Psychiatric disorders affect outcomes of antireflux operations for gastroesophageal reflux disease

Criteria of patient selection for magnetic sphincter augmentation

This article is an expert review of published literature with the goal of defining the ideal patient selection for Magnetic Sphincter Augmentation (MSA) in Anti-reflux Surgery (ARS). The authors performed a literature search of outcomes after MSA for different patient populations. Although MSA utilization has expanded to include patients with advanced gastroesophageal reflux disease (GERD), obese patients, and patients with a history of bariatric surgery there is still a paucity of data to support its definitive use in these cohorts. We concluded that younger patients with mild/moderate GERD as evidenced by objective studies in conjunction with normal motility on manometry have the most favorable outcomes after MSA. MSA should be avoided in patients with allergies to nickel, titanium, stainless steel, or ferrous materials. As the utilization of MSA in ARS continues to expand and as more robust data emerges the ideal patient for this device will likely expand as well.

Finding relief for the self-conscious esophagus: laparoscopic anti-reflux surgery and the esophageal hypersensitivity and anxiety scale

INTRODUCTION

Measures of mood and effective coping strategies have notable correlations with quality of life and treatment responses. There is evidence that patients with previously diagnosed anxiety disorders have less improvement in patient-reported outcome measures (PROMs) after laparoscopic anti-reflux surgery (LARS) and that objective pathology does not correlate well with symptom severity. We were interested in investigating whether anxiety and hypervigilance, as measured preoperatively with the esophageal hypervigilance anxiety scale (EHAS), is associated with the improvement in GERD-specific PROMs and EHAS scores 6 months after LARS.

METHODS

We performed a retrospective cohort study of 102 adult patients (31% men, average age 64) who underwent LARS. In the preoperative evaluation, baseline gastroesophageal reflux disease-health-related quality of life (GERD-HRQL), laryngopharyngeal reflux symptom index (LPR-RSI) and EHAS scores were collected in addition to the standard reflux workup, including endoscopy, manometry, barium swallow, and pH study. For all three surveys, a higher score represents worse symptom severity. At 6 months postoperatively, 70 patients completed repeat GERD-HRQL, LPR-RSI, and EHAS surveys. We then analyzed for surgical and patient-related factors associated with improvement in the 6-month postoperative GERD-HRQL and LPR-RSI scores.

RESULTS

There was a statistically significant decrease in the GERD-HRQL (25 vs. 2, p < 0.001), LPR-RSI (17 vs. 3, p < 0.001) and EHAS (34 vs. 15, p < 0.001) 6 months after LARS. On multivariable linear regression, a higher baseline EHAS score was independently associated with a greater improvement in GERD-HRQL (β 0.35, p < 0.001) and LPR-RSI (β 0.19, p = 0.03) 6-months after LARS. Additionally, the degree of improvement in EHAS, GERD-HRQL, and LPR-RSI was not influenced by the type of LARS performed or by the severity of disease.

CONCLUSION

These findings are consistent with literature suggesting that measures of psychoemotional health correlate better with symptom intensity than objective pathology. We found that patients with a higher EHAS score have greater symptom severity and lower quality of life at baseline. Novel findings to this study are that patients with a higher preoperative EHAS, a measure of psychoemotional health, actually benefitted more from surgery and not less, which has been the traditional view in the literature. Future studies are warranted to establish directionality and explore the role of preoperative cognitive behavioral therapy with LARS for patients with significant symptoms of hypervigilance and anxiety.

Psychoemotional factors and their influence on the quality of life in patients with GERD

Patient-reported outcomes (PROs) are integral to determining the success of foregut surgical interventions and psychoemotional factors have been hypothesized to impact the quality of life of patients. This study evaluates the correlation between PROs-specifically the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) and the Laryngopharangeal Reflux Symptom Index (LPR-RSI)-and the recently validated Esophageal Hypervigilance Anxiety Scale (EHAS). We hypothesize that patients with higher EHAS scores have significantly elevated GERD-HRQL LPR-RSI compared to those with normal scores. EHAS has been developed and validated in chronic esophageal disorders, but clinical impact is unknown. In this retrospective study, 197 patients (38% men, average age 56 ± 16) completed the following surveys:(1) EHAS, (2) GERD-HRQL, and (3) LPR-RSI. All patients referred for surgical evaluation of GERD completed the surveys as part of their pre-operative workup and post-operative follow-up In bivariate analysis, EHAS correlated with both GERD-HRQL (r 0.53, P = <0.001) and LPR-RSI (r 0.36, P = 0.009). Accounting for potential confounding with sex and age in multivariable linear regression models, a higher GERD-HRQL score (β 0.38; 95% CI 0.29 to 0.48; P = <0.001; Semipartial R² 0.20) and a higher LPR-RSI score (β 0.21; 95% CI 0.13 to 0.29; P = <0.001; Semipartial R² 0.08) were independently associated with higher EHAS. The observed relationship between mental health and GERD symptom intensity is consistent with the biopsychosocial paradigm of illness. Future studies focused on post-surgical outcomes following the incorporation of EHAS into perioperative care is needed to evaluate its effectiveness as a clinical decision support tool in ARS.

Long-term patient satisfaction and durability of laparoscopic anti-reflux surgery in a large Danish cohort: study protocol for a retrospective cohort study with development of a novel scoring system for patient selection

INTRODUCTION

Laparoscopic anti-reflux surgery is standard of care in surgical treatment of gastro-oesophageal reflux disease and is not without risks of adverse effects, including disruption of the fundoplication and postfundoplication dysphagia, in some cases leading to reoperation. Non-surgical factors such as pre-existing anxiety or depression influence postoperative satisfaction and symptom relief. Previous studies have focused on a short-term follow-up or only certain aspects of disease, such as reoperation or postoperative quality of life. The aim of this study is to evaluate long-term patient-satisfaction and durability of laparoscopic anti-reflux surgery in a large Danish cohort using a comprehensive multimodal follow-up, and to develop a clinically applicable scoring system usable in selecting patients for anti-reflux surgery.

METHODS AND ANALYSIS

The study is a retrospective cohort study utilising data from patient records and follow-up with patient-reported quality of life as well as registry-based data. The study population consists of all adult patients having undergone laparoscopic anti-reflux surgery at The Department of Surgery, Kolding Hospital, a part of Lillebaelt Hospital Denmark in an 11-year period. From electronic records; patient characteristics, preoperative endoscopic findings, reflux disease characteristics and details on type of surgery, will be identified. Disease-specific quality of life and dysphagia will be collected from a patient-reported follow-up. From Danish national registries, data on comorbidity, reoperative surgery, use of pharmacological anti-reflux treatment, mortality and socioeconomic factors will be included. Primary outcome of this study is treatment success at follow-up.

ETHICS AND DISSEMINATION

Study approval has been obtained from The Danish Patient Safety Agency, The Danish Health Data Authority and Statistics Denmark, complying to Danish and EU legislation. Inclusion in the study will require informed consent from participating subjects. The results of the study will be published in peer-reviewed medical journals regardless of whether these are positive, negative or inconclusive.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov (NCT03959020).

How to select patients for antireflux surgery? The ICARUS guidelines (international consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for antireflux surgery)

OBJECTIVE

Antireflux surgery can be proposed in patients with GORD, especially when proton pump inhibitor (PPI) use leads to incomplete symptom improvement. However, to date, international consensus guidelines on the clinical criteria and additional technical examinations used in patient selection for antireflux surgery are lacking. We aimed at generating key recommendations in the selection of patients for antireflux surgery.

DESIGN

We included 35 international experts (gastroenterologists, surgeons and physiologists) in a Delphi process and developed 37 statements that were revised by the Consensus Group, to start the Delphi process. Three voting rounds followed where each statement was presented with the evidence summary. The panel indicated the degree of agreement for the statement. When 80% of the Consensus Group agreed (A+/A) with a statement, this was defined as consensus. All votes were mutually anonymous.

RESULTS

Patients with heartburn with a satisfactory response to PPIs, patients with a hiatal hernia (HH), patients with oesophagitis Los Angeles (LA) grade B or higher and patients with Barrett's oesophagus are good candidates for antireflux surgery. An endoscopy prior to antireflux surgery is mandatory and a barium swallow should be performed in patients with suspicion of a HH or short oesophagus. Oesophageal manometry is mandatory to rule out major motility disorders. Finally, oesophageal pH (±impedance) monitoring of PPI is mandatory to select patients for antireflux surgery, if endoscopy is negative for unequivocal reflux oesophagitis.

CONCLUSION

With the ICARUS guidelines, we generated key recommendations for selection of patients for antireflux surgery.

Impact of psychiatric disorders on patient satisfaction after Nissen Fundoplication

BACKGROUND

Anxiety and depression have been associated with an increased perception of gastroesophageal reflux symptoms, but there is a paucity of data regarding the outcomes of laparoscopic Nissen Fundoplication (LNF) in this patient population.

METHODS

We performed a retrospective cohort study including all patients undergoing LNF between 2011 and 2017. Patients were stratified by baseline usage of serotonin-modulating medication or benzodiazepines as a proxy for depression and anxiety, respectively. Outcome measures included postoperative gastroesophageal health-related quality of life (GERD-HRQL) scores and overall satisfaction rates after surgery. A p value of < 0.05 was considered statistically significant.

RESULTS

The population consisted of 271 patients of which 103 patients had depression and 44 patients had anxiety. Patients with depression reported no significant difference in pre- or postoperative GERD-HRQL scores compared to patients without depression and long-term satisfaction rates after surgery were similar in both groups at 76% vs 71%, respectively (p = 0.55). Patients with anxiety reported higher baseline HRQL scores (34 vs. 29, p = 0.05). At long-term follow-up (15 months), patients with anxiety reported slightly worse HRQL scores compared to controls (7 vs. 4, p = 0.11) despite no difference in usage of anti-acid medications or need for endoscopic dilations between the two groups. Patients with anxiety were less likely to report being "satisfied" after surgery (40% vs. 71%, p = 0.01) compared to controls.

CONCLUSION

Patients with anxiety have higher subjective reporting of GERD symptoms and are more likely to report being "satisfied" during long-term follow-up after LNF. Patients on medication for depression appear to have similar reporting of GERD symptoms and derive as much benefit from LNF as patients that are not. While LNF does improve the symptom burden in patients with anxiety, satisfaction is rarely achieved in long-term follow-up.

Effects of psychological problems on surgical outcomes

Surgeons are becoming aware that surgical outcomes are not only based on technical skills. The impact of psychological problems on outcomes must be studied from both the patient's and the health care provider's viewpoint. Psychological problems may affect up to 20% of the population, with almost half of them non-treated. Surgeons have to deal with a significant number of patients with psychological problems, which affect surgical outcomes changing how symptoms, results and side effects are interpreted. Surgeons also face psychological problems at a significant rate. Although there are no studies on the effect of chronic psychological problems of the surgeon on outcomes, in simulated scenarios, acute stress usually leads to worse performance. Some initiatives can be implemented to improve outcomes based on the effect of psychological problems.

Psychiatric Illness Is Common in Elderly Fracture Patients

OBJECTIVES

To (1) describe the prevalence of psychiatric illness in fracture patients ≥70 years of age and (2) investigate the association between psychiatric illness and complications requiring unplanned readmission in elderly patients.

DESIGN

Retrospective cohort study.

PATIENTS/PARTICIPANTS

One thousand one hundred eighty-six patients ≥70 years of age with surgically treated fractures and ≥1-month follow-up treated from 2012 to 2017.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Complication requiring unplanned readmission.

RESULTS

Forty-four percent of patients ≥70 years of age have psychiatric comorbidities, and of those, 34% had >1 diagnosis. There was a higher rate of readmission among patients with psychiatric diagnosis compared with those without psychiatric diagnosis (35% vs. 21%, P < 0.001). There was a higher prevalence of psychiatric illness among patients 70 years of age or older compared with patients less than 70 years of age (44% vs. 39%, P = 0.007). Multivariate regression analysis controlling for age, sex, Charlson Comorbidity Index, dementia, delirium during admission, tobacco use, substance abuse, Injury Severity Score, fracture location, number of procedures, and number of fractures demonstrated an independent association between psychiatric illness and unplanned readmission (adjusted OR 1.54, 95% confidence interval, 1.15-2.07, P = 0.003).

CONCLUSIONS

Almost half of the elderly patients in the present cohort have psychiatric comorbidities. Furthermore, psychiatric illness is an independent predictor of unplanned readmission, which may have substantial consequences for recovery and cost of care. This emphasizes the need for more attention to these issues in geriatric patient populations and the need to identify means to influence the downstream consequences of these comorbidities.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Do patients with gastroesophageal reflux disease and somatoform tendencies benefit from antireflux surgery?

BACKGROUND

The clinical presentation of gastroesophageal reflux disease (GERD) shows a large symptom variation also in different intensities among patients. As several studies have shown, there is a large overlap in the symptomatic spectrum between proven GERD and other disorders such as dyspepsia, functional heartburn and/or somatoform disorders.

AIM

To prospectively evaluate the GERD patients with and without somatoform disorders before and after laparoscopic antireflux surgery.

METHODS

In a tertiary referral center for foregut surgery over a period of 3 years patients with GERD, qualifying for the indication of laparoscopic antireflux surgery, were investigated prospectively regarding their symptomatic spectrum in order to identify GERD and associated somatoform disorders. Assessment of symptoms was performed by an instrument for the evaluation of somatoform disorders [Somatoform Symptom Index (SSI) > 17]. Quality of life was evaluated by Gastrointestinal Quality of Life Index (GIQLI).

RESULTS

In 123 patients an indication for laparoscopic antireflux surgery was established and in 43 patients further medical therapy was suggested. The portion of somatoform tendencies in the total patient population was 20.48% (34 patients). Patients with a positive SSI had a preoperative GIQLI of 77 (32-111). Patients with a normal SSI had a GIQLI of 105 (29-140) (P < 0.0001). In patients with GERD the quality of life could be normalized from preoperative reduced values of GIQLI 102 (47-140) to postoperative values of 117 (44-144). In patients with GERD and somatoform disorders, the GIQLI was improved from preoperative GIQLI 75 (47-111) to postoperative 95 (44-122) (P < 0.0043).

CONCLUSION

Patients with GERD and associated somatoform disorders have significantly worse levels of quality of life. The latter patients can also benefit from laparoscopic fundoplication, however they will not reach a normal level.

Foregut symptoms, somatoform tendencies, and the selection of patients for antireflux surgery

A large variety of foregut symptoms can occur in patients with gastroesophageal reflux disease (GERD), which can overlap with other disorders such as somatoform disorders and dyspepsia. Due to unclear diagnostic situations, these patients are often not adequately treated. The aim of this study was the evaluation of patients with foregut symptoms, referred for possible antireflux surgery, regarding their relationship with GERD and somatization tendencies based on control data from an unselected population. Symptom evaluation and somatization screening were initiated both in volunteers and in patients with foregut symptoms and GERD. Unselected volunteers from a village population were also evaluated by symptom analysis and for somatisation tendency. In addition, patients with foregut symptoms were diagnosed for GERD, and symptom analysis and psychodiagnostic evaluation were performed. There is no major significant difference in the symptom-spectrum in patients with foregut symptoms, whether they have a proven pathologic acid exposure from GERD or not. The probability for the risk of somatization was 5.6% in the unselected population of nonpatient volunteers (n = 267). In patients with foregut symptoms (n = 750), the probability for the presence of somatoform tendencies was approximately 20%, independent whether these patients had a documented GERD or a normal esophageal acid exposure, implicating further diagnostic work-up for the selection of patients for antireflux surgery. There is a remarkable symptom load and variety in patients with GERD, in patients with foregut symptoms, and in an unselected population of volunteers. There is no difference in the risk for somatization between patients with foregut symptoms and those with documented GERD. Therapeutic decision making especially prior to antireflux surgery requires an awareness of mental and emotional challenges.

Psychosocial Factors Are Associated with Quality of Life After Laparoscopic Antireflux Surgery

BACKGROUND

Laparoscopic antireflux surgery (LARS) is the gold standard treatment for refractory gastroesophageal reflux disease (GERD). Traditional surgical outcomes following LARS are well described, but limited data exist regarding patient-reported outcomes. We aimed to identify preoperative characteristics that were independently associated with a high GERD health-related quality of life (GERD-HRQL) following LARS.

METHODS

Clinical data from our single institution foregut surgery database were used to identify all patients with GERD who underwent primary LARS from June 2010 to November 2015. Electronic health record data were reviewed to extract patient characteristics, diagnostic study characteristics, and operative data. Postoperative GERD-HRQL data were obtained through telephone follow-up. Variables hypothesized a priori to be associated with high GERD-HRQL after LARS, which were significant at P ≤ .2 on bivariate analysis, were entered into a multivariable linear regression model with GERD-HRQL as the outcome.

RESULTS

The study included 248 patients; 69.0% were female, 56.9% were married, and 58.1% had concurrent atypical symptoms. The most commonly performed fundoplications were Nissen (44.8%), Toupet (41.3%), and Dor (14.1%), respectively. The median follow-up interval was 3.4 years. The telephone response rate was 60.1%. GERD-HRQL scores improved from 24.8 (SD ±11.4) preoperatively to 3.0 (SD ±5.9) postoperatively. 79.9% of patients were satisfied with their condition at follow-up. On multivariable analysis, being married (P = .04) and absence of depression (P = .02) were independently associated with a higher postoperative QoL.

CONCLUSIONS

Strong social support and psychiatric well-being appear to be important predictors of a higher QoL following LARS. Optimizing social support and treating depression preoperatively and postoperatively may improve QoL outcomes for LARS patients.

Psychiatric Illness Is Common Among Patients with Orthopaedic Polytrauma and Is Linked with Poor Outcomes

BACKGROUND

Psychiatric disorders are common, and their functional consequences may be underappreciated by non-mental health-care providers. There exist limited data regarding the frequency of psychiatric illness in patients who sustain orthopaedic polytrauma. The purpose of this study was to describe the prevalence of psychiatric illness in patients with orthopaedic polytrauma, to determine whether psychiatric illnesses were identified and were accommodated by trauma providers, and, finally, to investigate any associations between postoperative complications and psychiatric illness.

METHODS

Three hundred and thirty-two skeletally mature patients with surgically treated axial and/or femoral fractures and injuries to other body systems (Injury Severity Score of ≥ 16 points) were identified from a database at a Level-I trauma center. These included 238 men and ninety-four women with a mean value (and standard deviation) of 39 ± 16 years for age and 27 ± 12 points for the Injury Severity Score. Records were reviewed for preexisting diagnoses of psychiatric disorders. The inpatient courses and discharge recommendations regarding treatment of psychiatric illness were analyzed. Complications in the six-month postoperative period were determined by an independent committee.

RESULTS

Preexisting psychiatric disorders were identified in 130 patients (39.2%), including depression in seventy-four patients (22.3%) and substance abuse in fifty-six patients (16.9%). Patients managed by an orthopaedic surgery service were less likely to receive their home psychiatric medications while hospitalized (p = 0.001) and were less likely to receive instructions for psychiatric follow-up at discharge (p = 0.087). Postoperative complications occurred in sixty-six patients (19.9%) overall; depression was an independent predictor of increased complications, with an odds ratio of 2.956 (95% confidence interval, 1.502 to 5.816).

CONCLUSIONS

Psychiatric illness was common among individuals who sustained orthopaedic polytrauma, and patients with depression had more complications. This study highlights the need for greater attention to mental health disorders in this population.

Dynamics of quality of life improvement after floppy Nissen fundoplication for gastroesophageal reflux disease

Introduction

Gastroesophageal reflux disease (GERD) has a negative impact on global quality of life (QOL) of patients. In patients affected by GERD, laparoscopic Nissen fundoplication is one of the most commonly performed laparoscopic procedures worldwide.

Aim

To prospectively analyze the dynamics of QOL as well as severity of pain in patients with GERD, before and after laparoscopic floppy Nissen fundoplication.

Material and methods

The study involved 104 consecutive patients operated on for GERD in whom laparoscopic floppy Nissen fundoplication was performed. QOL was assessed before surgery and 1, 3, 6, 12 and 24 months after. The following instruments were used: FACIT-G, FACIT-TS-G, GIQLI, GERD symptom scale.

Results

It was found that symptom relief and quality of life improvement presented different dynamics in the postoperative course. Observations revealed relief of symptoms 1 month after surgery and improvement in QOL related to the gastrointestinal tract and pain 3 months after surgery. Global QOL increased significantly as late as 12 months after surgery.

Conclusions

Gastroesophageal reflux disease is a chronic disease of long duration, leading to impairment of quality of life. Patients, apart from typical symptoms of GERD, suffer from pain of significant severity. QOL improves significantly after surgery. Surgical treatment results in relief of GERD symptoms, which leads to gradual improvement of QOL.

Preoperative factors predicting clinical outcome following laparoscopic fundoplication

BACKGROUND

Antireflux surgery is effective for the treatment of gastroesophageal reflux, but not all patients benefit equally from it. The challenge is to identify the patients who will ultimately benefit from antireflux surgery. The aim of this study was to identify preoperative factors that predict clinical outcome after antireflux surgery, with special interest in the influence of socioeconomic factors.

METHODS

Preoperative clinical and socioeconomic data from 1,650 patients who were to undergo laparoscopic fundoplication were collected prospectively. Clinical outcome measures (persistent heartburn, dysphagia, satisfaction) were assessed at short-term (1 year) and longer-term (≥ 3 years) follow-up.

RESULTS

At early follow-up, male gender (relative risk [RR] 1.091, p < 0.001) and the presence of a hiatus hernia (RR 1.065, p = 0.002) were independently associated with less heartburn. Male gender was also associated with higher overall satisfaction (RR 1.046, p = 0.034). An association was found between postoperative dysphagia and age (RR 0.988, p = 0.007) and the absence of a hiatus hernia (RR 0.767, p = 0.001). At longer-term follow-up, only male gender (RR 1.125, p < 0.001) was an independent prognostic factor for heartburn control. Male gender (RR 0.761, p = 0.001), the presence of a hiatus hernia (RR 0.823, p = 0.014), and cerebrovascular comorbidities (RR 1.306, p = 0.019) were independent prognosticators for dysphagia at longer-term follow-up. A hiatus hernia was the only factor associated with better overall satisfaction. Socioeconomic factors did not influence any clinical outcomes at short- and longer-term follow-up.

CONCLUSION

Male gender and hiatus hernia are associated with a better clinical outcome following laparoscopic fundoplication, whereas socioeconomic status does not influence outcome.

Surgical treatment of GERD: where have we been and where are we going?

Surgical management of gastroesophageal reflux disease has evolved from relatively invasive procedures requiring open laparotomy or thoracotomy to minimally invasive laparoscopic techniques. Although side effects may still occur, with careful patient selection and good technique, the overall symptomatic control leads to satisfaction rates in the 90% range. Unfortunately, the next evolution to endoluminal techniques has not been as successful. Reliable devices are still awaited that consistently produce long-term symptomatic relief with correction of pathologic reflux. However, newer laparoscopically placed devices hold promise in achieving equivalent symptomatic relief with fewer side effects. Clinical trials are still forthcoming.

Gastro oesophageal reflux disease (GORD)-related symptoms and its association with mood and anxiety disorders and psychological symptomology: a population-based study in women

BACKGROUND

Psychopathology seems to play a role in reflux pathogenesis and vice versa, yet few population-based studies have systematically investigated the association between gastro-oesophageal reflux disease (GORD) and psychopathology. We thus aimed to investigate the relationship between GORD-related symptoms and psychological symptomatology, as well as clinically diagnosed mood and anxiety disorders in a randomly selected, population-based sample of adult women.

METHODS

This study examined data collected from 1084 women aged 20-93 yr participating in the Geelong Osteoporosis Study. Mood and anxiety disorders were identified using the Structured Clinical Interview for DSM-IV-TR Research Version, Non-patient edition (SCID-I/NP), and psychological symptomatology was assessed using the General Health Questionnaire (GHQ-12). GORD-related symptoms were self-reported and confirmed by medication use where possible and lifestyle factors were documented.

RESULTS

Current psychological symptomatology and mood disorder were associated with increased odds of concurrent GORD-related symptoms (adjusted OR 2.1, 95% CI 1.3-3.5, and OR 3.0, 95% CI 1.7-5.6, respectively). Current anxiety disorder also tended to be associated with increased odds of current GORD-related symptoms (p = 0.1). Lifetime mood disorder was associated with a 1.6-fold increased odds of lifetime GORD-related symptoms (adjusted OR 1.6, 95% CI 1.1-2.4) and lifetime anxiety disorder was associated with a 4-fold increased odds of lifetime GORD-related symptoms in obese but not non-obese participants (obese, age-adjusted OR 4.0, 95% CI 1.8-9.0).

CONCLUSIONS

These results indicate that psychological symptomatology, mood and anxiety disorders are positively associated with GORD-related symptoms. Acknowledging this common comorbidity may facilitate recognition and treatment, and opens new questions as to the pathways and mechanisms of the association.

Coping strategies, health-related quality of life and psychiatric history in patients with aneurysmal subarachnoid haemorrhage

Purpose

Subarachnoid haemorrhage (SAH) reduces health-related quality of life (HRQoL) and increases the risk of psychiatric sequels such as depression and posttraumatic stress disorder. Especially those with a psychiatric history and those using maladaptive coping strategies are at risk for such sequels. The extent to which HRQoL after SAH was related to a history of psychiatric morbidity and to the use of various coping strategies was assessed.

Methods

Patients admitted to the Uppsala University Hospital with aneurysmal SAH (n = 59) were investigated prospectively. Seven months after SAH, data were collected using the Structured Clinical Interview for DSM-IV axis I disorders, the Short Form-36 (SF-36) Health Survey and the Jalowiec Coping Scale.

Results

Patients with SAH had lower HRQoL than the general Swedish population in all eight domains of the SF-36. The lower HRQoL was almost entirely in the subgroup with a psychiatric history. HRQoL was also strongly correlated to the use of coping. Physical domains of SF-36 were less affected than mental domains. Those with a psychiatric history used more coping than the remainder with respect to all emotional coping scales. Coping and the presence of a psychiatric history were more strongly related to mental than to physical components of HRQoL.

Conclusions

A psychiatric history and the use of maladaptive emotional coping were related to worse HRQoL, more to mental than to physical aspects.

Influence of psychopathological changes on quality of life after laparoscopic fundoplication for the treatment of gastroesophageal reflux

There are references in medical literature to the influence of psychopathological changes and their negative impact on the results of laparoscopic fundoplication. The objective of this study is to analyze the influence of psychological changes, as assessed by the General Health Questionnaire-28 (GHQ-28), on patients undergoing surgery for gastroesophageal reflux. This is a prospective study in a series of 103 consecutive patients (62 males and 41 females with a mean age of 40 years) undergoing laparoscopic fundoplication. In addition to functional studies, patients completed the SF-36, Gastrointestinal Quality of Life Index, and GHQ-28 before surgery. Functional tests and questionnaires were repeated 6 months after surgery. Patients were also questioned about their degree of satisfaction. Postoperative results of patients with a normal GHQ-28 and patients showing psychopathological changes as defined by the GHQ-28 questionnaire before surgery were compared. Overall, all patients experienced an improvement in their quality of life. Forty-one patients showed a pathological result in the preoperative GHQ-28 questionnaire. No differences were found in functional results and degree of satisfaction with surgery between patients with normal and pathological results in the preoperative GHQ-28 questionnaire. However, patients with a pathological result in the preoperative GHQ-28 had poorer results in all domains of the postoperative Gastrointestinal Quality of Life Index and SF36 quality of life questionnaires as compared to patients with a normal preoperative GHQ-28 questionnaire. Patients with pathological results in the preoperative GHQ-28 had poorer results in terms of postoperative quality of life despite having normal postoperative physiological studies; this decreased quality of life did not have an impact on the degree of satisfaction with surgery performed. The GHQ-28 does not therefore appear to serve as a predictor of postoperative satisfaction.

Predictors of clinical outcomes following fundoplication for gastroesophageal reflux disease remain insufficiently defined: a systematic review

OBJECTIVES

Surgical treatment is a therapeutic option for patients with gastroesophageal reflux disease (GERD). It is unclear which patient characteristics influence postoperative success. The purpose of this paper was to review the literature on prognostic factors for patients with GERD treated with fundoplication.

METHODS

We searched Medline and the Cochrane Library Central for studies from 1966 through July 2007. We identified additional studies by reviewing bibliographies of retrieved articles and by consulting experts. We included English language studies that evaluated factors potentially affecting the outcomes after surgical treatments in patients with GERD. We recorded baseline patient characteristics associated with treatment efficacy, details on the study design, comparators, and definitions of outcomes.

RESULTS

We assessed 6,318 abstracts; 53 cohorts and 10 case-control studies met our inclusion criteria. Age, body mass index, sex, esophagitis grade, and dysmotility were generally not associated with treatment outcomes. There were no consistent associations between preoperative response to acid suppression medications, baseline symptoms, baseline acid exposure, degree of lower esophageal sphincter competence, or position of reflux and surgical outcomes. Certain psychological factors might be associated with worse treatment outcomes.

CONCLUSIONS

Although several preoperative predictors of surgical outcomes have been described, the quality and consistency of the data were mixed and the strength of the associations remains unclear. Additional studies with improved methodological designs are needed to better define which patient characteristics are associated with surgical outcomes following fundoplication.

The use of medication after laparoscopic antireflux surgery

BACKGROUND

Laparoscopic antireflux surgery (LARS) significantly improves symptoms of gastro-esophageal reflux disease (GERD) and quality of life. Nevertheless, 14-62% of patients report using antisecretory medication after surgery, although only a tiny percentage has proven recurrence of GERD. We sought to determine symptoms of GERD, quality of life, and use of medication before and after LARS, and to compare our findings with those from previous studies.

METHODS

Five hundred fifty-three patients with GERD who underwent LARS were evaluated before and at 1 year after surgery. After surgery, multidisciplinary follow-up care was provided for all patients by surgeons, psychologists, dieticians, and speech therapists.

RESULTS

Symptoms of GERD and quality of life improved significantly and only 4.2% of patients still required medication after surgery [proton pump inhibitors (PPI) (98.4 vs. 2.2%; p < 0.01), prokinetics (9.6 vs. 1.1%; p < 0.01), and psychiatric medication (8 vs. 1.6%; p < 0.01)].

CONCLUSION

LARS significantly reduced medication use at 1-year follow-up. However, these effects might be attributed, in part, to the multidisciplinary follow-up care. Further studies are therefore required to investigate which patients may benefit from multidisciplinary follow-up care and whether its selective application may reduce the need for medication after LARS.

Gastrointestinal quality of life in patients after anti reflux surgery

A subset of patients does not report improvement of symptoms or satisfaction after antireflux surgery. The aim of this study is to assess the effect of pre-existing depression as a factor in patient satisfaction and gastrointestinal quality of life index (GIQLI) outcomes after antireflux surgery. Patients undergoing antireflux surgery who had filled a preoperative quality of life score and had more than 1 year follow-up were included in this study. Based on available history and self-reported medication use, patients were divided in two groups: with depression (group A) and without depression (group B). Fifty-four patients with completed preoperative GIQLI questionnaire were contacted for this study; 32 (59%) patients completed the postoperative questionnaire. Seven patients (22%) had psychological disorder (group A) in the form of depression The GIQLI in groups A and B increased significantly from 64.4 +/- 17.3 and 89.6 +/- 18.6 to 88.6 +/- 23.7 (P < 0.001) and 102.2 +/- 18.6 (P = 0.02), respectively, after the surgery. There was significant improvement in the quality of life in patients after antireflux surgery based on the GIQLI assessment. This improvement was also reported in patients with history of depression.

Who will fail laparoscopic Nissen fundoplication? Preoperative prediction of long-term outcomes

BACKGROUND

A small but significant percentage of patients are considered failures after laparoscopic Nissen fundoplication (LNF). We sought to identify preoperative predictors of failure in a cohort of patients who underwent LNF more than 10 years ago.

METHODS

Of 312 consecutive patients undergoing primary LNF between 1992 and 1995, recent follow-up was obtained from 166 patients at a mean of 11.0 +/- 1.2 years. Eight additional patients who underwent reoperation were lost to follow-up but are included. Failure is broadly defined as any reoperation, lack of satisfaction, or any severe symptoms at follow-up. Potential predictors evaluated included sex, age, body-mass index (BMI), response to acid reducing medications (ARM), psychiatric history, typical versus atypical symptoms, manometry, esophageal pH, and others. Logistic regression was used to assess significance of predictors in univariate analysis.

RESULTS

Of 174 known outcomes, 131 were classified as successful (75.3%), while 43 were failures (24.7%): 26 reoperations, 13 unsatisfied, and 13 with severe symptoms. Response and lack of response to ARM were associated with 77.1% and 56.0% success rates respectively (P = 0.035). Eighty five percent of patients with typical symptoms had a successful outcome, compared to only 41% with atypical symptoms (P < 0.001). Preoperative morbid obesity (BMI > 35 kg/m2) was associated with failure (P = 0.036), while obesity (BMI 30-34.9 kg/m2) was not. A history of psychiatric illness trended toward significance (P = 0.06).

CONCLUSIONS

In a cohort with 11 years follow-up after LNF, factors predictive of a successful outcome include preoperative response to ARM, typical symptoms, and BMI < 35 kg/m2. Patients with atypical symptoms, no response to ARM, or morbid obesity should be informed of their higher risk of failure. Some patients in these groups do have successful outcomes, and further research may clarify which of these patients can benefit from LNF.

Tradução e validação para a língua portuguesa (Brasil) de instrumentos específicos para avaliação de qualidade de vida na doença do refluxo gastroesofágico

INTRODUÇÃO: Estudos têm demonstrado ser a doença do refluxo gastroesofágico capaz de alterar a qualidade de vida e a produtividade no trabalho dos doentes por ela acometidos. Instrumentos para esse tipo de avaliação são provenientes, em sua maioria, de países de língua inglesa e/ou francesa. A utilização desses instrumentos em nosso meio demanda criterioso processo de tradução e validação. OBJETIVOS: Traduzir para língua portuguesa os questionários GERD-HRQL (Gastroesophageal Reflux Disease - Health Related Quality of Life), HBQOL (Heartburn Specific Quality of Life Instrument) e GSAS (Gastroesophageal Reflux Disease Symptom Assessment Scale) específicos para avaliação de qualidade de vida na doença do refluxo gastroesofágico. Testar suas propriedades psicométricas de confiabilidade e validade. MÉTODOS: Cento e trinta e dois pacientes com doença do refluxo gastroesofágico (idade média 54,9 anos, ± DP 13,9) atendidos no ambulatório de motilidade digestiva da Universidade Federal de São Paulo, SP, e de gastrocirurgia da Faculdade de Medicina de São José do Rio Preto, SP, aceitaram participar do presente estudo, fornecendo termo de consentimento pós-esclarecimento. Destes, 40 pacientes participaram da fase de pré-teste (28 do sexo feminino e 12 do sexo masculino, com idade média de 55,3 anos, ± DP 14,7) e 92 da fase de validação (64 do sexo feminino e 28 sexo masculino, com idade média 54,7 anos e ± DP 13,7). A tradução e adaptação cultural foi realizada de acordo com o método de GUILLEMIN et al., sendo a validação dos questionários traduzidos (GERD-HRQL, HBQOL e GSAS) realizada em relação aos instrumentos genérico SF-36 e sintomático ESDRGE (SQGERD). RESULTADOS: A adaptação cultural implicou na troca de quatro palavras no GERD-HRQL, seis no HBQOL e nove no GSAS. Posteriormente a esta fase, o questionário GSAS foi abandonado por problemas no cálculo do escore, sendo as propriedades de medidas testadas nos dois questionários remanescentes, esses se mostraram reprodutíveis para uso inter e intra-observador com valores de 0,980 e 0,968, respectivamente, para o GERD-HRQL, e valores que variaram de 0,868 a 0,972, respectivamente, para o HBQOL. O questionário HBQOL demonstrou alta consistência interna (>0,70) para três das quatro dimensões avaliadas (aspecto físico, dor, sono). Os resultados encontrados na fase de validação apresentaram bons níveis de correlação com os questionários SF-36 e ESDRGE (SQGERD). CONCLUSÕES: As versões para a língua portuguesa (Brasil) dos instrumentos GERD-HRQL e HBQOL, adaptadas ao padrão cultural brasileiro, configuram-se em opções válidas, confiáveis, com baixo nível de desgaste do paciente e de fácil aplicação para avaliação de qualidade de vida na DRGE em nosso meio. O instrumento HBQOL é a única opção de avaliação multidimensional de qualidade de vida atualmente disponível para uso no Brasil. A versão em português do instrumento GSAS mostrou-se inadequada para avaliação de qualidade de vida na DRGE em nosso meio.

The effect of laparoscopic Nissen fundoplication on laryngeal findings and voice quality

BACKGROUND

This study aimed to report the need for an ear, nose, and throat (ENT) specialist to evaluate the laryngeal findings and the voice quality of patients with gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) symptoms before and after surgery.

METHODS

For this study, 38 GERD patients who had a Reflux Symptom Index (RSI) score higher than 14 underwent complete assessment in the ENT department. Standard 24-h pH monitoring, esophageal motility assessment, a detailed ENT examination including the RSI, the Reflux Finding Score (RFS), and objective voice analysis were performed for all the patients before reflux surgery, then 6 to 8 months afterward.

RESULTS

The subject's mean RSI scores were 25.45 +/- 7.5 before and 16.52 +/- 5.06 after surgery (p < 0.05), and the mean RFS scores were, respectively, 10.37 +/- 2.7 and 5.5 +/- 1.45 (p < 0.05). The pre- and postoperative differences in the RSI and RFS scores and the voice parameters were statistically significant.

CONCLUSIONS

Objective voice analysis, RSI, and RFS can be used to evaluate the postoperative results for GERD patients with LPR symptoms. Examination of these patients by an ENT specialist is necessary before and after the operation.

Gastroesophageal reflux: prevalence of psychopathological disorders and quality of life implications

There is evidence in the literature that psychosocial aspects affect the symptoms and results of surgery for gastroesophageal reflux. The purpose of this study was to estimate the prevalence of psychopathological disorders measured using the General Health Questionnaire (GHQ-28) in a sample of patients with gastroesophageal reflux, and to assess the influence of such disorders on their quality of life. A prospective study was conducted in 74 consecutive patients before gastroesophageal reflux surgery; patients answered the GHQ-28, the health questionnaire SF-36, and the Gastrointestinal Quality of Life Index (GIQLI). The convergent validity of the GHQ-28 questionnaire as compared to the other two questionnaires and preoperative quality of life was tested. A pathological result of the GHQ-28 questionnaire was found in 38.3% of patients. A correlation was seen between the results of the GHQ-28 questionnaire and all categories of the SF-36 and GIQLI questionnaires. Patients with pathological results in the GHQ-28 questionnaire had poorer results in all dimensions of the SF-36 and GIQLI quality of life questionnaires as compared to patients with a normal result in the GHQ-28 questionnaire. In conclusion, 38.3% of patients with gastroesophageal reflux showed psychopathological disorders when administered the GHQ-28 questionnaire. These patients also had poorer results in quality of life studies.

The impact of gastroesophageal reflux disease on quality of life

BACKGROUND

Quality of life as a medical endpoint has become an important measure in clinical research.

METHODS

In this article, we review the recent literature that has examined the impact of gastroesophageal reflux disease (GERD) and its treatment of quality of life.

RESULTS

The increasing interest in measuring patients' quality of life as an outcome reflects an increasing awareness that traditional physiological endpoints often do not correlate well with patients' functional status, general well-being, and satisfaction with therapy. It has been shown that GERD has a significant impact on patients' quality of life; therefore, improvement of quality of life is one of the major goals of GERD treatment. This can be achieved by medical as well as surgical treatment.

CONCLUSION

In addition to the patients' perspective, quality of life is one of the major endpoints in medical research that will help provide more selective treatment regimens for our patients.

Psychological and emotional aspects of gastroesophageal reflux disease

A synergy exists between the psychological and physiological aspects of esophageal and other gastrointestinal symptoms. Based on a biopsychosocial model of disease, several multidisciplinary concepts of interventions in gastrointestinal disorders have been evaluated. The role of psychological factors in gastroesophageal reflux disease (GERD) has been under study. This article reviews psychological and emotional factors influencing GERD symptoms and treatment.

Endoscopic, deep mural implantation of Enteryx for the treatment of GERD: 6-month follow-up of a multicenter trial

OBJECTIVES

This prospective, multicenter, single-arm study evaluated the safety and efficacy of the endoscopic implantation of Enteryx, a biocompatible, non-biodegradable liquid polymer for the treatment of GERD.

METHODS

Eighty-five patients with heartburn symptoms responsive to proton pump inhibitor (PPI) use were enrolled. Inclusion requirements were HRQL score < or = 11 on PPI and > or = 20 off PPI, and 24-hour PH probe with > or = 5% total time at PH < or = 4. Patients with a hiatus hernia > 3 cm, grade 3 or 4 esophagitis, or esophageal motility disorder were excluded. Using a 4-mm needle tipped catheter during standard endoscopy, implants were made in 3-4 quadrants deep into the wall of the cardia. Use of PPI medications, pH-metry, manometry, GERD symptoms, and patient quality of life were assessed over a 6-month follow-up period.

RESULTS

At 6 months, PPI use was eliminated in 74% and reduced by > 50% in 10% of patients. The median HRQL score improved from 24.0 pre-implant (baseline off PPIs) to 4.0 at 6 months (p < 0.001). Mean total esophageal acid exposure time was 9.5% pretherapy and 6.7% at 6 months (p < 0.001). Mean LES length increased from 2.0 cm at baseline to 3.0 cm posttherapy (p = 0.003). There were no clinically serious adverse events. Transient mild-to-moderate chest pain commonly occurred after implantation.

CONCLUSIONS

The endoscopic implantation of Enteryx is a safe and effective therapy for eliminating or decreasing the need for PPI medications, improving GERD symptoms and patient quality of life, and decreasing esophageal acid exposure among patients suffering from GERD.

Expectations of patients with gastroesophageal reflux disease for the outcome of laparoscopic antireflux surgery

Goals of gastroesophageal reflux disease (GERD) treatment are symptom relief, healing of esophagitis, prevention of complications, and prevention of relapses. The aims of the current study were to evaluate a selected group of patients referred to our Department of General Surgery for presurgical examination (N = 70: 41 males and 29 females) for their expectations about laparoscopic antireflux surgery and to compare these expectations with the official medical treatment goals. The leading expectations for laparoscopic antireflux surgery were as follows: (1) for 92.8%, abatement of GERD-related symptoms, especially heartburn, regurgitation, and pain; (2) for 84.3%, a return to normal daily activities and life such as eating and drinking habits, sleeping habits, or work-related aspects; (3) for 72.9%, an improvement in quality of life; (4) for 52.9%, a successful surgical intervention without any complications or side effects; and (5) for 48.6%, protection from a Barrett esophagus and cancer risk. In contrast, only two patients answered that they would expect normalization of pH values and healing of esophagitis. The data show that the majority of patients have clear expectations about laparoscopic antireflux surgery. These expectations are partly related to official medical treatment goals. In general, patient-related aspects of outcome concerning expectations should be included as a standard in all official goals of GERD treatment and also in medical outcome studies. One of these aspects should absolutely be patients' quality of life.

Mid- and long-term quality of life assessments after laparoscopic fundoplication and refundoplication: a single unit review of more than 500 antireflux procedures

BACKGROUND

For the evaluation of surgical interventions, quality of life data are being increasingly used as an efficacy endpoint.

AIMS

To evaluate impact of laparoscopic fundoplication and laparoscopic refundoplication on quality of life as well as on patient satisfaction with the procedure for at least 5 years after surgical intervention.

PATIENTS

After more than 500 laparoscopic antireflux procedures, quality of life data have been prospectively reviewed and data compared with healthy individuals, untreated gastro-oesophageal reflux disease patients (n = 150) and successfully treated patients (n = B4) under adequate omeprazole therapy.

METHODS

Gastrointestinal Quality of Life Index has been used in all patients and evaluated the day before surgery and 5 times after surgery. Moreover, the SF-36 questionnaire has been used up to 2 years after surgical intervention, but only in patients who underwent laparoscopic redo-surgery (n = 49).

RESULTS

In both surgical groups, mean preoperative Gastrointestinal Quality of Life Index showed a significant (p < 0.01) impairment (before laparoscopic antireflux surgery: 90.4 +/- 10.3 points; before redo-surgery: 84.3 +/- 8.1 points) when compared with healthy individuals (mean: 122.6 +/- 8.5 points) and successfully treated patients with acid-suppressive therapy (mean: 121.4 +/- 9.2 points). After surgery, the mean Gastrointestinal Quality of Life Index increased significantly and remained stable for at least 5 years after laparoscopic antireflux surgery (120.8 +/- 8.6 points) or for at least 2 years after redo-proce-dure (120.9 +/- 7.2 points). Before laparoscopic refundoplication, 6 out of 8 SF-36 scores were significantly p < 0.05) decreased. Redo-surgery influenced these 6 scores significantly (p < 0.05-0.01), resulting in values comparable to those of general population. Patients' satisfaction with surgery was excellent or good in 95%.

CONCLUSION

Both, laparoscopic fundoplication as well as laparoscopic refundoplication are able to improve patients' quality of life significantly for at least 5 years. Therefore, quality of life data provide useful information to discuss different treatment options with patients.

Laparoscopic antireflux surgery in gastro-oesophageal reflux disease patients with concomitant anxiety disorders

BACKGROUND

Several psychological factors are known to affect the subjective outcome, such as quality of life, after laparoscopic antireflux surgery.

AIM

To evaluate: a. outcome of laparoscopic antireflux surgery in gastro-oesophageal reflux disease patients with concomitant anxiety disorders, b. potential effects of laparoscopic antireflux surgery on psychiatric comorbidities.

PATIENTS AND METHODS

Out of more than 550 patients who underwent laparoscopic antireflux surgery, 21 suffered from additional anxiety disorders. Outcome assessments included traditional data, evaluation of symptoms and side-effects, and quality of life. These data were evaluated before laparoscopic antireflux surgery and 6 weeks, 3 months and 1 year after surgery,

RESULTS

Post-operative lower oesophageal sphincter pressure and DeMeester score were normal in all patients. Subjective severity of anxiety disorders remained unchanged in 13 patients 1 year after surgery. One patient suffered from severe dysphagia and required single dilatation. In this patient, severity and frequency of panic attacks increased for approximately 6 months after laparoscopic antireflux surgery. In 7 patients, total relief of panic symptoms was reported within 3 months post-operatively. Severity of most gastro-oesophageal reflux disease-related symptoms decreased significantly after laparoscopic antireflux surgery, but severity of some symptoms remained stable in patients with continuing anxiety disorders. In all patients, Gastrointestinal Quality of Life Index increased significantly. This improvement was less marked in patients with continuing anxiety disorders. Patients presenting total relief of panic symptoms showed an outcome comparable to normal data.

CONCLUSIONS

Data obtained suggest that patients with concomitant anxiety disorders should not generally be excluded from laparoscopic antireflux surgery but should be selected more carefully. In these patients, surgery significantly improves quality of life and eliminates gastro-oesophageal reflux disease-related symptoms. Some patients demonstrated less symptomatic relief. In contrast, laparoscopic antireflux surgery was able to eliminate panic disorders in one third of our patients.