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Spechler SJ. Evaluation and Treatment of Patients with Persistent Reflux Symptoms Despite Proton Pump Inhibitor Treatment. Gastroenterol Clin North Am 2020; 49:437-450. [PMID: 32718563 DOI: 10.1016/j.gtc.2020.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite the exceptional efficacy of proton pump inhibitors (PPIs) in healing reflux esophagitis complicating gastroesophageal reflux disease (GERD), up to 40% of patients who take PPIs for GERD complain of persistent GERD symptoms. There is no clear consensus on the type, dosing, and duration of PPI therapy required to establish a diagnosis of PPI-refractory GERD symptoms, but most authorities do not consider patients "PPI-refractory" unless they have been on double-dose PPIs. This article discusses the mechanisms that might underlie heartburn that does not respond PPIs and an approach to the management of patients with PPI-refractory GERD symptoms.
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Affiliation(s)
- Stuart Jon Spechler
- Division of Gastroenterology, Center for Esophageal Diseases, Baylor University Medical Center, Center for Esophageal Research, Baylor Scott & White Research Institute, 3500 Gaston Avenue, 2 Hoblitzelle, Suite 250, Dallas, TX 75246, USA.
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52
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Oppenheimer EE, Schmit B, Sarosi GA, Thomas RM. Proton Pump Inhibitor Use After Hiatal Hernia Repair: Inhibitor of Recurrent Symptoms and Potential Revisional Surgery. J Surg Res 2020; 256:570-576. [PMID: 32805579 DOI: 10.1016/j.jss.2020.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/22/2020] [Accepted: 07/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Hiatal hernia recurrence after hiatal hernia repair (HHR) is often underdiagnosed and underreported but may present with recurrent gastroesophageal reflux disease (GERD) symptoms. Because of their availability, proton pump inhibitor (PPI) use is common and may mask patients who would benefit from revisional surgery, which has been shown to improve symptoms and quality of life. METHODS A retrospective analysis was performed to evaluate recurrence patterns of patients who underwent HHR, specifically for the indication of GERD, from 2007 to 2015 at a single Veterans Administration Medical Center. Clinicopathologic parameters were reviewed for association with hiatal hernia recurrence, including postoperative PPI use. RESULTS Sixty-four patients were identified with a median follow-up time of 57.8 mo. Thirty-eight patients developed an anatomic recurrence, which did not demonstrate any associated factors on univariate analysis. Seventy percent of patients remained or were restarted on PPI after their initial surgery. For patients with a documented recurrence, the median time to start a PPI was 224 d, but the time to identify recurrence on imaging or endoscopy was 712.5 d. Eleven (39.3%) patients had a reintervention for anatomic recurrence, of which all had developed recurrent symptoms of GERD. CONCLUSIONS Most patients who developed recurrent hiatal hernia were restarted on PPI without workup for their symptoms. The time of initiation of PPI was much earlier than the time of identification of a recurrent hiatal hernia. The use of PPIs in patients whom have undergone HHR may delay proper workup to identify recurrent hiatal hernia amenable to surgical repair and should be reserved until patients develop recurrent symptoms and have at least begun a diagnostic workup to rule out an anatomic cause for the recurrent symptoms.
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Affiliation(s)
- Eittel E Oppenheimer
- Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - Bradley Schmit
- Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - George A Sarosi
- Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, Florida; Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Ryan M Thomas
- Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, Florida; Department of Surgery, University of Florida College of Medicine, Gainesville, Florida.
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53
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Ferrari D, Asti E, Lazzari V, Siboni S, Bernardi D, Bonavina L. Six to 12-year outcomes of magnetic sphincter augmentation for gastroesophageal reflux disease. Sci Rep 2020; 10:13753. [PMID: 32792508 PMCID: PMC7426413 DOI: 10.1038/s41598-020-70742-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/27/2020] [Indexed: 12/23/2022] Open
Abstract
The magnetic sphincter augmentation (MSA) device has been proven safe and effective in controlling typical reflux symptoms and esophageal acid exposure for up to 6-year follow-up. Longer term outcomes have not been reported yet. A prospectively maintained database was reviewed to assess long-term safety and efficacy of the laparoscopic MSA procedure at a single referral center. Gastro-Esophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), use of proton-pump inhibitors (PPI), and esophageal acid exposure were compared to baseline. Favorable outcomes were defined as ≥ 50% improvement of GERD-HRQL total score and PPI discontinuation. Between March 2007 and March 2020, 335 patients met the study inclusion criteria, and 124 of them were followed from 6 to 12 years after surgery (median 9 years, IQR 2). Mean total GERD-HRQL score significantly improved from 19.9 to 4.01 (p < 0.001), and PPI were discontinued by 79% of patients. The mean total percent time with pH < 4 decreased from 9.6% at baseline to 4.1% (p < 0.001), with 89% of patients achieving pH normalization. Independent predictors of a favorable outcome were age at intervention < 40 years (OR 4.17) and GERD-HRQL score > 15 (OR 4.09). We confirm long-term safety and efficacy of MSA in terms of symptom improvement, decreased drug dependency, and reduced esophageal acid exposure.
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Affiliation(s)
- Davide Ferrari
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Emanuele Asti
- Division of General and Foregut Surgery, IRCCS Policlinico San Donato, Piazza E. Malan, 1, 20097, San Donato Milanese, MI, Italy
| | - Veronica Lazzari
- Division of General and Foregut Surgery, IRCCS Policlinico San Donato, Piazza E. Malan, 1, 20097, San Donato Milanese, MI, Italy
| | - Stefano Siboni
- Division of General and Foregut Surgery, IRCCS Policlinico San Donato, Piazza E. Malan, 1, 20097, San Donato Milanese, MI, Italy
| | - Daniele Bernardi
- Division of General and Foregut Surgery, IRCCS Policlinico San Donato, Piazza E. Malan, 1, 20097, San Donato Milanese, MI, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy. .,Division of General and Foregut Surgery, IRCCS Policlinico San Donato, Piazza E. Malan, 1, 20097, San Donato Milanese, MI, Italy.
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54
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Stefanova DI, Limberg JN, Ullmann TM, Liu M, Thiesmeyer JW, Beninato T, Finnerty BM, Schnoll-Sussman FH, Katz PO, Fahey TJ, Zarnegar R. Quantifying Factors Essential to the Integrity of the Esophagogastric Junction During Antireflux Procedures. Ann Surg 2020; 272:488-494. [DOI: 10.1097/sla.0000000000004202] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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55
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Park S, Kwon JW, Park JM, Park S, Hwang J, Seo KW. The characteristics of antireflux surgery compared to proton pump inhibitor treatment in Korea: a nationwide study using claim data from 2007 to 2016. Ann Surg Treat Res 2020; 98:254-261. [PMID: 32411630 PMCID: PMC7200601 DOI: 10.4174/astr.2020.98.5.254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/20/2020] [Accepted: 02/21/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose Laparoscopic antireflux surgery is not widely used in Korea, but published data suggest that its results are comparable to those of Western countries. The purpose of this study was to compare the clinical characteristics, medical utilization, and medical costs of antireflux surgery and proton pump inhibitor (PPI) treatments. Methods We used Korean patients who underwent fundoplication (n = 342, surgery group) and a 25% random sample of all patients diagnosed with gastroesophageal reflux disease (GERD) who were prescribed PPIs for more than 12 weeks (n = 130,987, medication group) between 2007 to 2016. We compared medical costs and utilization between the 2 groups. Results The average cost of fundoplication was $4,631. The costs of GERD treatment in the first year after surgery and during the follow-up period were $78.1 and $50.1 per month, respectively. In the surgery group, the average monthly medical expenses decreased as the year progressed, but the average monthly medical expenses ($137.5 per month) did not decrease in the medication group. After stratifying by age group, the medical costs of the surgery group were lower than those of the medication group for all ages except for patients between the ages of 70 and 79. The cost difference between the 2 groups was prominent between the ages of 20 and 49. Conclusion This study showed that a significant decrease in cost was observed 1 year after surgery, and it was more apparent in younger patients. Further research is needed to determine the appropriateness of antireflux surgery for each group of patients.
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Affiliation(s)
- Susan Park
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, Korea
| | - Jin-Won Kwon
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, Korea
| | - Joong-Min Park
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sungsoo Park
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Jinseub Hwang
- Division of Mathematics and Big Data Science, Daegu University, Daegu, Korea
| | - Kyung Won Seo
- Department of Surgery, Kosin University College of Medicine, Busan, Korea
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56
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Ayazi S, Zheng P, Zaidi AH, Chovanec K, Salvitti M, Newhams K, Hoppo T, Jobe BA. Clinical Outcomes and Predictors of Favorable Result after Laparoscopic Magnetic Sphincter Augmentation: Single-Institution Experience with More than 500 Patients. J Am Coll Surg 2020; 230:733-743. [DOI: 10.1016/j.jamcollsurg.2020.01.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 01/26/2020] [Accepted: 01/29/2020] [Indexed: 12/20/2022]
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57
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Hoyuela C. Should redo surgery for gastroesophageal reflux disease be performed in high-volume centers?An invited commentary on "Laparoscopic repeat surgery for gastro-oesophageal reflux disease: Results of the analyses of a cohort study of 117 patients from a multicenter experience" (Int J Surg 2020;76:121-127). Int J Surg 2020; 78:62-63. [PMID: 32304900 DOI: 10.1016/j.ijsu.2020.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/01/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Carlos Hoyuela
- Department of General and Digestive Surgery, Hospital Platón, Universitat Internacional de Catalunya, Platón 21, 08006, Barcelona, Spain.
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58
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Bonavina L, Fisichella PM, Gavini S, Lee YY, Tatum RP. Clinical course of gastroesophageal reflux disease and impact of treatment in symptomatic young patients. Ann N Y Acad Sci 2020; 1481:117-126. [PMID: 32266986 DOI: 10.1111/nyas.14350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 12/14/2022]
Abstract
In symptomatic young patients with gastroesophageal reflux symptoms, early identification of progressive gastroesophageal reflux disease (GERD) is critical to prevent long-term complications associated with hiatal hernia, increased esophageal acid and nonacid exposure, release of proinflammatory cytokines, and development of intestinal metaplasia, endoscopically visible Barrett's esophagus, and dysplasia leading to esophageal adenocarcinoma. Progression of GERD may occur in asymptomatic patients and in those under continuous acid-suppressive medication. The long-term side effects of proton-pump inhibitors, chemopreventive agents, and radiofrequency ablation are contentious. In patients with early-stage disease, when the lower esophageal sphincter function is still preserved and before endoscopically visible Barrett's esophagus develops, novel laparoscopic procedures, such as magnetic and electric sphincter augmentation, may have a greater role than conventional surgical therapy. A multidisciplinary approach to GERD by a dedicated team of gastroenterologists and surgeons might impact the patients' lifestyle, the therapeutic choices, and the course of the disease. Biological markers are needed to precisely assess the risk of disease progression and to tailor surveillance, ablation, and management.
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Affiliation(s)
- Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milano, Italy
| | - P Marco Fisichella
- Department of Surgery, Northwestern University, Feinberge School of Medicine, Chicago, Illinois
| | - Sravanya Gavini
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia.,Gut Research Group, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.,St George & Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Roger P Tatum
- Department of Surgery, University of Washington School of Medicine and VA Puget Sound Health Care System, Seattle, Washington
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59
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Markar SR, Arhi C, Wiggins T, Vidal-Diez A, Karthikesalingam A, Darzi A, Lagergren J, Hanna GB. Reintervention After Antireflux Surgery for Gastroesophageal Reflux Disease in England. Ann Surg 2020; 271:709-715. [DOI: 10.1097/sla.0000000000003131] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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60
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Laparoscopic repeat surgery for gastro-oesophageal reflux disease: Results of the analyses of a cohort study of 117 patients from a multicenter experience. Int J Surg 2020; 76:121-127. [DOI: 10.1016/j.ijsu.2020.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/20/2020] [Accepted: 03/03/2020] [Indexed: 01/21/2023]
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61
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Spechler SJ. Refractory Gastroesophageal Reflux Disease and Functional Heartburn. Gastrointest Endosc Clin N Am 2020; 30:343-359. [PMID: 32146950 DOI: 10.1016/j.giec.2019.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This report discusses the potential mechanisms that might underlie refractory GERD and functional heartburn, and how to distinguish among those mechanisms using a systematic evaluation that includes careful medical history, endoscopy with esophageal biopsy, esophageal manometry, and esophageal multichannel intraluminal impedance-pH monitoring. The report provides an approach to patient management that depends on the underlying mechanism identified by this systematic evaluation.
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Affiliation(s)
- Stuart Jon Spechler
- Division of Gastroenterology, Center for Esophageal Diseases, Baylor University Medical Center at Dallas, The Center for Esophageal Research, Baylor Scott & White Research Institute, 3500 Gaston Avenue, 2 Hoblitzelle, Suite 250, Dallas, TX 75246, USA.
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62
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Håkanson BS, Lundell L, Bylund A, Thorell A. Comparison of Laparoscopic 270° Posterior Partial Fundoplication vs Total Fundoplication for the Treatment of Gastroesophageal Reflux Disease: A Randomized Clinical Trial. JAMA Surg 2020; 154:479-486. [PMID: 30840057 DOI: 10.1001/jamasurg.2019.0047] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Importance Restoration of the esophagogastric junction competence is critical for effective long-term treatment of gastroesophageal reflux disease. Surgical repair results in such restoration, but mechanical adverse effects seem unavoidable. Minimizing these adverse effects without jeopardizing reflux control is warranted. Objective To determine whether partial fundoplication (PF) or total fundoplication (TF) is superior in laparoscopic antireflux surgery. Design, Setting, and Participants In this double-blind, randomized clinical trial of 1171 patients scheduled for laparoscopic antireflux surgery at a single university-affiliated center between November 19, 2001, and January 24, 2006, 456 patients were randomized and followed up for 5 years. Data were collected from November 2001 to April 2012, and data were analyzed from April 2012 to September 2018. Interventions A 270° posterior PF or a 360° Nissen TF. Main Outcomes and Measures Esophageal acid exposure at 3 years after surgery. Result Of the 456 randomized patients, 268 (58.8%) were male, and the mean (SD) age was 49.0 (11.7) years. A total of 229 patients were randomized to PF, and 227 patients were randomized to TF. At 3 years postoperatively, the median (interquartile range) esophageal acid exposure was reduced from 14.6% (9.8-21.9) to 1.8% (0.7-4.4) after PF and from 16.0% (10.4-22.7) to 2.5% (0.8-6.8) after TF (P = .31). Likewise, reflux symptoms were equally and effectively controlled. Early postoperative dysphagia (6 weeks) was common in both groups but then decreased toward normality. A small but statistically significant difference in favor of PF was noted in the mean (SD) scoring of dysphagia for liquids at 6 weeks (PF, 1.6 [0.9]; TF, 1.9 [1.3]; P = .01) and for solid food at 12 months (PF, 1.3 [1.0]; TF, 1.9 [1.4]; P < .001) and 24 months (PF, 1.3 [0.9]; TF, 1.7 [1.2]; P = .001). Quality of life was reduced before surgery but increased to normal values after surgery and remained so over 5-year follow-up, with no difference between the groups. Conclusions and Relevance The results from this randomized clinical trial suggest that although PF and TF could be recommended for treatment of gastroesophageal reflux disease, PF might be superior by inducing less dysphagia. Trial Registration ClinicalTrials.gov identifier: NCT03659487.
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Affiliation(s)
- Bengt S Håkanson
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - Lars Lundell
- Department of Clinical Sciences, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Ami Bylund
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - Anders Thorell
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Ersta Hospital, Stockholm, Sweden
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63
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Hospital Volume of Antireflux Surgery in Relation to Endoscopic and Surgical Re-interventions. Ann Surg 2020; 274:e1138-e1143. [DOI: 10.1097/sla.0000000000003776] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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64
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Esophageal Adenocarcinoma After Antireflux Surgery in a Cohort Study From the 5 Nordic Countries. Ann Surg 2019; 274:e535-e540. [DOI: 10.1097/sla.0000000000003709] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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65
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Guidozzi N, Wiggins T, Ahmed AR, Hanna GB, Markar SR. Laparoscopic magnetic sphincter augmentation versus fundoplication for gastroesophageal reflux disease: systematic review and pooled analysis. Dis Esophagus 2019; 32:5487251. [PMID: 31069388 DOI: 10.1093/dote/doz031] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 02/27/2019] [Indexed: 02/07/2023]
Abstract
Magnetic sphincter augmentation (MSA) has been proposed as a less invasive, more appealing alternative intervention to fundoplication for the treatment of gastroesophageal reflux disease (GERD). The aim of this study was to evaluate clinical outcomes following MSA for GERD control in comparison with laparoscopic fundoplication. A systematic electronic search for articles was performed in Medline, Embase, Web of Science, and Cochrane Library for single-arm cohort studies or comparative studies (with fundoplication) evaluating the use of MSA. A random-effects meta-analysis for postoperative proton pump inhibitor (PPI) use, GERD-health-related quality of life (GERD-HRQOL), gas bloating, ability to belch, dysphagia, and reoperation was performed. The systematic review identified 6 comparative studies of MSA versus fundoplication and 13 single-cohort studies. Following MSA, only 13.2% required postoperative PPI therapy, 7.8% dilatation, 3.3% device removal or reoperation, and esophageal erosion was seen in 0.3%. There was no significant difference between the groups in requirement for postoperative PPI therapy (pooled odds ratio, POR = 1.08; 95%CI 0.40-2.95), GERD-HRQOL score (weighted mean difference, WMD = 0.34; 95%CI -0.70-1.37), dysphagia (POR = 0.94; 95%CI 0.57-1.55), and reoperation (POR = 1.23; 95%CI 0.26-5.8). However, when compared to fundoplication MSA was associated with significantly less gas bloating (POR = 0.34; 95%CI 0.16-0.71) and a greater ability to belch (POR = 12.34; 95%CI 6.43-23.7). In conclusion, magnetic sphincter augmentation achieves good GERD symptomatic control similar to that of fundoplication, with the benefit of less gas bloating. The safety of MSA also appears acceptable with only 3.3% of patients requiring device removal. There is an urgent need for randomized data directly comparing fundoplication with MSA for the treatment of GERD to truly evaluate the efficacy of this treatment approach.
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Affiliation(s)
- Nadia Guidozzi
- Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Tom Wiggins
- Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Ahmed R Ahmed
- Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - George B Hanna
- Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Sheraz R Markar
- Department of Surgery and Cancer, Imperial College London, United Kingdom
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66
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Pauwels A, Boecxstaens V, Andrews CN, Attwood SE, Berrisford R, Bisschops R, Boeckxstaens GE, Bor S, Bredenoord AJ, Cicala M, Corsetti M, Fornari F, Gyawali CP, Hatlebakk J, Johnson SB, Lerut T, Lundell L, Mattioli S, Miwa H, Nafteux P, Omari T, Pandolfino J, Penagini R, Rice TW, Roelandt P, Rommel N, Savarino V, Sifrim D, Suzuki H, Tutuian R, Vanuytsel T, Vela MF, Watson DI, Zerbib F, Tack J. 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). Gut 2019; 68:1928-1941. [PMID: 31375601 DOI: 10.1136/gutjnl-2019-318260] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 05/28/2019] [Accepted: 05/29/2019] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Ans Pauwels
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Veerle Boecxstaens
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Department of Surgical Oncology, Oncological and Vascular Access Surgery, Leuven, Belgium.,Department of Oncology, KU Leuven, Leuven, Belgium
| | | | | | - Richard Berrisford
- Peninsula Oesophago-gastric Surgery Unit, Derriford Hospital, Plymouth, Plymouth, UK
| | - Raf Bisschops
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Guy E Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Serhat Bor
- Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Albert J Bredenoord
- Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - Michele Cicala
- Digestive Diseases, Universita Campus Bio Medico, Roma, Italy
| | - Maura Corsetti
- Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - Fernando Fornari
- Programa de Pós-Graduação: Ciências em Gastroenterologia e Hepatologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Chandra Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jan Hatlebakk
- Gastroenterology, Haukeland Sykehus, University of Bergen, Bergen, Norway
| | - Scott B Johnson
- Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, USA
| | - Toni Lerut
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Lars Lundell
- Department of Surgery, Karolinska, Stockholm, Sweden
| | - Sandro Mattioli
- Department of Medical and Surgical Sciences, Universita degli Studi di Bologna, Bologna, Emilia-Romagna, Italy
| | - Hiroto Miwa
- Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Taher Omari
- Department of Gastroenterology, Flinders University, Adelaide, Australia
| | - John Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Roberto Penagini
- Department of Pathophysiology and Transplantation, Ospedale Maggiore Policlinico, Milano, Lombardia, Italy
| | - Thomas W Rice
- Thoracic Surgery, Emeritus Staff Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, USA
| | - Philip Roelandt
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Nathalie Rommel
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Neurosciences, KU Leuven, Leuven, Belgium
| | - Vincenzo Savarino
- Internal Medicine and Medical Specialties, Universita di Genoa, Genoa, Italy
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University London, London, UK
| | - Hidekazu Suzuki
- Gastroenterology and Hepatology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Radu Tutuian
- Gastroenteroloy, Tiefenauspital Bern, Bern, Switzerland
| | - Tim Vanuytsel
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
| | | | - David I Watson
- Department of Surgery, Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia
| | - Frank Zerbib
- Department of Gastroenterology, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - Jan Tack
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
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Using Patient-reported Outcomes to Enhance Appropriateness in Low-risk Elective General Surgery. Ann Surg 2019; 269:41-42. [PMID: 29916867 DOI: 10.1097/sla.0000000000002864] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Maret-Ouda J, Wahlin K, Artama M, Brusselaers N, Färkkilä M, Lynge E, Mattsson F, Pukkala E, Romundstad P, Tryggvadóttir L, von Euler-Chelpin M, Lagergren J. Risk of Esophageal Adenocarcinoma After Antireflux Surgery in Patients With Gastroesophageal Reflux Disease in the Nordic Countries. JAMA Oncol 2019; 4:1576-1582. [PMID: 30422249 DOI: 10.1001/jamaoncol.2018.3054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Gastroesophageal reflux disease (GERD) is associated with a strong and severity-dependent increased risk of esophageal adenocarcinoma. Whether antireflux surgery prevents esophageal adenocarcinoma is a matter of uncertainty. Objectives To examine whether antireflux surgery is associated with reduced risk of esophageal adenocarcinoma and whether the risk is different between surgically and medically treated patients. Design, Setting, and Participants In this multinational, population-based retrospective cohort study from Denmark, Finland, Iceland, Norway, and Sweden, patients undergoing surgery were followed up for a median of 12.7 years, and a comparison group of patients receiving medication only were followed up for a median of 4.8 years. All patients with a registered diagnosis of GERD (or an associated disorder), including 48 414 individuals undergoing surgery and 894 492 receiving medication only, were included in the study. The study periods varied in the different countries depending on the year of initiation of registration and the date of data retrieval, from January 1, 1964, to December 21, 2014. Exposures Antireflux surgery for GERD. Main Outcomes and Measures The risk of esophageal adenocarcinoma over time after surgery was compared with that in a corresponding background population using standardized incidence ratios (SIRs) with 95% CIs and with patients with GERD who received medication using multivariable Cox proportional hazards regression, providing hazard ratios (HRs) with 95% CIs adjusted for confounders. Results In this study of 942 906 patients with GERD, 48 414 underwent antireflux surgery (median [interquartile range] age, 66.0 [58.0-73.0] years; 27 161 male [56.1%]) and 894 492 received medication only (median [interquartile range] age, 71.0 [62.0-78.0] years; 434 035 male [48.6%]). Among patients undergoing surgery, 177 developed esophageal adenocarcinoma. Esophageal adenocarcinoma risk decreased in a time-dependent manner after surgery compared with the background population (5 to <10 years after surgery: SIR, 7.63; 95% CI, 5.42-10.43; ≥15 years after surgery: SIR, 1.34; 95% CI, 0.98-1.80). Among patients with more severe and objectively determined GERD, the SIRs were 10.08 (95% CI, 6.98-14.09) at 5 to less than 10 years after surgery and 1.67 (95% CI, 1.15-2.35) at 15 years or more after surgery. The risk of esophageal adenocarcinoma did not change over time in surgical patients compared with patients who received medication only (5 to <10 years after surgery: HR, 2.02; 95% CI, 1.44-2.84; ≥15 years: HR, 1.80; 95% CI, 1.28-2.54). The risk remained stable over time in analyses restricted to severe reflux disease (5 to <10 years after surgery: HR, 1.81; 95% CI, 1.24-2.63; ≥15 years after surgery: HR, 1.69; 95% CI, 1.14-2.51). Conclusions and Relevance Medical and surgical treatment of GERD were associated with a similar reduced esophageal adenocarcinoma risk, with the risk decreasing to the same level as that in the background population over time, supporting the hypothesis that effective treatment of GERD might prevent esophageal adenocarcinoma.
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Affiliation(s)
- John Maret-Ouda
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Karl Wahlin
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Miia Artama
- Impact Assessment Unit, Department of Health Protection, National Institute for Health and Welfare, Tampere, Finland
| | - Nele Brusselaers
- Centre for Translational Microbiome Research, Department of Microbiology, Tumor, and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Science For Life Laboratory (SciLifeLab), Karolinska Institutet, Stockholm, Sweden
| | - Martti Färkkilä
- Clinic of Gastroenterology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Elsebeth Lynge
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Fredrik Mattsson
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Eero Pukkala
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland.,Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Pål Romundstad
- Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Laufey Tryggvadóttir
- Icelandic Cancer Registry, Icelandic Cancer Society, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | | | - Jesper Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,School of Cancer Sciences, King's College London, London, United Kingdom
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Ribolsi M, Giordano A, Guarino MPL, Tullio A, Cicala M. New classifications of gastroesophageal reflux disease: an improvement for patient management? Expert Rev Gastroenterol Hepatol 2019; 13:761-769. [PMID: 31327288 DOI: 10.1080/17474124.2019.1645596] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: Gastroesophageal reflux disease (GERD) is a very common and often debilitating disease. In the broad spectrum of GERD phenotypes, three main groups may be traditionally distinguished: 1) patients only affected by esophageal and/or extra-esophageal symptoms; 2) patients with erosive esophagitis and 3) patients with further complications. Areas covered: This review provides an overview on the current classifications of GERD patients, and their impact on their management. Expert opinion: In 2017, the GERD Consensus Working Group focused the attention on patients unresponsive to PPIs. In this scenario, a diagnosis of GERD might be confirmed by evident signs of erosive esophagitis and the finding of pH or multichannel intraluminal impedance-pH tests, such as more than 6%. The 'Lyon Consensus' panel of experts confirmed that positive indices of reflux-symptom association, without other altered parameters, represent reflux hypersensitivity. GERD requires a customized management; it is crucial to assess frequency and severity of symptoms and their response to an optimal course of therapy as well as to explore the endoscopic alterations and consider other diagnoses responsible for persistent symptoms.
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Affiliation(s)
- Mentore Ribolsi
- a Unit of Gastroenterology and Digestive Endoscopy, University Campus Bio Medico , Rome , Italy
| | - Antonio Giordano
- a Unit of Gastroenterology and Digestive Endoscopy, University Campus Bio Medico , Rome , Italy
| | | | - Alessandro Tullio
- a Unit of Gastroenterology and Digestive Endoscopy, University Campus Bio Medico , Rome , Italy
| | - Michele Cicala
- a Unit of Gastroenterology and Digestive Endoscopy, University Campus Bio Medico , Rome , Italy
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Holmberg D, Santoni G, Xie S, Lagergren J. Gastric bypass surgery in the treatment of gastro-oesophageal reflux symptoms. Aliment Pharmacol Ther 2019; 50:159-166. [PMID: 31165515 DOI: 10.1111/apt.15274] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/14/2019] [Accepted: 03/29/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastric bypass is considered an effective treatment of co-existing gastro-oesophageal reflux (GERD) and obesity. Previous studies have had small sample sizes, short follow-up or substantial loss to follow-up. AIM To assess the long-term risk of remaining/recurring reflux symptoms after gastric bypass. METHODS This was a nationwide cohort study of all adults with preoperative reflux who underwent gastric bypass in Sweden between 2006 and 2015, with complete follow-up through 2016. The outcome was remaining/recurring reflux symptoms, defined as use of proton pump inhibitors or histamine-2 receptor antagonists for >6 months after surgery. Cumulative incidence and risk factors of reflux were assessed with multivariable Poisson regression. RESULTS Among 2454 participants (81.7% female; mean age: 46.1 years, SD: 9.8 years), who were followed for median 4.6 years (interquartile range: 3.1-6.3 years), reflux recurred in 48.8% (95% confidence interval [95% CI], 46.8-51.0) of participants within 2 years of gastric bypass and remained stable up to 10 years after surgery (yearly change in incidence rate ratio [IRR] of 1.00; 95% CI, 0.99-1.02). Risk factors for recurring reflux were high preoperative dose of anti-reflux medication (IRR 1.77; 95% CI, 1.60-1.96 compared with low dose), older age (IRR 1.12; 95% CI 1.02-1.24 comparing age >50 with <40 years), female sex (IRR 1.28; 95% CI, 1.16-1.42) and comorbidity (IRR 1.26; 95% CI, 1.14-1.39 comparing Charlson Comorbidity Index ≥2 with 0). CONCLUSIONS Reflux symptoms decrease rapidly after gastric bypass, but around half of operated patients require continuous anti-reflux medication. The treatment efficacy of gastric bypass on reflux symptoms might have been overestimated.
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Affiliation(s)
- Dag Holmberg
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Giola Santoni
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Shaohua Xie
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jesper Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
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71
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Nabi Z, Reddy DN. Update on Endoscopic Approaches for the Management of Gastroesophageal Reflux Disease. Gastroenterol Hepatol (N Y) 2019; 15:369-376. [PMID: 31391807 PMCID: PMC6676348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Gastroesophageal reflux disease (GERD) is one of the most commonly encountered gastrointestinal diseases in outpatient clinics. Proton pump inhibitors (PPIs) are the cornerstone of the treatment of GERD. However, approximately one-third of patients have suboptimal response to PPIs. The management options in such cases include antireflux surgery or endoscopic antireflux treatments. Antireflux surgery is not popular due to its invasive nature and potential for adverse events. Therefore, minimally invasive endoscopic antireflux therapies are gaining popularity for the management of PPI-dependent and PPI-refractory GERD. These endoscopic therapies include radiofrequency application, endoscopic fundoplication modalities, and mucosal resection techniques. In appropriately selected patients, the response to these endoscopic modalities is encouraging. Unlike surgical fundoplication, endoscopic antireflux therapies are less likely to be associated with complications such as dysphagia and gas-bloat syndrome. On the other hand, antireflux surgery remains the ideal treatment in patients with a large hiatal hernia (laparoscopic Nissen fundoplication), morbid obesity (gastric bypass), and severe reflux esophagitis. Endoscopic treatment modalities bear the potential to narrow the treatment gap between PPIs and antireflux surgery. Long-term follow-up studies and randomized comparison with antireflux surgery are required to provide a clear understanding of the current role of endoscopic modalities in patients with PPI-refractory and PPI-dependent GERD.
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Affiliation(s)
- Zaheer Nabi
- Dr Nabi is a consultant gastroenterologist and Dr Reddy is chairman and chief gastroenterologist at the Asian Institute of Gastroenterology in Hyderabad, India
| | - D Nageshwar Reddy
- Dr Nabi is a consultant gastroenterologist and Dr Reddy is chairman and chief gastroenterologist at the Asian Institute of Gastroenterology in Hyderabad, India
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Abstract
PURPOSE The Swedish Prescribed Drugs and Health Cohort (SPREDH) is a Swedish population-based cohort based on data from four nationwide health data registers, created with the aim of investigating how the use of selected medications influences cancer risk and other outcomes. PARTICIPANTS The cohort includes 8 421 115 users of selected common medications who have been followed-up for a total of 82 281 720 person-years from 1 July 2005 to 31 December 2015. FINDING TO DATE The data in SPREDH were prospectively collected from the following national health data registers in Sweden: Prescribed Drug Register, Patient Register, Cancer Register and Causes of Death Register. Data on basic patient characteristics, use of the selected common medications, healthcare utilisation, diagnoses (including detailed information on cancers), and dates and causes of death are available for all cohort participants. The cohort currently includes 801 766 incident cancer cases. FUTURE PLANS The data in SPREDH can be used for various types of epidemiological research, particularly for examining how the use of the selected medications influences disease risk and other outcomes. We are initially planning cohort studies and nested case-control studies on selected medications in relation to the risk and prognosis of oesophageal and gastric cancers.
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Affiliation(s)
- Shao-Hua Xie
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Giola Santoni
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Mattsson
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Eivind Ness-Jensen
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- HUNT Research Centre, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Levanger, Norway
- Medical Department, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Jesper Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- School of Cancer and Pharmaceutical Sciences, King’s College London, London, UK
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Yadlapati R, Hungness ES, Pandolfino JE. Complications of Antireflux Surgery. Am J Gastroenterol 2018; 113:1137-1147. [PMID: 29899438 PMCID: PMC6394217 DOI: 10.1038/s41395-018-0115-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 04/11/2018] [Indexed: 12/11/2022]
Abstract
Antireflux surgery anatomically restores the antireflux barrier and is a therapeutic option for proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease or PPI intolerance. Laparoscopic fundoplication is the standard antireflux surgery, though its popularity has declined due to concerns regarding wrap durability and adverse events. As the esophagogastric junction is an anatomically complex and dynamic area subject to mechanical stress, wraps are susceptible to disruption, herniation or slippage. Additionally, recreating an antireflux barrier to balance bidirectional bolus flow is challenging, and wraps may be too tight or too loose. Given these complexities it is not surprising that post-fundoplication symptoms and complications are common. Perioperative mortality rates range from 0.1 to 0.2% and prolonged structural complications occur in up to 30% of cases. Upper gastrointestinal endoscopy with a comprehensive retroflexed examination of the fundoplication and barium esophagram are the primary tests to assess for structural complications. Management hinges on differentiating complications that can be managed with medical and lifestyle optimization versus those that require surgical revision. Reoperation is best reserved for severe structural abnormalities and troublesome symptoms despite medical and endoscopic therapy given its increased morbidity and mortality. Though further data are needed, magnetic sphincter augmentation may be a safer alternative to fundoplication.
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Affiliation(s)
- Rena Yadlapati
- University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
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77
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Katz PO, Katzka DA. Getting into a TIF(F) Over Fundoplication. Gastroenterology 2018; 154:1227-1228. [PMID: 29510128 DOI: 10.1053/j.gastro.2018.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Philip O Katz
- Division of Gastroenterology and Hepatology, Weill Cornell School of Medicine, Ithaca, New York
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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78
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Richter JE, Kumar A, Lipka S, Miladinovic B, Velanovich V. Efficacy of Laparoscopic Nissen Fundoplication vs Transoral Incisionless Fundoplication or Proton Pump Inhibitors in Patients With Gastroesophageal Reflux Disease: A Systematic Review and Network Meta-analysis. Gastroenterology 2018; 154:1298-1308.e7. [PMID: 29305934 DOI: 10.1053/j.gastro.2017.12.021] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 12/20/2017] [Accepted: 12/27/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS The effects of transoral incisionless fundoplication (TIF) and laparoscopic Nissen fundoplication (LNF) have been compared with those of proton pump inhibitors (PPIs) or a sham procedure in patients with gastroesophageal reflux disease (GERD), but there has been no direct comparison of TIF vs LNF. We performed a systematic review and network meta-analysis of randomized controlled trials to compare the relative efficacies of TIF vs LNF in patients with GERD. METHODS We searched publication databases and conference abstracts through May 10, 2017 for randomized controlled trials that compared the efficacy of TIF or LNF with that of a sham procedure or PPIs in patients with GERD. We performed a network meta-analysis using Bayesian methods under random-effects multiple treatment comparisons. We assessed ranking probability by surface under the cumulative ranking curve. RESULTS Our search identified 7 trials comprising 1128 patients. Surface under the cumulative ranking curve ranking indicated TIF had highest probability of increasing patients' health-related quality of life (0.96), followed by LNF (0.66), a sham procedure (0.35), and PPIs (0.042). LNF had the highest probability of increasing percent time at pH <4 (0.99), followed by PPIs (0.64), TIF (0.32), and the sham procedure (0.05). LNF also had the highest probability of increasing LES pressure (0.78), followed by TIF (0.72) and PPIs (0.01). Patients who underwent the sham procedure had the highest probability for persistent esophagitis (0.74), followed by those receiving TIF (0.69), LNF (0.38), and PPIs (0.19). Meta-regression showed a shorter follow-up time as a significant confounder for the outcome of health-related quality of life in studies of TIF. CONCLUSIONS In a systematic review and network meta-analysis of trials of patients with GERD, we found LNF to have the greatest ability to improve physiologic parameters of GERD, including increased LES pressure and decreased percent time pH <4. Although TIF produced the largest increase in health-related quality of life, this could be due to the shorter follow-up time of patients treated with TIF vs LNF or PPIs. TIF is a minimally invasive endoscopic procedure, yet based on evaluation of benefits vs risks, we do not recommend it as a long-term alternative to PPI or LNF treatment of GERD.
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Affiliation(s)
- Joel E Richter
- Department of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, Morsani College of Medicine, Tampa, Florida.
| | - Ambuj Kumar
- Department of Medicine, Division of Evidence Based Medicine and Outcomes Research, University of South, Florida Morsani College of Medicine, Tampa, Florida
| | - Seth Lipka
- Division of Digestive Diseases and Nutrition, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Branko Miladinovic
- Department of Medicine, Division of Evidence Based Medicine and Outcomes Research, University of South, Florida Morsani College of Medicine, Tampa, Florida
| | - Vic Velanovich
- Division of General Surgery, University of South Florida, Tampa, Florida
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Vercellini P, Viganò P, Buggio L, Somigliana E. "We Can Work It Out:" The Hundred Years' War between Experts of Surgical and Medical Treatment for Symptomatic Deep Endometriosis. J Minim Invasive Gynecol 2017; 25:356-359. [PMID: 29031679 DOI: 10.1016/j.jmig.2017.09.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 09/29/2017] [Indexed: 12/27/2022]
Affiliation(s)
- Paolo Vercellini
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.
| | - Paola Viganò
- San Raffaele Scientific Institute, Università Vita Salute, Milan, Italy
| | - Laura Buggio
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
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