Despite high satisfaction, majority of gastro-oesophageal reflux disease patients continue to use proton pump inhibitors after antireflux surgery

Minimally Invasive Roux-en-Y Gastric Bypass for Fundoplication failure offers Excellent Gastroesophageal Reflux Control

Roux-en-Y gastric bypass (RYGB) may represent a superior alternative to reoperative fundoplication in patients with symptomatic failure. Our goal was to assess early outcomes of patients after RYGB for failed fundoplication. Records of patients who underwent fundoplication takedown and RYGB from March 2007 to June 2013 were reviewed for demographics, comorbidities, operative findings, and perioperative outcomes. Data are reported as medians (range). Forty-five patients who had undergone 64 prior antireflux procedures (range, one to three fundoplications) were identified. Median patient age was 56 years (range, 25 to 72 years) with a body mass index of 33 kg/m2 (range, 22 to 51 kg/m2). Most patients had comorbidities: hypertension (60%), anxiety/ depression (44.4%), dyslipidemia (33.3%), asthma (31%), obstructive sleep apnea (26.7%), arthritis (22.2%), and diabetes (11.1%). Median symptom-free interval was 3 years (range, 0 to 25 years). All patients had an anatomic reason for failure: 83 per cent had a hiatal hernia and 35 per cent had a slipped Nissen fundoplication. The procedures were accomplished laparoscopically in 28, robotically in 13, and open in four cases. Median operative time was 367 minutes (range, 190 to 600 minutes) and estimated blood loss averaged 100 mL (range, 25 to 500 mL). Five patients (11%) required reoperation: one for an anastomotic leak, one for anastomotic obstruction, and three for early obstruction resulting from adhesions. Two patients developed respiratory failure requiring prolonged mechanical ventilation. Length of stay averaged four days (range, 1 to 33 days) with two readmissions: one for melena and one for vomiting and dehydration; neither required intervention. There was no mortality. At 11 months of follow-up (range, 2.3 to 54 months), 93.3 per cent of patients were symptom-free. When primary fundoplication for gastroesophageal reflux disease fails, fundoplication takedown and RYGB can be accomplished safely with minimally invasive techniques. The conversion to a RYGB has an acceptable perioperative morbidity and excellent early symptom control, and, therefore, should be considered for reoperative patients gastroesophageal reflux disease.

How to select patients for antireflux surgery? The ICARUS guidelines (international consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for antireflux surgery)

OBJECTIVE

Antireflux surgery can be proposed in patients with GORD, especially when proton pump inhibitor (PPI) use leads to incomplete symptom improvement. However, to date, international consensus guidelines on the clinical criteria and additional technical examinations used in patient selection for antireflux surgery are lacking. We aimed at generating key recommendations in the selection of patients for antireflux surgery.

DESIGN

We included 35 international experts (gastroenterologists, surgeons and physiologists) in a Delphi process and developed 37 statements that were revised by the Consensus Group, to start the Delphi process. Three voting rounds followed where each statement was presented with the evidence summary. The panel indicated the degree of agreement for the statement. When 80% of the Consensus Group agreed (A+/A) with a statement, this was defined as consensus. All votes were mutually anonymous.

RESULTS

Patients with heartburn with a satisfactory response to PPIs, patients with a hiatal hernia (HH), patients with oesophagitis Los Angeles (LA) grade B or higher and patients with Barrett's oesophagus are good candidates for antireflux surgery. An endoscopy prior to antireflux surgery is mandatory and a barium swallow should be performed in patients with suspicion of a HH or short oesophagus. Oesophageal manometry is mandatory to rule out major motility disorders. Finally, oesophageal pH (±impedance) monitoring of PPI is mandatory to select patients for antireflux surgery, if endoscopy is negative for unequivocal reflux oesophagitis.

CONCLUSION

With the ICARUS guidelines, we generated key recommendations for selection of patients for antireflux surgery.

Post-surgical gastrointestinal reflux disease: Status quo and treatment

Reflux is a common and tricky morbidity after gastrointestinal surgery which is caused by the destruction of physiological anti-reflux barriers, greatly affecting patients' postoperative quality of life. Gastroenterologists are now actively trying very hard to explore feasible, effective, and safe anti-reflux approaches. Conservative medical treatment, typically with proton pump inhibitors, is easily accepted by patients, however, its long-term adverse events are noteworthy. In the surgical aspect, laparoscopic anti-reflux surgery is gaining more and more popularity, after the first case of fundoplication. Besides, other operations, such as bariatric surgery, pediatric surgery, and pulmonary transplantation, are also frequently complicated by post-operative digestive reflux. Herein we systematically review the status quo and treatment modalities for post-surgical reflux disease, with the hope to facilitate surgeons to cope with this challenging issue appropriately.

Laparoscopic Nissen Fundoplication: Analysis of 162 patients

METHODS

One hundred and sixty-two patients with GERD were treated surgically with LNF from October 2006 to March 2010. Diagnoses were made by using upper gastrointestinal system (GIS) endoscopy and 24-hour pH monitoring, and all the patients underwent routine LNF surgery. The patients were questioned regarding complaints and proton pump inhibitor (PPI) usage during the postoperative period, and forty patients who had postoperative GIS symptoms were included. Upper GIS endoscopy with antral biopsy for Helicobacter pylori (HP) identification and multichannel intraluminal impedance pH(MII-pH) monitoring were applied Results:The median postoperative follow-up time was 1.84 ± 0.850 (0.29-3.48) years. PPI treatment frequency was 37.5% (15 patients) in the 40 symptomatic 40 patients, or 9.26% in all 162 patients who were operated on. The reason for PPI usage in three patients (7.5%) was regarded as recurrence. HP positivity was 67.5% in the symptomatic patients and 73.3% in the PPI treated group; 40% (six patients) recovery was achieved in the HP (+) patients by using an HP eradication treatment protocol. The operated patients displayed statistically significant results in increased quality of life (p = 0.001) and lowered DeMeester scores (p = 0.000) during the postoperative period when compared to preoperative period.

CONCLUSION

PPI treatment alone during the postoperative period does not indicate recurrence. One of the most important reasons for recurrence is antral gastritis secondary to HP infection; PPI usage diminishes remarkably with an HP eradication protocol. MII-pH monitoring is an effective method of determining recurrences due to reflux and their types in postoperative symptomatic patients.

Evaluation of clinical outcome after laparoscopic antireflux surgery in clinical practice: still a controversial issue

Background. Laparoscopic antireflux surgery has shown to be effective in controlling gastroesophageal reflux (GERD). Yet, a universally accepted definition and evaluation for treatment success/failure in GERD is still controversial. The purpose of this paper is to assess if and how the outcome variables used in the different studies could possibly lead to an homogeneous appraisal of the limits and indications of LARS. Methods. We analyzed papers focusing on the efficacy and outcome of LARS and published in English literature over the last 10 years. Results. Symptoms scores and outcome variables reported are dissimilar and not uniform. The most consistent parameter was patient's satisfaction (mean satisfaction rate: 88.9%). Antireflux medications are not a trustworthy outcome index. Endoscopy and esophageal manometry do not appear very helpful. Twenty-four hours pH metry is recommended in patients difficult to manage for recurrent typical symptoms. Conclusions. More uniform symptoms scales and quality of life tools are needed for assessing the clinical outcome after laparoscopic antireflux surgery. In an era of cost containment, objective evaluation tests should be more specifically addressed. Relying on patient's satisfaction may be ambiguous, yet from this study it can be considered a practical and simple tool.

Trends and perioperative outcomes of inpatient antireflux surgery in the United States, 1993-2006

Antireflux surgery is an effective treatment for gastroesophageal reflux disease, but postoperation complications and durability may be problematic. The objective of the study was to determine whether inpatient antireflux surgery continued to decline in the United States due to concerns about its long-term effectiveness and the popularity of gastric bypass surgery and to assess recent changes in its perioperative outcomes. Using the Nationwide Inpatient Sample, we identified adult patients undergoing inpatient antireflux surgery during 1993-2006 and compared the trends of inpatient antireflux surgery with inpatient gastric bypass surgery. Perioperative complications included laceration, splenectomy, transfusion, esophageal dilation, total parenteral nutrition, and infection. Inpatient antireflux surgery increased from 9173 in 1993 to 32 980 in 2000 (+260%) but then decreased to 19 668 in 2006 (-40%). Compared with 2000, patients undergoing inpatient antireflux surgery in 2006 were older (49.9 ± 32.4 vs. 54.6 ± 33.6 years) and had a longer length of stay (3.1 ± 10.0 vs. 3.7 ± 13.4 days), more complications (4.7% vs. 6.1%), and higher mortality (0.26% vs. 0.54%) (all P < 0.05). Compared with inpatient gastric bypass surgery, length of stay was longer and mortality was higher for inpatient antireflux surgery in 2006, but neither was significant controlling for age. In 2006, perioperative outcomes of inpatient antireflux surgery were better in high-volume hospitals (all P < 0.01). Inpatient antireflux surgery continued to decline in the United States from 2000 to 2006, concomitant with a dramatic increase in inpatient gastric bypass surgery. Older patient age and worsening perioperative outcomes for inpatient antireflux surgery suggest increased medical complexity and possibly a larger share of reoperations over time. Designating centers of excellence for antireflux surgery based on local expertise may improve outcomes.

Cost-effectiveness of proton pump inhibitors versus laparoscopic Nissen fundoplication for patients with gastroesophageal reflux disease: a systematic review of the literature

BACKGROUND

Gastroesophageal reflux disease is a common condition in Western countries. It is unknown whether medical or surgical treatment is more cost-effective. This study was conducted to determine whether laparoscopic Nissen fundoplication or treatment by proton pump inhibitors is the most cost-effective for gastroesophageal reflux disease in the long term.

METHODS

Medline, EMBASE, and Cochrane databases were searched for articles published between January 1990 and 2010. The search results were screened by two independent reviewers for economic evaluations comparing costs and effects of laparoscopic Nissen fundoplication and proton pump inhibitors in adults eligible for both treatments. Cost and effectiveness or utility data were extracted for both treatment modalities. The quality of the economic evaluations was scored using a dedicated checklist, as were the levels of evidence.

RESULTS

Four publications were included; all were based on decision analytic models. The economic evaluations were all of similar quality and all based on data with a variety of evidence levels. Surgery was more expensive than medical treatment in three publications. Two papers reported more quality-adjusted life-years for surgery. However, one of these reported more symptom-free months for medical treatment. In two publications surgery was considered to be the most cost-effective treatment, whereas the other two favored medical treatment.

CONCLUSIONS

The results with regard to cost-effectiveness are inconclusive. All four economic models are based on high- and low-quality data. More reliable estimates of cost-effectiveness based on long-term trial data are needed.

Correlation between recurrent heartburn after laparoscopic fundoplication and intra-esophageal acid reflux

AIM: To determine whether patients complaining of recurrent heartburn after laparoscopic fundoplication have abnormal 24-h esophageal pH monitoring results and if there are any specific symptoms and/or factors could be linked to abnormal postoperative pH study results.

METHODS: Patients who complained of recurrent heartburn after laparoscopic fundoplication were enrolled to undergo endoscopy, manometry, and 24-h esophageal pH monitoring. Routine follow-ups were performed and symptoms were scored, recorded and statistically analyzed.

RESULTS: Approximately 82% of patients who had normal pH study results had acid exposure (pH < 4) in less than 1% of the total time. Postoperative pH study results were found be to be significantly associated with the following three factors: partial fundoplication (P = 0.039, P < 0.001, P = 0.015), onset of recurrent symptoms after surgery, and control effects of preoperative antacid therapy.

CONCLUSION: There is no objective evidence demonstrating the development of recurrent acid reflux in the majority of patients complaining of recurrent heartburn after laparoscopic fundoplication.

Gastrointestinal symptoms and patient satisfaction more than 1 year after laparoscopic Nissen fundoplication

BACKGROUND

Symptoms from poorly controlled gastroesophageal reflux disease (GERD) such as heartburn and regurgitation often resolve after laparoscopic Nissen fundoplication. Unfortunately, new gastrointestinal symptoms such as bloating may occur for some patients. Accurate data regarding the gastrointestinal symptoms experienced by patients who have had a laparoscopic fundoplication may help patients to make more informed decisions about pursuing surgery for their reflux disease.

METHODS

Patients more than 12 months after a laparoscopic Nissen fundoplication were mailed symptom surveys. Before surgery, all the patients had medically refractory esophageal symptoms (heartburn, regurgitation, or both). Surveys included the Gastrointestinal Quality of Life Index (GIQLI) and questions regarding satisfaction, reintervention, and medication use. Responses for individual GIQLI items were evaluated to determine the gastrointestinal symptoms experienced by fundoplication patients and the relationship of these symptoms to patient satisfaction.

RESULTS

Of the 76 patients eligible for inclusion in the survey, 48 returned complete surveys (63%). The mean time since surgery was 28±9 months. No patient experienced frequent regurgitation, and few (10%) reported frequent heartburn at follow-up assessment. No patient required redo fundoplication during the follow-up period. Acid reduction medications were resumed by 25% of the patients, but not all of these patients resumed medications for recurrent GERD symptoms (15% total). After surgery, frequent bloating (21%) and excessive flatus (46%) were often noted. Satisfaction with the results of surgery was high, including 83% of the patients.

CONCLUSIONS

Few patients report frequent regurgitation or heartburn after laparoscopic Nissen fundoplication. Although some patients resume acid reduction medications, many do so for reasons other than recurrent GERD symptoms. Most fundoplication patients are quite satisfied with the symptomatic results of surgery, although frequent functional gastrointestinal symptoms are common.

The laparoscopic Nissen fundoplication--a better operation?

BACKGROUND

Laparoscopic Nissen fundoplication has become the method of choice in antireflux surgery replacing its open counterpart before the long-term results of controlled clinical trials were available. METHODS AND AIM: Review of the literature to highlight the long-term results of laparoscopic Nissen fundoplication.

RESULTS

Long-term symptom relief regarding significant reflux symptoms of heartburn and regurgitation can be achieved by laparoscopic fundoplication in 84% to 97% and patients' overall satisfaction with the result of their laparoscopic fundoplication surgery is high, ranging from 86% to 96%. The long-term results of randomised trials have shown no statistically significant differences in subjective symptomatic outcome between laparoscopic and open Nissen fundoplication. Complaints regarding the scar, incisional hernias and higher incidence of defective wraps were associated with the open approach.

CONCLUSION

At long-term follow-up the laparoscopic Nissen fundoplication has a similar long-term subjective symptomatic outcome as the open procedure but laparoscopic Nissen fundoplication is associated with a significantly lower incidence of incisional hernias and defective fundic wraps at endoscopy, defining laparoscopic Nissen fundoplication as the procedure of choice in surgical management of gastro-oesophageal reflux disease.

Medical or surgical management of GERD patients with Barrett's esophagus: the LOTUS trial 3-year experience

INTRODUCTION

The long-term management of gastroesophageal reflux in patients with Barrett's esophagus (BE) is not well supported by an evidence-based consensus. We compare treatment outcome in patients with and without BE submitted to standardized laparoscopic antireflux surgery (LARS) or esomeprazole treatment.

METHODS

In the Long-Term Usage of Acid Suppression Versus Antireflux Surgery trial (a European multicenter randomized study), LARS was compared with dose-adjusted esomeprazole (20-40 mg daily). Operative difficulty, complications, symptom outcomes [Gastrointestinal Symptom Rating Scale (GSRS) and Quality of Life in Reflux and Dyspepsia (QOLRAD)], and treatment failure at 3 years and pH testing (after 6 months) are reported.

RESULTS

Of 554 patients with gastroesophageal reflux disease, 60 had BE-28 randomized to esomeprazole and 32 to LARS. Very few BE patients on either treatment strategy (four of 60) experienced treatment failure during the 3-year follow-up. Esophageal pH in BE patients was significantly better controlled after surgical treatment than after esomeprazole (p = 0.002), although mean GSRS and QOLRAD scores were similar for the two therapies at baseline and at 3 years. Although operative difficulty was slightly greater in patients with BE than those without, there was no difference in postoperative complications or level of symptomatic reflux control.

CONCLUSION

In a well-controlled surgical environment, the success of LARS is similar in patients with or without BE and matches optimized medical therapy.

Surgical management of gastroesophageal reflux disease in obesity

Bariatric surgery is ubiquitous today. In the obese patient with comorbid gastroesophageal reflux disease (GERD), it is increasingly being used as an alternative to fundoplication because it not only has an effect on GERD but also on other comorbid illnesses. Traditional GERD surgery is designed to augment the mechanical barriers against reflux, decrease acid production in the stomach, improve gastric emptying, or divert bile from the stomach. Roux-en-Y gastric bypass addresses these issues in addition to resulting in profound weight loss in patients. Banding may have a positive influence in patients' GERD, though to a lesser extent. The duodenal switch provides excellent control for patients with alkaline reflux. A revision of the 1991 National Institutes of Health guidelines for determining bariatric surgical candidates is overdue, and it may be feasible to consider expanding the body mass index and comorbidity requirements to reflect the benefits offered by these techniques for GERD patients.

Asia-Pacific consensus on the management of gastroesophageal reflux disease: update

BACKGROUND AND AIMS

Since the publication of the Asia-Pacific GERD consensus in 2004, more data concerning the epidemiology and management of gastroesophageal reflux disease (GERD) have emerged. An evidence based review and update was needed.

METHODS

A multidisciplinary group developed consensus statements using the Delphi approach. Relevant data were presented, and the quality of evidence, strength of recommendation, and level of consensus were graded.

RESULTS

GERD is increasing in frequency in Asia. Risk factors include older age, male sex, race, family history, higher socioeconomic status, increased body mass index, and smoking. Symptomatic response to a proton pump inhibitor (PPI) test is diagnostic in patients with typical symptoms if alarm symptoms are absent. A negative pH study off therapy excludes GERD if a PPI test fails. The role for narrow band imaging, capsule endoscopy, and wireless pH monitoring has not yet been undefined. Diagnostic strategies in Asia must consider coexistent gastric cancer and peptic ulcer. Weight loss and elevation of head of bed improve reflux symptoms. PPIs are the most effective medical treatment. On-demand therapy is appropriate for nonerosive reflux disease (NERD) patients. Patients with chronic cough, laryngitis, and typical GERD symptoms should be offered twice daily PPI therapy after excluding non-GERD etiologies. Fundoplication could be offered to GERD patients when an experienced surgeon is available. Endoscopic treatment of GERD should not be offered outside clinical trials.

CONCLUSIONS

Further studies are needed to clarify the role of newer diagnostic modalities and endoscopic therapy. Diagnostic strategies for GERD in Asia must consider coexistent gastric cancer and peptic ulcer. PPIs remain the cornerstone of therapy.

Systematic review: endoluminal therapy for gastro-oesophageal reflux disease: evidence from clinical trials

During the last few decades many endoscopic interventions have been developed as an alternative for the treatment of gastro-oesophageal reflux disease (GORD). In many countries, these interventions are thus being performed in the general clinical setting. The aim of this study is to systematically review the evidence on the effect of endoscopic therapies for GORD. A systematic search of the literature on this subject in English, indexed in MEDLINE (1966 to May 2007) and in the Cochrane Library, was carried out. For the study selection, retrospective and prospective open-label and randomized, sham-controlled trials were taken into account. The exclusion criteria included the following: case series that included fewer than 10 patients, abstracts, studies involving children or those with a follow-up shorter than 3 months. For data extraction, two reviewers, using standardized forms, independently abstracted data on study design and methods, population, sample size, function studies (e.g. pH-metry), type of endoscopic treatment, follow-up, health-related and quality of life scores, outcomes and complications. Data synthesis involved the following: 43 studies, including four randomized, sham-controlled trials that met the inclusion criteria, out of 4182 citations. The primary end point in most studies was the reduction of the use of proton pump inhibitors (PPIs) by more than 50%. In view of these findings, the majority of studies suggested the efficacy of endoluminal therapies for the control of symptoms in GORD. In the sham-controlled studies, the effect of placebo was, nevertheless, as high as 50%. Most studies were small feasibility studies, with follow-ups of less than 1 year. No study comparing endoscopic techniques with other established treatment options such as PPIs existed. All endoscopic therapies were associated with a small but important percentage of mild to severe complications, which included perforation, abscess and death. In conclusion, the data from most of the short-term follow-up and the few sham-controlled studies demonstrate that subgroups of patients experienced improvement or resolution of typical GORD symptoms and decreased PPI usage. Currently, however, there are not enough scientific and clinical data on safety, efficacy and durability to support the use of endoluminal therapies for GORD in routine clinical practice.

Review article: the role of surgery in gastro-oesophageal reflux disease

BACKGROUND

Rates for laparoscopic fundoplication are declining in the United States and there is no consensus on the indications for referral to surgery in gastro-oesophageal reflux disease.

AIM

To highlight recent studies on the outcomes of laparoscopic fundoplication in adults that cast doubt on the traditional indications for surgery in reflux disease.

RESULTS

Patients who are well maintained on medical therapy have more to lose with surgical intervention than to gain, and should not be offered surgery. Likewise, the notion that surgery prevents oesophageal cancer is a hypothesis that is not supported by current evidence, therefore surgical intervention should not be offered to these patients. The only clear-cut candidates for surgery include: patients with anatomic abnormalities such as a large hiatus hernia, or those with persistent regurgitation that causes troublesome symptoms despite medical therapy; and carefully selected patients with extra-oesophageal disorders who have symptoms of reflux disease such as heartburn and regurgitation, an incomplete response to medical therapy and persistent plus demonstrable reflux on pH or impedance testing that is associated with their symptoms. Patients should be aware of the high likelihood of needing continued acid inhibitory therapy following surgery and the possibility of side-effects.

CONCLUSION

Only a few carefully selected patients should undergo fundoplication for reflux disease.

Recurrent heartburn after laparoscopic fundoplication is not always recurrent reflux

INTRODUCTION

A small cohort of patients present after antireflux surgery complaining of recurrent heartburn. Many of these patients have been empirically recommenced on proton pump inhibitors.

OBJECTIVE

The aim of this study was to determine whether patients with symptoms that suggest recurrent reflux had objective evidence of reflux, and to determine predictors of recurrent reflux.

METHODS

We identified all patients from an existing database who had undergone pH monitoring for "recurrent heartburn" after fundoplication. These patients were then cross-referenced to another database, which recorded the outcomes for patients who had undergone a laparoscopic fundoplication. Patients complaining of dysphagia or other problems without heartburn were excluded from analysis.

RESULTS

Seventy-six patients were identified who met the inclusion criteria. Fifty-six (74%) of these had a normal 24-h pH study. Thirty-five patients (63%) with a normal pH study were on medication for heartburn at the time of referral. Three factors were found to be associated with an abnormal 24-h pH study: a partial fundoplication (P = 0.039), onset of symptoms 6 months or more after surgery (P < 0.001), and a good symptom response when antireflux medication was recommenced (P = 0.015).

CONCLUSIONS

Not all patients complaining of recurrent heartburn after fundoplication have evidence of abnormal reflux. Objective evidence of abnormal esophageal acid exposure should be confirmed before recommencing antireflux medication.

Antireflux surgery for non-erosive and erosive reflux disease in community practice

BACKGROUND

Antireflux surgery has been mainly evaluated in tertiary referral centres. Data regarding post-operative outcome in non-erosive reflux disease are lacking.

AIM

To assess long-term outcome after antireflux surgery performed in a community practice setting.

METHODS

We selected consecutively 60 non-erosive reflux disease patients and 61 erosive oesophagitis patients with symptomatic gastro-oesophageal reflux disease. After surgery, each subject answered a validated disease-specific health-related quality of life questionnaire and another questionnaire focusing on symptoms, late morbidity and drug use.

RESULTS

After a 43-month median follow-up, an excellent outcome was reported by less than two-thirds of patients. Quality of life scores were lower in the non-erosive reflux disease group, especially in female patients. Non-erosive reflux disease patients reported more daily symptoms and more reflux-related symptoms (P = 0.04). Proton-pump inhibitor use was higher in non-erosive reflux disease patients (P < 0.005). Multivariate analysis identified four independent predictive factors associated with better outcome, namely male gender, abnormal preoperative acid exposure, a long duration of symptoms and surgical expertise.

CONCLUSIONS

In community practice, the results of antireflux surgery are inferior to those reported by tertiary centres. Outcome seems poorer in non-erosive reflux disease especially in female patients. Nearly one-third of the non-erosive reflux disease patients continue to take proton-pump inhibitors. These results highlight the need for careful selection of patients before antireflux surgery.