Nissen fundoplication improves gastric motility in patients with delayed gastric emptying

Poor Gastric Emptying in Patients with Paraesophageal Hernias: Pyloroplasty, Per-Oral Pyloromyotomy, BoTox, or Wait and See?

Gastric emptying delay may be caused with both functional and anatomic derangements. Gastroparesis is suspected in patients presenting with certain foregut symptoms without anatomic obstruction. Data are still emerging regarding the best treatment of this condition. In cases where large paraesophageal hernias alter the upper gastrointestinal anatomy, it is difficult to know if gastroparesis also exists. Management of hiatal hernias is also still evolving, with various strategies to reduce recurrence being actively investigated. In this article, we present a systematic review of the existing literature around the management of gastroparesis and the management of paraesophageal hernias when they occur separately. In addition, since there are limited data to guide diagnosis and management of these conditions when they are suspected to coexist, we provide a rational strategy based on our own experience in patients with paraesophageal hernias who have symptoms or studies that raise suspicion for a coexisting functional disorder.

Laparoscopic Posterior Partial Fundoplication for Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common condition that greatly impacts quality of life. Management options include medical and surgical therapies. Nonoperative management typically relies on longitudinal use of acid-suppressive medications such as proton pump inhibitors, which is associated with a significant financial burden and an increasing number of recognized side effects. The surgical management of GERD is focused on correction of the lower esophageal sphincter dysfunction by means of a fundoplication, thus limiting acid and nonacid gastroesophageal reflux. Multiple techniques have been described, including use of complete (360°) fundoplication or partial fundoplication in either an anterior (180°) or posterior (220-270°) position. Recent studies have shown that the total and the partial fundoplications are similarly effective in controlling GERD. A partial fundoplication may also be advantageous when treating patients with GERD and poor esophageal motility. This article focuses on the posterior partial (modified Toupet) fundoplication, with attention to the key elements of the preoperative workup, appropriate patient selection, and important technical steps that are associated with the best outcomes.

Ameliorating Effects and Autonomic Mechanisms of Transcutaneous Electrical Acustimulation in Patients With Gastroesophageal Reflux Disease

BACKGROUND/AIM

Gastric dysmotility is one of pathophysiologies of gastroesophageal reflux disease (GERD). The aim of this study was to investigate the effects of transcutaneous electrical acustimulation (TEA) on gastric accommodation and gastric slow waves, and evaluate possible mechanisms in patients with GERD.

METHODS

Thirty patients were studied in two randomized sessions of sham-TEA and TEA with the measurements of esophageal high-resolution manometry (HRM), gastric accommodation assessed by a nutrient-drinking test, electrogastrogram (EGG), electrocardiogram (ECG), and postprandial dyspeptic symptoms.

RESULTS

Compared with sham-TEA, TEA improved nutrient drinking-induced fullness (42.0 ± 3.3 vs. 31.0 ± 3.5, P = 0.003) at 10 min after the drink, and belching right after the drink (22.0 ± 4.6 vs. 11.7 ± 3.1, P = 0.012) and at 10 min (16.0 ± 3.8 vs. 3.0 ± 1.5, P = 0.002) after the drink. TEA also improved gastric accommodation (954 ± 37 mL vs. 857 ± 47 mL, P = 0.001) and normalized maximal drink-induced impairment in gastric slow waves. Concurrently, TEA enhanced vagal activity assessed from spectral analysis of heart rate variability in the postprandial state (0.42 ± 0.03 vs. 0.49 ± 0.04, P = 0.039). The vagal activity was positively correlated with the percentage of normal slow waves (r = 0.528; P = 0.003) and negatively correlated with the regurgitation score (r = -0.408, P = 0.025).

CONCLUSIONS

Acute TEA increases gastric accommodation, improves gastric slow waves, and reduces postprandial fullness and belching, possibly mediated via the vagal mechanisms.

Spatial Patterns From High-Resolution Electrogastrography Correlate With Severity of Symptoms in Patients With Functional Dyspepsia and Gastroparesis

BACKGROUND & AIMS

Invasive gastric electrical mapping has revealed spatial abnormalities of the slow wave in subjects with gastroparesis and functional gastrointestinal disorders. Cutaneous high-resolution electrogastrography (HR-EGG) is a non-invasive method that can detect spatial features of the gastric slow wave. We performed HR-EGG in subjects with active foregut symptoms to evaluate associations between gastric myoelectric abnormalities, symptoms (based on a validated questionnaire), and gastric emptying.

METHODS

We performed a case-control study of 32 subjects, including 7 healthy individuals (controls), 7 subjects with functional dyspepsia and normal gastric emptying, and 18 subjects with gastroparesis, from a tertiary care program. All subjects were assessed by computed tomography imaging of the abdomen and HR-EGG and completed the PAGI-SYM questionnaire on foregut symptoms, which includes the gastroparesis cardinal symptom index. We performed volume reconstruction of the torso and stomach from computed tomography images to guide accurate placement of the HR-EGG array.

RESULTS

Spatial slow-wave abnormalities were detected in 44% of subjects with foregut symptoms. Moreover, subjects with a higher percentage of slow waves with aberrant propagation direction had a higher total gastroparesis cardinal symptom index score (r = 0.56; P < .001) and more severe abdominal pain (r = 0.46; P = .009). We found no correlation between symptoms and traditional EGG parameters.

CONCLUSIONS

In case-control study, we found that the genesis of symptoms of functional dyspepsia and gastroparesis is likely multifactorial, including possible contribution from gastric myoelectric dysfunction. Abnormal spatial parameters, detected by cutaneous HR-EGG, correlated with severity of upper gastrointestinal symptoms, regardless of gastric emptying. This noninvasive, repeatable approach might be used to identify patients for whom gastric myoelectric dysfunction contributes to functional dyspepsia and gastroparesis.

Salvage Options for Fundoplication Failure

PURPOSE OF REVIEW

Gastroesophageal reflux disease (GERD) affects millions of people worldwide. Many patients with medically refractory symptoms ultimately undergo antireflux surgery, most often with a laparoscopic fundoplication. Symptoms related to GERD may persist or recur. Revisional surgery is necessary in some patients.

RECENT FINDINGS

A reoperative fundoplication is the most commonly performed salvage procedure for failed fundoplication. Although redo fundoplication has been reported to have increased risk of morbidity compared with primary cases, increasing experience with the minimally invasive approach to reoperative surgery has significantly improved patient outcome with acceptable resolution of reflux symptoms in the majority of patients. Recurrence of reflux symptoms after an initial fundoplication requires a thorough work-up and a thoughtful approach. While reoperative fundoplication is the most common procedure performed, there are other options and the treatment should be tailored to the patient, their history, and the mechanism of fundoplication failure.

Per-Oral Pyloromyotomy (POP) for Medically Refractory Post-Surgical Gastroparesis

BACKGROUND

Post-surgical gastroparesis (psGP) is putatively related to vagal denervation from either therapeutic transection or inadvertent injury. Here, we present a series of patients undergoing endoscopic per-oral pyloromyotomy (POP) as a treatment for medically refractory psGP.

METHODS

Patients identified from a prospectively maintained database of patients undergoing POP procedures at our institution from January 2016 to January 2018 were included. Surgical history, symptom scores, and gastric emptying studies before and 3 months after POP were additionally recorded.

RESULTS

During the study period, 177 POP procedures were performed, of which 38 (21.5%) were for psGP. The study cohort was 84.2% female with a mean body mass index of 27.6 kg/m² and mean age of 55.2 years. Common comorbidities included hypertension (34.2%), depression (31.6%), and gastroesophageal reflux disease (28.9%). Hiatal/paraesophageal hernia repair (39.5%) or fundoplication (36.8%) preceded psGP diagnosis most often. The mean operative time was 30 ± 20 min. There were no intraoperative complications. Mean postoperative length of stay was 1.2 days. There were two readmissions within 30 days, one for melena and one for dehydration. The mean improvement in total Gastroparesis Symptom Index Score was 1.29 (p = 0.0002). The mean 4-h gastric retention improved from a pre-POP mean of 46.4 to 17.9% post-POP. Normal gastric emptying was noted in 50% of subjects with available follow-up imaging.

CONCLUSION

POP is a safe and effective endoscopic therapy for patients with psGP. POP should be considered a reasonable first-line option for patients with medically refractory psGP and may allow stomach preservation.

Surgical Management for Gastroparesis

Gastroparesis is a debilitating chronic condition of indeterminate cause. Although conservative management is the mainstay of treatment, a significant percentage of patients will need interventions. Interventions range from supportive measures, such as feeding tubes, to more radical surgeries, including endoscopic pyloromyotomy (per oral pyloromyotomy), laparoscopic pyloroplasty, laparoscopic gastric stimulator placement, and even subtotal or total gastrectomy. The authors present some current treatment algorithms focused on the treatment side of the spectrum along with outcomes data to support the various approaches.

Submucosal surgery: novel interventions in the third space

Traditional surgeries involve accessing body cavities, such as the abdomen and thorax, via incisions that divide skin and muscle. These operations result in postoperative pain and convalescence, and a risk of complications such as wound infection and hernia. The development of flexible endoscopy allowed diseases as varied as gastrointestinal bleeding and colon adenomas to be treated without incisions, but this technique is restricted by its endoluminal nature. A novel category of surgical endoscopic procedures has recently been developed that uses flexible endoscopic techniques to enter and access the submucosa of the gastrointestinal tract. Through this approach, the advantages of incisionless endoscopy can be applied to areas of the body that previously could only be reached with surgery. This Review introduces this new class of interventions by describing two examples of such submucosal surgeries for the treatment of benign gastrointestinal disease: per-oral endoscopic myotomy and per-oral pyloromyotomy. The approach to pre-procedure patient evaluation, operative technique, and the published outcomes are discussed, as well as potential future applications of similar techniques and procedures in this so-called third space.

Laparoscopic partial sleeve gastrectomy with fundoplication for gastroesophageal reflux and delayed gastric emptying

BACKGROUND

A difficult management problem for the upper gastrointestinal surgeon exists when a patient presents with symptomatic and refractory severe delayed gastric emptying. Surgical treatment is further complicated by coexisting gastro-oesophageal reflux. No universal surgical strategy exists for this problem.

METHODS

A novel surgical strategy combines partial sleeve gastrectomy (SG) and hiatus hernia (HH) repair with fundoplication. A review of treating four such patients is described with objective outcome data.

RESULTS

Overall, solid gastric emptying improved in all, from median 350 (163-488) min pre-operatively to 108 (84-135) at 10 months (3-24) post-operatively, corresponding to 67% improvement. Primary symptoms resolved in all; however, one patient had recurrent symptoms. GERD-HRQL also improved in all, from median 23 (3-25) to 4 (0-8) at 21 months (6-30, 83% improvement). Gas bloat improved in three. All had post-operative gastroscopies showing intact repair and absent oesophagitis, with no patient requiring post-operative PPI. Patient weight reduced by median 11% (7-20) post-operatively. There was no significant peri-operative morbidity.

CONCLUSIONS

With careful patient selection and work-up, SG and HH repair with fundoplication may improve quality of life by coupling adequate reflux control with improved gastric emptying.

Early human experience with per-oral endoscopic pyloromyotomy (POP)

INTRODUCTION

Gastroparesis is a condition characterized by delayed gastric emptying, and a constellation of symptoms, including nausea, vomiting, early satiety, and bloating. Although current surgical options such as pyloroplasty have been shown to be effective, an endoscopic submucosal myotomy technique may be applied to divide the pyloric sphincter without surgical access. Such endoscopic technique may provide the benefits of a natural orifice procedure, and improve gastric emptying in gastroparetic patients.

METHODS AND PROCEDURES

Per-oral pyloromyotomy (POP) was performed in seven female patients aged 33-65 years (mean 51 years). All patients had a pre-operative work-up that included upper endoscopy, and a gastric emptying study. A pH study, and esophageal manometry were also performed when a concomitant fundoplication was considered.

RESULTS

POP was technically successful in all seven cases. There were no immediate procedural complications. Perioperative, complications included: one patient with an upper GI bleed 2 weeks post-procedure, necessitating transfusions, and endoscopic clipping of a pyloric channel ulcer; one patient who experienced difficulty swallowing post operatively, delaying discharge by 1 day; and one patient who developed a hospital-acquired pneumonia, delaying discharge by several days. Six of the seven patients experienced significant symptomatic improvement following the procedure. Three month follow-up nuclear medicine solid-phase gastric emptying studies are currently available for 5 of the 7 patients. Normal gastric emptying at 4 h was noted in four of five patients (80 %). One patient did not respond to endoscopic management subsequently underwent an uneventful laparoscopic pyloroplasty, which also failed to significantly improve her symptoms.

CONCLUSION

POP is a technically safe and feasible endoscopic procedure. Early follow-up suggests promising symptomatic improvement as well as objective improvement in gastric emptying. Additional clinical experience is required to establish the role of this technique in the management of gastroparesis.

Preoperative diagnostic workup before antireflux surgery: an evidence and experience-based consensus of the Esophageal Diagnostic Advisory Panel

BACKGROUND

Gastroesophageal reflux disease (GERD) is a very prevalent disorder. Medical therapy improves symptoms in some but not all patients. Antireflux surgery is an excellent option for patients with persistent symptoms such as regurgitation, as well as for those with complete symptomatic resolution on acid-suppressive therapy. However, proper patient selection is critical to achieve excellent outcomes.

STUDY DESIGN

A panel of experts was assembled to review data and personal experience with regard to appropriate preoperative evaluation for antireflux surgery and to construct an evidence and experience-based consensus that has practical application.

RESULTS

The presence of reflux symptoms alone is not sufficient to support a diagnosis of GERD before antireflux surgery. Esophageal objective testing is required to physiologically and anatomically evaluate the presence and severity of GERD in all patients being considered for surgical intervention. It is critical to document the presence of abnormal distal esophageal acid exposure, especially when antireflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach.

CONCLUSIONS

Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. Additional studies with long-term follow-up are required to evaluate the diagnostic and therapeutic benefit of new technologies, such as oropharyngeal pH testing, multichannel intraluminal impedance, and hypopharyngeal multichannel intraluminal impedance, in the context of patient selection for antireflux surgery.

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.

Long-term outcomes after laparoscopic antireflux surgery

OBJECTIVES

We studied the long-term outcomes of laparoscopic antireflux surgery (LARS) and the factors that determine it, as neither has been previously well established.

METHODS

From September 1993 (start of our program) to September 1999, 441 patients underwent LARS. Preoperative symptoms and the results of esophageal functional studies as well as details of the operation and follow-up were recorded prospectively in our database. In 2004, with the help of a private investigator, we were able to contact 288 (65%). There were no differences in presentation profiles of those patients contacted and those we could not.

RESULTS

At a median follow-up of 69 months, individual symptoms, among those who had it preoperatively, were as follows: heartburn (N = 282) improved in 254 (90%) and resolved in 188 (67%); regurgitation (N = 258) improved in 238 (92%) and resolved 199 (70%); dysphagia (N = 123) improved in 96 (78%) and resolved in 76 (62%); cough (N = 119) improved in 82 (69%) and resolved in 48 (40%); and hoarseness (N = 106) improved in 73 (69%) and resolved in 50 (47%). Univariate regression analysis showed that the presence of heartburn (P= 0.02), male gender (P= 0.03), and younger age (P= 0.04) predicted symptom resolution, whereas preoperative dysphagia (P= 0.03), airway manifestations (P= 0.03), bloating (P= 0.04), and defective esophageal motility (P= 0.08) were negative predictive factors. By multivariate analysis, male gender, dysphagia, and age remained significant (P < 0.05). Seven patients (2%) developed a new onset of dysphagia; 32 patients (11%) developed new or increased diarrhea and 27 patients (9%) developed bloating postoperatively. One hundred nineteen patients (41%) were taking some form of antacid medication; 66 (23%) patients were using PPIs and 10 (3%) had undergone reoperation.

CONCLUSION

LARS provides effective long-term relief of GERD. Younger patients, men, and those without dysphagia are predictors of superior outcomes.

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.

Post-surgical and obstructive gastroparesis

Post-surgical gastroparesis (PSG) is recognized as a consequence of vagal nerve injury following upper abdominal surgery. It has been well documented following vagotomy for peptic ulcer surgery. With the increasing role of surgical treatment in the management of GERD and morbid obesity, PSG is now being diagnosed after fundoplication and bariatric surgery. PSG has also been reported after heart and lung transplantation, possibly due to opportunistic viral infection or motor-inhibitory effects of the immunosuppressive drugs, in addition to vagal nerve injury. Initial postoperative management of PSG should be conservative as many symptoms following abdominal surgery resolve with time. This occurs possibly because the enteric nervous system is able to adapt to the loss of vagal input or vagal reinnervation occurs. Persistent symptoms are difficult to manage and require a multidisciplinary team approach. Gastric electrical stimulation has shown promise in small series.

Preoperative gastric emptying and patterns of reflux as predictors of outcome after laparoscopic fundoplication

BACKGROUND

Some studies have suggested that patients with predominantly upright reflux have a poor outcome after laparoscopic antireflux surgery. It has been proposed that this might be related to gastric emptying. The aim of this study was to evaluate the relationship between preoperative upright reflux pattern, gastric emptying rate and outcome after laparoscopic fundoplication.

METHODS

Patients presenting for antireflux surgery underwent 24-h ambulatory pH testing and dual-isotope radionuclide gastric emptying studies. Reflux pattern was determined by the acid exposure in the distal oesophagus (percentage of time at pH < 4) during supine and upright posture. Outcome after fundoplication was assessed by a standardized postal questionnaire administered at 3 months, and 1, 2 and 5 years after surgery.

RESULTS

Of 372 patients identified from a prospectively maintained database, 109 had upright reflux, 57 supine reflux and 206 bipositional reflux. Overall patient satisfaction was not influenced by reflux pattern at any time after surgery. Delayed gastric emptying was documented in 31.0 per cent of patients, but there was no relationship with reflux pattern.

CONCLUSION

Patients with upright reflux did not have a less favourable outcome after fundoplication. Categorizing patients according to reflux pattern is of no value in predicting outcome or selecting patients for surgery.

Pyloroplasty with fundoplication in the treatment of combined gastroesophageal reflux disease and bloating

BACKGROUND

Although gastroparesis does not influence gastroesophageal reflux disease (GERD) or antireflux surgery, many patients with GERD will also suffer from gastroparesis-related bloating as a distinct symptom different from GERD-related symptoms. The purpose of this study was to assess whether a pyloroplasty with a fundoplication will improve bloating symptoms in these patients.

METHODS

A prospectively gathered database of all patients undergoing antireflux surgery was reviewed. All patients underwent history, physical examination, upper gastrointestinal endoscopy, esophageal manometry, 24-hour esophageal pH monitoring, and, selectively, contrast upper gastrointestinal radiography. Patients with symptoms of bloating also underwent gastric emptying scintigraphy. All patients completed the GERD-Health Related Quality of Life (HRQL) symptom severity questionnaire. One of the items of this instrument relates to bloating. The item is scored from 0 (asymptomatic) to 5 (incapacitating) based on descriptive anchors. Patients with symptomatic GERD and objective findings by physiologic testing were offered antireflux surgery. Those with delayed gastric emptying (defined as T(1/2) > 120 minutes) were also offered a pyloroplasty. Operations performed included a laparoscopic or open Nissen or Toupet fundoplication with a Heineke-Mickulicz pyloroplasty. Postoperatively, patients completed the GERD-HRQL and had a gastric emptying scintigraphy performed.

RESULTS

Three-hundred and sixty-nine patients underwent antireflux surgery; of these, 35 patients also had a pyloroplasty. Twenty-eight (80%) of these patients reported significant symptomatic improvement. The median preoperative bloating score improved from 4 to 1 postoperatively (P < 0.05), and the median gastric emptying scintigraphy T(1/2) improved from 244 to 112 minutes (P < 0.05).

CONCLUSIONS

Although gastroparesis may not contribute to symptoms of GERD, it can contribute to symptoms of bloating. Bloating symptoms improved in 80% of patients with the addition of a pyloroplasty. Therefore, addition of pyloroplasty to a fundoplication in patients with gastroparesis-related bloating can improve bloating symptoms.

Delayed gastric emptying in patients undergoing antireflux surgery: analysis of a treatment algorithm

PURPOSE

Controversy remains about the treatment of patients with mild delayed gastric emptying (90 min < emptying half-time [T(1/2)] < 180 min) who undergo antireflux surgery. This retrospective, nonrandomized study reviewed the records of patients treated from January 1996 through October 2003, during which time we applied two treatment algorithms for patients with mild delayed gastric emptying. The goal of this study was to determine whether the most recent treatment algorithm was effective in reducing the need for a concomitant gastric drainage procedure, pyloroplasty.

MATERIALS AND METHODS

Eighteen patients with mild delayed gastric emptying underwent antireflux surgery plus pyloroplasty (group A) before 2001, and 13 patients with mild delayed gastric emptying underwent antireflux surgery plus gastric decompression with percutaneous endoscopic gastrostomy placement (group B) starting in 2001. We reviewed indications for the procedure, complications, and outcomes. Primary outcome measures for this study were recurrence of gastroparesis symptoms and need for pyloroplasty.

RESULTS

The average T(1/2) was similar for both groups A and B: 129 min and 123 min, respectively. Eleven of 13 patients (85%) in group B experienced resolution of gastroparesis symptoms, improved gastric emptying times, or both; only 1 patient (8%) underwent subsequent pyloroplasty for treatment failure. Only one serious percutaneous endoscopic gastrostomy-related event occurred (tube migration), and no patients died. Significantly fewer patients in group B required total pyloroplasty (8% vs. 56% in group A; P < 0.008), and significantly fewer required pyloroplasty for symptomatic control (15% vs. 56% in group A; P < 0.03).

CONCLUSION

A treatment algorithm incorporating percutaneous endoscopic gastrostomy tube placement at the time of antireflux surgery for gastric decompression successfully managed antireflux surgery patients with mild delayed gastric emptying. This approach allows for a more selective use of pyloroplasty.

The current role of laparoscopic surgery for gastroesophageal reflux disease in infants and children

BACKGROUND

The benefits of surgery for gastroesophageal reflux disease (GERD) in infants and children have been questioned in the recent literature. The goal of this review was to determine the best current practice for the diagnosis and management of this disease.

METHODS

The literature was reviewed for all recent English language publications on the management of GERD in 8- to 10-year-old patients.

RESULTS

In infants and children, GERD has multiple etiologies, and an understanding of these is important for determining which patients are the best surgical candidates. Proton pump inhibitors (PPIs) have become the mainstay of current treatment for primary GERD. Although laparoscopic surgery appears to be better than open surgery, there remains some morbidity and complications that careful patient selection can minimize.

CONCLUSION

Surgery for GERD should be performed only after failure of medical management or for specific problems that mandate it.

Gastric emptying of glucose solution and associated plasma concentrations of GLP-1, GIP, and PYY before and after fundoplication

BACKGROUND

This study was designed to assess the relationship between gastric emptying of glucose solution and the ensuing plasma concentrations of glucagon-like peptide-1 (GLP-1), peptide YY (PYY), and glucose-dependent insulinotropic polypeptide (GIP) in patients having undergone fundoplication for gastroesophageal reflux (GERD).

SUBJECTS AND METHODS

In 10 male patients the emptying of 50% glucose solution was determined scintigraphically and its relationship with plasma glucose, GLP-1, PYY, and GIP concentrations was studied before and 3 months after fundoplication.

RESULTS

In the first 30 min after glucose ingestion, emptying was significantly (p = 0.048) faster after fundoplication than before. Emptying and GLP-1 and GIP correlated: the faster the emptying during the first 30 min the greater the concentrations integrated over that period (p = 0.04; p = 0.01; p = 0.02). Emptying and PYY concentrations were unrelated. In the 120-180 min. period, blood glucose concentrations were lower the faster the emptying in the initial 30 min (p = 0.06) and the entire 50-min recording period (p = 0.03) had been. The GLP-1 concentrations integrated over the first 30 min correlated inversely with the integrated plasma glucose during the third hour after ingestion (p = 0.004).

CONCLUSIONS

After fundoplication, gastric emptying may, if accelerated in its initial phases, give rise to greater and earlier increases in plasma glucose, GLP-1, and GIP concentrations and thus to reactive hypoglycemia.

Nutrition support for neurologically impaired children: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

Undernutrition, growth failure, overweight, micronutrient deficiencies, and osteopenia are nutritional comorbidities that affect the neurologically impaired child. Monitoring neurologically impaired children for nutritional comorbidities is an integral part of their care. Early involvement by a multidisciplinary team of physicians, nurses, dieticians, occupational and speech therapists, psychologists, and social workers is essential to prevent the adverse outcomes associated with feeding difficulties and poor nutritional status. Careful evaluation and monitoring of severely disabled children for nutritional problems are warranted because of the increased risk of nutrition-related morbidity and mortality.

Functional Problems Following Esophageal Surgery

Functional problems following esophageal surgery for GERD are not infrequent. The majority of patients improve with time. Careful patient selection and attention to surgical technique are key factors in preventing such functional disorders. When anatomic abnormalities related to the fundoplication are identified, reoperation may offer symptom relief. Before embarking on re-fundoplication, a thorough preoperative evaluation of the esophageal physiology is recommended.

The failed fundoplication

Fundoplication is the standard surgical approach to gastroesophageal reflux (GER) in a child. Although successful in many patients, there is a significant risk of complications and failure, especially in high-risk patients such as those with certain types of associated anomalies, diffuse motility disorders, chronic pulmonary disease, neurologic impairment, and young infants. Fundoplication failure can take the form of persistent reflux-related symptoms, symptoms that are caused by complications of the surgery, or anatomic problems such a para-esophageal hernia or migration of the wrap into the mediastinum. The most effective strategy for treatment of the child undergoing fundoplication is to prevent failure by careful patient selection, individualization of the operation based on the patient's anatomy and physiology, and meticulous attention to the technical details of the operation. Options for the child with a failed fundoplication include medical management, jejunal feeding using a percutaneous tube or a Roux-en-Y jejunostomy, revision of the fundoplication, or esophagogastric dissociation. If the fundoplication is to be revised, the same principles of patient selection, individualization of the operation, and attention to technique must be used to optimize the chance of success. The primary goal in the treatment of GER is to improve quality of life for the patient and the family.

Clinical experience with the Stretta procedure

The benchmarks in GERD therapy comprise the commonly prescribed anti-secretory drugs (H2RAs and PPIs) and anti-reflux surgery. Although drugs are typically safe, cost and patient compliance are challenges to long-term management. Furthermore, while heartburn may be controlled with aggressive medical therapy, other symptoms such as regurgitation may persist, reducing patient satisfaction and adversely affecting quality of life. Surgical anti-reflux procedures, most commonly laparoscopic Nissen fundoplication, improve GERD symptoms and normalize esophageal acid exposure in most patients. Patient perception of the potential risk of abdominal surgery and general anesthesia may limit willingness to undergo surgery resulting in only a small portion of GERD sufferers that actually undergo anti-reflux surgery each year. Overall, the Stretta procedure is well tolerated, with an acceptably low incidence of complications and obviates the need for anti-secretory drug therapy for most patients at the 6- and 12-month follow-up. GERD symptom scores, heartburn, satisfaction, and SF-36 scores significantly improve over the baseline and this effect lasts at least 12 months. The symptomatic improvement after Stretta at 12 months in one trial (GERD score, 27 to 9) is similar to that reported by Velanovich after fundoplication (GERD score, 27 to 3). Furthermore, the significant reduction in median esophageal acid exposure time (distal 10.6% to 6.2%, proximal 1.9% to 0.9%), provides objective evidence of an anti-reflux effect. Although the reported studies have been non-randomized, the objective improvement observed in esophageal acid exposure and the persistence of GERD symptom score improvement with repeated measure analysis over a course of 12 months make a significant placebo effect unlikely. Stretta is a promising new technology for the treatment of GERD that should be considered for patients who wish to discontinue a lifelong anti-secretory medication regimen or who have incomplete GERD symptom control on drugs, but are not yet accepting anti-reflux surgery.