Impact of laparoscopic fundoplication for the treatment of laryngopharyngeal reflux: review of the literature. Int J Otolaryngol. 2012;2012:291472. [PMID: 22220174 PMCID: PMC3246726 DOI: 10.1155/2012/291472]

The Role of High-Resolution Manometry Before and Following Antireflux Surgery: The Padova Consensus

BACKGROUND

In the last 2 decades the development of high-resolution manometry (HRM) has changed and revolutionized the diagnostic assessment of patients complain foregut symptoms. The role of HRM before and after antireflux procedure remains unclear, especially in surgical practice, where a clear understanding of esophageal physiology and hiatus anatomy is essential for optimal outcome of antireflux surgery (ARS). Surgeons and gastroenterologists (GIs) agree that assessing patients following antireflux procedures can be challenging. Although endoscopy and barium-swallow can reveal anatomic abnormalities, physiological information on HRM allowing insight into the cause of eventually recurrent symptoms could be key to clinical decision-making.

METHODS

A multidisciplinary international working group (14 surgeons and 15 GIs) collaborated to develop consensus on the role of HRM pre-ARS and post-ARS, and to develop a postoperative classification to interpret HRM findings. The method utilized was detailed literature review to develop statements, and the RAND/University of California, Los Angeles Appropriateness Methodology (RAM) to assess agreement with the statements. Only statements with an approval rate >80% or a final ranking with a median score of 7 were accepted in the consensus. The working groups evaluated the role of HRM before ARS and the role of HRM following ARS.

CONCLUSIONS

This international initiative developed by surgeons and GIs together, summarizes the state of our knowledge of the use of HRM pre-ARS and post-ARS. The Padova Classification was developed to facilitate the interpretation of HRM studies of patients underwent ARS.

Overall satisfaction following laparoscopic fundoplication for patients with atypical extraesophageal symptoms: A comparative cohort study

BACKGROUND

Some patients with gastroesophageal reflux (GERD) experience extraesophageal symptoms, which are considered due to laryngopharyngeal reflux (LPR). Most studies evaluating fundoplication for LPR report outcomes from individuals who also have typical esophageal GERD symptoms. Information is limited for patients with LPR but no GERD symptoms. To determine whether LPR patients benefit from fundoplication outcomes were determined for individuals with LPR ± GERD and also those without LPR.

METHODS

Patients undergoing fundoplication from 1997 to 2015 were identified and divided into three symptom groups: LPR only, LPR and GERD, and GERD only. Heartburn, dysphagia, and satisfaction were assessed using 0-10 analog scores and compared at short (1-2 years) and later (5 years) follow-up.

RESULTS

2204 patients underwent fundoplication. 24 patients had LPR only, 130 patients had LPR and GERD, and matched to 1319 patients with GERD only. At 1-2 years follow-up, the LPR only group had lower satisfaction scores than those with GERD symptoms (± concurrent LPR) (7.00 ± 3.49 vs. 8.41 ± 2.42, p = 0.019, and mean ± s.d.). At 1-2 years, 68.1% of the LPR only group had a good outcome (satisfaction score: 7-10) versus 84.6% with LPR and GERD and 84.1% with GERD only.

CONCLUSION

At 1-2 years follow-up, patients with LPR only were less satisfied following fundoplication compared with patients with typical GERD (±LPR). However, some patients with LPR only did benefit and might be considered for surgery if appropriately counseled. Outcomes were similar for patients with LPR and typical GERD and those with only typical symptoms.

Response of Laryngopharyngeal Symptoms to Transoral Incisionless Fundoplication in Patients with Refractory Proven Gastroesophageal Reflux

OBJECTIVE

Patients with laryngopharyngeal reflux (LPR) symptoms may not respond to proton pump inhibitors (PPI) if they have an alternative laryngeal diagnosis or high-volume reflux. Transoral incisionless fundoplication (TIF) or TIF with concomitant hiatal hernia repair (cTIF) are effective in decreasing symptoms of gastroesophageal reflux disease (GERD) but are not well studied in patients with LPR symptoms. This prospective multicenter study assessed the patient-reported and clinical outcomes after TIF/cTIF in patients with LPR symptoms and proven GERD.

METHODS

Patients with refractory LPR symptoms (reflux symptom index [RSI] > 13) and with erosive esophagitis, Barrett's esophagus, and/or pathologic acid reflux by distal esophageal pH testing were evaluated before and after a minimum of 6 months after TIF/cTIF. The primary outcome was normalization of RSI. Secondary outcomes were >50% improvement in GERD-Health-Related Quality of Life (GERD-HRQL), normalization of esophageal acid exposure time, discontinuation of PPI, and patient satisfaction.

RESULTS

Forty-nine patients had TIF (n = 26) or cTIF (n = 23) with at least 6 months follow-up. Mean pre- and post TIF/cTIF RSI were 23.6 and 5.9 (mean difference: 17.7, P < .001). Post TIF/cTIF, 90% of patients had improved GERD-HQRL score, 85% normalized RSI, 75% normalized esophageal acid exposure time, and 80% discontinued PPI. No serious procedure-related adverse events occurred. Patient satisfaction was 4% prior to TIF/cTIF and 73% after TIF/cTIF (P < .001).

CONCLUSION

In patients with objective evidence of GERD, TIF, or cTIF are safe and effective in controlling LPR symptoms as measured by normalization of RSI and improvement in patient satisfaction after TIF/cTIF.

LEVEL OF EVIDENCE

Level 4.

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.

A Comparison of Alkaline Water and Mediterranean Diet vs Proton Pump Inhibition for Treatment of Laryngopharyngeal Reflux

Importance

Laryngopharyngeal reflux (LPR) is a common disorder with protean manifestations in the head and neck. In this retrospective study, we report the efficacy of a wholly dietary approach using alkaline water, a plant-based, Mediterranean-style diet, and standard reflux precautions compared with that of the traditional treatment approach of proton pump inhibition (PPI) and standard reflux precautions.

Objective

To determine whether treatment with a diet-based approach with standard reflux precautions alone can improve symptoms of LPR compared with treatment with PPI and standard reflux precautions.

Design, Setting, and Participants

This was a retrospective medical chart review of 2 treatment cohorts. From 2010 to 2012, 85 patients with LPR that were treated with PPI and standard reflux precautions (PS) were identified. From 2013 to 2015, 99 patients treated with alkaline water (pH >8.0), 90% plant-based, Mediterranean-style diet, and standard reflux precautions (AMS) were identified. The outcome was based on change in Reflux Symptom Index (RSI).

Main Outcomes and Measures

Recorded change in the RSI after 6 weeks of treatment.

Results

Of the 184 patients identified in the PS and AMS cohorts, the median age of participants in each cohort was 60 years (95% CI, 18-82) and 57 years (95% CI, 18-93), respectively (47 [56.3%] and 61 [61.7%] were women, respectively). The percentage of patients achieving a clinically meaningful (≥6 points) reduction in RSI was 54.1% in PS-treated patients and 62.6% in AMS-treated patients (difference between the groups, 8.05; 95% CI, -5.74 to 22.76). The mean reduction in RSI was 27.2% for the PS group and 39.8% in the AMS group (difference, 12.10; 95% CI, 1.53 to 22.68).

Conclusions and Relevance

Our data suggest that the effect of PPI on the RSI based on proportion reaching a 6-point reduction in RSI is not significantly better than that of alkaline water, a plant-based, Mediterranean-style diet, and standard reflux precautions, although the difference in the 2 treatments could be clinically meaningful in favor of the dietary approach. The percent reduction in RSI was significantly greater with the dietary approach. Because the relationship between percent change and response to treatment has not been studied, the clinical significance of this difference requires further study. Nevertheless, this study suggests that a plant-based diet and alkaline water should be considered in the treatment of LPR. This approach may effectively improve symptoms and could avoid the costs and adverse effects of pharmacological intervention as well as afford the additional health benefits associated with a healthy, plant-based diet.

Nissen fundoplication vs proton pump inhibitors for laryngopharyngeal reflux based on pH-monitoring and symptom-scale

AIM

To compare the outcomes between laparoscopic Nissen fundoplication (LNF) and proton pump inhibitors (PPIs) therapy in patients with laryngopharyngeal reflux (LPR) and type I hiatal hernia diagnosed by oropharyngeal pH-monitoring and symptom-scale assessment.

METHODS

From February 2014 to January 2015, 70 patients who were diagnosed with LPR and type I hiatal hernia and referred for symptomatic assessment, oropharyngeal pH-monitoring, manometry, and gastrointestinal endoscopy were enrolled in this study. All of the patients met the inclusion criteria. All of the patients underwent LNF or PPIs administration, and completed a 2-year follow-up. Patients’ baseline characteristics and primary outcome measures, including comprehensive and single symptoms of LPR, PPIs independence, and satisfaction, and postoperative complications were assessed. The outcomes of LNF and PPIs therapy were analyzed and compared.

RESULTS

There were 31 patients in the LNF group and 39 patients in the PPI group. Fifty-three patients (25 in the LNF group and 28 in the PPI group) completed reviews and follow-up. Oropharyngeal pH-monitoring parameters were all abnormal with high acid exposure, a large amount of reflux, and a high Ryan score, associated reflux symptom index (RSI) score. There was a significant improvement in the RSI and LPR symptom scores after the 2-year follow-up in both groups (P < 0.05), as well as typical symptoms of gastroesophageal reflux disease. Improvement in the RSI (P < 0.005) and symptom scores of cough (P = 0.032), mucus (P = 0.011), and throat clearing (P = 0.022) was significantly superior in the LNF group to that in the PPI group. After LNF and PPIs therapy, 13 and 53 patients achieved independence from PPIs therapy (LNF: 44.0% vs PPI: 7.14%, P < 0.001) during follow-up, respectively. Patients in the LNF group were more satisfied with their quality of life than those in the PPI group (LNF: 62.49 ± 28.68 vs PPI: 44.36 ± 32.77, P = 0.004). Body mass index was significantly lower in the LNF group than in the PPI group (LNF: 22.2 ± 3.1 kg/m²vs PPI: 25.1 ± 2.9 kg/m², P = 0.001).

CONCLUSION

Diagnosis of LPR should be assessed with oropharyngeal pH-monitoring, manometry, and the symptom-scale. LNF achieves better improvement than PPIs for LPR with type I hiatal hernia.

Nissen Fundoplication for Laryngopharyngeal Reflux After Patient Selection Using Dual pH, Full Column Impedance Testing

Objectives:

Prior studies demonstrate inconsistent diagnostic strategies for laryngopharyngeal reflux disease (LPR) patients who are offered laparoscopic Nissen fundoplication (Nissen). Superior symptom resolution outcomes are demonstrated in patients with accompanying typical gastroesophageal reflux (GERD) symptoms. This study aims to evaluate the efficacy of selecting patients with LPR complaints for Nissen using full column, dual pH impedance catheters (multichannel intraluminal impedance catheters [MII]).

Methods:

All patients who underwent Nissen for management of LPR symptoms refractory to at least 3 months of twice daily (BID) proton pump inhibitor (PPI) therapy with reflux symptom index (RSI) of 13 or higher and who had demonstrable reflux on MII were included. Pre- and (minimum) 16 week post-Nissen RSI scores as well as LPR-specific complaints were collected.

Results:

Eleven patients met criteria. Nine subjects (5 female, 4 male) had complete data. All 9 (100%) achieved improvement in RSI. The average pre-Nissen RSI was 31.7, and average post-Nissen RSI was 10 ( P < .001). Six (67%) subjects dropped below an RSI of 13. Seven subjects (78%) had resolution of their primary LPR symptom, and 6 (67%) subjects had resolution of all LPR symptoms.

Conclusions:

Patients with LPR who are selected using dual pH and full column impedance are likely to demonstrate improvement in RSI following Nissen.

Supraesophageal Reflux: Correlation of Position and Occurrence of Acid Reflux-Effect of Head-of-Bed Elevation on Supine Reflux

BACKGROUND

Supraesophageal reflux of gastric contents can contribute to perennial nasopharyngitis, cough, and asthma. However, effective treatment strategies for supraesophageal reflux disease (SERD) remain inadequately defined.

OBJECTIVE

The purpose of this study is to assess the prevalence and timing of SERD and to investigate the efficacy of head-of-bed elevation in its treatment.

METHODS

A retrospective chart review of patients seen at Scripps Clinic Division of Allergy, Asthma and Immunology was performed who had undergone overnight nasopharyngeal pH monitoring with a commercially available nasopharyngeal pH-monitoring device, Dx-pH Measurement System from Restech, San Diego, Calif. Subjects with reflux were classified based on the position of reflux as either supine only, upright only, or both supine and upright. In a subset of subjects with supine-only reflux, pH monitoring was compared before and after elevating the head of bed 6 inches.

RESULTS

Adequate nasopharyngeal pH-monitoring data were obtained for 235 patients. Reflux was detected in 113 (48%) patients. The pattern of reflux observed was 62 (55%) supine only, 4 (4%) upright only, and 47 (42%) upright and supine. Sequential overnight nasopharyngeal pH monitoring before and after head-of-bed elevation was obtained in 13 individuals with supine-only reflux. Ten subjects demonstrated significant improvement, 8 of whom demonstrated complete resolution of supine reflux with 6 inches of head-of-bed elevation.

CONCLUSION

This study provides new evidence that SERD frequently occurs in the supine position and that 6 inches of head-of-bed elevation is effective in reducing supine SERD.