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

Expanding the role of pneumatic dilation for nonachalasia patients: a comparative study

BACKGROUND AND AIMS

Treatment options for nonachalasia obstructive disorders of the esophagogastric junction (EGJ) are limited. The aim of this study was to assess the treatment efficacy of pneumatic dilation (PD) for the disorders of EGJ outflow obstruction (EGJOO) and postfundoplication EGJ obstruction (PF-EGJO) and to assess attitudes regarding training in PD.

METHODS

This was a 2-part study. The main study was a prospective, single-center study comparing treatment outcomes after PD in patients with EGJOO and PF-EGJO, defined using manometry criteria, versus achalasia. Treatment success was defined as a post-PD Eckardt score (ES) of ≤2 at the longest duration of follow-up available. In a substudy, a 2-question survey was sent to 78 advanced endoscopy fellowship sites in the United States regarding training in PD.

RESULTS

Of the 58% of respondents to the advanced endoscopy program director survey, two-thirds reported no training in PD at their program. The primary rationale cited was lack of a clinical need for PD. Sixty-one patients (15 achalasia, 32 EGJOO, and 14 PF-EGJO) were included in the main study with outcomes available at a mean follow-up of 8.8 months. Overall, mean ES decreased from 6.30 to 2.89 (P < .0001), and a mean percentage of improvement in symptoms reported by patients was 55.3%. ES ≤2 was achieved by 33 of 61 patients (54.1%).

CONCLUSIONS

PD is an effective treatment for the nonachalasia obstructive disorders of the EGJ. There may be a current gap in training and technical expertise in PD.

Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics

Dysphagia is a common symptom with significant impact on quality of life. Our diagnostic armamentarium was primarily limited to endoscopy and barium esophagram until the advent of manometric techniques in the 1970s, which provided the first reliable tool for assessment of esophageal motor function. Since that time, significant advances have been made over the last 3 decades in our understanding of various esophageal motility disorders due to improvement in diagnostics with high-resolution esophageal manometry. High-resolution esophageal manometry has improved the sensitivity for detecting achalasia and has also enhanced our understanding of spastic and hypomotility disorders of the esophageal body. In this review, we discuss the current approach to diagnosis and therapeutics of various esophageal motility disorders.

Pneumatic dilation for the treatment of persistent post-laparoscopic fundoplication dysphagia: long-term efficacy and safety

BACKGROUND

Post-laparoscopic fundoplication (LF) dysphagia occurs in 5%-17% of patients and optimal management remains a topic of expert discussion. We assessed the efficacy and safety of pneumatic dilation (PD) in patients with persistent post-lLF dysphagia.

METHODS

Medical files of patients treated with PD for persistent post-fundoplication-associated dysphagia were reviewed. The primary outcome was long-term clinical success. Secondary endpoints were initial clinical success, dysphagia recurrence rate, and PD-related complication incidence.

RESULTS

Overall, 46 patients (74% women, 57.9±11.9 years) underwent 74 PD (mean: 1.6±0.8). A 30 mm, 35 mm, and 40 mm balloon was used in 45.9%, 43.2%, and 10.8%, respectively, of dilations. Among 45 patients with available follow-up, the overall long-term success rate of PD was 31/45 (68.9% [55.4-82.4]). Initial clinical success was 36/45 (80% [68.3-91.7]). Dysphagia recurred in 9 patients (25%; 95%CI 10.9-39.1) and 4 of these were effectively treated with a new dilation. Among 14 non-responders to PD, 11 underwent surgery. Four complications (2 perforations, 1 muscularis dilaceration, and 1 peri-procedural bleeding) occurred in 4 patients (incidence: 5.4% [95%CI; 0.3-10.6]) and were treated with partially covered self-expandable esophageal stents andhemostatic clips.

CONCLUSIONS

Pneumatic balloon dilation for post-fundoplication-associated symptoms is associated with a satisfactory long-term success rate and acceptable safety profile.

Analysis of Rates, Causes, and Risk Factors for 90-Day Readmission After Surgery for Large Hiatal Hernia: A Two-Center Study

Background: Hospital readmissions have become a more examined indicator of surgical care delivery and quality. There is scarcity of data in the literature on the rate, risk factors, and most common reasons of readmission following major hiatal hernia surgery. The primary endpoint was 90-day readmission after surgery for large hiatal hernia. Secondary endpoint was to examine which characteristics related with a higher risk of readmission. Methods: A retrospective review of two distinct institutional databases was performed for patients who had surgery for a large hiatal hernia between January 2012 and December 2019. Demographic, perioperative, and outpatient data were collected from the medical record. Results: A total of 71 patients met the inclusion criteria, most of them suffering from a type III hernia (66.2%). Mean operative time was 146 (±56.5) minutes and median length of stay (LOS) was 6 days (interquartile range = 3). The overall morbidity was 21.1% and the in-hospital mortality was 1.4%. The 30- and 90-day readmission rates were 7% and 8.5%, respectively. The mean time to readmission was 14.3 (±15.6) days. The reasons for 90-day hospital readmission were dysphagia (50%), pneumonia (16.7%), congestive heart failure (16.7%), and bowel obstruction (16.7%). Grade of esophagitis ≥2, presence of Barrett's esophagus, and LOS longer than 8 days were significant risk factors for unplanned readmission within 90 days. Conclusion: We observed that about 6 out of 71 patients who had surgery readmitted within 90 days (8.5%). Readmissions were most often linked to esophagitis ≥2, presence of Barrett's esophagus, and LOS longer than 8 days. These findings point to the necessity for focused treatments before, during, and after hospitalization to decrease morbidity and extra costs in this high-risk population.

Pneumatic dilation for persistent dysphagia after antireflux surgery, a multicentre single-blind randomised sham-controlled clinical trial

OBJECTIVE

There is no evidence-based treatment for persistent dysphagia after laparoscopic fundoplication. The aim of this study was to evaluate the effect of pneumatic dilation on persistent dysphagia after laparoscopic fundoplication.

DESIGN

We performed a multicentre, single-blind, randomised sham-controlled trial of patients with persistent dysphagia (>3 months) after laparoscopic fundoplication. Patients with an Eckardt symptom score ≥4 were randomly assigned to pneumatic dilation (PD) using a 35 mm balloon or sham dilation. Primary outcome was treatment success, defined as an Eckardt score <4 and a minimal reduction of 2 points in the Eckardt score after 30 days. Secondary outcomes included change in stasis on timed barium oesophagogram, change in high-resolution manometry parameters and questionnaires on quality of life, reflux and dysphagia symptoms.

RESULTS

Forty-two patients were randomised. In the intention-to-treat analysis, the success rates of PD (7/21 patients (33%)) and sham dilation (8/21 patients (38%)) were similar after 30 days (risk difference -4.7% (95% CI (-33.7% to 24.2%) p=0.747). There was no significant difference in change of stasis on the timed barium oesophagogram after 2 min (PD vs sham: median 0.0 cm, p25-p75 range 0.0-4.3 cm vs median 0.0 cm, p25-p75 range 0.0-0.0; p=0.122) or change in lower oesophageal sphincter relaxation pressure (PD vs sham: 10.54±6.25 vs 14.60±6.17 mm Hg; p=0.052). Quality of life, reflux and dysphagia symptoms were not significantly different between the two groups.

CONCLUSION

Pneumatic dilation with a 35 mm balloon is not superior to sham dilation for the treatment of persistent dysphagia after fundoplication.

Postoperative Dysphagia Following Esophagogastric Fundoplication: Does the Timing to First Dilation Matter?

BACKGROUND

Postoperative dysphagia after anti-reflux surgery typically resolves in a few weeks. However, even after the initial swelling has resolved at 6 weeks, dysphagia can persist in 30% of patients necessitating esophageal dilation. The purpose of this study was to investigate the effect of esophageal dilation on postoperative dysphagia, the recurrence of reflux symptoms, and the efficacy of pneumatic dilations on postoperative dysphagia.

METHODS

A prospectively collected database was reviewed for patients who underwent partial/complete fundoplication with/without paraesophageal hernia repair between 2006 and 2014. Patient age, sex, BMI, DeMeester score, procedure type, procedure duration, length of stay, postoperative dysphagia, time to first pneumatic dilation, number of dilations, and the need for reoperations were collected.

RESULTS

The study included 902 consecutive patients, 71.3% females, with a mean age of 57.8 ± 14.7 years. Postoperative dysphagia was noted in 26.3% of patients, of whom 89% had complete fundoplication (p < 0.01). Endoscopic dilation was performed in 93 patients (10.3%) with 59 (63.4%) demonstrating persistent dysphagia. Recurrent reflux symptoms occurred in 35 (37.6%) patients who underwent endoscopic dilation. Patients who underwent a dilation for symptoms of dysphagia were less likely to require a revisional surgery later than patients who had dysphagia but did not undergo a dilation before revisional surgery (17.2% vs 41.7%, respectively, p < 0.001) in the 4-year follow-up period. The duration of initial dilation from surgery was inversely related to the need for revisional surgery (p = 0.047), while more than one dilation was not associated with additive benefit.

CONCLUSION

One attempt at endoscopic dilation of the esophagogastric fundoplication may provide relief in patients with postoperative dysphagia and can be used as a predictive factor for the need of revision. However, there is an increased risk for recurrent reflux symptoms and revisional surgery may ultimately be indicated for control of symptoms.

Utilizing functional lumen imaging probe in directing treatment for post-fundoplication dysphagia

BACKGROUND

Esophagogastric junction obstruction (EGJO) post-fundoplication (PF) is difficult to identify with currently available tests. We aimed to assess the diagnostic accuracy of EGJ opening on functional lumen imaging probe (FLIP) and dilation outcome in FLIP-detected EGJO in PF dysphagia.

METHODS

We prospectively collected data on PF patients referred to Esophageal Clinic over 18 months. EGJO diagnosis was made by (a) endoscopist's description of a narrow EGJ/wrap area, (b) appearance of wrap obstruction or contrast/tablet retention on esophagram, or (c) EGJ-distensibility index (DI) < 2.8 mm²/mmHg on real-time FLIP. In patients with EGJO and dysphagia, EGJ dilation was performed to 20 mm, 30 mm, or 35 mm in a stepwise fashion. Outcome was assessed as % dysphagia improvement during phone call or on brief esophageal dysphagia questionnaire (BEDQ) score.

RESULTS

Twenty-six patients were included, of whom 17 (65%) had a low EGJ-DI. No patients had a hiatal hernia greater than 3 cm. Dysphagia was the primary symptom in 17/26 (65%). In 85% (κ = 0.677) of cases, EGJ assessment (tight vs. open) was congruent between the combination of endoscopy (n = 26) and esophagram (n = 21) vs. EGJ-DI (n = 26) on FLIP. Follow-up data were available in 11 patients who had dilation based on a low EGJ-DI (4 with 20 mm balloon and 7 with ≥ 30 mm balloon). Overall, the mean % improvement in dysphagia was 60% (95% CI 37.7-82.3%, p = 0.0001). Nine out of 11 patients, including 6 out of 7 undergoing pneumatic dilation, had improvement ≥ 50% in dysphagia (mean % improvement 72.2%; 95% CI 56.1-88.4%, p = 0.0001).

CONCLUSIONS AND INFERENCES

Functional lumen imaging probe is an accurate modality for evaluating for EGJ obstruction PF. FLIP may be used to select patients who may benefit from larger diameter dilation.

UK guidelines on oesophageal dilatation in clinical practice

These are updated guidelines which supersede the original version published in 2004. 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. The original guidelines have undergone extensive revision by the 16 members of the Guideline Development Group with representation from individuals across all relevant disciplines, including the Heartburn Cancer UK charity, a nursing representative and a patient representative. The methodological rigour and transparency of the guideline development processes were appraised using the revised Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.Dilatation of the oesophagus is a relatively high-risk intervention, and is required by an increasing range of disease states. Moreover, there is scarcity of evidence in the literature to guide clinicians on how to safely perform this procedure. These guidelines deal specifically with the dilatation procedure using balloon or bougie devices as a primary treatment strategy for non-malignant narrowing of the oesophagus. The use of stents is outside the remit of this paper; however, for cases of dilatation failure, alternative techniques-including stents-will be listed. The guideline is divided into the following subheadings: (1) patient preparation; (2) the dilatation procedure; (3) aftercare and (4) disease-specific considerations. A systematic literature search was performed. The Grading of Recommendations Assessment, Develop-ment and Evaluation (GRADE) tool was used to evaluate the quality of evidence and decide on the strength of recommendations made.

The effect of pneumatic dilation in management of postfundoplication dysphagia

BACKGROUND

Fundoplication surgery is a commonly performed procedure for gastro-esophageal reflux disease or hiatal hernia repair. Up to 10% of patients develop persistent postoperative dysphagia after surgery. Data on the effectiveness of pneumatic dilation for treatment are limited. The aim of this study was to evaluate clinical outcomes and identify clinical factors associated with successful response to pneumatic dilation among patients with persistent postfundoplication dysphagia (PPFD).

METHODS

We retrospectively evaluated patients who had undergone pneumatic dilation for PPFD between 1999 and 2016. Patients with dysphagia or achalasia prior to fundoplication were excluded. Demographic information, surgical history, severity of dysphagia, and clinical outcomes were collected. Data pertaining to esophagram, manometry, endoscopy, and pneumatic dilation were also collected.

RESULTS

We identified 38 patients (82% female, 95% Caucasian, and median age 59 years) with PPFD who completed pneumatic dilation. The median postfundoplication dysphagia score was 2. Eleven patients had abnormal peristalsis on manometry. Seventeen patients reported response (seven complete) with an average decrease of 1 in their dysphagia score. Fifteen patients underwent reoperation due to PPFD. Hiatal hernia repair was the only factor that predicts a higher response rate to pneumatic dilation. Only one patient in our study developed complication (pneumoperitoneum) from pneumatic dilation.

CONCLUSION & INFERENCES

We found that pneumatic dilation to be a safe treatment option for PPFD with moderate efficacy. Patients who developed PPFD after a hiatal hernia repair may gain the greatest benefit after pneumatic dilation. We were not able to identify additional clinical, radiological, endoscopic, or manometric parameters that were predictive of response.

Post-Nissen Dysphagia and Bloating Syndrome: Outcomes After Conversion to Toupet Fundoplication

INTRODUCTION

Protracted dysphagia and bloating are potential troublesome side effects following Nissen fundoplication. The aim of this study was to evaluate the effects of conversion from Nissen to Toupet on dysphagia and bloating.

METHODS

The study used a retrospective chart review of all patients who had undergone conversion from Nissen to Toupet between 2001 and 2014. Endpoints were to determine the effect of conversion on dysphagia, bloating, and reflux control.

RESULTS

Twenty-five patients underwent conversion at a median of 3.7 years (1.4-10.5) after initial fundoplication. Indications were dysphagia in 19 (76%) and bloating syndrome in 6 (24%) patients. The median operative time was 104 min (86-146). There were no serious complications or mortality. Median follow-up was 27 months (0.8-130). Dysphagia was relieved in 16 (84%) and bloating in all 6 patients. Two patients developed reflux requiring a redo-Nissen. Two patients had persistent dysphagia and required endoscopic dilation. The GERD-HRQL post-conversion showed a median score of 5 (3-13).

CONCLUSIONS

Conversion relieved dysphagia in 84% and bloating in 100%. Significant recurrence of GERD was rare. Given the absence of serious complications, conversion should be considered in patients with severe bloating or dysphagia.

Post-fundoplication symptoms and complications: Diagnostic approach and treatment

Laparoscopic Nissen fundoplication is currently considered the surgical treatment of choice for gastroesophageal reflux disease (GERD) and its long-term effectiveness is above 90%. Adequate patient selection and the experience of the surgeon are among the predictive factors of good clinical response. However, there can be new, persistent, and recurrent symptoms after the antireflux procedure in up to 30% of the cases. There are numerous causes, but in general, they are due to one or more anatomic abnormalities and esophageal and gastric function alterations. When there are persistent symptoms after the surgical procedure, the surgery should be described as "failed". In the case of a patient that initially manifests symptom control, but the symptoms then reappear, the term "dysfunction" could be used. When symptoms worsen, or when symptoms or clinical situations appear that did not exist before the surgery, this should be considered a "complication". Postoperative dysphagia and dyspeptic symptoms are very frequent and require an integrated approach to determine the best possible treatment. This review details the pathophysiologic aspects, diagnostic approach, and treatment of the symptoms and complications after fundoplication for the management of GERD.

Identification of preoperative risk factors for persistent postoperative dysphagia after laparoscopic antireflux surgery

BACKGROUND

Postoperative dysphagia is common after antireflux surgery and generally runs a self-limiting course. Nevertheless, part of these patients report long-term dysphagia. Inadequate surgical technique is a well documented cause of this result.

AIM

This retrospective study evaluated the preoperative risk factors not surgery-related for persistent dysphagia after primary laparoscopic antireflux surgery.

METHODS

Patients who underwent laparoscopic antireflux surgery by the modified technique of Nissen were evaluated in the preoperative period retrospectively. Postoperative severity of dysphagia was evaluated prospectively using a stantardized scale. Dysphagia after six weeks were defined as persistent. Statistical tests of association and logistic regression were used to identify risk factors associated with persistent dysphagia.

RESULTS

A total of 55 patients underwent primary antireflux surgery by a single surgeon team. Of these, 25 patients had preoperative dysphagia (45,45%). Persistent postoperaive dysphagia was reported by 20 (36,36%). Ten patients (18,18%) required postoperative endoscopic dilatation for dysphagia. There was statistical association between satisfaction with surgery and postoperative dysphagia and requiring the use of antireflux medication after the procedure; and between preoperative dysphagia and postoperative dysphagia. Logistic regression identified significant preopertive dysphagia as risk factor for persistent postoperative dysphagia. No correlations were found with preoperative manometry.

CONCLUSIONS

Patients with significant preoperative dysphagia were more likely to report persistent postoperative dysphagia. This study confirms that the current manometric criteria used to define esophageal dysmotility are not reliable to identify patients at risk for post-fundoplication dysphagia. Minucious review of the clinical history about the presence and intensity of preoperative dysphagia is important in the selection of candidates for antireflux surgery.

Pureed by gastrostomy tube diet improves gagging and retching in children with fundoplication

BACKGROUND

Children with feeding disorders requiring Nissen fundoplication may develop gagging and retching following gastrostomy feedings. We developed a "pureed by gastrostomy tube" (PBGT) diet in an attempt to treat these symptoms and provide adequate nutrition and hydration.

METHODS

Children post- fundoplication surgery with symptoms of gagging and retching with gastrostomy feedings were selected from our interdisciplinary feeding team. An individualized PBGT diet was designed to meet the child's nutrition goals. The child's weight gain was recorded at each follow-up visit. A telephone survey was performed to determine parents' perceptions of the child's symptoms and oral feeding tolerance.

RESULTS

Thirty-three children (mean age, 34.2 months) participated in the trial. Average weight gain on the PBGT diet was 6.2 g/d. Seventeen children (52%) were reported to have a 76%-100% reduction in gagging and retching. Twenty-four children (73%) were reported to have a ≥ 50% decrease in symptoms. No child had worsened symptoms on the PBGT diet. Nineteen children (57%) were reported to have an increase in oral intake on the PBGT diet.

CONCLUSIONS

A PBGT diet is an effective means of providing nutrition to children with feeding disorders. In children post-fundoplication surgery, a PBGT diet may decrease gagging and retching behaviors.

Postoperative problems 2011: fundoplication and obesity surgery

Although the surgical treatment of both GERD and obesity is very successful, these procedures have a significant impact on the physiology and function of the proximal GI tract. With the increasing prevalence of both GERD and obesity, more and more patients present at the motility outpatient clinic with symptoms related to surgical interventions for these medical problems. In this review, we describe the main complications following antireflux surgery: dysphagia, gas bloat syndrome, recurrent (persistent) GERD symptoms, and dyspeptic symptoms. The most common motility-related complications of obesity surgery are dumping syndrome and esophageal dysmotility.

Postoperative dysphagia is not predictive of long-term failure after laparoscopic antireflux surgery

INTRODUCTION

Dysphagia is a common postoperative symptom after laparoscopic antireflux surgery, usually attributed to postoperative edema or a "too tight" fundoplication. Although it is usually self-limited, it occasionally requires endoscopic dilation and rarely revisionary surgery. It has not been previously described whether postoperative dysphagia is associated with poorer long-term reflux control after fundoplication.

METHODS

We hypothesized that the presence of dysphagia in the early postoperative period is associated with long-term failure of the antireflux procedure and recurrence of gastroesophageal reflux disease (GERD) symptoms. A retrospective review of a prospectively maintained database of patients undergoing antireflux surgery was performed. The study population included patients, who underwent primary laparoscopic Nissen fundoplication between the years 1991 and 2010. The presence of dysphagia on their first postoperative visit (<30 days) was used to classify them in the early-dysphagia (ED) and the no-early-dysphagia (NED) groups. The recurrence of heartburn or regurgitation, as well as the pH studies on long-term follow-up (more than 6 months) were compared between the two groups. A grading system (range 0-4) was used to measure the severity of foregut symptoms.

RESULTS

1223 patients underwent primary laparoscopic Nissen fundoplications during the study period and met the inclusion criteria. Both short and long-term follow-up was available in 821 patients, who were analyzed. 423 patients were included in the ED group, whereas 398 in the NED group. The mean regurgitation score of the ED group on the long-term follow-up was 0.25 compared to 0.20 for the NED group (P = 0.21). The heartburn score was 0.38 for the ED group compared to 0.33 for the NED group (P = 0.38). Long-term dysphagia was higher in the ED group. These findings were confirmed when ED patients were subclassified based on the degree of early post-operative dysphagia. Of the 821 patients, 599 underwent routine postoperative pH testing. The mean DeMeester score in the ED group (n = 308) was 11.7 compared to 13.2 for the NED group (n = 291; P = 0.54). The percentage of patients with abnormal pH testing was similar between the two groups.

CONCLUSIONS

Early postoperative dysphagia is not associated with worse long-term GERD symptom control after primary laparoscopic antireflux surgery.

Persistent dysphagia after laparoscopic fundoplication for gastro-esophageal reflux disease

Persistent postoperative dysphagia is a potentially severe complication of fundoplication for gastroesophageal reflux disease (GERD). The aim of this retrospective study was to analyze our experience of laparoscopic fundoplication for GERD in 276 consecutive patients, to determine the frequency of postoperative dysphagia and assess treatments and outcomes. There was no relation between preoperative dysphagia, present in 24 patients (8.7%), and postoperative DeMeester grade 2 or 3 dysphagia, present in 25 patients (9.1%). Ten (3.6%) patients had clinically significant postoperative dysphagia, eight (2.9%) underwent esophageal dilation, with symptom improvement in five. Four (1.4%) of our patients (two with failed dilation) and 11 patients receiving antireflux surgery elsewhere, underwent re-operation for persistent dysphagia 12 months (median) after the first operation. DeMeester grade 0 or 1 dysphagia was obtained in 10/13 evaluable patients. Our experience is fully consistent with that of the recent literature. Redo surgery is necessary in only a small fraction of operated patients with GERD with good probability of resolving the dysphagia. Best outcomes are obtained when an anatomical cause of the dysphagia is documented preoperatively.

Management of esophageal symptoms following fundoplication

Laparoscopic antireflux surgery has emerged as a widely used and effective management option for the properly selected patient with gastroesophageal reflux disease. Poor symptomatic outcomes occur even in the best of hands, the most common being recurrent or persistent heartburn (or atypical symptoms) and dysphagia. When heartburn predominates, the initial management step is an anatomical and physiologic evaluation to determine whether acid reflux is controlled and if the postoperative neoanatomy is appropriate. If anatomical evaluation indicates surgical failure (eg, slipped or loose fundoplication, recurrent hiatal hernia), earlier re- operation may be warranted. Objective evidence of ongoing acid reflux or a reflux-symptom association despite anatomical integrity indicates reintroduction of antireflux medical therapy. Evidence favoring physiologic and anatomical success should direct treatment toward functional heartburn, including the use of tricyclic antidepressants. Dysphagia in the immediate postoperative setting mandates reassurance, as conservative measures alone often suffice while postoperative changes resolve. With persistent dysphagia, anatomical and physiologic evaluation is again indicated in the search for a mechanical-, motility-, or reflux-related symptom basis. Dilation techniques can prevent the need for re-operation, but persistent dysphagia associated with distorted postoperative anatomy will likely require surgical intervention. Regardless of the indication, re-operation carries substantial morbidity and reduced success rates compared with the initial procedure. These procedures mandate careful patient selection and referral to a center with thorough surgical experience.

Metabolic changes in the lower esophageal sphincter influencing the result of anti-reflux surgical interventions in chronic gastroesophageal reflux disease

AIM: With the availability of a minimally invasive approach, anti-reflux surgery has recently experienced a renaissance as a cost-effective alternative to life-long medical treatment in patients with gastroesophageal reflux disease (GERD). We are not aware of the fact whether reflux episodes causing complaints for a long time i.e., at least for one year are associated with metabolic changes in the lower esophageal sphincter, and if so, whether these may influence functional results achieved after anti-reflux surgery.

METHODS: Between 1 January 2001 and 31 December 2002 we performed anti-reflux surgery on 79 patients. Muscle samples were taken from the lower esophageal sphincter (LES) in 33 patients during anti-reflux surgery. Inclusion criteria were: LES resting pressure below 10 mmHg and a marked, pH proven acid exposure to the esophagus of at least one year’ duration, causing subjective complaints and requiring continuous proton pump inhibitor treatment. Control samples were obtained from muscle tissue in the gastroesophageal junction that had been removed from 17 patients undergoing gastric or esophageal resection. Metabolic and lysosomal enzyme activities and special protein concentrations 16 parameters in total were evaluated in tissue taken from control specimens and tissue taken from patients with GERD. The biochemical parameters of these intra-operative biopsies were used to correlate the results of anti-reflux operations (Visick I and II-III).

RESULTS: In the reflux-type muscle, we found a significant increase of the energy-enzyme activities e.g., creatine kinase, lactate dehydrogenase, β-hydroxybutyrate dehydrogenase, and aspartate aminotransaminase-. The concentration of the structural protein S-100 and the myofibrillar protein troponin I were also significantly increased. Among lysosomal enzymes, we found that the activities of cathepsin B, tripeptidyl-peptidase I, dipeptidyl-peptidase II, β-hexosaminidase B, β-mannosidase and β-galactosidase were significantly decreased as compared to the control LES muscles. By analyzing the activity values of the 9 patients in Visick groups II and III at two months post-surgery, we found a significant increase in the activity of the so-called energy-enzyme values and in the concentration of structural and myofibrillar proteins as compared to the rest of the reflux patients.

CONCLUSION: Our results call attention to the metabolic changes that occurred in the LES muscles of reflux patients. The developing hypertrophy-like changes of LES muscles may be a reason for complaints after anti-reflux surgery, which consisted mainly of reports of persisting dysphagia.

The management of patients who have "failed" antireflux surgery

Gastroenterologists may be called upon to manage patients who have had antireflux surgery that failed. The available literature on this topic comprises predominantly reports on retrospective, observational studies written by surgeons who often have focused on how technical deficiencies in performing the operation led to the failure. Such reports are of limited value to the gastroenterologist seeking guidance on patient management. Furthermore, comparisons among the reports are confounded by the lack of a standardized definition for failed antireflux surgery. This report critically reviews the available literature, and suggests a practical approach to the management of patients who have symptoms that were not completely relieved, that reappeared later, or that were caused by antireflux surgery.

Esophageal motor disorders

Motor dysfunction is an important cause of oropharyngeal dysphagia and distal esophageal symptoms. Minimally invasive surgical methods of managing Zenker diverticula and achalasia, important disorders associated with these presentations, continue to take center stage in the literature. Detection and characterization of hypomotility before antireflux surgery may be less important than systematically excluding achalasia, as the vague and variable presentations of this motor disorder become appreciated. The many processes that can mimic idiopathic achalasia continue to be exposed.