Standardization of surgical technique in antireflux surgery: the LOTUS Trial experience

Hiatal Hernia Repair With Tension-Free Mesh or Crural Sutures Alone in Antireflux Surgery: A 13-Year Follow-Up of a Randomized Clinical Trial

Importance

Antireflux surgery is an effective treatment of gastroesophageal reflux disease (GERD), but the durability of concomitant hiatal hernia repair remains challenging. Previous research reported that the use of a mesh-reinforced, tension-free technique was associated with more dysphagia for solid foods after 3 years without reducing hiatal hernia recurrence rates compared with crural sutures alone, but the long-term effects of this technique have not been assessed.

Objective

To assess the long-term anatomical and functional outcomes of using a mesh for hiatal hernia repair in patients with GERD.

Design, Setting, and Participants

A double-blind, randomized clinical trial was performed at a single center (Ersta Hospital, Stockholm, Sweden) from January 11, 2006, to December 1, 2010. A total of 159 patients were recruited and randomly assigned. Data for the current analysis were collected from September 1, 2021, to March 31, 2022. All analyses were conducted with the intention-to-treat population.

Interventions

Closure of the diaphragmatic hiatus with crural sutures alone vs a tension-free technique using a nonabsorbable polytetrafluoroethylene mesh (Bard CruraSoft).

Main Outcomes and Measures

The primary outcome was radiologically verified recurrent hiatal hernia after more than 10 years. Secondary outcomes were dysphagia scores (ranging from 1 to 4, with 1 indicating no episodes of dysphagia and 4 indicating more than 3 episodes of dysphagia per day) for solid and liquid foods, generic 36-Item Short Form Health Survey and disease-specific Gastrointestinal Symptom Rating Scale symptom assessment scores, proton pump inhibitor consumption, and reoperation rates. Intergroup comparisons of parametric data were performed using t tests; for nonparametric data, Mann-Whitney U, χ2, or Fisher exact tests were used. For intragroup comparisons vs the baseline at follow-up times, the Friedman test was used, and post hoc analysis was performed using Wilcoxon matched pairs.

Results

Of 145 available patients, follow-up data were obtained from 103 (response rate 71%; mean [SD] age at follow-up, 65 [11.3] years; 55 [53%] female), with 53 initially randomly assigned to mesh reinforcement, and 50 to crural suture alone. The mean (SD) follow-up time was 13 (1.1) years. The verified radiologic hiatal hernia recurrence rates were 11 of 29 (38%) in the mesh group vs 11 of 35 (31%) in the suture group (P = .61). However, 13 years postoperatively, mean (SD) dysphagia scores for solids remained significantly higher in the mesh group (mean [SD], 1.9 [0.7] vs 1.6 [0.9]; P = .01).

Conclusions and Relevance

Findings from this long-term follow-up of a randomized clinical trial suggest that tension-free crural repair with nonabsorbable mesh does not reduce the incidence of hiatal hernia recurrence 13 years postoperatively. This finding combined with maintained higher dysphagia scores does not support the routine use of tension-free polytetrafluoroethylene mesh closure in laparoscopic hiatal hernia repair for treatment of GERD.

Trial Registration

ClinicalTrials.gov Identifier: NCT05069493.

A systematic review of the power of standardization in pediatric neurosurgery

In the current neurosurgical field, there is a constant emphasis on providing the best care with the most value. Such work requires the constant optimization of not only surgical but also perioperative services. Recent work has demonstrated the power of standardized techniques in limiting complication while promoting optimal outcomes. In this review article, protocols addressing operative and perioperative care for common pediatric neurosurgical procedures are discussed. These articles address how various institutions have optimized procedures through standardization. Our objective is to improve patient outcomes through the optimization of protocols.

Clinical Outcomes of a Laparoscopic Total vs a 270° Posterior Partial Fundoplication in Chronic Gastroesophageal Reflux Disease: A Randomized Clinical Trial

Importance

The efficacy of fundoplication operations in the management of gastroesophageal reflux disease (GERD) has been documented. However, few prospective, controlled series report long-term (>10 years) efficacy and postfundoplication concerns, particularly when comparing various types of fundoplication.

Objective

To compare long-term (>15 years) results regarding mechanical complications, reflux control, and quality of life between patients undergoing posterior partial fundoplication (PF) or total fundoplication (TF) (270° vs 360°) in surgical treatment for GERD.

Design, Setting, and Participants

A double-blind randomized clinical trial was performed at a single center (Ersta Hospital, Stockholm, Sweden) from November 19, 2001, to January 24, 2006. A total of 456 patients were recruited and randomized. Data for this analysis were collected from August 1, 2019, to January 31, 2021.

Interventions

Laparoscopic 270° posterior PF vs 360° TF.

Main Outcomes and Measures

The main outcome was dysphagia scores for solid and liquid food items after more than 15 years. Generic (36-Item Short-Form Health Survey) and disease-specific (Gastrointestinal Symptom Rating Scale) quality of life and proton pump inhibitor consumption were also assessed.

Results

Among 407 available patients, relevant data were obtained from 310 (response rate, 76%; mean [SD] age, 66 [11.2] years; 184 [59%] men). A total of 159 were allocated to a PF and 151 to a TF. The mean (SD) follow-up time was 16 (1.3) years. At 15 years after surgery, mean (SD) dysphagia scores were low for both liquids (PF, 1.2 [0.5]; TF, 1.2 [0.5]; P = .58) and solids (PF, 1.3 [0.6]; TF, 1.3 [0.5]; P = .97), without statistically significant differences between the groups. Reflux symptoms were equally well controlled by the 2 types of fundoplications as were the improvements of quality-of-life scores.

Conclusions and Relevance

The long-term findings of this randomized clinical trial indicate that PF and TF are equally effective for controlling GERD and quality of life in the long term. Although PF was superior in the first years after surgery in terms of less dysphagia recorded, this difference did not prevail when assessed a decade later.

Trial Registration

ClinicalTrials.gov Identifier: NCT04182178.

OUP accepted manuscript

Background

Fundoplication is an essential step in para-oesophageal hernia (POH) repair, but which type minimizes postoperative mechanical complications is controversial.

Methods

This was a randomized, double-blind clinical trial conducted between May 2009 and October 2018. Patients with symptomatic POH were allocated to either a total (Nissen) or a posterior partial (Toupet) fundoplication after hernia reduction and crural repair. The primary outcome was dysphagia (Ogilvie dysphagia scores) at 6 months postoperatively. Secondary outcomes were peri- and postoperative complications, swallowing difficulties assessed by the Dakkak dysphagia score, gastro-oesophageal reflux, quality of life (QoL), and radiologically confirmed hernia recurrence.

Results

A total of 70 patients were randomized to a Nissen (n = 32) or a Toupet (n = 38) fundoplication. Compared with baseline, Ogilvie dysphagia scores were stable at the 3- and 6-month follow-up in the Nissen group (P = 0.075 and 0.084 respectively) but significantly improved in the Toupet group (from baseline mean (s.d.): 1.4 (1.1) to 0.5 ( 0.8) at 3 months, and 0.5 (0.6) at 6 months; P = 0.003 and P = 0.001 respectively). At 6 months, Dakkak dysphagia scores were significantly higher in the Nissen group than in the Toupet group (mean (s.d.): 10.4 (7.9) versus 5.1 (7.2); P = 0.003). QoL scores improved throughout the follow-up. However, at 3 and 6 months postoperatively, the absolute median improvement (⍙) from preoperative values in the mental component scores of the Short Form-36 QoL questionnaire was significantly higher in the Toupet group (median (i.q.r.): 7.1 (−0.6 to 15.2) versus 1.0 (−5.4 to 3.3) at 3 months, and 11.2 (1.4 to 18.3) versus 0.4 (−9.4 to 7.5) at 6 months; (P = 0.010 and 0.003 respectively)). At 6 months, radiologically confirmed POH recurrence occurred in 11 of 24 patients (46 per cent) of the Nissen group and in 15 of 32 patients (47 per cent) of the Toupet group (P = 1.001).

Conclusions

A partial posterior wrap (Toupet fundoplication) showed reduced obstructive complications and improved QoL compared with a total (Nissen) fundoplication following POH repair.

Registration number: NCT04436159 (http://www.clinicaltrials.gov)

Fundoplication is superior to medical therapy for Barrett's esophagus disease regression and progression: a systematic review and meta-analysis

BACKGROUND

Fundoplication and medical management are current mainstays for management of Barrett's esophagus (BE), however our understanding of differences in outcomes between these two treatments is limited. The aim of this study was to perform a systematic review and meta-analysis to evaluate the efficacy of these interventions on BE disease regression and progression.

METHODS AND PROCEDURES

A comprehensive search in MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Library databases was performed on February 22, 2021. Inclusion criteria were studies with both medical and surgical management comparators, BE diagnosis prior to treatment, patients aged ≥ 18 years, and studies with greater than five patients. Primary outcomes of interest included evaluating changes in histopathologic BE regression and disease progression between interventions. Meta-analysis was performed using a Mantel-Haenszel random-effects model (RevMan 5.4.1).

RESULTS

A total of 7231 studies were retrieved after initial search with nine studies (1 randomized trial, 7 prospective cohorts, 1 retrospective cohort) meeting final inclusion criteria. Of included studies, 890 (65%) patients received medical management while 470 (35%) received surgical management. Medical management included proton pump inhibitors (n = 807, 91%; 6 studies), H2-receptor blockers (n = 40, 4% patients; 3 studies), and combination therapy (n = 43, 5%; 1 study). Nissen fundoplication was the most commonly performed type of fundoplication (n = 265, 93%). Median length of follow-up ranged from 1.5-7 years. Meta-analysis revealed that fundoplication was associated with improved histopathologic regression of metaplasia/low-grade dysplasia (OR 4.38; 95% CI 2.28-8.42; p < 0.00001) and disease progression to dysplasia/adenocarcinoma (OR 0.34; 95% CI 0.12-0.96; p = 0.04) compared to medical therapy.

CONCLUSION

Fundoplication is superior to medical therapy with regards to improved odds of histopathologic BE disease regression and disease progression. Additional randomized trials which directly compare medical management and surgical intervention are required to delineate the optimal delivery and timing of these interventions.

Mind the Gap: Current Treatment Alternatives for GERD Patients Failing Medical Treatment and Not Ready for a Fundoplication

BACKGROUND

Gastroesophageal reflux disease is associated with Barrett esophagus, esophageal adenocarcinoma, and significantly impacts quality of life. Medical management is the first line therapy with surgical fundoplication as an alternative therapy. However, a small portion of patients who fail medical therapy are referred for surgical consultation. This creates a "gap" in therapy for those patients dissatisfied with medical therapy but are not getting referred for surgical consultation. Three procedures have been designed to address these patients. These include radiofrequency ablation (RFA) of the lower esophageal sphincter, transoral incisionless fundoplication (TIF), and magnetic sphincter augmentation.

MATERIALS AND METHODS

A Pubmed literature review was conducted of all publications for RFA, TIF, and MSA. Four most common endpoints for the 3 procedures were compared at different intervals of follow-up. These include percent of patients off proton pump inhibitors (PPIs), GERD-HRQL score, DeMeester score, and percent of time with pH <4. A second query was performed for patients treated with PPI and fundoplications to match the same 4 endpoints as a control.

RESULTS

Variable freedom from PPI was reported at 1 year for RFA with a weighted mean of 62%, TIF with a weighted mean of 61%, MSA with a weighted mean of 85%, and fundoplications with a weighted mean of 84%. All procedures including PPIs improved quality-of-life scores but were not equal. Fundoplication had the best improvement followed by MSA, TIF, RFA, and PPI, respectively. DeMeester scores are variable after all procedures and PPIs. All MSA studies showed normalization of pH, whereas only 4 of 17 RFA studies and 3 of 11 TIF studies reported normalization of pH.

CONCLUSIONS

Our literature review compares 3 rival procedures to treat "gap" patients for gastroesophageal reflux disease with 4 common endpoints. Magnetic sphincter augmentation appears to have the most reproducible and linear outcomes but is the most invasive of the 3 procedures. MSA outcomes most closely mirrors that of fundoplication.

Clinical outcomes of gastroesophageal reflux disease-related chronic cough following antireflux fundoplication

BACKGROUND

Despite the effectiveness of antireflux fundoplication for typical gastroesophageal reflux disease, outcomes regarding surgical therapy for patients with gastroesophageal reflux disease-related chronic cough are currently unclear. The purpose of this study was to evaluate whether antireflux surgery for patients with chronic cough is effective, and to assess the correlation between indexes, such as symptom index and symptom association probability, and response to surgery.

METHODS

We performed a retrospective review of a prospectively collected database from a 3-site institution from 2013 to 2017. Of 1149 patients who underwent antireflux surgery, 41 presented with chronic cough as a main symptom related to gastroesophageal reflux disease. Preoperatively, patients underwent a symptom assessment, esophagogastroduodenoscopy, esophageal 24-h pH monitoring, and manometry. Patients were followed up at 6 weeks and 12 months post-surgery.

RESULTS

Thirty-three (80.5%) patients underwent Nissen fundoplication, while 8 (19.5%) underwent Toupet fundoplication. Isolated chronic cough was present in 8 (19.5%) patients, and median (range) DeMeester score was 28.9 (0.3-96.7). After 12-month follow-up, chronic cough was absent in 28 (68.3%) patients (P = .02). Typical reflux symptoms responded well to surgery, but response was not optimal. Postoperative dysphagia and atypical reflux symptoms were slightly worse on long-term follow-up; however, differences were not significant (P ≥ .2). When examining how the different symptom indexes correlated with complete, partial, or no response in patients with gastroesophageal reflux disease-related cough, there was no notable agreement on predicted response to surgery.

CONCLUSIONS

Antireflux surgery, although less predictable, is effective for the treatment of gastroesophageal reflux disease-related chronic cough.

Nissen fundoplication and dyspeptic symptoms: is the water load test useful?

BACKGROUND

The water load test is a simple, cheap and standardized method to evaluate gastric distension and gastric motility responses. We have previously shown that in patients with mild erosive or non-erosive esophagitis this test is frequently abnormal, suggesting an altered gastric function. The aim was to evaluate the water load test score before and after Nissen fundoplication in reflux patients.

METHODS

Thirty-one patients (16 men, 15 women, mean age 46.5 y) were studied before and 3 months after Nissen fundoplication by stationary esophageal manometry, wireless Bravo pH system monitoring (48 hours), and water load test. A dyspepsia symptom questionnaire was also completed before and after surgery. Data were compared with those of 35 controls.

RESULTS

All patients had pH-monitoring positive for pathological acid exposure and/or related-reflux symptoms in the absence of motility disorders. Basal symptoms scores were higher in patients compared to controls and improved after surgery, except than postprandial fullness, early satiation, and bloating, that were significantly increased. At baseline, all patients ingested significantly lower water volumes than controls, with a tendency to early onset of fullness and nausea, respectively. After surgery, the water volumes were significantly lower than presurgery.

CONCLUSIONS

In patients with reflux-related symptoms, with or without esophagitis, the water load test is frequently abnormal, suggesting an altered gastric function. Nissen fundoplication is associated with a relatively higher incidence of bloating, epigastric pain and fullness. These preliminary data could explain the incomplete resolution of symptoms after surgery in some patients, and suggest the use of additional studies to explore the gastric function in presurgical evaluation.

A Hill Gastropexy Combined with Nissen Fundoplication Appears Equivalent to a Collis-Nissen in the Management of Short Esophagus

INTRODUCTION

A Collis gastroplasty combined with a Nissen fundoplication is commonly used when a shortened esophagus is encountered. An alternative combines intra-abdominal fixation of the gastroesophageal junction via a Hill gastropexy with a Nissen fundoplication to maintain length and avoid juxtaposing acid-secreting tissue against the diseased esophagus.

METHODS

A retrospective case-controlled analysis of 106 consecutive patients with short esophagus undergoing Hill-Nissen (HN) or Collis-Nissen (CN) was compared to a cohort of 105 matched patients without short esophagus undergoing primary Nissen fundoplication (NF).

RESULTS

At a median follow-up of 27 months, all groups (HN:CN:NF) improved significantly over preoperative baseline with no differences in overall complications (18 vs 16 vs 19%, p = 0.78), DeMeester score (11.1 vs 19.1 vs 14.2, p = 0.49), postoperative PPI use (16 vs 22 vs 15%, p = 0.24), anatomic recurrences (11.7 vs 5.5 vs 7%, p = 0.43), or quality of life (6.8 vs 6.7 vs 6.4, p = 0.3).

CONCLUSIONS

The management of shortened esophagus with Hill-Nissen is safe and as effective as Collis gastroplasty with Nissen fundoplication. Both options appear to produce similar outcomes to patients requiring only a Nissen fundoplication suggesting a shortened esophagus does not beget an inferior outcome.

New Approaches to Gastroesophageal Reflux Disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is the most common gastrointestinal disorder of the esophagus. It is a chronic, progressive disorder that presents most typically with heartburn and regurgitation and atypically with chest pain, dysphagia, chronic cough, globus, or sore throat. The mainstay for diagnosis and characterization of the disorder is esophagoduodenoscopy (EGD), high-resolution esophageal manometry, and symptom-associated ambulatory esophageal pH impedance monitoring. Additional studies that can be useful in certain clinical presentations include gastric scintigraphy and oral contrast upper gastrointestinal radiographic series.

DISCUSSION

Refractory GERD can be surgically managed with various techniques. In obese individuals, laparoscopic Roux-en-Y gastric bypass should be considered due to significant symptom improvement and lower incidence of recurrent symptoms with weight loss. Otherwise, laparoscopic Nissen fundoplication is the preferred surgical technique for treatment of this disease with concomitant hiatal hernia repair when present for either procedure. The short-term risks associated with these procedures include esophageal or gastric injury, pneumothorax, wound infection, and dysphagia. Emerging techniques for treatment of this disease include the Linx Reflux Management System, EndoStim LES Stimulation System, Esophyx® and MUSE™ endoscopic fundoplication devices, and the Stretta endoscopic ablation system. Outcomes after surgical management of refractory GERD are highly dependent on adherence to strict surgical indications and appropriate patient-specific procedure selection.

YouTube as a Potential Training Resource for Laparoscopic Fundoplication

OBJECTIVE

To analyze the surgical proficiency and educational quality of YouTube videos demonstrating laparoscopic fundoplication (LF).

DESIGN

In this cross-sectional study, a search was performed on YouTube for videos demonstrating the LF procedure. The surgical and educational proficiency was evaluated using the objective component rating scale, the educational quality rating score, and total video quality score. Statistical significance was determined by analysis of variance, receiver operating characteristic curve, and odds ratio analysis.

RESULTS

A total of 71 videos were included in the study; 28 (39.4%) videos were evaluated as good, 23 (32.4%) were moderate, and 20 (28.2%) were poor. Good-rated videos were significantly longer (good, 22.0 ± 5.2min; moderate, 7.8 ± 0.9min; poor, 8.5 ± 1.0min; p = 0.007) and video duration was predictive of good quality (AUC, 0.672 ± 0.067; 95% CI: 0.541-0.802; p = 0.015). For good quality, the cut-off video duration was 7:42 minute. This cut-off value had a sensitivity of 67.9%, a specificity of 60.5%, and an odds ratio of 3.23 (95% CI: 1.19-8.79; p = 0.022) in predicting good quality. Videos uploaded from industrial sources and with a higher views/days online ratio had a higher objective component rating scale and total video quality score. In contrast, the likes/dislikes ratio was not predictive of video quality.

CONCLUSIONS

Many videos showing the LF procedure have been uploaded to YouTube with varying degrees of quality. A process for filtering LF videos with high surgical and educational quality is feasible by evaluating the video duration, uploading source, and the views/days online ratio. However, alternative videos platforms aimed at professionals should also be considered for educational purposes.

Laparoscopic alternatives to fundoplication for gastroesophageal reflux: the role of magnetic augmentation and electrical stimulation of the lower esophageal sphincter

Reflux symptoms are very common, and despite modern medication they are a major cause of disease burden and loss of quality of life worldwide. Laparoscopic anti-reflux surgery is the only current effective alternative but suffers from the risks of long-term side effects. Surgery also suffers variation in standards and outcomes. Magnetic augmentation and electrical stimulation of the lower esophageal sphincter represent promising innovative procedures in the field.

Complications Following Surgery for Gastroesophageal Reflux Disease and Achalasia

Surgical procedures to treat reflux disease are common, but good outcomes rely on both a thorough preoperative workup and careful surgical techniques. Although complications are uncommon, surgeons should recognize these and possess the skills to overcome them in clinical practice.

Efficiency improvement in the operating room

BACKGROUND

In the changing health care environment, health systems, hospitals, and health care providers must focus on improving efficiency to meet an increasing demand for high-quality, low-cost health care. Much has been written about strategies and efforts to improve efficiency in the perioperative periods, yet the time when the patient is in the operating room-the intraoperative period-has received less attention. Yet, this is the period in which surgeons may have the most influence.

METHODS

Systematically review published efforts to improve intraoperative efficiency; assess the outcomes of these efforts, and propose standardized reporting of future studies.

RESULTS

A total of 39 studies were identified that met inclusion criteria. These divided naturally into small (single operative team), medium (multi-operative team), and large (institutional) interventions. Most studies used time or money as their metric for efficiency, though others were used as well.

CONCLUSIONS

There is substantial opportunity to enhance operating room efficiency during the intraoperative period. Surgeons may have a particular role in procedural efficiency, which has been relatively unstudied. Common themes were standardizing tasks, collecting and using actionable data, and maintaining effective team communication.

Laparoscopic fundoplication surgery versus medical management for gastro-oesophageal reflux disease (GORD) in adults

BACKGROUND

Gastro-oesophageal reflux disease (GORD) is a common condition with 3% to 33% of people from different parts of the world suffering from GORD. There is considerable uncertainty about whether people with GORD should receive an operation or medical treatment for controlling the condition.

OBJECTIVES

To assess the benefits and harms of laparoscopic fundoplication versus medical treatment for people with gastro-oesophageal reflux disease.

SEARCH METHODS

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group (UGPD) Trials Register (June 2015), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 6, 2015), Ovid MEDLINE (1966 to June 2015), and EMBASE (1980 to June 2015) to identify randomised controlled trials. We also searched the references of included trials to identify further trials.

SELECTION CRITERIA

We considered only randomised controlled trials (RCT) comparing laparoscopic fundoplication with medical treatment in people with GORD irrespective of language, blinding, or publication status for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials and independently extracted data. We calculated the risk ratio (RR) or standardised mean difference (SMD) with 95% confidence intervals (CI) using both fixed-effect and random-effects models with RevMan 5 based on available case analysis.

MAIN RESULTS

Four studies met the inclusion criteria for the review, and provided information on one or more outcomes for the review. A total of 1160 participants in the four RCTs were either randomly assigned to laparoscopic fundoplication (589 participants) or medical treatment with proton pump inhibitors (571 participants). All the trials included participants who had had reflux symptoms for at least six months and had received long-term acid suppressive therapy. All the trials included only participants who could undergo surgery if randomised to the surgery arm. All of the trials were at high risk of bias. The overall quality of evidence was low or very low. None of the trials reported long-term health-related quality of life (HRQoL) or GORD-specific quality of life (QoL).The difference between laparoscopic fundoplication and medical treatment was imprecise for overall short-term HRQOL (SMD 0.14, 95% CI -0.02 to 0.30; participants = 605; studies = 3), medium-term HRQOL (SMD 0.03, 95% CI -0.19 to 0.24; participants = 323; studies = 2), medium-term GORD-specific QoL (SMD 0.28, 95% CI -0.27 to 0.84; participants = 994; studies = 3), proportion of people with adverse events (surgery: 7/43 (adjusted proportion = 14.0%); medical: 0/40 (0.0%); RR 13.98, 95% CI 0.82 to 237.07; participants = 83; studies = 1), long-term dysphagia (surgery: 27/118 (adjusted proportion = 22.9%); medical: 28/110 (25.5%); RR 0.90, 95% CI 0.57 to 1.42; participants = 228; studies = 1), and long-term reflux symptoms (surgery: 29/118 (adjusted proportion = 24.6%); medical: 41/115 (35.7%); RR 0.69, 95% CI 0.46 to 1.03; participants = 233; studies = 1).The short-term GORD-specific QoL was better in the laparoscopic fundoplication group than in the medical treatment group (SMD 0.58, 95% CI 0.46 to 0.70; participants = 1160; studies = 4).The proportion of people with serious adverse events (surgery: 60/331 (adjusted proportion = 18.1%); medical: 38/306 (12.4%); RR 1.46, 95% CI 1.01 to 2.11; participants = 637; studies = 2), short-term dysphagia (surgery: 44/331 (adjusted proportion = 12.9%); medical: 11/306 (3.6%); RR 3.58, 95% CI 1.91 to 6.71; participants = 637; studies = 2), and medium-term dysphagia (surgery: 29/288 (adjusted proportion = 10.2%); medical: 5/266 (1.9%); RR 5.36, 95% CI 2.1 to 13.64; participants = 554; studies = 1) was higher in the laparoscopic fundoplication group than in the medical treatment group.The proportion of people with heartburn at short term (surgery: 29/288 (adjusted proportion = 10.0%); medical: 59/266 (22.2%); RR 0.45, 95% CI 0.30 to 0.69; participants = 554; studies = 1), medium term (surgery: 12/288 (adjusted proportion = 4.2%); medical: 59/266 (22.2%); RR 0.19, 95% CI 0.10 to 0.34; participants = 554; studies = 1), long term (surgery: 46/111 (adjusted proportion = 41.2%); medical: 78/106 (73.6%); RR 0.56, 95% CI 0.44 to 0.72); participants = 217; studies = 1) and those with reflux symptoms at short-term (surgery: 6/288 (adjusted proportion = 2.0%); medical: 53/266 (19.9%); RR 0.10, 95% CI 0.05 to 0.24; participants = 554; studies = 1) and medium term (surgery: 6/288 (adjusted proportion = 2.1%); medical: 37/266 (13.9%); RR 0.15, 95% CI 0.06 to 0.35; participants = 554; studies = 1) was less in the laparoscopic fundoplication group than in the medical treatment group.

AUTHORS' CONCLUSIONS

There is considerable uncertainty in the balance of benefits versus harms of laparoscopic fundoplication compared to long-term medical treatment with proton pump inhibitors. Further RCTs of laparoscopic fundoplication versus medical management in patients with GORD should be conducted with outcome-assessor blinding and should include all participants in the analysis. Such trials should include long-term patient-orientated outcomes such as treatment-related adverse events (including severity), quality of life, and also report on the social and economic impact of the adverse events and symptoms.

Closer to the Mean

Variation, long accepted to be the norm in otolaryngologic surgical practice, has recently come under scrutinization. Efforts can be seen daily in the operating room to standardize procedures with time-outs, checklists, and protocols. The thought is that by enforcing repetition and eliminating variation, it is possible to decrease human error and reduce cost. However, there is understandable resistance from surgeons in removing the “art” from surgery. We propose that standardization, if appropriately put into practice, can improve surgical outcomes and efficiency and even enhance resident education.

Recent advancement of therapeutic endoscopy in the esophageal benign diseases

Over the past 30 years, the field of endoscopy has witnessed several advances. With the advent of endoscopic mucosal resection, removal of large mucosal lesions have become possible. Thereafter, endoscopic submucosal resection was refined, permitting en bloc removal of large superficial neoplasms. Such techniques have facilitated the development of antireflux mucosectomy, a promising novel treatment for gastroesophageal reflux. The introduction and use of over the scope clips has allowed for endoscopic closure of defects in the gastrointestinal tract, which were traditionally treated with surgical intervention. With the development of per-oral endoscopic myotomy (POEM), the treatment of achalasia and spastic disorders of the esophagus have been revolutionized. From the submucosal tunnelling technique developed for POEM, Per oral endoscopic tumor resection of subepithelial tumors was made possible. Simultaneously, advances in biotechnology have expanded esophageal stenting capabilities with the introduction of fully covered metal and plastic stents, as well as biodegradable stents. Once deemed a primarily diagnostic tool, endoscopy has quickly transcended to a minimally invasive intervention and therapeutic tool. These techniques are reviewed with regards to their application to benign disease of the esophagus.

Barrett's oesophagus: treatment with surgery

Barrett's oesophagus develops as a consequence of gastro-oesophageal reflux disease and may progress to oesophageal adenocarcinoma. Antireflux surgery is an option for patients with reflux disease, but the efficacy and impact on the natural history of disease in patients with Barrett's oesophagus is controversial. This review addresses the existing data on these important issues.

Would you have laparoscopic Nissen fundoplication again? A patient satisfaction survey in a UK population

OBJECTIVE

Laparoscopic Nissen fundoplication (LNF) effectively reduces objective gastro-oesophageal reflux. It can however cause side effects which affect quality of life or fail to improve subjective reflux symptoms. This study aims to assess patient satisfaction following LNF by assessing whether patients would have the procedure again.

DESIGN

Telephone survey using a structured questionnaire. Participation was voluntary.

SETTING

UK Foundation Trust (two university hospitals).

PATIENTS

All patients who had LNF performed by a single surgeon between November 2008 and June 2012.

MAIN OUTCOME MEASURES

Primarily, current reflux symptoms, antiacid medication requirement and whether participants would choose to have the procedure again (should they still have their initial symptoms). Further measures were conversion to open procedure, need for redo or reversal, and mortality.

RESULTS

99 patients underwent LNF in the quoted period; 71 were contactable and willing to participate. Of the 99, two required redo operations (neither of whom was contactable), and one had a reversal (primary operation included). Median time since the operation was 33 months (range 5-48 months). Compared with preoperatively, 72% rated their current reflux-symptom severity as ≤2/10, 23% as 3-6/10 and 4% as 7-10/10. 75% were not taking any antiacid medication. 89% of patients said that they would have the procedure again.

CONCLUSIONS

This study provides supporting evidence that LNF improves reflux symptoms and decreases medication use at intermediate-term follow-up. These results will aid counselling and reassurance of patients regarding the risks and benefits of LNF as the majority of postoperative patients were sufficiently satisfied to choose the operation again.

Modern medical and surgical management of difficult-to-treat GORD

Approximately 30-40% of patients taking proton pump inhibitors (PPIs) for presumed gastro-oesophageal reflux (GOR) symptoms do not achieve adequate symptom control, especially when no oesophageal mucosal breaks are present at endoscopy and when extra-oesophageal symptoms are concerned. After failure of optimization of medical therapy, a careful work up is mandatory that aims at determining whether symptoms are related to GOR or not. Most patients with refractory symptoms do not have GOR-related symptoms. Some may have symptoms related to weakly acidic reflux and/or oesophageal hypersensitivity. Baclofen is currently the only antireflux compound available as add-on therapy to PPIs, but its poor tolerability limits its use in clinical practice. There is room for pain modulators in patients with hypersensitive oesophagus and functional heartburn. Antireflux surgery is a suitable option in patients responding to medical therapy who want to avoid taking medication or if persisting symptoms can be clearly attributed to poorly controlled GOR.

[The Mexican consensus on gastroesophageal reflux disease. Part II]

OBJECTIVE

To update the themes of endoscopic and surgical treatment of Gastroesophageal Reflux Disease (GERD) from the Mexican Consensus published in 2002.

METHODS

Part I of the 2011 Consensus dealt with the general concepts, diagnosis, and medical treatment of this disease. Part II covers the topics of the endoscopic and surgical treatment of GERD. In this second part, an expert in endoscopy and an expert in GERD surgery, along with the three general coordinators of the consensus, carried out an extensive bibliographic review using the Embase, Cochrane, and Medline databases. Statements referring to the main aspects of endoscopic and surgical treatment of this disease were elaborated and submitted to specialists for their consideration and vote, utilizing the modified Delphi method. The statements were accepted into the consensus if the level of agreement was 67% or higher.

RESULTS

Twenty-five statements corresponding to the endoscopic and surgical treatment of GERD resulted from the voting process, and they are presented herein as Part II of the consensus. The majority of the statements had an average level of agreement approaching 90%.

CONCLUSION

Currently, endoscopic treatment of GERD should not be regarded as an option, given that the clinical results at 3 and 5 years have not demonstrated durability or sustained symptom remission. The surgical indications for GERD are well established; only those patients meeting the full criteria should be candidates and their surgery should be performed by experts.

Minimal access surgery compared with medical management for gastro-oesophageal reflux disease: five year follow-up of a randomised controlled trial (REFLUX)

OBJECTIVES

To determine the long term clinical effectiveness of laparoscopic fundoplication as an alternative to drug treatment for chronic gastro-oesophageal reflux disease (GORD).

DESIGN

Five year follow-up of multicentre, pragmatic randomised trial (with parallel non-randomised preference groups).

SETTING

Initial recruitment in 21 UK hospitals.

PARTICIPANTS

Responders to annual questionnaires among 810 original participants. At entry, all had had GORD for >12 months.

INTERVENTION

The surgeon chose the type of fundoplication. Medical therapy was reviewed and optimised by a specialist. Subsequent management was at the discretion of the clinician responsible for care, usually in primary care.

MAIN OUTCOME MEASURES

Primary outcome measure was self reported quality of life score on disease-specific REFLUX questionnaire. Other measures were health status (with SF-36 and EuroQol EQ-5D questionnaires), use of antireflux medication, and complications.

RESULTS

By five years, 63% (112/178) of patients randomised to surgery and 13% (24/179) of those randomised to medical management had received a fundoplication (plus 85% (222/261) and 3% (6/192) of those who expressed a preference for surgery and for medical management). Among responders at 5 years, 44% (56/127) of those randomised to surgery were taking antireflux medication versus 82% (98/119) of those randomised to medical management. Differences in the REFLUX score significantly favoured the randomised surgery group (mean difference 8.5 (95% CI 3.9 to 13.1), P<0.001, at five years). SF-36 and EQ-5D scores also favoured surgery, but were not statistically significant at five years. After fundoplication, 3% (12/364) had surgical treatment for a complication and 4% (16) had subsequent reflux-related operations-most often revision of the wrap. Long term rates of dysphagia, flatulence, and inability to vomit were similar in the two randomised groups.

CONCLUSIONS

After five years, laparoscopic fundoplication continued to provide better relief of GORD symptoms than medical management. Adverse effects of surgery were uncommon and generally observed soon after surgery. A small proportion had re-operations. There was no evidence of long term adverse symptoms caused by surgery.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN15517081.

Length and pressure of the reconstructed lower esophageal sphincter is determined by both crural closure and Nissen fundoplication

BACKGROUND

Laparoscopic Nissen fundoplication is comprised of: a wrap thought responsible for the lower esophageal sphincter function and crural closure performed to prevent herniation. We hypothesized gastroesophageal junction competence effected by Nissen fundoplication results from closure of the crural diaphragm and creation of the fundoplication.

METHODS

Patients with uncomplicated reflux undergoing Nissen fundoplication were prospectively enrolled. After hiatal dissection, patients were randomized to crural closure followed by fundoplication (group 1) or fundoplication followed by crural closure (group 2). Intra-operative high-resolution manometry collected sphincter pressure and length data after complete dissection and after each component repair.

RESULTS

Eighteen patients were randomized. When compared to the completely dissected hiatus, the mean sphincter length increased 1.3 cm (p < 0.001), and mean sphincter pressure was increased by 13.7 mmHg (p < 0.001). Groups 1 and 2 had similar sphincter length and pressure changes. Crural closure and fundal wrap contribute equally to sphincter length, although crural closure appears to contribute more to sphincter pressure.

CONCLUSION

The Nissen fundoplication restores the function of the gastroesophageal junction and thus the reflux barrier by means of two main components: the crural closure and the construction of a 360° fundal wrap. Each of these components is equally important in establishing both increased sphincter length and pressure.

Gastric exocrine and endocrine cell morphology under prolonged acid inhibition therapy: results of a 5-year follow-up in the LOTUS trial

BACKGROUND

Sustained acid inhibition with PPI stimulates gastrin secretion, exerting a proliferative drive on enterochromaffin-like cells (ECL cells) of the oxyntic mucosa. It may also accelerate development of gastric gland atrophy in Helicobacter pylori-infected individuals.

AIMS

To evaluate gastric exocrine and endocrine cell changes in GERD patients randomised to laparoscopic antireflux surgery (LARS, n = 288) or long-term (5 years) esomeprazole (ESO) treatment (n = 266).

METHODS

Antral and corpus biopsies were taken at endoscopy and serum gastrin and chromogranin A levels were assayed, at baseline and after 1, 3 and 5 years' therapy.

RESULTS

Biopsies were available at each time point for 158 LARS patients and 180 ESO patients. In H. pylori-infected subjects, antral mucosal inflammation and activity improved significantly (P < 0.001) and stabilised after 3 years on esomeprazole while no change in inflammation was observed after LARS. Oxyntic mucosal inflammation and activity remained stable on esomeprazole but decreased slightly over time after LARS. Neither intestinal metaplasia nor atrophy developed in the oxyntic mucosa. ECL cell density increased significantly after ESO (P < 0.001), corresponding with an increase in circulating gastrin and chromogranin A. After LARS, there was a significant decrease in ECL cell density (P < 0.05), accompanied by a marginal decrease in gastrin and chromogranin.

CONCLUSIONS

Antral gastritis improved in H. pylori-infected GERD patients after 5 years on esomeprazole, with little change in laparoscopic antireflux surgery patients, who acted as a control. Despite a continued proliferative drive on enterochromaffin-like cells during esomeprazole treatment, no dysplastic or neoplastic lesions were found and no safety concerns were raised. NCT 00251927.

Hiatal hernia, Barrett's esophagus, and long-term symptom control after laparoscopic fundoplication for gastroesophageal reflux

BACKGROUND

The aim of this study was to determine the long-term symptom control after laparoscopic fundoplication for gastroesophageal reflux disease (GERD), and possible prognostic factors.

METHODS

A cohort of 271 patients, operated on at a university hospital from 1996 through 2002, was eligible for evaluation after a median interval of 102 months (range = 12-158). The time between surgery and recurrence of reflux symptoms (i.e., time to treatment failure) served as the end point for statistical analysis. Putative risk factors for symptom recurrence were analyzed by univariate analysis and by using Cox's multiple-hazards regression.

RESULTS

According to Kaplan-Meier estimates, the rate of reflux symptom recurrence was 15 % after 108 months, 11 % in cases without intestinal metaplasia, but 43 % in patients with long-segment (≥ 3 cm) Barrett's esophagus (BE; p < 0.0001). Reflux symptoms recurred in 22 % of cases with a hiatal hernia (HH) ≥ 3 cm before operation, but only in 7 % with smaller or absent HH (p = 0.005). Multivariate analysis revealed a relative risk of 6.6 (CI = 3.0-13.0) for long-segment BE and 3.0 (CI = 1.7-10.1) for HH ≥ 3 cm. A strong statistical interaction was found between HH ≥ 3 cm and long-segment BE: the small group (n = 18) of cases exhibiting both risk factors had an exaggerated recurrence rate of 72 % at 108 months.

CONCLUSIONS

Laparoscopic fundoplication for symptomatic GERD provided a long-lasting abolition of reflux symptoms in 231 of 271 (85 %) patients. HH ≥ 3 cm and long-segment BE were shown as independent prognostic factors favoring recurrence.

SSAT maintenance of certification: literature review on gastroesophageal reflux disease and hiatal hernia

BACKGROUND

This article reviews the current literature pertaining to the diagnosis and management of gastroesophageal reflux disease (GERD) and hiatal hernia.

DISCUSSION

GERD is one of the most common gastrointestinal disorders in the USA. For effective management, a conclusive diagnosis must be made. Most patients are effectively managed by acid suppression therapy, whereas others require procedural treatment. Endoluminal treatment of GERD is an option, but long-term results of this therapy are unknown. The "gold standard" surgical treatment of GERD is laparoscopic Nissen fundoplication. Large hiatal hernias are difficult to manage with a relatively high rate of recurrent hiatal hernia.

CONCLUSION

Whether or not to use mesh at the hiatus to decrease this occurrence is currently debatable.

Total or posterior partial fundoplication in the treatment of GERD: results of a randomized trial after 2 decades of follow-up

OBJECTIVE AND BACKGROUND

We lack long-term data (>10 years) on the efficacy of antireflux surgery when evaluated within the framework of randomized clinical trials Hereby we report the outcome of a randomized trial comparing open total (I) and a Toupet posterior partial fundoplication (II) performed between 1983 and 1991.

METHODS

One hundred and thirty-seven patients with gastroesophageal reflux disease and were enrolled into the study. The mean follow up has now reached 18 years. During these years 26% had died and 16% were unable to trace for follow up. Symptom outcomes were assessed by the use of validated self-reporting questionnaires.

RESULTS

Long-term control of heartburn and acid regurgitation (reported as no or mild symptoms) were reported by 80% and 82% after a total fundoplication (I) and corresponding figures were 87% and 90% after a partial posterior fundoplication (II), respectively (n.s.).The dysphagia scores were low 4.6 ± 1.3 (SEM) in group I and 3.3 ± 0.9 (SEM) in group II (n.s). The point prevalences of rectal flatulence and gas distension related complaints were of similar magnitude in the 2 groups. Twenty-three percentage of the patients in the total fundoplication group noted some ability to vomit compared with 31% in the partial posterior fundoplication group.

CONCLUSIONS

Both a total and a partial posterior fundoplication maintain a high level of reflux control after 2 decades of follow up. The previously reported differences in mechanical side effects, in favor of the partial wrap, seemed to disappear over time.

Partial or total fundoplication (with or without division of the short gastric vessels): which is the best laparoscopic choice in GERD surgical treatment?

BACKGROUND

Gastroesophageal reflux disease (GERD) has emerged as one of the most common diseases in the modern civilization.The immense success of laparoscopic surgery as an effective treatment of GERD has established the minimally invasive surgery as the gold standard for this condition with lower morbidity and mortality, shorter hospital stay, faster recovery, and reduced postoperative pain.

METHODS

Articles were sourced from PubMed and Medline, using the MeSH terms "gastroesophageal reflux disease" and "laparoscopic surgery" and "fundoplication technique." The selection of articles was based on peer review, journal, relevance, and English language.

RESULTS AND CONCLUSIONS

There are some controversies with regard to the technique. First, whether total or partial fundoplication is the more appropriate treatment for GERD; second, if a total fundoplication (360 degrees) is performed, what is the effect of fundic mobilization and the division of short gastric vessels. In this review article the authors evaluate the most recent articles to establish the parameters for a "gold standard technique" in antireflux surgery.

Surgical therapy of gastro-oesophageal reflux disease

Surgery should always be looked upon as complementary to medical therapy in the long-term management of patients with chronic GORD. Available medical therapies are effective and adequate for the control of disease manifestations in the great majority of GORD patients. For patients who have a suboptimal disease control under medical therapy and in those who for various reasons want to discuss an alternative to medical long-term therapy, the following message can be transmitted. Anti reflux surgery is a well-documented effective long-term therapeutic alternative to control GORD. The outcome after surgery is dependent on the experience and quality of the surgeon. These operations are safe but mortality can never attain a zero level and the morbidity has to be realised. Anti reflux surgery has to be centralised within each country. With the aim of optimising the outcome of anti reflux surgery, the surgeon has to perform and master a delicate act of balance on the choice between various fundoplication procedures. On one hand we have the total fundoplication with its proved efficacy regarding reflux control but with it associated somewhat more frequent mechanical side-effects. The posterior partial fundoplication has obvious advantages with less postfundoplication complaints without compromising the level of reflux control and can therefore often be recommended. Most studies present very promising results following anterior partial fundoplications. The spectrum of postfundoplication symptoms can be minimised provided that the surgeon fully comprehend the mechanism of action of these procedures and adhere to technical perfectionism. Evaluation and management of failures after anti reflux surgery have to be centralised within each country.

Long-term outcome of microscopic esophagitis in chronic GERD patients treated with esomeprazole or laparoscopic antireflux surgery in the LOTUS trial

OBJECTIVES

Gastroesophageal reflux disease (GERD)-associated changes in esophageal histology have been reported mainly after short-term medical antireflux therapy, and few individual lesions have been examined. We report detailed histological findings from the LOTUS study, at baseline and at 1 and 3 years after laparoscopic antireflux surgery (LARS) or esomeprazole treatment in patients with chronic GERD.

METHODS

LOTUS is a long-term, open, parallel-group, multicenter, randomized, controlled trial conducted in 11 European countries that compared LARS (n=248) with esomeprazole 20-40 mg daily (n=266). Biopsies from the distal esophagus 2 cm above the Z-line and at the Z-line were taken at baseline, and 1 and 3 years. The following lesions were assessed: basal cell hyperplasia (BCH), papillary elongation (PE), intercellular space dilatations (ISDs), intraepithelial eosinophils (EOSs), neutrophils, and necrosis/erosion. A severity score (SS, range 0-2) was calculated by taking the average score of all assessable lesions.

RESULTS

All lesions were more severe on Z-line biopsies than at 2 cm, and almost all improved significantly from baseline to 1 and 3 years. The average SS (from 2 cm to Z-line) changed from 0.95 to 0.57 (1 year) and to 0.49 (3 years) on esomeprazole, and from 0.91 to 0.56 (1 year) and to 0.52 (3 years) after LARS (P<0.001 for both treatments at 1 and 3 years, with no significant difference between treatments). The proportions of patients with severe histological changes decreased from approximately 50% at baseline to 11% at 3 years.

CONCLUSIONS

Both continuous esomeprazole treatment and laparoscopic fundoplication are associated with significant and similar overall improvement in microscopic esophagitis after 1 year that is maintained at 3 years.

Nationwide survey of long-term results of laparoscopic antireflux surgery in Sweden

OBJECTIVE

Excellent results after laparoscopic antireflux surgery (LARS) have been reported from specialized clinics. These good results were not confirmed in a nationwide survey that studied procedures carried out in 1995-96 in Sweden. Critics pointed out that this study included the learning curve of laparoscopy. Therefore, we have repeated the survey after >5000 LARS procedures have been performed.

MATERIAL AND METHODS

A random sample of 236 patients operated on in 2000 was identified (Group I) and compared to the population operated on in 1995-96 (Group II). Both groups received a disease-specific questionnaire 4 years after surgery.

RESULTS

In Group I, 6.8% of patients had had a second procedure, 16.4% used antireflux medications regularly and 14.9% were dissatisfied. The results for Group II were 6.0%, 19.5% and 15.0%, respectively. Patients reporting any of these three conditions were classified as treatment failures. Treatment failure occurred in 25.4% and 29.0% of patients in Groups I and II, respectively.

CONCLUSIONS

The nationwide long-term outcome after LARS in Sweden demonstrates that approximately a quarter of patients experience some sort of treatment failure. The results seem to be consistent, even though the surgical technique ought to be well implemented after >8years of common use.

Medical versus surgical management for gastro-oesophageal reflux disease (GORD) in adults

BACKGROUND

Gastro-oesophageal reflux disease (GORD) is a common condition with up to 20% of patients from Westernised countries experiencing heartburn, reflux or both intermittently. It is unclear whether medical or surgical (laparoscopic fundoplication) management is the most clinically and cost-effective treatment for controlling GORD.

OBJECTIVES

To compare the effects of medical management versus laparoscopic fundoplication surgery on health-related and GORD-specific quality of life (QOL) in adults with GORD.

SEARCH STRATEGY

We searched CENTRAL (Issue 2, 2009), MEDLINE (1966 to May 2009) and EMBASE (1980 to May 2009). We handsearched conference abstracts and reference lists from published trials to identify further trials. We contacted experts in the field for relevant unpublished material.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials comparing medical management with laparoscopic fundoplication surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data from articles identified for inclusion and assessed the methodological quality of eligible trials. Primary outcomes were: health-related and GORD-specific QOL, heartburn, regurgitation and dysphagia.

MAIN RESULTS

Four trials were included with a total of 1232 randomised participants. Health-related QOL was reported by four studies although data were combined using fixed-effect models for two studies (Anvari 2006; REFLUX Trial 2008). There were statistically significant improvements in health-related QOL at three months and one year after surgery compared to medical therapy (mean difference (MD) SF36 general health score -5.23, 95% CI -6.83 to -3.62; I(2) = 0%). All four studies reported significant improvements in GORD-specific QOL after surgery compared to medical therapy although data were not combined. There is evidence to suggest that symptoms of heartburn, reflux and bloating are improved after surgery compared to medical therapy, but a small proportion of participants have persistent postoperative dysphagia. Overall rates of postoperative complications were low but surgery is not without risk and postoperative adverse events occurred although they were uncommon. The costs of surgery are considerably higher than the cost of medical management although data are based on the first year of treatment therefore the cost and side effects associated with long-term treatment of chronic GORD need to be considered.

AUTHORS' CONCLUSIONS

There is evidence that laparoscopic fundoplication surgery is more effective than medical management for the treatment of GORD at least in the short to medium term. Surgery does carry some risk and whether the benefits of surgery are sustained in the long term remains uncertain. Treatment decisions for GORD should be based on patient and surgeon preference.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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