The effect of medical therapy and antireflux surgery on dysphagia in patients with gastroesophageal reflux disease without esophageal stricture

Lap. Nissen fundoplication leads to better respiratory symptom control than Toupet in the long term of 20 years

INTRODUCTION

Having performed anti-reflux surgery for thirty years, it was important to reexamine our patients in the long term to enlarge the body of evidence concerning classical and extraesophageal symptoms that are differently controlled by Nissen or Toupet fundoplication.

OBJECTIVES

We report a cohort of 155 GERD patients who underwent fundoplication within a tailored approach between 1994 and 2000. Changes in the perioperative functional outcome, GERD symptoms, and quality of life are being analyzed 10 and 20 years after the operation.

RESULTS

The operation resulted in a superior quality of life compared to a patient cohort treated with PPI therapy. We found that both surgical methods (laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication) cure classical symptoms equally (heartburn, regurgitation, and dysphagia). GERD patients receiving a Toupet fundoplication seem more likely to suffer from extraesophageal GERD symptoms 10 and 20 years after surgery than patients with a Nissen fundoplication. On the other hand, some patients with Nissen fundoplication report dysphagia even 10 and 20 years after surgery.

CONCLUSION

Both the laparoscopic Nissen and Toupet fundoplications provide excellent symptom control in the long term. Moreover, the Nissen fundoplication seems to be superior in controlling extraesophageal reflux symptoms, but at the expense of dysphagia. In summary, tailoring the operation based on symptoms seems advantageous.

3D Food Printing Applications Related to Dysphagia: A Narrative Review

Dysphagia is a condition in which the swallowing mechanism is impaired. It is most often a result of a stroke. Dysphagia has serious consequences, including choking and aspiration pneumonia, which can both be fatal. The population that is most affected by it is the elderly. Texture-modified diets are part of the treatment plan for dysphagia. This bland, restrictive diet often contributes to malnutrition in patients with dysphagia. Both energy and protein intake are of concern, which is especially worrying, as it affects the elderly. Making texture-modified diets more appealing is one method to increase food intake. As a recent technology, 3D food printing has great potential to increase the appeal of textured foods. With extrusion-based printing, both protein and vegetable products have already been 3D printed that fit into the texture categories provided by the International Dysphagia Diet Standardization Initiative. Another exciting advancement is 4D food printing which could make foods even more appealing by incorporating color change and aroma release following a stimulus. The ultra-processed nature of 3D-printed foods is of nutritional concern since this affects the digestion of the food and negatively affects the gut microbiome. There are mitigating strategies to this issue, including the addition of hydrocolloids that increase stomach content viscosity and the addition of probiotics. Therefore, 3D food printing is an improved method for the production of texture-modified diets that should be further explored.

Diagnostic Efficacy of 24-hr Esophageal pH Monitoring in Patients with Refractory Gastroesophageal Reflux Disease

BACKGROUND:

Gastric reflux is one of the most important causes of the referral of patients to the internal clinic, which in some cases causes problems for patients due to resistance to common treatments. Therefore, timely diagnosis and treatment of this group of patients are very important.

AIM:

The purpose of the present study was to determine the off-proton pump inhibitor (off-PPI) 24 h pH-impedance analyses in patients with refractory gastroesophageal reflux disease (GERD) attending to Taleghani Hospital since 2009 to 2017.

METHODS:

In this observational descriptive-comparative off-PPI study, 572 patients with refractory GERD who were referred to Taleghani Hospital in Tehran from 2009 to 2017 were selected, and the results of 24 h pH Impedance analysis were then assessed.

RESULTS:

The results of 24h pH-impedance indicated that 7% of cases belonged to Pure Acid Reflux followed by weakly Acid (1%), non-acid (0.3%), mixed & gas (5.2%), functional (58.4%) and oesophagal hypersensitivity (28%). Furthermore, weakly acid plus acid was also found to be 8% and Weakly Acid + Acid + Non-Acid were determined as 8.3%.

CONCLUSIONS:

Our findings suggested that nearly more than half of the patients with refractory GERD would have a functional disorder in the 24h pH-impedance analysis.

Hiatus Hernia as a Cause of Dysphagia

PURPOSE OF REVIEW

This review aims to discuss the putative relationship between hiatus hernia and dysphagia.

RECENT FINDINGS

Proposed mechanisms of dysphagia in patients with hiatus hernia are usually difficult to identify, but recent advances in technology (high-resolution manometry with or without concomitant impedance, ambulatory pH with impedance, videofluoroscopy, and the endoluminal functional lumen imaging probe (EndoFLIP)) and methodology (inclusion of swallows of various consistencies and volumes or shifting position during the manometry protocol) can help induce symptoms and identify the underlying disorder. Chronic reflux disease is often associated with hiatus hernia and is the most common underlying etiology. Dysmotility because of impaired contractility and vigor can occur as a consequence of repeated acid exposure from the acid pocket within the hernia, and the resultant poor clearance subsequently worsens this insult. As such, dysphagia appears to be more common with increasing hiatus hernia size. Furthermore, mucosal inflammation can lead to fibrotic stricture formation and in turn obstruction. On the other hand, there appears to be a difference in the pathophysiology of smaller sliding hernias, in that those with dysphagia are more likely to have extrinsic compression at the crural diaphragm as compared to those with reflux symptoms only. Sliding hiatus hernia, especially when small, does not commonly lead to dysmotility and dysphagia; however, in those patients with symptoms, the underlying etiology can be sought with new technologies and, in particular, the reproduction of normal eating and drinking during testing.

Soft Electronics Enabled Ergonomic Human-Computer Interaction for Swallowing Training

We introduce a skin-friendly electronic system that enables human-computer interaction (HCI) for swallowing training in dysphagia rehabilitation. For an ergonomic HCI, we utilize a soft, highly compliant ("skin-like") electrode, which addresses critical issues of an existing rigid and planar electrode combined with a problematic conductive electrolyte and adhesive pad. The skin-like electrode offers a highly conformal, user-comfortable interaction with the skin for long-term wearable, high-fidelity recording of swallowing electromyograms on the chin. Mechanics modeling and experimental quantification captures the ultra-elastic mechanical characteristics of an open mesh microstructured sensor, conjugated with an elastomeric membrane. Systematic in vivo studies investigate the functionality of the soft electronics for HCI-enabled swallowing training, which includes the application of a biofeedback system to detect swallowing behavior. The collection of results demonstrates clinical feasibility of the ergonomic electronics in HCI-driven rehabilitation for patients with swallowing disorders.

Over 250 Laparoendoscopic Single Site (LESS) Fundoplications: Lessons Learned

Laparoendoscopic single site (LESS) surgery is a more recent advance in the progression of minimally invasive surgery. This study was undertaken to assess lessons learned after our first 250 LESS fundoplications for gastroesophageal reflux disease (GERD). All patients undergoing LESS fundoplications were prospectively followed from 2008 to 2014. Patients scored the frequency/severity of their symptoms before/after LESS fundoplication using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Patients also scored satisfaction with their incision using a Likert scale (1 = revolting to 10 = beautiful). A total of 300 patients undergoing LESS fundoplication for GERD were not different by age or gender. Surgeons undertook 190 Nissen fundoplications and 110 Toupet fundoplications; 28 of which were “redo” fundoplications. Preoperative symptoms were notable, especially heartburn (frequency = 8, severity = 7). Symptoms were ameliorated postoperatively (e.g., heartburn: frequency = 0, severity = 0, P < 0.01). Postoperatively, patients scored satisfaction of their incisions with a median score of 10. Eighty-three per cent of patients were at least satisfied with their overall experience; 92 per cent would undergo the operation again knowing what they know now. Patients report significant symptom relief, high satisfaction, and excellent cosmesis after LESS fundoplication. LESS fundoplication safely ameliorates symptoms of GERD with pronounced satisfaction, in part, because of the cosmetic outcome (i.e., lack of scaring), and its application is encouraged.

Therapeutic strategies for laryngeal manifestations of gastroesophageal reflux disease

Gastroesophageal reflux disease is increasingly associated with ear, nose, and throat symptoms, including laryngitis. Many patients are unaware of the gastroesophageal etiology of their symptoms. A variety of criteria are used to diagnose this condition, including laryngoscopy, esophagogastroduodenoscopy, and the use of ambulatory pH and impedance monitoring. However, no test serves as the gold standard for the diagnosis given their lack of sensitivity and specificity for reflux disease. Numerous trials have assessed the role of proton pump inhibitor therapy in patients with laryngopharyngeal reflux and most have revealed no benefit to acid suppression over placebo. Despite many uncertainties there has been some progress regarding the role of acid-suppressive therapy as well as other agents in this unique group of patients. In this review we explore therapeutic options and their rationale for patients with laryngeal signs and symptoms.

Late results after laparoscopic fundoplication denote durable symptomatic relief of gastroesophageal reflux disease

BACKGROUND

Late outcomes after laparoscopic Nissen fundoplication are only now becoming available. This study was undertaken to document late outcomes after laparoscopic Nissen fundoplication.

METHODS

Five hundred ten patients underwent laparoscopic Nissen fundoplication >10 years ago and were prospectively followed. Preoperatively and postoperatively, patients scored the frequency and severity of symptoms (from 0 = never/not bothersome to 10 = always/very bothersome). Symptom scores before and after fundoplication were compared. Median symptom scores are presented.

RESULTS

Early after fundoplication, significant improvements were noted in the frequency and severity of symptoms (e.g., for heartburn, from 8 to 0 and from 8 to 0, respectively, P < .001 for each). Late after fundoplication, significant improvements were maintained in the palliation of symptoms (e.g., frequency and severity for heartburn, 2, 1; respectively). At latest follow-up, 89% of patients were pleased with their symptom resolution.

CONCLUSIONS

With long-term follow-up, laparoscopic Nissen fundoplication durably and significantly palliates symptoms of gastroesophageal reflux disease. This trial promotes the application of laparoscopic Nissen fundoplication.

Guidelines for the diagnosis and management of gastroesophageal reflux disease: an evidence-based consensus

Gastroesophageal reflux disease (GERD) is one of the most common disorders in medical practice. A number of guidelines and recommendations for the diagnosis and management of GERD have been published in different countries, but a Brazilian accepted directive by the standards of evidence-based medicine is still lacking. As such, the aim of the Brazilian GERD Consensus Group was to develop guidelines for the diagnosis and management of GERD, strictly using evidence-based medicine methodology that could be clinically used by primary care physicians and specialists and would encompass the needs of physicians, investigators, insurance and regulatory bodies. A total of 30 questions were proposed. Systematic literature reviews, which defined inclusion and/or exclusion criteria, were conducted to identify and grade the available evidence to support each statement. A total of 11,069 papers on GERD were selected, of which 6,474 addressed the diagnosis and 4,595, therapeutics. Regarding diagnosis, 51 met the requirements for the analysis of evidence-based medicine: 19 of them were classified as grade A and 32 as grade B. As for therapeutics, 158 met the evidence-based medicine criteria; 89 were classified as grade A and 69 as grade B. In the topic Diagnosis, answers supported by publications grade A and B were accepted. In the topic Treatment only publications grade A were accepted: answers supported by publications grade B were submitted to the voting by the Consensus Group. The present publication presents the most representative studies that responded to the proposed questions, followed by pertinent comments. Follow examples. In patients with atypical manifestations, the conventional esophageal pH-metry contributes little to the diagnosis of GERD. The sensitivity, however, increases with the use of double-channel pH-metry. In patients with atypical manifestations, the impedance-pHmetry substantially contributes to the diagnosis of GERD. The examination, however, is costly and scarcely available in our country. The evaluation of the histological signs of esophagitis increases the diagnostic probability of GERD; hence, the observation of the dimensions of the intercellular space of the esophageal mucosa increases the probability of diagnostic certainty and also allows the analysis of the therapeutic response. There is no difference in the clinical response to the treatment with PPI in two separate daily doses when compared to a single daily dose. In the long term (>1 year), the eradication of H. pylori in patients with GERD does not decrease the presence of symptoms or the high recurrence rates of the disease, although it decreases the histological signs of gastric inflammation. It seems very likely that there is no association between the eradication of the H. pylori and the manifestations of GERD. The presence of a hiatal hernia requires larger doses of proton-pump inhibitor for the clinical treatment. The presence of permanent migration from the esophagogastric junction and the hernia dimensions (>2 cm) are factors of worse prognosis in GERD. In this case, hiatal hernias associated to GERD, especially the fixed ones and larger than 2 cm, must be considered for surgical treatment. The outcomes of the laparoscopic fundoplication are adequate.

Preoperative lower esophageal sphincter manometry data neither impact manifestations of GERD nor outcome after laparoscopic Nissen fundoplication

BACKGROUND

Experience with laparoscopic antireflux surgery (LARS) in patients with gastroesophageal reflux disease (GERD) and manometrically intact lower esophageal sphincter (LES) is limited. The disease pattern may be different and LARS may fail to control reflux or result in higher rates of dysphagia. This is the first study investigating the impact of preoperative LES manometry data not only on manifestations of GERD and subjective outcome alone but also on objective outcomes 1 year after LARS.

METHODS

Three hundred fifty-one GERD patients underwent LARS and had subjective symptom and quality of life assessment, upper gastrointestinal endoscopy, barium swallow esophagogram, 24-h esophageal pH monitoring, and manometry pre- and 1 year postoperatively. Patients were divided into those with a preoperatively intact versus defective LES based on intraabdominal length and resting pressure. Baseline and 1-year postoperative follow-up data were compared.

RESULTS

Preoperative manifestations of GERD were similar in each group. Postoperatively, all symptoms except flatulence, quality of life scores, and objective manifestations improved significantly in each group.

CONCLUSIONS

The preoperative manometric character of the LES neither impacts the manifestations of GERD nor subjective and objective outcomes after LARS. Patients with GERD and manometrically intact LES have no higher risk for postoperative dysphagia.

Does combined multichannel intraluminal esophageal impedance and manometry predict postoperative dysphagia after laparoscopic Nissen fundoplication?

Laparoscopic Nissen fundoplication (LNF) is an effective treatment for gastroesophageal reflux disease; however, some patients develop dysphagia postoperatively. Manometry is used to evaluate disorders of peristalsis, but has not been proven useful to identify which patients may be at risk for postoperative dysphagia. Multichannel intraluminal impedance (MII) evaluates the effective clearance of a swallowed bolus through the esophagus. We hypothesized that MII combined with manometry may detect those patients most at risk of developing dysphagia after LNF. Between March 2003 and January 2007, 74 patients who agreed to participate in this study were prospectively enrolled. All patients completed a preoperative symptom questionnaire, MII/manometry, and 24-h pH monitoring. All patients underwent LNF. Symptom questionnaires were administered postoperatively at a median of 18 months (range: 6-46 months), and we defined dysphagia (both preoperatively and postoperatively) as occurring more than once a month with a severity >or=4 (0-10 Symptom Severity Index). Thirty-two patients (43%) reported preoperative dysphagia, but there was no significant difference in pH monitoring, lower esophageal sphincter pressure/relaxation, peristalsis, liquid or viscous bolus transit (MII), or bolus transit time (MII) between patients with and without preoperative dysphagia. In those patients reporting preoperative dysphagia, the severity of dysphagia improved significantly from 6.8 +/- 2 to 2.6 +/- 3.4 (P < 0.001) after LNF. Thirteen (17%) patients reported dysphagia postoperatively, 10 of whom (75%) reported some degree of preoperative dysphagia. The presence of postoperative dysphagia was significantly more common in patients with preoperative dysphagia (P= 0.01). Patients with postoperative dysphagia had similar lower esophageal sphincter pressure and relaxation, peristalsis, and esophageal clearance to those without dysphagia. Neither MII nor manometry predicts dysphagia in patients with gastroesophageal reflux disease or its occurrence after LNF. The presence of dysphagia preoperatively is the only predictor of dysphagia after LNF.

The use of medication after laparoscopic antireflux surgery

BACKGROUND

Laparoscopic antireflux surgery (LARS) significantly improves symptoms of gastro-esophageal reflux disease (GERD) and quality of life. Nevertheless, 14-62% of patients report using antisecretory medication after surgery, although only a tiny percentage has proven recurrence of GERD. We sought to determine symptoms of GERD, quality of life, and use of medication before and after LARS, and to compare our findings with those from previous studies.

METHODS

Five hundred fifty-three patients with GERD who underwent LARS were evaluated before and at 1 year after surgery. After surgery, multidisciplinary follow-up care was provided for all patients by surgeons, psychologists, dieticians, and speech therapists.

RESULTS

Symptoms of GERD and quality of life improved significantly and only 4.2% of patients still required medication after surgery [proton pump inhibitors (PPI) (98.4 vs. 2.2%; p < 0.01), prokinetics (9.6 vs. 1.1%; p < 0.01), and psychiatric medication (8 vs. 1.6%; p < 0.01)].

CONCLUSION

LARS significantly reduced medication use at 1-year follow-up. However, these effects might be attributed, in part, to the multidisciplinary follow-up care. Further studies are therefore required to investigate which patients may benefit from multidisciplinary follow-up care and whether its selective application may reduce the need for medication after LARS.

Subjective results and symptomatic outcome after fundoplication revision

OBJECTIVE

In a small proportion of patients, fundoplication fails and a reoperation is required. However, there are few reports on the symptomatic outcome after reoperative antireflux surgery. The aim of this study was to evaluate the results after fundoplication revision.

MATERIAL AND METHODS

All patients (n=71) undergoing fundoplication revision between 1997 and 2005 were included in this study. The follow-up data were collected both from the hospital records and during postoperative control visits, including a personal interview using a structured questionnaire; follow-up was completed by 61 patients (88.4%).

RESULTS

The primary fundoplications included both open (n=21) and laparoscopic (n=40) approaches; 92% (n=56) of the reoperations were open procedures. The morbidity rate was 21% and the reoperation rate 16%. Fifty-six percent (n=34) of the patients regarded the result of their reoperative surgery as excellent, good or satisfactory at a mean follow-up of 51 months; 66% of the patients had no significant reflux symptoms after re-fundoplication. With the benefit of hindsight, 77% of the patients would again choose to undergo re-fundoplication, but only 48% of the patients would again primarily choose surgical treatment. Mortality rate was 1.4% (n=1) and in three patients the reoperative treatment required total gastrectomy.

CONCLUSIONS

These suboptimal results show that surgical treatment for gastro-oesophageal reflux disease in general is far from being perfect and this is even more marked after reoperative antireflux surgery, as fundoplication revision can result in severe complications. This emphasizes the importance of proper patient selection for both initial and reoperative antireflux surgery.

Comparison of long-term outcome of laparoscopic and conventional nissen fundoplication: a prospective randomized study with an 11-year follow-up

OBJECTIVE

The aim of this study was to compare the long-term objective and subjective outcomes of laparoscopic and open Nissen fundoplication in a randomized clinical trial with an 11-year follow-up.

SUMMARY BACKGROUND DATA

Laparoscopic Nissen fundoplication has become the method of choice in antireflux surgery, replacing its open counterpart despite the lack of long-term results from controlled clinical studies.

METHODS

Between April 1992 and June 1995, 110 consecutive patients were randomized to either laparoscopic (LAP) or conventional (open) Nissen fundoplication. The objective long-term follow-up consisted of an upper gastrointestinal endoscopy and a clinical assessment; the subjective long-term outcome was investigated by personal interviews using a structured questionnaire.

RESULTS

Forty-nine patients in the LAP group and 37 patients in the open group were available for evaluation. Late subjective results, including postoperative symptoms and evaluation of the surgical result, were similar in both groups. With the benefit of hindsight, 73.7% of the patients in the open group and 81.8% in the LAP group would again choose surgical treatment (P = 0.3042). In the LAP group, there were 5 (13.2%) partially or totally disrupted plications compared with the 14 (40.0%) disrupted plications in the open group (P = 0.0152). There were 10 incisional hernias in the open group compared with none in the LAP group (P < 0.001).

CONCLUSIONS

At long-term follow-up, the open and LAP approaches for the Nissen fundoplication have similar long-term subjective symptomatic outcome despite the significantly higher incidence of incisional hernias and defective fundic wraps at endoscopy in the open group defining laparoscopic Nissen fundoplication as the procedure of choice in surgical management of gastroesophageal reflux disease.

Late subjective results and symptomatic outcome after laparoscopic fundoplication

Laparoscopic fundoplication is generally accepted as a routine surgical approach in the treatment of moderate or severe gastro-esophageal reflux disease. However, there are few reports on the long-term results after this procedure. Between 1996 and 2001, 468 patients underwent laparoscopic Nissen fundoplication of which 464 patients were available for follow-up. The follow-up data were collected both from the hospital records and by a structured questionnaire, which were completed by 441 patients (95%). Eighty-nine percent (n=394) of the patients regarded the result of their surgery excellent, good, or satisfactory at a median follow-up of 51 months. With the benefit of hindsight 83% of the patients would again choose surgical treatment. Eighty-seven percent of the patients had no significant reflux symptoms. Bloating or increased flatulence were the most common side-effects. One hundred thirty-two patients (30%) had started to use antireflux medications postoperatively, but only 51 of them used it daily. Laparoscopic Nissen fundoplication provides a good and effective alternative to a life-long use of antireflux medication.

Surgeons' experience with laparoscopic fundoplication after the early personal experience: does it have an impact on the outcome?

BACKGROUND

The adverse outcomes of laparoscopic fundoplication are more likely during the initial 20 cases performed by each individual surgeon. This study aimed to evaluate the impact of substantial surgical experience versus experience beyond the learning curve on the early and late objective and subjective results.

METHODS

The patients were divided into two groups according to the surgeon. In group 1 (n = 230), all the patients underwent surgery by a surgeon with substantial experience in laparoscopic fundoplication. In group 2 (n = 118), the patients were treated by a total of seven surgeons whose personal experience exceeded the individual learning curve, but was distinctively less than that of the group 1 surgeon.

RESULTS

The conversion rate was 2.2% in group 1 and 4.4% in group 2. The median operating time was 65 min in group 1 and 70 min in group 2 (p = 0.0020). The occurrence of immediate complications was 3.5% in group 1 and 7.6% in group 2 (p = 0.0892). At 6 months after surgery, 7.4% of the patients in group 1 and 16.1% of the patients in group 2 reported that dysphagia disturbed their daily lives (p = 0.0115). The late subjective results, including postoperative symptoms and evaluation of the surgical result, were similar in the two groups.

CONCLUSIONS

Substantial experience with the procedure is associated with a shorter operating time and somewhat fewer complications, conversions, and early dysphagia episodes. This supports the provision of expert supervision even after the initial learning phase of 20 individual procedures. The patients' long-term subjective symptomatic outcome was similar in the two groups. Substantial experience does not provide better late results than surgical experience beyond the learning curve.

Healing of severe reflux esophagitis with PPI does not improve esophageal dysmotility

Esophageal dysmotility is frequently associated with gastroesophageal reflux disease (GERD). The aim of this study was to investigate the relationship between the severity of reflux esophagitis and esophageal dysmotility and evaluate the effect of prolonged treatment with proton pump inhibitor (lansoprazole 30 mg/day) on esophageal motility in patients with severe reflux esophagitis associated with esophageal motility disorder. Twelve healthy subjects (HS) and 100 patients with reflux disease were involved in the study consisting of two parts: (i) comparison of esophageal motility in HS and patients with non-eroseive reflux disease (NERD), mild esophagitis and severe esophagitis; (ii) effect of 3-6 months lansoprazole therapy on esophageal motility in 23 patients with severe esophagitis, pathologic acid reflux and esophageal peristaltic dysfunction. Results included the following. (i) Esophageal dysmotility was noted in both patients with NERD and erosive GERD. (ii) Severe esophagitis was associated with severe esophageal dysmotility. (iii) Healing of severe esophagitis did not improve esophageal dysmotility. The resting lower esophageal sphincter pressure was 3.9 mmHg (range 1.7-20) before treatment and 4.8 mmHg (range 1.2-18.3) after esophagitis healing (P = 0.23, vs. before treatment), the amplitude of distal esophageal contraction was 28.8 mmHg (range 10.9-80.6) before treatment and 33.3 mmHg (range 10.0-72.5) after esophagitis healing (P = 0.59, vs. before treatment) and the frequency of failed peristalsis was 70% (range 0-100%) before treatment and 70% (range 0-100%) after esophagitis healing (P = 0.78, vs. before treatment). Both esophageal motility disorders and acid reflux play important roles in the mechanism of GERD, especially in severe esophagitis. Esophageal dysmotility is not secondary to acid reflux and esophagitis; it should be a primary motility disorder.

Reflux, dysphagia, and gas bloat after laparoscopic fundoplication in patients with incidentally discovered hiatal hernia and in a control group

BACKGROUND

Laparoscopic fundoplication effectively controls reflux symptoms in patients with gastroesophageal reflux disease (GERD). However, symptom relapse and side effects, including dysphagia and gas bloat, may develop after surgery. The aim of the study was to assess these symptoms in patients who underwent laparoscopic fundoplication, as well as in control subjects and patients with hiatal hernia.

METHODS

A standardized, validated questionnaire on reflux, dysphagia, and gas bloat was filled out by 115 patients with a follow-up of 1 to 7 years after laparoscopic fundoplication, as well as by 105 subjects with an incidentally discovered hiatal hernia and 238 control subjects.

RESULTS

Patients who underwent fundoplication had better reflux scores than patients with hiatal hernia ( P = .0001) and similar scores to control subjects ( P = .11). They also had significantly more dysphagia and gas bloat than patients with hiatal hernia and controls ( P < .005 for all comparisons). Gas bloat and dysphagia were more severe in hiatal hernia patients than in controls ( P < 0.005). After fundoplication, the 25% of the patients with the shortest follow-up (1.5 +/- 0.2 years) and the 25% patients with the longest follow-up (5.8 +/- 0.6 years) had similar reflux, dysphagia, and gas bloat scores ( P = .43, .82, and .85, respectively).

CONCLUSION

In patients with severe GERD, laparoscopic fundoplication decreases reflux symptoms to levels found in control subjects. These results appear to be stable over time. However, patients who underwent fundoplication experience more dysphagia and gas bloat than controls and patients with hiatal hernia-symptoms that should be seen as a side effect of the procedure and of GERD itself.

Nissen or partial posterior fundoplication: which antireflux procedure has a lower rate of side effects?

INTRODUCTION

In patients with gastroesophageal reflux disease (GERD) it is still controversial as to which type of antireflux procedure-the Nissen or the partial posterior fundoplication-offers the lower rate of side effects in the long term.

PATIENTS AND METHODS

In this follow-up study the Nissen fundoplication was performed only in GERD patients with normal oesophageal peristalsis. The partial posterior fundoplication was preserved for patients with weak peristalsis. Only patients with effective postoperative control of GERD were included in the study. The study groups consisted of 77 patients who underwent the Nissen fundoplication and 132 patients who underwent partial posterior fundoplication. Clinical assessment of side effects was performed after a median of 52 months following surgery. Manometric assessment of the lower esophageal sphincter (LES) and of esophageal peristalsis was achieved 6 months after surgery.

RESULTS

Side effects such as dysphagia, bloating, inability to belch and vomit, epigastric pain and early satiety were significantly more common after the Nissen fundoplication than after partial posterior fundoplication. Improvement of the antireflux barrier was equal in both groups; however, LES relaxation was incomplete following the Nissen fundoplication but normal after partial posterior fundoplication. Partial posterior fundoplication resulted in improved oesophageal peristalsis, whereas the Nissen fundoplication caused slight impairment of peristalsis.

CONCLUSIONS

Partial posterior fundoplication is a more physiological antireflux procedure than the Nissen fundoplication, and, therefore, this operation has now become our preferred technique for all GERD patients.

The Nissen fundoplication: indication, technical aspects and postoperative outcome

INTRODUCTION

Gastroesophageal reflux disease (GERD) is the most common foregut disease, with a great impact on quality of life and with intestinal, respiratory and cardiac symptoms and implications of carcinogenesis of the oesophagus. Medical therapy often fails, due to the complex pathophysiology of GERD. Surgery can cure the disease, since it is able to restore the anti-reflux barrier. It improves quality of life and prevents carcinogenesis.

METHODS

Review of the literature and presentation of our own experience and data in a series of more than 4,000 evaluated patients referred for suspected reflux disease, of whom 382 have been operated on.

CONCLUSION

The laparoscopic Nissen fundoplication is the most commonly used operation technique. It provides good long-term results in the majority of patients. However, due to an increase of outflow resistance of the oesophagus this operation is associated with some postoperative side effects. Therefore, alternative anti-reflux procedures may be indicated in selected patients.

Robot-assisted laparoscopic partial posterior fundoplication with the DaVinci system: initial experiences and technical aspects

BACKGROUND

This pilot study evaluated the role of the DaVinci operation robot for laparoscopic antireflux surgery.

PATIENTS AND METHODS

A robot-assisted laparoscopic Toupet-fundoplication was performed on nine consecutive patients with severe gastroesophageal reflux disease using the DaVinci robot system. The operative procedure was performed in the same way as for the conventional laparoscopic procedure. Clinical assessment and endoscopic and manometric follow-up investigations were performed 6 months after surgery in six of the patients.

RESULTS

The mean robotic operative time was 173 min (120-235). A mean of 25 min (12-45) was required to establish the pneumoperitoneum, to set the trocars, and to place the robot arms. There were no intraoperative complications. Six months after surgery none of the patients suffered from reflux symptoms and none of the patients had acute esophagitis. Postoperatively one patient complained of mild transient dysphagia. However, persistent dysphagia was not found in any of the patients. One further patient complained of mild bloating. No other side effects occurred. Manometrically there was a significant improvement in the function of the lower esophageal sphincter.

CONCLUSIONS

The robot-assisted partial posterior fundoplication is a safe procedure and provides a high-quality three-dimensional camera image that is superior to that with the conventional laparoscopic device. The handling of the instruments is precise, and intracorporeal suturing and knot tying is much easier than without the robotic technique. The procedure allows for an accurate approximation of the hiatal crura and for precise construction of the fundic wrap. However, robotic surgery is expensive and the setup of the system is time consuming at present.

Esophageal pneumatic dilation for postfundoplication dysphagia: safety, efficacy, and predictors of outcome

OBJECTIVE

Persistent dysphagia occurs in 5-10% of patients after fundoplication. The cause is obscure in most cases, and the management has not been well established. The aim of this study is to evaluate the clinical outcomes and the predictors of success for esophageal pneumatic dilations in patients with dysphagia after fundoplication.

METHODS

We retrospectively reviewed 14 patients who underwent pneumatic dilation for persistent postfundoplication dysphagia. All patients had esophageal manometry before dilations.

RESULTS

There were nine responders to pneumatic dilations (30-40-mm balloons). The nadir lower esophageal sphincter (LES) relaxation pressure was the only significant predictor for successful dilation and was higher among the responders than nonresponders (median 10 mm Hg vs 5 mm Hg). All six of 14 patients with nadir LES pressure > or = 10 mm Hg had a good response. There was no significant difference in the LES basal pressure between the responders and nonresponders (median 20 mm Hg vs 12 mm Hg). The median distal peristaltic amplitude (74 mm Hg vs 69 mm Hg), percent of failed peristalsis (8% vs 45%), and ramp pressure (19 mm Hg vs 17 mm Hg) did not differ significantly between the responders and nonresponders. No perforations occurred.

CONCLUSIONS

Pneumatic dilation is a reasonably safe and effective treatment for patients with postfundoplication dysphagia. Raised nadir LES relaxation pressure seems to be a useful predictor of successful outcome.

Characterization of long-term outcomes after Toupet fundoplication: symptoms, medication use, and health status

GOALS AND BACKGROUND

Fundoplication is increasingly used for the treatment of gastroesophageal reflux disease (GERD). Few studies have tracked patient outcomes of the Toupet method for more than 1 year. Further clinical, physiologic, and patient-based outcome measures have not been well characterized for this method. The current study conducts a long-term, comprehensive outcome evaluation in patients receiving Toupet fundoplication.

STUDY

Fifty-five patients who had previously undergone fundoplication were examined. In a subset of 24 patients, esophagogastroduodenoscopy was used to assess the severity of reflux esophagitis. Manometry and ambulatory pH monitoring also were performed.

RESULTS

Patients were studied 2.9 (+/- 0.7) years after surgery. Sixty-seven percent of the sample reported heartburn, 51% reported postoperative bloating, 33% reported regurgitation, and 20% reported dysphagia. Thirty-three percent reported the use of prescription medications for GERD-related symptoms. Health status was diminished relative to population norms. Degree of GERD severity was associated with symptom reports and medication use.

CONCLUSIONS

Although fundoplication is thought to be a curative procedure, the current findings suggest that many patients take symptomatic therapies and report symptoms and diminished health status up to 2 years after the procedure. These outcomes are associated with physiologic findings. Thus, these findings suggest that symptom-free status and absence of medication use cannot be assumed for all patients after Toupet fundoplication.

Standard antireflux operations in patients who have Barrett's esophagus. Current results

Several therapeutic options exist for patients who have BE, and treatment should be individualized (Fig. 1). The best option in patients who have a high surgical risk or who reject surgery is lifelong conservative treatment, adjusting the PPI dosage with pH-metric controls. In patients who have a low surgical risk the best option is Nissen fundoplication. Only in cases in which esophageal shortening prevents a tension-free fundoplication from being done is a Collis gastroplasty associated with a fundoplication indicated. Other options may be indicated only in exceptional circumstances: (a) duodenal switch, when, after multiple failures with previous surgery, the approach to the esophagogastric junction is extremely difficult; and (b) esophageal resection, when there is a nondilatable esophageal stenosis and in cases in which the histologic study reveals the presence of high-grade dysplasia. Whatever treatment is used, an endoscopic surveillance program is mandatory, since, with the exception of total esophagectomy, no therapeutic option completely eliminates the risk for progression to adenocarcinoma.

Efficacy of medical therapy and antireflux surgery to prevent Barrett's metaplasia in patients with gastroesophageal reflux disease

OBJECTIVE

To investigate whether Barrett's metaplasia may develop despite effective medical therapy.

SUMMARY BACKGROUND DATA

Gastroesophageal reflux disease has a multifactorial etiology. Therefore, medical treatment may not prevent complications of reflux disease.

METHODS

Eighty-three patients with reflux disease and mild esophagitis were prospectively studied for the development of Barrett's metaplasia while receiving long-term therapy with proton pump inhibitors and cisapride. Only patients who had effective control of reflux symptoms and esophagitis were included. The surveillance time was 2 years. The outcome of these 83 patients was compared with that of 42 patients in whom antireflux surgery was performed with a median follow-up of 3.5 years.

RESULTS

Twelve (14.5%) patients developed Barrett's while receiving medical therapy; this was not seen after surgery. Patients developing Barrett's had a weaker lower esophageal sphincter and peristalsis before treatment than patients with uncomplicated disease.

CONCLUSIONS

Antireflux surgery is superior to medical therapy in the prevention of Barrett's metaplasia. Therefore, patients with reflux disease who have a weak lower esophageal sphincter and poor esophageal peristalsis should undergo antireflux surgery, even if they have only mild esophagitis.

Dysphagia after antireflux surgery

BACKGROUND

Dysphagia is experienced by many patients after antireflux surgery. This literature review examines factors associated with the development, prediction and management of postoperative dysphagia.

METHODS

Published studies examining issues related to dysphagia, gastro-oesophageal reflux and fundoplication were reviewed.

RESULTS

Postoperative dysphagia is usually temporary but proves troublesome for 5--10 per cent of patients. Technical modifications, such as a partial wrap, division of short gastric vessels and method of hiatal closure, have not conclusively reduced its incidence. There is no reliable preoperative test to predict dysphagia.

CONCLUSION

It is uncertain whether postoperative dysphagia arises from patient predilection or is largely a consequence of mechanical changes created by fundoplication. Anatomical errors account for a significant proportion of patients referred for correction of dysphagia but these are uncommon in large single-institution studies. Abnormal manometry cannot predict dysphagia and, on current evidence, 'tailoring' the operation does not prevent its occurrence.

DYSPHAGIA in Psychiatric Patients

1. Psychiatric patients in acute and long-term care settings may be at high risk for dysphagia and its sequelae. 2. The prevalence of dysphagia in the psychiatric population is higher than commonly believed. 3. Routine screening is essential for the safety and management of psychiatric patients at risk for dysphagia.

Complete fundoplication is not associated with increased dysphagia in patients with abnormal esophageal motility

Abnormal esophageal motility is a relative contraindication to complete (360-degree) fundoplication because of a purported risk of postoperative dysphagia. Partial fundoplication, however, may be associated with increased postoperative esophageal acid exposure. Our aim was to determine if complete fundoplication is associated with increased postoperative dysphagia in patients with abnormal esophageal motor function. Medical records of 140 patients (79 females; mean age 48 +/- 1.1 years) who underwent fundoplication for gastroesophageal reflux disease (GERD) were reviewed retrospectively to document demographic data, symptoms, and diagnostic test results. Of the 126 patients who underwent complete fundoplication, 25 met manometric criteria for abnormal esophageal motility (#30 mm Hg mean distal esophageal body pressure or #80% peristalsis), 68 had normal esophageal function, and 33 had incomplete manometric data and were therefore excluded from analysis. Of the 11 patients who underwent partial fundoplication, eight met criteria for abnormal esophageal motility, two had normal esophageal function, and one had incomplete data and was therefore excluded. After a median follow-up of 2 years (range 0.5 to 5 years), patients were asked to report heartburn, difficulty swallowing, and overall satisfaction using a standardized scoring scale. Complete responses were obtained in 72%. Sixty-five patients who underwent complete fundoplication and had manometric data available responded (46 normal manometry; 19 abnormal manometry). Outcomes were compared using the Mann-Whitney U test. After complete fundoplication, similar postoperative heartburn, swallowing, and overall satisfaction were reported by patients with normal and abnormal esophageal motility. Likewise, similar outcomes were reported after partial fundoplication. This retrospective study found equally low dysphagia rates regardless of baseline esophageal motility; therefore a randomized trial comparing complete versus partial fundoplication in patients with abnormal esophageal motility is warranted.