Effect of partial and total laparoscopic fundoplication on esophageal body motility

LAPAROSCOPIC ANTIREFLUX SURGERY: WERE OLD QUESTIONS ANSWERED? PARTIAL OR TOTAL FUNDOPLICATION?

Laparoscopic total fundoplication is currently considered the gold standard for the surgical treatment of gastroesophageal reflux disease. Short-term outcomes after laparoscopic total fundoplication are excellent, with fast recovery and minimal perioperative morbidity. The symptom relief and reflux control are achieved in about 80 to 90% of patients 10 years after surgery. However, a small but clinically relevant incidence of postoperative dysphagia and gas-related symptoms is reported. Debate still exists about the best antireflux operation; during the last three decades, the surgical outcome of laparoscopic partial fundoplication (anterior or posterior) were compared to those achieved after a laparoscopic total fundoplication. The laparoscopic partial fundoplication, either anterior (180°) or posterior, should be performed only in patients with gastroesophageal reflux disease secondary to scleroderma and impaired esophageal motility, since the laparoscopic total fundoplication would impair esophageal emptying and cause dysphagia.

Nissen Versus Toupet Fundoplication For Gastro-oesophageal Reflux Disease, Short And Long-term Outcomes. A Systematic Review And Meta-analysis

BACKGROUND

Gastroesophageal reflux disease (GERD) remains one of the most commonly encountered gastrointestinal disorders. Proton pump inhibitors still show an inadequate effect on about 10% to 40% of the patients. Laparoscopic antireflux surgery is the surgical alternative for managing GERD in patients who are not responding to proton pump inhibitors.

AIM OF THE STUDY

This study objected at comparing laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication (LTF) concerning the short-term and long-term outcomes.

PATIENTS AND METHODS

This is a systematic review and meta-analysis that evaluated the studies comparing between Nissen fundoplication and LTF for the treatment of GERD. Studies were obtained by searching on the EMBASE, the Cochrane Central Register of Controlled Trials, and PubMed central database.

RESULTS

The LTF group showed significantly longer operation time, less postoperative dysphagia and gas bloating, less pressure on the lower esophageal sphincter, and higher Demeester scores. No statistically significant differences were found between the 2 groups in the perioperative complications, the recurrence of GERD, the reoperation rate, the quality of life, or the reoperation rate.

CONCLUSION

LTF is favored for the surgical treatment of GERD being of lower postoperative dysphagia and gas bloating rates. These benefits were not at the expense of significantly additional perioperative complications or surgery failure.

The prevalence of gastroesophageal reflux disease in named manometric patterns of dysmotility according to the Chicago Classification 4.0

Esophageal motility disorders (EMD) may be considered primary disorders only in the absence of gastroesophageal reflux disease (GERD). If GERD is present, treatment should be directed toward correction of the abnormal reflux. The actual prevalence of GERD in manometric dysmotility patterns according to the new Chicago Classification 4.0 (CC4) is still elusive. This study aims to evaluate the prevalence of GERD in patients with esophageal motility disorders according to the CC4. We reviewed 400 consecutive patients that underwent esophageal manometry and pH monitoring. Esophageal motility was classified according to the CC4 and GERD + was defined by a DeMeester score > 14.7. Normal motility or unclassified dysmotility was present in 290 (73%) patients, with GERD+ in 184 of them (63%). There were a total of 110 patients (27%) with named esophageal motility disorders, with GERD+ in 67 (61%). The incidence of ineffective esophageal motility was 59% (n = 65) with 69% GERD +, diffuse esophageal spasm was 40% (n = 44) with 48% GERD +, and hypercontractile esophagus was 0.01% (n = 1) with 100% GERD +. There was no correlation between the presence of GERD and the number of non-peristaltic swallows. Our results show that: (i) manometry only is not enough to select patients' treatment as >60% of patients with named esophageal motility disorders have GERD; (ii) there was no correlation between the presence of GERD and the number of non-peristaltic swallows.

Factors affecting the treatment outcomes of laparoscopic fundoplication for erosive reflux esophagitis: findings of esophageal pathological function tests

PURPOSE

To identify the factors that affect laparoscopic fundoplication (LF) treatment efficacy in patients with erosive gastroesophageal reflux disease (e-GERD) esophagitis, based on the findings of multichannel intraluminal impedance pH (MII-pH) and high-resolution manometry (HRM).

METHODS

The subjects were 102 patients with e-GERD diagnosed by endoscopy, who underwent LF as the initial surgery. To analyze the findings of MII-pH and HRM, the patients were divided into two groups: a cured group (CR), comprised of patients whose esophagitis was cured postoperatively; and a recurrence group (RE), comprised of patients who suffered recurrent esophagitis.

RESULTS

There were 96 patients in the CR group and 6 in the RE group. MII-pH indicated that the acid reflux time, the longest reflux time, and the number of refluxes longer than 5 min, were significantly higher in the RE group than in the CR group (p = 0.0028, p = 0.0008, p = 0.012, respectively). The HRM indicated that only the distal contractile integral (DCI) was significantly lower in the RE group (p = 0.0109).

CONCLUSION

The results of this study indicate that esophageal clearance may affect the treatment outcome of LF. Based on the findings of MII-pH, the longest reflux time and the number of refluxes longer than 5 min were important factors influencing the therapeutic effect, whereas based on the HRM, the DCI value was most important.

Ineffective Esophageal Motility in Patients with GERD is no Contraindication for Nissen Fundoplication

BACKGROUND

Patients with preoperative ineffective esophageal motility (IEM) are thought to be at increased risk for postoperative dysphagia leading to the recommendations for tailoring or avoiding anti-reflux surgery in these patients. The aim of this study was to evaluate if IEM has an influence on postoperative outcome after laparoscopic Nissen fundoplication (LNF).

METHODS

Seventy-two consecutive patients with IEM underwent LNF and were case-matched with 72 patients without IEM based on sex, age, BMI, HH size, total pH percentage time, total number of reflux episodes and the presence of BE. Standardized interview assessing postoperative gastrointestinal symptoms, proton pump inhibitor intake, GERD-health-related-quality-of-life (GERD-HRQL), alimentary satisfaction and patients' overall satisfaction was evaluated.

RESULTS

Although a higher rate of preoperative dysphagia was observed in patients with IEM (29% IEM vs. 11% no IEM, p = 0.007), there was no significant difference in rates of dysphagia postoperatively (2 IEM vs. 1 no IEM, p = 0.559). Furthermore, no distinction was found in the postoperative outcome regarding symptom relief, quality of life, gas bloating syndrome, ability to belch and/or vomit or revision surgery between the two groups.

CONCLUSION

Although preoperative IEM has an influence on GERD presentation, it has no effect on postoperative outcome after LNF. IEM should not be a cause for avoiding LNF, as is has been shown as the most effective and safe anti-reflux treatment.

Tailoring Endoscopic and Surgical Treatments for Gastroesophageal Reflux Disease

The incidence of gastroesophageal reflux disease (GERD) remains on the rise. Pathophysiology of GERD is multifactorial, revolving around an incompetent esophagogastric junction as an antireflux barrier, with other comorbid conditions contributing to the disease. Proton pump inhibitors remain the most common treatment of GERD. Endoscopic therapy has gained popularity as a less invasive option. The presence of esophageal dysmotility complicates the choice of surgical fundoplication. Most literature demonstrates that fundoplication is safe in the setting of ineffective or weak peristalsis and that postoperative dysphagia cannot be predicted by preoperative manometry parameters. More data are needed on the merits of endoluminal approaches to GERD.

Outcomes of Laparoscopic Nissen Fundoplication in Patients with Manometric Patterns of Esophageal Motility Disorders

The manometric pattern of either diffuse esophageal spasm (DES), nutcracker esophagus (NE), or hypertensive lower esophageal sphincter (HLES) in the presence of gastroesophageal reflux disease (GERD) is considered a secondary finding and treatment should be directed toward GERD. This study aims to evaluate the outcomes of laparoscopic Nissen fundoplication (LNF) in patients with manometric patterns of esophageal motility disorders. Patients with GERD confirmed by pH monitoring and manometric pattern of DES (simultaneous contractions 20 to 90% of wet swallows), NE (increased mean distal amplitude greater than 180 mmHg), or HLES (lower esophageal sphincter pressure greater than 45 mmHg) who underwent LNF were studied. A group of 50 consecutive patients with normal esophageal motility who underwent LNF were used as control subjects. Groups were comparable to control subjects for age, gender, preoperative symptoms, hiatal hernia, and Barrett's esophagus, except for NE that had younger individuals and a lower rate of hiatal hernia. Symptomatic outcome was similar when groups were compared with control subjects. Transient dysphagia was present in the postoperative period in 33, 7, 0, and 20 per cent of the patients with HLES, DES, NE, and control subjects, respectively. LNF is an adequate treatment for patients with GERD and manometric patterns of esophageal motility disorders.

Surgical Management of Gastroesophageal Reflux Disease in Patients with Severe Esophageal Dysmotility

BACKGROUND

Gastroesophageal reflux disease (GERD) and esophageal dysmotility are often disqualifying criteria for fundoplication due to dysphagia complications. A tailored partial fundoplication may improve GERD in patients with severe esophageal motility disorders. We evaluate this approach on GERD improvement in non-achalasia esophageal dysmotility patients.

METHODS

A single-institution prospective database was reviewed (2007-2016), with inclusion criteria of GERD, previous diagnosis of non-achalasia esophageal motility disorder, and laparoscopic partial fundoplication. Diagnosis of previous achalasia diagnosis or diffused esophageal spasm was excluded. Motility studies, pre- and post-upper gastrointestinal imaging (UGI), esophageal symptom scores, antacid, and PPI use were collected pre-op, 6 months, 12 months, and long-term (LT). Statistical analysis was made using SPSS v.23.0.0, α = 0.05.

RESULTS

Fifty-two patients met the inclusion criteria. A total of 17.3% had esophageal body amotility, 79.6% had severe esophageal dysmotility. A total of 65.9% women (mean age 64 ± 15.7), mean peristalsis 45.3 ± 32.6%, and failed peristalsis 36.0 ± 32.2%. Mean LES residual pressure was 15.0 ± 18.0 mmHg, and 40.7% had hypotensive LES. Mean follow-up time was 25 months [1-7 years], with significant improvement in symptoms and reduction in PPI and antacid use at all time-points compared to pre-op. A total of 74% had UGI studies at 12 months; all showed persistent dysmotility. Six patients had radiographic hiatal hernia recurrence, with only one being clinically symptomatic postoperatively. Three required dilation for persistent dysphagia.

CONCLUSIONS

A tailored partial fundoplication may be effective in symptom relief for non-achalasia patients with esophageal motility disorders and GERD. Significant symptom improvement, low HHR, and PPI use clearly indicate this approach to be effective for this population.

THE ROLE OF THE TRANSDIAPHRAGMATIC PRESSURE GRADIENT IN THE PATHOPHYSIOLOGY OF GASTROESOPHAGEAL REFLUX DISEASE

ABSTRACT Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract in the Western world. GERD pathophysiology is multifactorial. Different mechanisms may contribute to GERD including an increase in the transdiaphragmatic pressure gradient (TPG). The pathophysiology of GERD linked to TPG is not entirely understood. This review shows that TPG is an important contributor to GERD even when an intact esophagogastric barrier is present in the setting of obesity and pulmonary diseases.

Gastroesophageal Reflux and Idiopathic Pulmonary Fibrosis

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease of unknown origin that affects about 40,000 new patients every year in the USA. Albeit the disease is labelled as idiopathic, it is thought that pathologic reflux, often silent, plays a role in its pathogenesis through a process of microaspiration of gastric contents.

AIMS

The aim of this study was to review the available evidence linking reflux to IPF, and to study the effect of medical and surgical therapy on the natural history of this disease.

RESULTS

Medical therapy with acid-reducing medications controls the production of acid and has some benefit. However, reflux and aspiraion of weakly acidic or alkaline gastric contents can still occur. Better results have been reported after laparoscopic anti-reflux surgery, as this form of therapy re-establishes the competence of the lower esophageal sphincter, therefore stopping any type of reflux.

CONCLUSIONS

A phase II NIH study in currently in progress in the USA to determine the role of antireflux surgery in patients with GERD and IPF. The hope is that this simple operations might alter the natural history of IPF, avoiding progression and the need for lung transplantation.

Antireflux Surgery and Barrett's Esophagus: Myth or Reality?

BACKGROUND

It may seem questionable if antireflux surgery still has a role in the management of patients with Barrett's esophagus (BE) in the current era when antireflux surgery is facing a steady decline, obesity is increasing, pharmacologic treatment for gastroesophageal reflux disease (GERD) is in its splendor, and endoscopic techniques are used more frequently. It is questionable if patients with BE should be operated to stop GERD and to prevent cancer. The aim of this study was to determine the role of antireflux surgery in patients with BE.

METHODS

Literature review.

RESULTS

The role of antireflux operations is, in fact, very controversial and neglected. BE is a different phenotype of GERD with a distinct pathophysiology linked to severe reflux of bile and acid, due to a marked anatomic disruption of the gastroesophageal barrier. Published series show that a fundoplication adequately controls GERD and symptoms in BE patients. A fundoplication (or even better a bile diversion antireflux procedure) may prevent esophageal adenocarcinoma.

CONCLUSIONS

In conclusion, a fundoplication efficiently controls GERD and symptoms in BE patients. A fundoplication (or even better a bile diversion procedure) may also prevent esophageal adenocarcinoma.

Understanding the Chicago Classification: From Tracings to Patients

Current parameters of the Chicago classification include assessment of the esophageal body (contraction vigour and peristalsis), lower esophageal sphincter relaxation pressure, and intra-bolus pressure pattern. Esophageal disorders include achalasia, esophagogastric junction outflow obstruction, major disorders of peristalsis, and minor disorders of peristalsis. Sub-classification of achalasia in types I, II, and III seems to be useful to predict outcomes and choose the optimal treatment approach. The real clinical significance of other new parameters and disorders is still under investigation.

Omission of preoperative esophageal manometry does not alter operative approach or postoperative dysphagia following laparoscopic paraesophageal hernia repair

Routine esophageal manometry for surgical planning before laparoscopic paraesophageal hernia (PEH) has been advocated in an effort to reduce the likelihood of postoperative dysphagia. The purpose of this study is to investigate whether omitting routine preoperative esophageal manometry is associated with a change in the type of fundoplication performed and with an increase in the incidence of postoperative dysphagia. A retrospective cohort study of consecutive patients with and without preoperative esophageal manometry undergoing PEH repair was performed between January 2011 and July 2014 at an academic medical center. Demographic and outcome data were collected in a prospective database. The primary outcome measures were the type of fundoplication performed and postoperative disease-specific quality-of-life (GERD-HRQL) dysphagia score. Secondary outcome measures were total GERD-HRQL score, proton pump inhibitor (PPI) use, and requirement for endoscopic dilation. One hundred twenty-five patients underwent laparoscopic PEH repair. Forty-seven (37%) patients had preoperative manometry and 79 (63%) did not. Patients who did not have manometry were older (67.9 ± 14.3 vs. 61.7 ± 13.5, P = 0.02), but the groups did not differ in terms of BMI, gender, PPI use, baseline GERD-HRQL dysphagia score, or baseline total GERD-HRQL score. Sixty-nine (87%) patients without manometry and 43 (93%) patients with manometry underwent a complete fundoplication (P = 0.55). At a median follow-up of 16 (4-44) months, the median GERD-HRQL dysphagia scores (0(0-1) vs. 0(0-1); P = 0.66) and total GERD-HRQL scores (3(1-8) vs. 4(0-8); P = 0.72) were equivalent between the groups. Equivalent proportion of patients without and with preoperative manometry used PPI (9% vs. 21%; P = 0.06) and required endoscopic dilation (6% vs. 6%; P = 0.99) in the postoperative period. Omission of routine preoperative manometry prior to laparoscopic PEH repair is not associated with a change in the type of fundoplication performed, an increased incidence of postoperative dysphagia, or an increased requirement for postoperative endoscopic dilation.

Primary Esophageal Motility Disorders: Beyond Achalasia

The best-defined primary esophageal motor disorder is achalasia. However, symptoms such as dysphagia, regurgitation and chest pain can be caused by other esophageal motility disorders. The Chicago classification introduced new manometric parameters and better defined esophageal motility disorders. Motility disorders beyond achalasia with the current classification are: esophagogastric junction outflow obstruction, major disorders of peristalsis (distal esophageal spasm, hypercontractile esophagus, absent contractility) and minor disorders of peristalsis (ineffective esophageal motility, fragmented peristalsis). The aim of this study was to review the current diagnosis and management of esophageal motility disorders other than achalasia.

Laparoscopic Partial Fundoplication in Case of Gastroesophageal Reflux Disease Patient with Absent Esophageal Motility

The surgical indications for the treatment of gastroesophageal reflux disease (GERD) in patients with esophageal motility disorders have been debated. We report a case of antireflux surgery performed in a patient with absent esophageal motility as categorized by the Chicago classification (2011). A 54-year-old man underwent laparoscopic Toupet fundoplication due to apparent GERD and desire to discontinue all medications. After surgery, his subjective symptoms improved. Furthermore, objective findings including manometry and 24-hour pH-metry also improved. In our experience, antireflux surgery can improve GERD symptoms patients, even with absent esophageal motility.

Upper aerodigestive tract disorders and gastro-oesophageal reflux disease

A wide variety of symptoms and diseases of the upper aerodigestive tract are associated to gastro-oesophageal reflux disease (GORD). These disorders comprise a large variety of conditions such as asthma, chronic otitis media and sinusitis, chronic cough, and laryngeal disorders including paroxysmal laryngospasm. Laryngo-pharyngeal reflux disease is an extraoesophageal variant of GORD that can affect the larynx and pharynx. Despite numerous research efforts, the diagnosis of laryngopharyngeal reflux often remains elusive, unproven and controversial, and its treatment is then still empiric. Aim of this paper is to review the current literature on upper aerodigestive tract disorders in relation to pathologic gastro-oesophageal reflux, focusing in particular on the pathophysiology base and results of the surgical treatment of GORD.

Esophageal motility abnormalities in gastroesophageal reflux disease

Esophageal motility abnormalities are among the main factors implicated in the pathogenesis of gastroesophageal reflux disease. The recent introduction in clinical and research practice of novel esophageal testing has markedly improved our understanding of the mechanisms contributing to the development of gastroesophageal reflux disease, allowing a better management of patients with this disorder. In this context, the present article intends to provide an overview of the current literature about esophageal motility dysfunctions in patients with gastroesophageal reflux disease. Esophageal manometry, by recording intraluminal pressure, represents the gold standard to diagnose esophageal motility abnormalities. In particular, using novel techniques, such as high resolution manometry with or without concurrent intraluminal impedance monitoring, transient lower esophageal sphincter (LES) relaxations, hypotensive LES, ineffective esophageal peristalsis and bolus transit abnormalities have been better defined and strongly implicated in gastroesophageal reflux disease development. Overall, recent findings suggest that esophageal motility abnormalities are increasingly prevalent with increasing severity of reflux disease, from non-erosive reflux disease to erosive reflux disease and Barrett’s esophagus. Characterizing esophageal dysmotility among different subgroups of patients with reflux disease may represent a fundamental approach to properly diagnose these patients and, thus, to set up the best therapeutic management. Currently, surgery represents the only reliable way to restore the esophagogastric junction integrity and to reduce transient LES relaxations that are considered to be the predominant mechanism by which gastric contents can enter the esophagus. On that ground, more in depth future studies assessing the pathogenetic role of dysmotility in patients with reflux disease are warranted.

Idiopathic pulmonary fibrosis and gastroesophageal reflux. Implications for treatment

BACKGROUND

Even though the pathogenesis of idiopathic pulmonary fibrosis (IPF) is unknown, there is mounting evidence that abnormal reflux (GERD) and aspiration of gastric contents may play a role in the pathogenesis of this disease.

AIMS

The aims of this study were to determine in patients with GERD and IPF: (a) the clinical presentation, (b) the esophageal function, and (c) the reflux profile.

METHODS

We compared the clinical presentation, the esophageal function (as defined by high-resolution manometry), and the reflux profile (by dual sensor pH monitoring) in 80 patients with GERD (group A) and in 22 patients with GERD and IPF (group B).

RESULTS

Heartburn was present in less than 60 % of patients with GERD and IPF. Lower esophageal sphincter pressure and peristalsis were normal in both groups, while the upper esophageal sphincter (UES) was more frequently hypotensive in IPF patients (p = 0.008). In patients with GERD and IPF, the proximal esophageal acid exposure was higher (p = 0.047) and the supine acid clearance was slower as compared with patients with GERD only (p < 0.001).

CONCLUSIONS

The results of this study show that in patients with GERD and IPF: (a) reflux is frequently silent, (b) with the exception of a weaker UES, the esophageal function is preserved, and (c) proximal reflux is more common, and in the supine position, it is coupled with a slower acid clearance. Because these factors predisposing IPF patients to the risk of aspiration, antireflux surgery should be considered early after the diagnosis of IPF and GERD is established.

The pulmonary side of reflux disease: from heartburn to lung fibrosis

INTRODUCTION

Gastroesophageal reflux disease (GERD) is the most prevalent gastrointestinal disorder in the USA. Heartburn is the symptom most commonly associated with this disease, and the highly commercialized medical treatment directed toward relief of this symptom represents a 10-billion-dollar-per-year industry.

DISCUSSION

Unfortunately, there is often little awareness that GERD can be potentially a lethal disease as it can cause esophageal cancer. Furthermore, there is even less awareness about the relationship between GERD and respiratory disorders with the potential for severe morbidity and even mortality.

Laparoscopic total fundoplication for gastroesophageal reflux disease. How I do it

INTRODUCTION

A laparoscopic fundoplication is considered today the procedure of choice for the treatment of gastroesophageal reflux disease (GERD).

DISCUSSION

Several eponyms are used in the literature to denote different antireflux operations: Nissen, Nissen-Rossetti, Toupet, Lind, Guarner, Hill, and Dor. We feel that it is more important to focus on the technical elements which make a fundoplication effective and long lasting. The type of fundoplication (total vs. partial) is tailored to the quality of esophageal peristalsis as documented by the preoperative manometry. In the USA, a partial fundoplication is chosen only for patients with very impaired or absent esophageal peristalsis.

CONCLUSION

This article describes the technique of laparoscopic total fundoplication for GERD. Partial fundoplication is performed following the same technical elements as the total fundoplication. A 240° to 270° wrap rather than a 360° wrap is performed.

Impact of minimally invasive surgery on the treatment of benign esophageal disorders

Thanks to the development of minimally invasive surgery, the last 20 years have witnessed a change in the treatment algorithm of benign esophageal disorders. Today a laparoscopic operation is the treatment of choice for esophageal achalasia and for most patients with gastroesophageal reflux disease. Because the pathogenesis of achalasia is unknown, treatment is palliative and aims to improve esophageal emptying by decreasing the functional obstruction at the level of the gastro-esophageal junction. The refinement of minimally invasive techniques accompanied by large, multiple randomized control trials with long-term outcome has allowed the laparoscopic Heller myotomy and partial fundoplication to become the treatment of choice for achalasia compared to endoscopic procedures, including endoscopic botulinum toxin injection and pneumatic dilatation. Patients with suspected gastroesophageal reflux need to undergo a thorough preoperative workup. After establishing diagnosis, treatment for gastroesophageal reflux should be individualized to patient characteristics and a decision about an operation made jointly between surgeon and patient. The indications for surgery have changed in the last twenty years. In the past, surgery was often considered for patients who did not respond well to acid reducing medications. Today, the best candidate for surgery is the patient who has excellent control of symptoms with proton pump inhibitors. The minimally invasive approach to antireflux surgery has allowed surgeons to control reflux in a safe manner, with excellent long term outcomes. Like achalasia and gastroesophageal reflux, the treatment of patients with paraesophageal hernias has also seen a major evolution. The laparoscopic approach has been shown to be safe, and durable, with good relief of symptoms over the long-term. The most significant controversy with laparoscopic paraesophageal hernia repair is the optimal crural repair. This manuscript reviews the evolution of these techniques.

Weak and absent peristalsis

BACKGROUND

Weak and absent esophageal peristalsis are frequently encountered esophageal motility disorders, which may be associated with dysphagia and which may contribute to gastroesophageal reflux disease. Recently, rapid developments in the diagnostic armamentarium have taken place, in particular, in high-resolution manometry with or without concurrent intraluminal impedance monitoring.

PURPOSE

This article aims to review the current insights in the terminology, pathology, pathophysiology, clinical manifestations, diagnostic work-up,and management of weak and absent peristalsis.

Barrett's esophagus: surgical treatments

The following on surgical treatments for Barrett's esophagus includes commentaries on the indications for antireflux surgery after medical treatment; the effects of the various procedures on the lower esophageal sphincter; the role of impaired esophageal motility and delayed gastric emptying in the choice of the surgical procedure; indications for associated highly selective vagotomy, duodenal switch, and gastric electrical stimulation; therapeutic strategies for detection and treatment of shortened esophagus; the role of antireflux surgery on the regression of metaplastic mucosa and the risk of malignant progression; the detection of asymptomatic reflux brfore bariatric surgery; the role of non-GERD symptoms on the results of surgery; and the indications of Collis gastroplasty and choice of the type of fundoplication.

Is there an association between hiatal hernia and ineffective esophageal motility in patients with gastroesophageal reflux disease?

INTRODUCTION

The pathophysiology of gastroesophageal reflux disease is multifactorial, where esophageal motility is one of the factors implicated in its genesis. However, there is still no consensus on the existence of an association between esophageal dysmotility and hiatal hernia in patients with gastroesophageal reflux disease. The objective of this study was to establish the prevalence of esophageal dysmotility in patients with hiatal hernia and to determine if herniation is a factor related to esophageal dysmotility in patients with gastroesophageal reflux disease.

METHODS

The study included 356 patients with a clinical diagnosis of gastroesophageal reflux disease submitted to upper digestive endoscopy and esophageal functional diagnostics. Hiatal hernia was defined endoscopically by a distance equal to or greater than 2 cm between the diaphragmatic constriction and the squamocolumnar junction and esophageal dysmotility when the esophageal manometry identified the amplitude of the peristaltic waves in the distal esophagus as <30 mmHg and/or less than 80% of effective contractions. For univariate statistical analysis, the patients were divided into two groups: with and without hiatal hernia. Poisson regression models were used to estimate crude and adjusted prevalence ratios (PR) of esophageal dysmotility according to hiatal hernia.

RESULTS

Gastroesophageal reflux disease patients with hiatal hernia had a prevalence of esophageal dysmotility equal to 14.8% and those without hiatal hernia, a prevalence of 7.7% (p = 0.041). Patients with hiatal hernia also showed a higher frequency of erosive esophagitis (47.5% versus 24.2%, p < 0.001), lower low esophageal sphincter pressure (10.4 versus 13.10; p < 0.001), and higher frequency of individuals with abnormal pH-metry values (p < 0.001). The crude PR for esophageal dysmotility, according to the presence of hiatal hernia, was 1.92 (confidence interval (CI), 1.04-3.53; p = 0.037), but this association did not persist when controlled for age, esophagitis, altered pH-metry, and altered low esophageal sphincter (adjusted PR, 1.69; CI, 0.68-4.15; p = 0.257).

CONCLUSION

Despite the prevalence of esophageal dysmotility in the hiatal hernia group being higher than that in the group without hiatal hernia, the association between these variables in individuals with gastroesophageal reflux disease disappeared when controlling for age, esophagitis, altered pH-metry, and altered low esophageal sphincter, leading us to believe that in these patients, hiatal hernia is not an independent risk factor for dysmotility.

High-resolution manometric characteristics help differentiate types of distal esophageal obstruction in patients with peristalsis

BACKGROUND

High-resolution manometry (HRM) can identify obstructive motor features at the esophagogastric junction and abnormalities in esophageal bolus transit. We sought to determine if HRM patterns can differentiate functional from organic mechanical lower esophageal sphincter (LES) obstruction.

METHODS

Segmental characteristics of peristalsis were examined using HRM in symptomatic subjects with elevated postdeglutitive residual pressure gradients across the LES (≥5mmHg). Sixteen consecutive patients with non-achalasic mechanical fixed obstruction were compared with 13 patients with elevated pressure gradients yet no mechanical obstruction and 14 asymptomatic controls. Pressure volumes were determined in mmHg cm s for peristaltic segments defined on HRM Clouse plots using an on-screen pressure volume measurement tool.

KEY RESULTS

Residual pressure gradients were similarly elevated in both patient groups. A visually conspicuous and distinctive shift in the proportionate pressure strengths of the second and third peristaltic segments was apparent across groups. Whereas the ratios of peak pressures and pressure volumes between second and third segments approached 1 in controls (0.92, 0.98), pressures shifted to the second segment in mechanical obstruction (peak pressure ratio: 1.2±0.4; pressure volume ratio: 1.8±0.9) and to the third segment in functional obstruction (peak ratio: 0.7±0.2; volume ratio: 0.5±0.2; P<0.02 for any comparison of either group with controls). A threshold volume ratio of 1.0 correctly segregated 93% of obstruction (P<0.0001); visual pattern inspection was equally effective.

CONCLUSIONS & INFERENCES

When elevated residual pressure gradients are present in non-achalasic patients, topographic characteristics of peristalsis can differentiate fixed mechanical obstruction from functional obstruction.

Effects of ursodeoxycholic acid in esophageal motility and the role of the mucosa. An experimental study

Esophageal motor abnormalities are frequently found in patients with gastroesophageal reflux disease. The role of bile in reflux-induced dysmotility is still elusive. Furthermore, it is questionable weather mucosal or muscular stimulation leads to motor dysfunction. The aims of this study were to analyze (i) the effect of bile in the amplitude of esophageal contractions; and (ii) the effect of mucosal versus muscular stimulation. Eighteen guinea pig esophagi were isolated, and its contractility assessed with force transducers. Three groups were studied. In group A (n= 6), the entire esophagus was incubated in 100 µmL ursodeoxycholic acid for 1 hour; in group B (n= 6) the mucosal layer was removed and the muscular layer incubated in 100 µmL ursodeoxycholic acid for 1 hour; and in group C (n= 6) (control group) the entire esophagus was incubated in saline solution. In all groups, five sequential contractions induced by 40 mm KCl spaced by 5 minutes were measured before and after incubation. Contractions amplitudes before incubation were 1.319 g, 0.306 g, and 1.795 g, for groups A, B, and C, respectively. There were no differences between groups A and C (P= 0.633), but there were differences between groups A and B (P= 0.039), and B and C (P= 0.048). After incubation amplitude of contraction were 0.709 g, 0.278 g, and 1.353 g for groups A, B, and C, respectively. Only group A showed difference when pre and post-stimulation amplitudes were compared (P= 0.030). Our results show that (i) bile exposure decreases esophageal contraction amplitude; and (ii) the esophageal mucosa seems to play an important role in esophageal motility.

Value of preoperative esophageal function studies before laparoscopic antireflux surgery

BACKGROUND

The value of esophageal manometry and ambulatory pH monitoring before laparoscopic antireflux surgery (LARS) has been questioned because tailoring the operation to the degree of hypomotility often is not required. This study evaluated a consecutive cohort of patients referred for esophageal function studies in preparation for LARS to determine the rates of findings that would alter surgical decisions.

METHODS

High-resolution manometry (HRM) was performed for each subject using a 21-lumen water-perfused system, and motor function was characterized. Gastroesophageal reflux disease (GERD) was evident from ambulatory pH monitoring if thresholds for acid exposure time and/or positive symptom association probability were passed.

RESULTS

Of 1,081 subjects (age, 48.4 ± 0.4 years; 56.7% female) undergoing preoperative HRM, 723 (66.9%) also had ambulatory pH testing performed. Lower esophageal sphincter (LES) hypotension (38.9%) and nonspecific spastic disorder (NSSD) of the esophageal body (36.1%) were common. Obstructive LES pathophysiology was noted in 2.5% (achalasia in 1%; incomplete LES relaxation in 1.5%), and significant esophageal body hypomotility in 4.5% (aperistalsis in 3.2%; severe hypomotility in 1.3%) of the subjects. Evidence of GERD was absent in 23.9% of the subjects. Spastic disorders were more frequent in the absence of GERD (43.9% vs. 23.1% with GERD; p < 0.0001), whereas hypomotility and normal patterns were more common with GERD.

CONCLUSIONS

Findings considered absolute or relative contraindications for standard 360º fundoplication are detected in 1 of 14 patients receiving preoperative HRM. Additionally, spastic findings associated with persistent postoperative symptoms are detected at esophageal function testing that could be used in preoperative counseling and candidate selection. Physiologic testing remains important in the preoperative evaluation of patients being considered for LARS.

Importance of a multidisciplinary approach for the treatment of Barrett's esophagus

Barrett's esophagus is a consequence of gastroesophageal reflux disease. Today, it is the most common cause of esophageal adenocarcinoma. Cancer is usually the end results of a cascade of events whereby metaplasia changes into low- and high-grade dysplasia and eventually cancer. Today, we have the unique opportunity to block this cascade and avoid the development of esophageal cancer. A multidisciplinary approach with a team composed of radiologists, gastroenterologists, pathologists, and surgeons allows individualization of care and the best results.

Role of minimally invasive surgery in the modern treatment of Barrett's esophagus

Gastroesophageal reflux disease (GERD) is a highly prevalent disease. Population studies have demonstrated that a significant proportion of individuals weekly experience GERD symptoms. Barrett's esophagus (BE), defined by the presence of intestinal metaplasia (columnar epithelium with goblet cells), is considered a consequence of chronic reflux. This review defines the role of surgery in the modern treatment of BE, taking into consideration the pathophysiology of the disease and the new endoscopic procedures available at present.

Correlation between pathological distal esophageal acid exposure and ineffective esophageal motility

AIM

To assess the correlation between esophageal dysmotility, characterized as inefficient esophageal motility (IEM), and the presence of pathological acid reflux due to a structurally defective lower esophageal sphincter (LES), hiatus hernia. (HH), or esophagitis in patients with suspected gastroesophageal reflux disease (GERD).

METHODS

311 patients referred for GERD diagnostic procedures in a gastroesopahgeal motility laboratory were included in the study. Patients underwent an interview regarding their clinical symptoms, upper endoscopy (UE), stationary esophageal manometry, and 24-h esophageal pH-metry. The following risk factors of patients in the negative pH-metry group were compared to those in the positive pH-metry group: IEM, defective LES, HH, and esophagitis. The association between IEM and positive pH-metry results was first assessed by means of univariate analysis and later determined with multivariate logistic regression analysis.

RESULTS

Out of the total of 311 studied patients, 208 met the inclusion criteria; 88 had normal and 120 had positive pH-metry results. Univariate analysis revealed that the occurrence of IEM, defective LES, and HH was significantly greater in the positive pH-metry group. Following logistic regression analysis, the occurrence of IEM remained significantly greater in the positive pH-metry group.

CONCLUSIONS

IEM is associated with the presence of abnormal acid reflux, as assessed by 24-h esophageal pH-metry, regardless of the presence of defective LES, HH, or esophagitis.

Gastroesophageal reflux disease: From pathophysiology to treatment

This review focuses on the pathophysiology of gastroesophageal reflux disease (GERD) and its implications for treatment. The role of the natural anti-reflux mechanism (lower esophageal sphincter, esophageal peristalsis, diaphragm, and trans-diaphragmatic pressure gradient), mucosal damage, type of refluxate, presence and size of hiatal hernia, Helicobacter pylori infection, and Barrett’s esophagus are reviewed. The conclusions drawn from this review are: (1) the pathophysiology of GERD is multifactorial; (2) because of the pathophysiology of the disease, surgical therapy for GERD is the most appropriate treatment; and (3) the genesis of esophageal adenocarcinoma is associated with GERD.

Gastroesophageal reflux and altered motility in lung transplant rejection

BACKGROUND

Lung transplantation has become an effective therapeutic option for selected patients with end stage lung disease. Long-term survival is limited by chronic rejection manifest as bronchiolitis obliterans syndrome (BOS). The aspiration of gastric contents has been implicated as a causative or additive factor leading to BOS. Gastroesophageal reflux (GER) and altered foregut motility are common both before and after lung transplantation. Further, the normal defense mechanisms against reflux are impaired in the allograft. Recent studies using biomarkers of aspiration have added to previous association studies to provide a growing body of evidence supporting the link between rejection and GER. Further, the addition of high-resolution manometry (HRM) and impedance technology to characterize bolus transit and the presence and extent of reflux regardless of pH might better identify at-risk patients. Although additional prospective studies are needed, fundoplication appears useful in the prevention or treatment of post-transplant BOS.

PURPOSE

This review will highlight the existing literature on the relationship of gastroesophageal reflux and altered motility to lung transplant rejection, particularly BOS. The article will conclude with a discussion of the evaluation and management of patients undergoing lung transplantation at our center.

Evidence-based appraisal in laparoscopic Nissen and Toupet fundoplications for gastroesophageal reflux disease

AIM: To demonstrate the optimal surgical procedure for gastroesophageal reflux disease.

METHODS: The electronic databases of Medline, Elsevier, Springerlink and Embase over the last 16 years were searched. All clinical trials involved in the outcomes of laparoscopic Nissen fundoplication (LNF) and laparoscopic Toupet fundoplication (LTF) were identified. The data of assessment in benefits and adverse results of LNF and LTF were extracted and compared using meta-analysis.

RESULTS: We ultimately identified a total of 32 references reporting nine randomized controlled trials, eight prospective cohort trials and 15 retrospective trials. These studies reported a total of 6236 patients, of whom 4252 (68.18%) underwent LNF and 1984 (31.82%) underwent LTF. There were no differences between LNF and LTF in patients’ satisfaction, perioperative complications, postoperative heartburn, reflux recurrence and re-operation. Both LNF and LTF enhanced the function of lower esophageal sphincter and improved esophagitis. The postoperative dysphagia, gas-bloating syndrome, inability to belch and the need for dilatation after LNF were more common than after LTF. Subgroup analyses showed that dysphagia after LNF and LTF was similar in patients with normal esophageal peristalsis (EP), but occurred more frequently in patients with weak EP after LNF than after LTF. Furthermore, patients with normal EP after LNF still had a higher risk of developing dysphagia than did patients with abnormal EP after LTF.

CONCLUSION: Compared with LNF, LTF offers equivalent symptom relief and reduces adverse results.

Endoscopic full-thickness plication for the treatment of gastroesophageal reflux disease using multiple Plicator implants: 12-month multicenter study results

BACKGROUND

The full-thickness Plicator (Ethicon Endosurgery, Sommerville, NJ, USA) was developed for endoscopic treatment of gastroesophageal reflux disease (GERD). The goal is to restructure the antireflux barrier by delivering transmural pledgeted sutures through the gastric cardia. To date, studies using this device have involved the placement of a single suture to create the plication. The purpose of this study was to evaluate the 12-month safety and efficacy of this procedure using multiple implants to restructure the gastroesophageal (GE) junction.

METHODS

A multicenter, prospective, open-label trial was conducted at four tertiary centers. Eligibility criteria included symptomatic GERD [GERD Health-Related Quality-of-Life (GERD-HRQL) questionnaire, off of medication], and pathologic reflux (abnormal 24-h pH) requiring daily proton pump inhibitor therapy. Patients with Barrett's epithelium, esophageal dysmotility, hiatal hernia > 3 cm, and esophagitis (grade III or greater) were excluded. All patients underwent endoscopic full-thickness plication with linear placement of at least two transmural pledgeted sutures in the anterior gastric cardia.

RESULTS

Forty-one patients were treated. Twelve months post treatment, 74% of patients demonstrated improvement in GERD-HRQL scores by > or = 50%, with mean decrease of 17.6 points compared with baseline (7.8 vs. 25.4, p < 0.001). Using an intention-to-treat model, 63% of patients had symptomatic improvements of > or = 50%, with mean GERD-HRQL decrease of 15.0 (11.0 vs. 26.0, p < 0.001). The need for daily proton pump inhibitor (PPI) therapy was eliminated in 69% of patients at 12 months on a per-protocol basis, and 59% on an intention-to-treat basis. Adverse events included postprocedure abdominal pain (44%), shoulder pain (24%), and chest pain (17%). No long-term adverse events occurred.

CONCLUSIONS

Endoscopic full-thickness plication using multiple Plicator implants can be used safely and effectively to improve GERD symptoms and reduce medication use.

Laparoscopic Nissen fundoplication is a good option in patients with abnormal esophageal motility

BACKGROUND

Patients with gastroesophageal reflux disease (GERD) and abnormal esophageal motility are the most controversial subgroup of surgically treated patients because of potentially increased risk of postoperative dysphagia. Our study aim was to determine if Nissen fundoplication is associated with increased postoperative dysphagia in patients with ineffective esophageal motility.

METHODS

Medical records of all adult (>18 years old) patients who underwent laparoscopic Nissen fundoplication for GERD over 8 years were reviewed retrospectively. Of the 151 patients, 28 (group A) met manometric criteria for abnormal esophageal motility (<30 mmHg mean contractile pressure or <80% peristalsis), whereas 63 (group B) had normal esophageal function. Sixty patients had no manometric data and were therefore excluded from analysis. Follow-up time ranged from 1 month to 5 years. Outcomes (postoperative dysphagia, recurrence of GERD symptoms, free of medications) were compared between groups.

RESULTS

Group A had higher age and American Society of Anesthesiologists (ASA) score (p = 0.016 and 0.020), but this did not correlate with outcome. Two patients (7.1%) in group A and three patients (5.3%) in group B had postoperative dysphagia. When adjusted for follow-up time, there was no significant difference between the groups (p = 0.94). Group B had more cases of recurrent heartburn (10.7% versus 3.6%, p = 0.039), and more patients in this group were back on medications (21.4% versus 7.1%, p < 0.05)

CONCLUSIONS

This retrospective study found equally low rates of dysphagia following Nissen fundoplication regardless of baseline esophageal motility. Preoperative esophageal dysmotility therefore does not seem to be a contraindication for laparoscopic Nissen fundoplication.

Gastroesophageal reflux disease and connective tissue disorders: pathophysiology and implications for treatment

INTRODUCTION

It has been postulated that in patients with connective tissue disorders (CTD) and gastroesophageal reflux disease (GERD), esophageal function is generally deteriorated, often with complete absence of peristalsis. This belief has led to the common recommendation of avoiding antireflux surgery for fear of creating or worsening dysphagia.

METHODS

We hypothesized that in most patients with CTD and GERD: (a) esophageal function is often preserved; (b) peristalsis is more frequently absent when end-stage lung disease (ESLD) is also present; (c) a tailored surgical approach (partial or total fundoplication) based on the findings of esophageal manometry allows control of reflux symptoms without a high incidence of postoperative dysphagia. Forty-eight patients with CTD were evaluated by esophageal manometry and 24-hour pH monitoring (EFT). Twenty patients (group A) had EFT because of foregut symptoms, and 28 patients with ESLD (group B) had EFT as part of the lung transplant evaluation. Two hundred and eighty-six consecutive patients with GERD by pH monitoring served as a control group (group C). A laparoscopic fundoplication was performed in two group A patients (total), eight group B patients (three patients total, five patients partial) and in all group C patients (total).

RESULTS

Esophageal peristalsis was preserved in all patients with CTD and GERD. In contrast, peristalsis was absent in about half of patients when ESLD was also present. A tailored surgical approach resulted in control of reflux symptoms in all patients. One patient only developed postoperative dysphagia, which resolved with two Savary dilatations.

CONCLUSION

These data show that esophageal motor function is preserved in most patients with CTD, so that they should be offered antireflux surgery early in the course of their disease to prevent esophageal and respiratory complications. In patients with ESLD in whom peristalsis is absent, a partial rather than a total fundoplication should be performed, as it allows control of reflux symptoms while avoiding postoperative dysphagia.

Advances in esophageal motor disorders

PURPOSE OF REVIEW

Esophageal motor disorders, often leading to dysphagia and chest pain, continue to pose diagnostic and therapeutic problems. In the past 12 months important new information regarding esophageal motor disorders was published. This information will be reviewed in this paper.

RECENT FINDINGS

A number of studies have addressed the issue of heterogeneity in achalasia, the best defined esophageal motility disorder. The spastic esophageal motility disorders nutcracker esophagus and diffuse esophageal spasm may coexist with gastroesophageal reflux disease, which has consequences for the management of patients with these disorders. The entity labelled ineffective esophageal motility is associated with reflux esophagitis, but also with morbid obesity. For the detection of disordered transit caused by ineffective esophageal motility, application of intraluminal impedance monitoring in conjunction with manometry leads to improved diagnosis. New data on the effect of Nissen fundoplication on esophageal motility were published during the last year.

SUMMARY

Recent knowledge on the heterogeneity of achalasia and the association of spastic esophageal motor disorders and ineffective motility with reflux disease will help the clinician in the management of patients with these disorders.

Antireflux surgery for patients with end-stage lung disease before and after lung transplantation

BACKGROUND

Gastroesophageal reflux disease (GERD) is prevalent among patients with end-stage lung disease (ESLD). This disease can lead to microaspiration and may be a risk factor for lung damage before and after transplantation. A fundoplication is the best way to stop reflux, but little is known about the safety of elective antireflux surgery for patients with ESLD. This study aimed to report the safety of laparoscopic fundoplication for patients with ESLD and GERD before or after lung transplantation.

METHODS

Between January 1997 and January 2007, 305 patients were listed for lung transplantation, and 189 patients underwent the procedure. In 2003, routine esophageal studies were added to the pretransplantation evaluation. After the authors' initial experience, gastric emptying studies were added as well.

RESULTS

A total of 35 patients with GERD or delayed gastric emptying were referred for surgical intervention. A laparoscopic fundoplication was performed for 32 patients (27 total and 5 partial). For three patients, a pyloroplasty also was performed. Two patients had a pyloroplasty without fundoplication. Of the 35 operations, 15 were performed before and 20 after transplantation. Gastric emptying of solids or liquids was delayed in 12 (92%) of 13 posttransplantation studies and 3 (60%) of 5 pretransplantation studies. All operations were completed laparoscopically, and 33 patients recovered uneventfully (94%). The median hospital length of stay was 2 days (range, 1-34 days) for the patients admitted to undergo elective operations. Hospitalization was not prolonged for the three patients who had fundoplications immediately after transplantation.

CONCLUSIONS

The results of this study show that laparoscopic antireflux surgery can be performed safely by an experienced multidisciplinary team for selected patients with ESLD before or after lung transplantation, and that gastric emptying is frequently abnormal and should be objectively measured in ESLD patients.