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Trudgill NJ, Sifrim D, Sweis R, Fullard M, Basu K, McCord M, Booth M, Hayman J, Boeckxstaens G, Johnston BT, Ager N, De Caestecker J. British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring. Gut 2019; 68:1731-1750. [PMID: 31366456 PMCID: PMC6839728 DOI: 10.1136/gutjnl-2018-318115] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 06/13/2019] [Accepted: 06/16/2019] [Indexed: 12/11/2022]
Abstract
These guidelines on oesophageal manometry and gastro-oesophageal reflux monitoring supersede those produced in 2006. Since 2006 there have been significant technological advances, in particular, the development of high resolution manometry (HRM) and oesophageal impedance monitoring. The guidelines were developed by a guideline development group of patients and representatives of all the relevant professional groups using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. A systematic literature search was performed and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tool was used to evaluate the quality of evidence and decide on the strength of the recommendations made. Key strong recommendations are made regarding the benefit of: (i) HRM over standard manometry in the investigation of dysphagia and, in particular, in characterising achalasia, (ii) adjunctive testing with larger volumes of water or solids during HRM, (iii) oesophageal manometry prior to antireflux surgery, (iv) pH/impedance monitoring in patients with reflux symptoms not responding to high dose proton pump inhibitors and (v) pH monitoring in all patients with reflux symptoms responsive to proton pump inhibitors in whom surgery is planned, but combined pH/impedance monitoring in those not responsive to proton pump inhibitors in whom surgery is planned. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG.
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Affiliation(s)
- Nigel J Trudgill
- Sandwell and West Birmingham Hospitals NHS Trust, West Bomwich, UK
| | - Daniel Sifrim
- Centre of Gastroenterology Research, Queen Mary University London, London, UK
| | - Rami Sweis
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Fullard
- West Hertfordshire Hospitals NHS Trust, Watford, Hertfordshire, UK
| | - Kumar Basu
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - John Hayman
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Guy Boeckxstaens
- Gastroenterology, University Hospital, KU Leuven, Leuven, Belgium
| | - Brian T Johnston
- Department of Gastroenterology, Belfast Health and Social Care Trust, Belfast, UK
| | - Nicola Ager
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
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Dantas RO, Santos CM, Cassiani RA, Alves LMT, Nascimento WV. POSTFUNDOPLICATION DYSPHAGIA CAUSES SIMILAR WATER INGESTION DYNAMICS AS ACHALASIA. ARQUIVOS DE GASTROENTEROLOGIA 2016; 53:98-102. [PMID: 27305416 DOI: 10.1590/s0004-28032016000200009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 01/12/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND - After surgical treatment of gastroesophageal reflux disease dysphagia is a symptom in the majority of patients, with decrease in intensity over time. However, some patients may have persistent dysphagia. OBJECTIVE - The objective of this investigation was to evaluate the dynamics of water ingestion in patients with postfundoplication dysphagia compared with patients with dysphagia caused by achalasia, idiopathic or consequent to Chagas' disease, and controls. METHODS - Thirty-three patients with postfundoplication dysphagia, assessed more than one year after surgery, together with 50 patients with Chagas' disease, 27 patients with idiopathic achalasia and 88 controls were all evaluated by the water swallow test. They drunk, in triplicate, 50 mL of water without breaks while being precisely timed and the number of swallows counted. Also measured was: (a) inter-swallows interval - the time to complete the task, divided by the number of swallows during the task; (b) swallowing flow - volume drunk divided by the time taken; (c) volume of each swallow - volume drunk divided by the number of swallows. RESULTS - Patients with postfundoplication dysphagia, Chagas' disease and idiopathic achalasia took longer to ingest all the volume, had an increased number of swallows, an increase in interval between swallows, a decrease in swallowing flow and a decrease in water volume of each swallow compared with the controls. There was no difference between the three groups of patients. There was no correlation between postfundoplication time and the results. CONCLUSION - It was concluded that patients with postfundoplication dysphagia have similar water ingestion dynamics as patients with achalasia.
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Affiliation(s)
- Roberto Oliveira Dantas
- Departamento de Clinica Médica da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto SP, Brasil., Universidade de São Paulo, Departamento de Clinica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto SP , Brazil
| | - Carla Manfredi Santos
- Departamento de Clinica Médica da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto SP, Brasil., Universidade de São Paulo, Departamento de Clinica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto SP , Brazil
| | - Rachel Aguiar Cassiani
- Departamento de Clinica Médica da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto SP, Brasil., Universidade de São Paulo, Departamento de Clinica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto SP , Brazil
| | - Leda Maria Tavares Alves
- Departamento de Clinica Médica da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto SP, Brasil., Universidade de São Paulo, Departamento de Clinica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto SP , Brazil
| | - Weslania Viviane Nascimento
- Departamento de Clinica Médica da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto SP, Brasil., Universidade de São Paulo, Departamento de Clinica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto SP , Brazil
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Wang YT, Tai LF, Yazaki E, Jafari J, Sweis R, Tucker E, Knowles K, Wright J, Ahmad S, Kasi M, Hamlett K, Fox MR, Sifrim D. Investigation of Dysphagia After Antireflux Surgery by High-resolution Manometry: Impact of Multiple Water Swallows and a Solid Test Meal on Diagnosis, Management, and Clinical Outcome. Clin Gastroenterol Hepatol 2015; 13:1575-83. [PMID: 25956839 DOI: 10.1016/j.cgh.2015.04.181] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 04/13/2015] [Accepted: 04/14/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Management of patients with dysphagia, regurgitation, and related symptoms after antireflux surgery is challenging. This prospective, case-control study tested the hypothesis that compared with standard high-resolution manometry (HRM) with single water swallows (SWS), adding multiple water swallows (MWS) and a solid test meal increases diagnostic yield and clinical impact of physiological investigations. METHODS Fifty-seven symptomatic and 12 asymptomatic patients underwent HRM with SWS, MWS, and a solid test meal. Dysphagia and reflux were assessed by validated questionnaires. Diagnostic yield of standard and full HRM studies with 24-hour pH-impedance monitoring was compared. Pneumatic dilatation was performed for outlet obstruction on HRM studies. Clinical outcome was assessed by questionnaires and an analogue scale with "satisfactory" defined as at least 40% symptom improvement requiring no further treatment. RESULTS Postoperative esophagogastric junction pressure was similar in all groups. Abnormal esophagogastric junction morphology (double high pressure band) was more common in symptomatic than in control patients (13 of 57 vs 0 of 12, P = .004). Diagnostic yield of HRM was 11 (19%), 11 (19%), and 33 of 57 (58%), with SWS, MWS, and solids, respectively (P < .001); it was greatest for solids in patients with dysphagia (19 of 27, 70%). Outlet obstruction was present in 4 (7%), 11 (19%), and 15 of 57 patients (26%) with SWS, MWS, and solids, respectively (P < .009). No asymptomatic control had clinically relevant dysfunction on solid swallows. Dilatation was performed in 12 of 15 patients with outlet obstruction during the test meal. Symptom response was satisfactory, good, or excellent in 7 of 12 (58%) with no serious complications. CONCLUSIONS The addition of MWS and a solid test meal increases the diagnostic yield of HRM studies in patients with symptoms after fundoplication and identifies additional patients with outlet obstruction who benefit from endoscopic dilatation.
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Affiliation(s)
- Yu Tien Wang
- Centre for Digestive Disease, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Ling Fung Tai
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Etsuro Yazaki
- Centre for Digestive Disease, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Jafar Jafari
- Centre for Digestive Disease, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Rami Sweis
- Department of Gastroenterology, St Thomas' Hospital, London, United Kingdom
| | - Emily Tucker
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Kevin Knowles
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Jeff Wright
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Saqib Ahmad
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Madhavi Kasi
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Katharine Hamlett
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Mark R Fox
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham University Hospitals, Nottingham, United Kingdom; Zürich Neurogastroenterology and Motility Research Group, Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland.
| | - Daniel Sifrim
- Centre for Digestive Disease, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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Baker ME, Einstein DM. Barium esophagram: does it have a role in gastroesophageal reflux disease? Gastroenterol Clin North Am 2014; 43:47-68. [PMID: 24503359 DOI: 10.1016/j.gtc.2013.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The barium esophagram is an integral part of the assessment and management of patients with gastroesophageal reflux disease (GERD) before, and especially after, antireflux procedures. While many of the findings on the examination can be identified with endosocopy, a gastric emptying study and an esophageal motility examination, the barium esophagram is better at demonstrating the anatomic findings after anti-reflux surgery, especially in symptomatic patients. These complementary examinations, when taken as a whole, fully evaluate a patient with suspected GERD as well as symptomatic patients after antireflux procedures.
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Affiliation(s)
- Mark E Baker
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Abdominal Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Cancer Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - David M Einstein
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Abdominal Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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5
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Gastric volvulus after laparoscopic fundoplication: a rare complication after Heller-Dor operation for achalasia. Esophagus 2013. [DOI: 10.1007/s10388-012-0359-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Dysphagia postfundoplication: more commonly hiatal outflow resistance than poor esophageal body motility. Surgery 2012; 152:584-92; discussion 592-4. [PMID: 22939748 DOI: 10.1016/j.surg.2012.07.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 07/10/2012] [Indexed: 01/05/2023]
Abstract
BACKGROUND Historically, risk assessment for postfundoplication dysphagia has been focused on esophageal body motility, which has proven to be an unreliable prediction tool. Our aim was to determine factors responsible for persistent postoperative dysphagia. METHODS Fourteen postfundoplication patients with primary dysphagia were selected for focused study. Twenty-five asymptomatic post-Nissen patients and 17 unoperated subjects served as controls. Pre- and postoperative clinical and high-resolution manometry parameters were compared. RESULTS Thirteen of the 14 symptomatic patients (92.9%) had normal postoperative esophageal body function, determined manometrically. In contrast, 13 of 14 (92.9%) had evidence of esophageal outflow obstruction, 9 of 14 (64.3%) manometrically, and 4 of 14 (28.6%) on endoscopy/esophagram. Median gastroesophageal junction integrated relaxation pressure was significantly greater (16.2 mm Hg) in symptomatic than in asymptomatic post-Nissen patients (11.1 mm Hg, P = .05) or unoperated subjects (10.6 mm Hg, P = .02). Sixty-four percent (9/14) of symptomatic patients had an increased mean relaxation pressure. Dysphagia was present in 9 of 14 (64.3%) preoperatively, and elevated postoperative relaxation pressure was independently associated with dysphagia. CONCLUSION These data suggest that postoperative alterations in hiatal functional anatomy are the primary factors responsible for post-Nissen dysphagia. Impaired relaxation of the neo-high pressure zone, recognizable as an abnormal relaxation pressure, best discriminates patients with dysphagia from those without symptoms postfundoplication.
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Raeside MC, Madigan D, Myers JC, Devitt PG, Jamieson GG, Thompson SK. Post-fundoplication contrast studies: is there room for improvement? Br J Radiol 2011; 85:792-9. [PMID: 21791506 DOI: 10.1259/bjr/57095992] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE Since the mid-1990s, laparoscopic fundoplication for gastro-oesophageal reflux disease has become the surgical procedure of choice. Several surgical groups perform routine post-operative contrast studies to exclude any (asymptomatic) anatomical abnormality and to expedite discharge from hospital. The purpose of this study was to determine the accuracy and interobserver reliability for surgeons and radiologists in contrast study interpretation. METHODS 11 surgeons and 13 radiologists (all blinded to outcome) retrospectively reviewed the contrast studies of 20 patients who had undergone a laparoscopic fundoplication. Each observer reported on fundal wrap position, leak or extravasation of contrast and contrast hold-up at the gastro-oesophageal junction (on a scale of 0-4). A κ coefficient was used to evaluate interobserver reliability. RESULTS Surgeons were more accurate than radiologists in identifying normal studies (specificity = 91.6% vs 78.9%), whereas both groups had similar accuracy in identifying abnormal studies (sensitivity = 82.3% vs 85.2%). There was higher agreement amongst surgeons than amongst radiologists when determining wrap position (κ = 0.65 vs 0.54). Both groups had low agreement when classifying a wrap migration as partial or total (κ = 0.33 vs 0.06). Radiologists were more likely to interpret the position of the wrap as abnormal (relative risk = 1.25) while surgeons reported a greater degree of hold-up of contrast at the gastro-oesophageal junction (mean score = 1.17 vs 0.86). CONCLUSION Radiologists would benefit from more information about the technical details of laparoscopic anti-reflux surgery. Standardised protocols for performing post-fundoplication contrast studies are needed.
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Affiliation(s)
- M C Raeside
- Department of Radiology, Royal Adelaide Hospital, Adelaide, SA, Australia
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8
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Nissen Fundoplication and Gastrointestinal-Related Complications: A Guide for the Primary Care Physician. South Med J 2009; 102:1041-5. [DOI: 10.1097/smj.0b013e3181b672eb] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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9
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Bruley des Varannes S. [Functional exploration of esophageal reflux]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2006; 30:742-9. [PMID: 16801896 DOI: 10.1016/s0399-8320(06)73307-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
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Blom D, Bajaj S, Liu J, Hofmann C, Rittmann T, Derksen T, Shaker R. Laparoscopic Nissen fundoplication decreases gastroesophageal junction distensibility in patients with gastroesophageal reflux disease. J Gastrointest Surg 2005; 9:1318-25. [PMID: 16332489 DOI: 10.1016/j.gassur.2005.08.032] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2005] [Accepted: 08/20/2005] [Indexed: 01/31/2023]
Abstract
Laparoscopic Nissen fundoplication (LNF) is the surgical treatment of choice for gastroesophageal reflux disease (GERD). Post-LNF complications, such as gas bloat syndrome, inability to belch and vomit, and dysphagia, remain too common and prevent LNF from being more highly recommended. It remains controversial as to whether preoperative assessment can predict the development of post-LNF complications. Some authors have shown a correlation between pre-LNF manometry characteristics and post-LNF dysphagia, and others have not. We hypothesize that many post-LNF complications are caused by a decrease in the distensibility of the GEJ and that standard manometry is at best an indirect measure of this. The aim of this study is to directly measure the effect of LNF on gastroesophageal junction (GEJ) distensibility (GEJD). The lower esophageal sphincter (LES) of 15 patients undergoing LNF was characterized using standard manometry. The GEJD before and after a standardized LNF was measured using a specialized catheter, containing an infinitely compliant bag, placed within the LES. GEJD was measured, as dV/dP over volumes 5 to 25 mL distended at a rate of 20 mL/min. Mean dP +/- standard error of the mean for each volume was calculated, and distensibility curves were generated and compared. Measurements were also taken after abolishing LES tone by mid-esophageal balloon distension. Patient symptoms were recorded before and after surgery. Statistical analysis was performed by two-way repeated-measures analysis of variance, paired t test, and the Tukey test. Laparoscopic Nissen fundoplication led to a statistically significant increase in Delta pressure over each volume tested and therefore a significant decrease in the distensibility of the GEJ. Abolition of LES tone had no statistical effect on GEJD after fundoplication. There were no complications, and none of the patients developed the symptom of dysphagia postoperatively. These are the first direct measurements to show that LNF significantly reduces the distensibility of the GEJ. We hypothesize that the magnitude of this reduction may be the vital variable in the development of post-LNF complications and specifically post-LNF dysphagia. The intraoperative measurement of LES distensibility may provide a means for avoiding this feared and other post-LNF complications in the future.
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Affiliation(s)
- Dennis Blom
- Division of Minimally Invasive and Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA
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Ducrotté P, Leblanc-Louvry I. [Sequelae of sub-mesocolic surgery]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2005; 29:839-45. [PMID: 16294154 DOI: 10.1016/s0399-8320(05)86356-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Affiliation(s)
- Philippe Ducrotté
- Hépato-Gastroentérologie et Nutrition, Polyclinique, 76031 Rouen Cedex
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Abstract
In children with medically refractory gastroesophageal reflux disease (GERD), fundoplication is effective and safe. However, in a subset of patients, gastrointestinal dysfunction occurs postoperatively. Symptoms include chest pain, persistent dysphagia in 5%, gas bloat in 2% to 4%, diarrhea in up to 20%, and dumping syndrome in up to 30%. Symptoms are often nonspecific, arising from recurrent or persistent GERD, anatomic complications such as disrupted or herniated wrap, functional disturbances such as rapid gastric emptying or altered gastric accommodation, or alternative diagnoses such as cyclic vomiting syndrome or food allergy. Detailed investigation, including various combinations of pHmetry, videofluoroscopy, endoscopy, motility studies, and dumping provocation testing, may be required to clarify pathophysiology and guide management.
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Affiliation(s)
- Frances Connor
- Department of Gastroenterology, Hepatology and Nutrition, Royal Children's Hospital, Herston Road, Herston, Brisbane, QLD 4029, Australia.
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Richards CA, Smith VV, Milla PJ, Spitz L, Andrews PLR. The histological appearances of Nissen-type fundoplication in the ferret. Neurogastroenterol Motil 2003; 15:121-8. [PMID: 12680911 DOI: 10.1046/j.1365-2982.2003.00391.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Nissen fundoplication is of proven effectiveness in the surgical control of gastro-oesophageal reflux. However, our understanding of the effects of fundoplication upon foregut physiology is incomplete and post-operative symptoms are often poorly understood. This experimental study aimed systematically to characterize the tissue response to fundoplication in an animal model, to improve understanding of the effects of anti-reflux surgery upon foregut physiology. Nissen-type fundoplication was performed in the ferret, and the tissue response at 3 months examined histologically. Sham-operated animals that underwent laparotomy but no dissection or wrap, acted as controls. In fundoplicated animals, serosal fibrosis was observed in the gut wall, with patchy replacement of muscle by fibrous tissue. The ventral and dorsal vagal nerve trunks were identified intact within the wrap. In cases where the wrap had spontaneously disrupted, fibrosis was more extensive and there was evidence of nerve damage. This is the first systematic description of the histopathological response to Nissen fundoplication. In the intact wrap, the vagal trunks appear spared, but there is fibrosis in the serosa, extending into the muscularis of the distal oesophagus and region of the cardia. These findings are discussed in relation to the effects of Nissen fundoplication upon gastric physiology and postoperative symptoms.
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Affiliation(s)
- C A Richards
- Department of Physiology, St George's Hospital Medical School, London, UK
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Huguier M, Barrier A, Houry S. [Surgical treatment of gastroesophageal reflux disease in adults]. ANNALES DE CHIRURGIE 2001; 126:618-28. [PMID: 11676232 DOI: 10.1016/s0003-3944(01)00583-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/17/2023]
Abstract
Pathological gastroesophageal reflux is common. The aim of this review was to compare the results of different surgical techniques. Papers were selected on Medline from 1990 to April 2001. A critical analysis was performed, concerning definitions of included patients, surgical techniques, and criteria of evaluation. For comparison, the results of 23 randomized studies were mainly selected. Their heterogeneity has not allowed a meta-analysis. A few techniques had poorer results than others: simple closure of His angle, Hill operation, Belsey Mark IV technique, and Angelchik prosthesis. In most studies, results of partial fundoplication on reflux were as good as those of total Nissen fundoplication and fewer patients had postoperative dysphagia. In a double blind trial, immediate advantages of laparoscopic approach were less important than those observed in non comparative studies. Another trial was interrupted after inclusion of 103 patients because of the higher rate of side-effects in the laparoscopic group. These results may help the surgeon in the choice of a technique. Patients have to be informed of potential adverse effects of the different techniques chosen by their surgeon.
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Affiliation(s)
- M Huguier
- Service de chirurgie générale et digestive, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France.
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Jailwala J, Massey B, Staff D, Shaker R, Hogan W. Post-fundoplication symptoms: the role for endoscopic assessment of fundoplication integrity. Gastrointest Endosc 2001; 54:351-6. [PMID: 11522977 DOI: 10.1067/mge.2001.117548] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Fundoplication is now almost exclusively a laparoscopic procedure. The aim of this study was the comparison of the diagnostic usefulness of endoscopy and barium esophagram in the detection of fundoplication abnormalities. METHODS Twenty-two patients presented with symptoms post-laparoscopic (Nissen) fundoplication that included dysphagia (14 patients), heartburn (5 patients), dyspepsia (2 patients), and chest pain (1 patient). Barium esophagram and upper endoscopy were performed in all patients and the results were compared. Key features included presence of esophagitis, resistance to endoscope passage, location of the wrap relative to the diaphragmatic hiatus, location of squamocolumnar junction greater than 1 cm proximal to the wrap zone, and the appearance of the wrap (intact, loose, disrupted, or tight). RESULTS The key features explained symptoms in 20 of 22 patients. Endoscopy detected twice as many key features as radiography. Disruption of the wrap or excessive proximal location of the squamocolumnar junction proximal to the wrap zone were the most incriminating endoscopic findings. Resistance to endoscope passage was rarely encountered and the esophagram was more accurate in detecting an overly tight wrap. CONCLUSIONS Endoscopic evaluation is more accurate than barium esophagram in detecting post-fundoplication abnormalities. The appearance of the fundoplication wrap and an abnormal proximal location of the squamocolumnar junction appear to be major endoscopic clues in diagnosis of post-fundoplication problems.
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Affiliation(s)
- J Jailwala
- Division of Gastroenterology and Hepatology, Digestive Diseases Center and MCW Dysphagia Institute, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA
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