Primary laparoscopic fundoplication in selected patients with gastroesophageal reflux disease

Long-term efficacy and quality of life after antireflux surgery

BACKGROUND

Antireflux surgery (ARS) has been found to be an effective treatment of gastro-esophageal reflux disease (GERD); however, the long-term effects are uncertain. This study aimed to evaluate the long-term efficacy of ARS on quality of life, symptom severity, and use of proton pump inhibitors (PPIs).

METHODS

A validated GERD Health-Related Quality of Life (GERD-HRQL) Questionnaire was sent to 419 patients who underwent ARS at Aarhus University Hospital from January 2012 to April 2020. Patient records were reviewed retrospectively. The Danish National Prescription Registry was used to collect data on the use of PPIs before and after ARS.

RESULTS

A response rate of 71% resulted in a total of 164 patients included in the study with a median follow-up time of 4.8 years (interquartile range: 2.5-6.7). The total GERD-HRQL median score at follow-up was 11.5 (IQR: 4-22). The proportion of patients experiencing daily symptoms of heartburn and regurgitation was significantly reduced pre- to postoperatively from 90 to 70% to 32% and 29%, respectively. Five years after surgery, 47% of patients had completely ceased PPI usage, while 44% were long-term users.

CONCLUSION

A lasting long-term effect of ARS on GERD symptoms was found, although almost a third of patients still experience heartburn and/or regurgitation daily. Almost half of patients were not taking PPIs 5 years after ARS, but 44% became long-term users. Patients should be made aware that long-term PPI therapy often is necessary following ARS.

Hiatal Hernias Revisited-A Systematic Review of Definitions, Classifications, and Applications

INTRODUCTION

A hiatal hernia (HH) can be defined as a condition in which elements from the abdominal cavity herniate through the oesophageal hiatus in the mediastinum and, in the majority of cases, parts of the proximal stomach. Today, the role of HHs within the complex entity of gastroesophageal reflux disease (GERD) is very important with regard to its pathophysiology, severity, and therapeutic and prognostic options. Despite this, the application and stringent use of the worldwide accepted classification (Skinner and Belsey: Types I-IV) are lacking. The aim of this study was to carry out a systematic review of the clinical applications of HH classifications and scientific documentation over time, considering their value in diagnosis and treatment.

METHODS

Following the PRISMA concept, all abstracts published on pubmed.gov until 12/2023 (hiatal hernia) were reviewed, and those with a focus and clear description of the application of the current HH classification in the full-text version were analysed to determine the level of classification and its use within the therapeutic context.

RESULTS

In total, 9342 abstracts were screened. In 9199 of the abstracts, the reports had a different focus than HH, or the HH classification was not used or was incompletely applied. After further investigation, 60 papers were used for a detailed analysis, which included more than 12,000 patient datapoints. Among the 8904 patients, 83% had a Type I HH; 4% had Type II; 11% had Type III; and 1% had Type IV. Further subgroup analyses were performed. Overall, the precise application of the HH classification has been insufficient, considering that only 1% of all papers and only 54% of those with a special focus on HH have documented its use.

CONCLUSIONS

The application and documentation of a precise HH classification in clinical practice and scientific reports are decreasing, which should be rectified for the purpose of scientific comparability.

Pressure dynamics of the esophagogastric junction at rest and during inspiratory maneuvers after Nissen fundoplication

Low sphincter pressure and inability of the crural diaphragm to elevate it at the esophagogastric junction are important pathophysiological mechanisms of gastroesophageal reflux disease (GERD). The object of this study was to depict how Nissen fundoplication changed the resting and inspiratory pressures of the anti-reflux barrier. We selected 14 patients (eight males; mean age 42.7 years; mean body mass index 27.8) for surgery. They answered symptoms questionnaires and underwent high-resolution manometry (HRM) before and 6 months after Nissen fundoplication. We used a standard manometric protocol (resting and liquid swallows) and assessment of esophagogastric junction (EGJ) pressure metrics during standardized forced inspiratory maneuvers against increasing loads (Threshold Maneuvers). We used the Wilcoxon test for comparison of pre and postoperative data. After fundoplication, heartburn and regurgitation scores diminished remarkably (from 4.5 and 2, respectively, to zero; P = 0.002 and P = 0.0005, respective medians). Also, the median expiratory EGJ pressure had a significant increase from 8.1 to 18.1 mmHg (P = 0.002), while mean respiratory pressure and EGJ contractility integral (EGJ-CI) increased without statistical significance (P = 0.064 and P = 0.06, respectively). Axial EGJ displacement was lower after fundoplication. The EGJ relaxation pressure (P = 0.001), the mean distal esophageal intrabolus pressure (P = 0.01) and the distal latency (P = 0.017) increased after fundoplication. There was a reduction in the contraction front velocity (P = 0.043). During evaluation with standardized inspiratory maneuvers, the inspiratory EGJ pressures (under loads of 12, 24, 36 and 48 cmH2O) were lower after surgery for all loads (median for load 12 cmH2O: 145.6 vs. 102.7 mmHg; P = 0.004). Fundoplication and hiatal closure increased the expiratory EGJ pressure and promoted a great GERD symptom relief. The surgery seemed to overcompensate a reduced EGJ mobility and inspiratory pressure.

Gastrointestinal Quality of Life in Gastroesophageal Reflux Disease: A Systematic Review

BACKGROUND

The Gastrointestinal Quality of Life Index (GIQLI) is a well-established instrument for the assessment of quality of life (QOL) in gastrointestinal (GI) diseases. The purpose of this literature review was to investigate QOL by means of GIQLI in patients with gastroesophageal reflux disease (GERD) prior to any interventional therapy. There are several reports on GIQLI data; however, comparisons from different countries and/or different GERD cohorts assessing the same disease have to date not been conducted.

METHODS

The GIQLI uses 36 items around 5 dimensions (GI symptoms [19 items], emotional dimension [5 items], physical dimension [7 items], social dimension [4 items], and therapeutic influences [1 item]). A literature search was conducted on the application of GIQLI in GERD patients prior to interventional therapy using reports in PubMed. Data on the mean GIQLI as well as index data for the 5 dimensions as originally validated were extracted from the published patient cohorts. A comparison with the normal healthy control group from the original publication of the GIQLI validation conducted by Eypasch was performed. Data are presented descriptively as GIQLI points as well as a reduction from 100% maximum possible index points (max 144 index points = highest QOL).

RESULTS

In total, 77 abstracts from studies using the GIQLI on patients with GERD were identified. After screening for content, 21 publications were considered for further analysis. Ten studies in GERD patients comprised complete calculations of all dimensions and were included in the analysis. Data from 1,682 study patients were evaluated with sample sizes ranging from 33 to 568 patients (median age of 789 females and 858 males: 51.8 years). The median overall GIQLI for the patient group was 91.7 (range 86-102.4), corresponding to 63.68% of the maximum GIQLI. The dimensions with the largest deviation from the respective maximum score were the physical dimension (55% of maximum) followed by the emotional dimension (60% of maximum). In summary, the GIQLI level in GERD cohorts was reduced to 55-75% of the maximum possible index.

CONCLUSIONS

Severe GERD causes substantial reductions in the patient's QOL. The level of GIQLI can carry between different studied GERD cohorts from different departments and countries. GIQLI can be used as an established tool to assess the patient's condition in various dimensions.