The modern investigation and management of gastro-oesophageal reflux disease (GORD)

Outcome Evaluation of Laparoscopic and Open Nissen Fundoplication in Children—A Systematic Review and Meta-Analysis

Our aim was to estimate the efficacy of laparoscopic and open Nissen fundoplication (ONF) in the treatment of gastroesophageal reflux disease (GERD) in children. An electronic systematic review of the published literature was conducted in Cochrane Library, MEDLINE (PubMed), and EmBase in October 2015 in English and without time restrictions. The participants, interventions, and comparisons in the clinical question translated directly into eligibility criteria for study inclusion and exclusion. Study information extraction and methodological quality assessments were accomplished by two reviewers independently. Methodological quality was assessed by using the “Criteria for judging risk of bias in the ‘Risk of bias’ assessment tool.” Odds ratio (OR) with 95 per cent confidence interval was computed as summary statistics. Fixed-effects model was used and a pooled OR was calculated with the Mantel–Haenszel method initially. If the studies were heterogeneous, then the DerSimonian and Laird random effects model was used for meta-analysis. Outcome indices included mortality of patients, recurrence of GERD, reoperation of GERD, patients with complications, length of postoperative hospital stay, and surgery duration of laparoscopic Nissen fundoplication (LNF) and ONF. Statistical analyses were carried out by using Review Manager 5.2. The duration of follow-up varied between two days and four years. Children operated with LNF had a higher recurrence rate of GERD than those undergoing ONF. The pooled OR of LNF versus ONF was 2.98 (95% confidence interval = 1.29–6.87) while the heterogeneity was I2 = 47 per cent and P = 0.13. Statistical analysis showed that there was no significant difference for mortality, reoperation, and complication. The mean duration of surgery was significantly longer in the LNF than the ONF group while the results of length of postoperative hospital stay remained inconformity. In this meta-analysis, children operated with LNF had a higher recurrence rate of GERD than those undergoing ONF. Meanwhile, when considering the outcomes of mortality, reoperation, and complications, there was no significant difference. The mean duration of surgery was significantly longer in the LNF than the ONF group while no consistent conclusion of length of postoperative hospital stay was found.

Refractory gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a condition that develops when the reflux of stomach contents into the esophagus causes troublesome symptoms, esophageal injury, and/or complications. Use of proton pump inhibitors (PPI) remains the standard therapy for GERD and is effective in most patients. Those whose symptoms are refractory to PPIs should be evaluated further and other treatment options should be considered, according to individual patient characteristics. Response to PPIs could be total (no symptoms), partial (residual breakthrough symptoms), or absent (no change in symptoms). Patients experiencing complete response do not usually need further management. Patients with partial response can be treated surgically or by using emerging endoscopic therapies. Patients who exhibit no response to PPI need further evaluation to rule out other causes.