease (GERD) in patients with globus, the globus symptom score has been shown to be significantly higher in patients with GERD than in those without GERD. This definite association between GERD and globus leads to the practical division of patients with globus into two groups: the GERD/laryngopharyngeal reflux (LPR)-induced and non-GERD/LPR groups. When the presence of GERD or LPR or both is established in patients with globus, management of this condition should be considered. Owing to limitations in the technology for the detection of GERD/LPR, precise discrimination between the two groups is still difficult. For practical purposes, empirical approaches for targeting GERD in patients with globus appear to be justified. A 24 h pH-metry/multichannel intraluminal impedance test may increase the detection of reflux events in patients with globus.

SUMMARY

A practical approach for dividing patients with globus into GERD/LPR-induced and non-GERD/LPR groups is introduced.

Laryngopharyngeal reflux disease treated with laparoscopic fundoplication

The objective of this clinical prospective study was to find out if laparoscopic Nissen fundoplication is an effective treatment in laryngopharyngeal reflux disease. Twenty-two consecutive patients, 16 female and 6 male, who were referred to laparoscopic fundoplication and operated by a senior gastroenterology surgeon were included in this study. Their mean age was 41 years (SD 13), and ranged from 18 to 64. The patients selected for surgical treatment had LPRD with several vocal and laryngeal symptoms. The status findings were typical for laryngopharyngeal reflux and the symptoms and signs had responded to antireflux medication. Vocal symptoms were interviewed and patients underwent laryngoscopy, esophagogastroscopy, and 24-h esophageal pH monitoring. The follow-up of symptoms and signs were 3 months after beginning of medication, before surgery, 3 months, and 1 year after surgery. The number of patients experiencing vocal symptoms decreased during the medical treatment, from the situation before medical treatment to the situation before surgery (P < 0.001), from the situation before surgery to the situation 3 months (P < 0.001) and 1 year post operation (P < 0.001), but no significant changes were found from the situation 3 months to 1 year post operation. Voice quality improved significantly only from the time point before surgery to 3 months post operation. Three months after medical treatment, laryngeal and pharyngeal findings did not decrease significantly, but several findings decreased significantly (P < 0.001) from the time point before surgery compared to 3 months and to 1 year post operation. Based on this study, the laparoscopic fundoplication is an effective and safe treatment of LPRD.

Cough and its importance in COPD

Patients with COPD most frequently complain of breathlessness and cough and these are both increased during exacerbations. Studies have generally focused on quality of life during end-stage disease, where breathlessness becomes dominant and cough less important. There are very little data on the frequency and severity of cough in COPD or its impact on quality of life at different stages of disease. Little is known about the factors that influence objective cough counts in COPD. Cough may be a marker for progressive disease in milder COPD patients who continue to smoke, and it may be useful in case-finding for milder disease in the community. The cough reflex sensitivity is heightened in COPD compared with healthy volunteers and similar to that in subjects with asthma. The degree of airflow obstruction does not predict cough reflex sensitivity or objective cough counts, implying an independent process. Effective treatments for cough in COPD have not yet been identified. Improved outcome measures of cough, a better understanding of cough in the natural history of COPD, and its importance to patients are needed.

Laryngopharyngeal reflux: Current concepts in pathophysiology, diagnosis, and treatment

Laryngopharyngeal reflux (LPR) is the backflow of gastric contents into the pharynx and larynx. The diagnosis of LPR is primarily based on symptoms, including dysphonia, dysphagia, globus, throat-clearing, and post-nasal drip. The gold standard for diagnosis is dual-probe 24-hour pH testing with the upper probe positioned above the upper oesophageal sphincter. Treatment may require 3 months or more of twice-daily proton pump inhibitors along with lifestyle modifications. This review details the pathophysiology, symptoms, findings, treatment, and current controversies in LPR.

Laparoscopic Nissen fundoplication effectively relieves symptoms in patients with laryngopharyngeal reflux

INTRODUCTION

The utility of laparoscopic Nissen fundoplication in the treatment of laryngopharyngeal reflux symptoms remains controversial. We hypothesized that a carefully selected population with these symptoms would benefit from antireflux surgery.

MATERIALS AND METHODS

Sixty-one consecutive patients have undergone antireflux surgery for laryngopharyngeal reflux at a single institution. Preoperative evaluation including upper endoscopy, laryngoscopy, and 24-h ambulatory pharyngeal pH probe monitoring confirmed the diagnosis. Patients completed two validated symptom assessment instruments preoperatively and at multiple time points postoperatively.

RESULTS

Patients were followed for up to 3 years with a mean follow-up of 15.2 months. A significant improvement in reflux symptom index score (preoperative= 1.5+/-7.4 vs 3 years=12.4+/-10.9, p<0.01), laryngopharyngeal reflux health-related quality of life overall score (preoperative=55.0+/-26.0 vs 3 years=11.3+/-13.9, p<0.01), and symptom domain scores (voice, cough, throat clearing, and swallowing) occurred within 1 month of surgery and remained improved over the course of the study.

CONCLUSION

Laparoscopic Nissen fundoplication is effective in relieving the symptoms of laryngopharyngeal reflux in a carefully selected patient population. Benefits are seen within 1 month of surgery and persist for at least 3 years.

Common Diagnoses and Treatments in Professional Voice Users

Common problems among all patients seen by the laryngologist are also common among professional voice users. These include laryngopharyngeal reflux, muscle tension dysphonia, fibrovascular vocal fold lesions (eg, nodules and polyps), cysts, vocal fold scarring, changes in vocal fold mobility, and age-related changes. Microvascular lesions and their associated sequelae of vocal fold hemorrhage and laryngitis due to voice overuse are more common among professional voice users. Much more common among professional voice users is the negative impact that voice problems have on their ability to work, on their overall sense of well-being, and sometimes on their very sense of self. This article reviews the diagnosis and treatment options for these and other problems among professional voice users, describing the relevant roles of medical treatment, voice therapy, and surgery. The common scenario of multiple concomitant entities contributing to a symptom complex is underscored. Emphasis is placed on gaining insight into the "whole" patient so that individualized management plans can be developed. Videos of select diagnoses accompany this content online.

[Results of laparoscopic fundoplication in gastroesophageal reflux disease with atypical manifestations]

INTRODUCTION

Gastroesophageal reflux disease (GERD) may present with typical (heartburn and regurgitation) and atypical symptoms (cough, asthma, non-cardiac chest pain). Laparoscopic fundoplication has been performed for approximately 10 years, with results similar to or better than those obtained with open antireflux procedures. The aim of this study was to evaluate the clinical and functional results of laparoscopic fundoplication in patients with GERD and atypical symptoms.

PATIENTS AND METHOD

There were 158 consecutive patients with GERD who underwent a 360 degrees laparoscopic fundoplication (January 1999 to March 2006) and 27 patients had atypical symptoms. All patients underwent preoperative manometry and 24 hour pH-metry and 78% underwent the same tests postoperatively (at 6 months). Data from hospital records were analyzed and a clinical telephone survey was conducted.

RESULTS

There was no mortality and no conversions were required. The median length of follow-up was 21 months. All atypical symptoms (cough, chest pain, asthma, dysphonia and hoarseness) were significantly reduced (p < 0.05). There was no relationship between symptom persistence in five patients and pathologic acid reflux, except in one patient. Eighty-nine percent of the patients responded to the telephone survey; of these, 79% had no symptoms. The median satisfaction score was 9 (from 0 to 10).

CONCLUSIONS

Laparoscopic fundoplication for GERD with atypical symptoms is a safe procedure with good results (clinical and functional) in trained groups patients. Moreover a high satisfaction rate is obtained.

Extraesophageal manifestations of gastroesophageal reflux disease

Gastroesophageal reflux disease often presents as heartburn and acid reflux, the so-called "typical" symptoms. However, a subgroup of patients presents a collection of signs and symptoms that are not directly related to esophageal damage. These are known collectively as the extraesophageal manifestations of gastroesophageal reflux disease. Principal among such manifestations are bronchospasm, chronic cough and laryngitis, which are classified as atypical symptoms. These manifestations comprise a heterogeneous group. However, some generalizations can be made regarding all of the subgroups. First, although the correlation between gastroesophageal reflux disease and the extraesophageal manifestations has been well established, a cause-and-effect relationship has yet to be definitively elucidated. In addition, the main proposed pathogenic mechanisms of extraesophageal reflux are direct injury of the extraesophageal tissue (caused by contact with gastric acid) and the esophagobronchial reflex, which is mediated by the vagus nerve. Furthermore, gastroesophageal reflux disease might not be considered in the differential diagnosis of patients presenting only the atypical symptoms. In this article, we review the extraesophageal manifestations of gastroesophageal reflux disease, discussing its epidemiology, pathogenesis, diagnosis and treatment. We focus on the most extensively studied and well-established presentations.

The development of the GERD-HRQL symptom severity instrument

The Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) instrument was introduced approximately 10 years ago to provide a quantitative method of measuring symptom severity in gastroesophageal reflux disease (GERD). Since that time the instrument has been used to assess treatment response to medication, endoscopic procedures, and surgery for GERD. However, the development of the instrument has progressed over the course of several years, and there is no one source which reviews this progress. The purpose of this article is to summarize the development and testing of the GERD-HRQL. The GERD-HRQL was initially developed to measure the typical symptoms of GERD. It was initially determined to have face validity and subsequent studies assessed its content validity, criterion validity, concurrent validity, predictive validity and construct validity. Reliability was determined by the test-retest method. Responsiveness was determined by the effects of treatment. This instrument is practical, with little administrative burden. There are few missing responses. Because there are 51 possible scores, the instrument has a high level of precision; and because of the response anchors, cannot have a floor effect, and only 4/372 patients reached the highest score of 50, implying little ceiling effect. The instrument has been translated into several languages, and appears valid, reliable and practical in each.