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

Pathophysiology of gastroesophageal reflux disease-which factors are important?

Background

Pathophysiology of gastroesophageal reflux disease (GERD) shows a multifactorial background. Different anatomical and functional alterations can be determined such as weakness of the lower esophageal sphincter (LES), changes in anatomy by a hiatal hernia (HH), an impaired esophageal motility (IEM), and/or an associated gastric motility problem with either duodeno-gastro-esophageal reflux (DGER) or delayed gastric emptying (DGE). The purpose of this study is to assess a large GERD-patient population to quantitatively determine different pathophysiologic factors contributing to the disease.

Methods

For this analysis only patients with documented GERD (pathologic esophageal acid exposure) were selected from a prospectively maintained databank. Investigations: history and physical, body mass index, endoscopy, esophageal manometry, 24 h-pH-monitoring, 24 h-bilirbine-monitoring, radiographic-gastric-emptying or scintigraphy, gastrointestinal quality of life index (GIQLI).

Results

In total, 728 patients (420 males; 308 females) were selected for this analysis. Mean age: 49.9 years; mean BMI: 27.2 kg/m² (range, 20-45 kg/m²); mean GIQLI of 91 (range: 43-138; normal level: 121); no esophagitis: 30.6%; minor esophagitis (Savary-Miller type 1 or Los Angeles Grade A): 22.4%; esophagitis [2-4]/B-D: 36.2%; Barrett's esophagus 10%. Presence of pathophysiologic factors: HH 95.4%; LES-incompetence 88%, DGER 55%, obesity 25.6%, IEM 8.8%, DGE 6.8%.

Conclusions

In our evaluation of GERD patients, the most important pathophysiologic components are anatomical alterations (HH), LES-incompetence and DGER.

ISHLT consensus document on lung transplantation in patients with connective tissue disease: Part III: Pharmacology, medical and surgical management of post-transplant extrapulmonary conditions statements

Patients with connective tissues disease (CTD) are often on immunomodulatory agents before lung transplantation (LTx). Till now, there's no consensus on the safety of using these agents perioperative and post-transplant. The International Society for Heart and Lung Transplantation-supported consensus document on LTx in patients with CTD addresses the risk and contraindications of perioperative and post-transplant management of the biologic disease-modifying antirheumatic drugs (bDMARD), kinase inhibitor DMARD, and biologic agents used for LTx candidates with underlying CTD, and the recommendations and management of non-gastrointestinal extrapulmonary manifestations, and esophageal disorders by medical and surgical approaches for CTD transplant recipients.

VALIDATION OF A NEW WATER-PERFUSED HIGH-RESOLUTION MANOMETRY SYSTEM

Background:

High-resolution manometry is more costly but clinically superior to conventional manometry. Water-perfused systems may decrease costs, but it is unclear if they are as reliable as solid-state systems, and reference values are interchangeable.

Aim:

To validate normal values for a new water-perfusion high-resolution manometry system.

Methods:

Normative values for a 24-sensors water perfused high-resolution manometry system were validated by studying 225 individuals who underwent high resolution manometry for clinical complaints. Patients were divided in four groups: group 1 - gastroesophageal reflux disease; group 2 - achalasia; group 3 - systemic diseases with possible esophageal manifestation; and group 4 - dysphagia.

Results:

In group 1, a hypotonic lower esophageal sphincter was found in 49% of individuals with positive 24 h pH monitoring, and in 28% in pH-negative individuals. In groups 2 and 3, aperistalsis was found in all individuals. In group 4, only one patient (14%) had normal high-resolution manometry.

Conclusions:

The normal values determined for this low-cost water-perfused HRM system with unique peristaltic pump and helicoidal sensor distribution are discriminatory of most abnormalities of esophageal motility seen in clinical practice.

Factors associated with esophageal motility improvement after bilateral lung transplant in patients with an aperistaltic esophagus

OBJECTIVES

We reported that esophageal peristalsis can improve after lung transplant (LTx), even in patients with pretransplant esophageal aperistalsis. This improvement was associated with better outcomes. We analyzed preoperative factors and sought to predict persistent aperistalsis or motility improvement in patients with pre-LTx esophageal aperistalsis.

METHODS

Patients with esophageal aperistalsis who underwent LTx between January 2013 and December 2016 were included. Preoperative barium esophagrams were blinded and re-examined; subjective scores were assigned to motility and dilation patterns. Postoperative high-resolution manometry was used to divide patients into 2 groups: persistent esophageal aperistalsis (PEA) or improved esophageal peristalsis (IEP).

RESULTS

We identified 29 patients: 20 with restrictive lung disease, 7 with obstructive lung disease, and 2 with pulmonary arterial hypertension. Post-LTx, 10 patients had PEA and 19 had IEP (mean age, 53.3 ± 6.6 years and 61.2 ± 10.6 years, respectively; P = .04). All 9 patients (100%) with obstructive lung disease or pulmonary arterial hypertension but only 10 of 20 patients (50%) with restrictive lung disease had IEP post-LTx (P = .01). All 4 patients with scleroderma had PEA. Nearly absent contractility on preoperative esophagrams was more prevalent in the PEA group than in the IEP group (100% vs 58.8%; P = .06). No further differences were observed between the groups.

CONCLUSIONS

Patients with esophageal aperistalsis and obstructive lung disease or pulmonary arterial hypertension, but not patients with restrictive lung disease and scleroderma, are likely to have IEP post-LTx. Additional studies may determine whether subjective esophagram assessment can help predict IEP post-LTx in patients with restrictive lung disease without scleroderma.

The need for a holistic approach for SSc-ILD - achievements and ambiguity in a devastating disease

Systemic sclerosis (SSc) is a multi-organ autoimmune disease with complex interactions between immune-mediated inflammatory processes and vascular pathology leading to small vessel obliteration, promoting uncontrolled fibrosis of skin and internal organs. Interstitial lung disease (ILD) is a common but highly variable manifestation of SSc and is associated with high morbidity and mortality. Treatment approaches have focused on immunosuppressive therapies, which have shown some efficacy on lung function. Recently, a large phase 3 trial showed that treatment with nintedanib was associated with a reduction in lung function decline. None of the conducted randomized clinical trials have so far shown convincing efficacy on other outcome measures including quality of life determined by patient reported outcomes. Little evidence is available for non-pharmacological treatment and supportive care specifically for SSc-ILD patients, including pulmonary rehabilitation, supplemental oxygen, symptom relief and adequate information. Improved management of SSc-ILD patients based on a holistic approach is necessary to support patients in maintaining as much quality of life as possible throughout the disease course and to improve long-term outcomes.

Comparison of short-term outcomes for connective tissue disease-related interstitial lung disease and idiopathic pulmonary fibrosis after lung transplantation

Background

Pulmonary involvement is common in connective tissue disease (CTD), and respiratory failure is a major cause of morbidity and mortality in CTD-related interstitial lung disease (CTD-ILD). Lung transplantation is thus important for these patients. However, survival, outcomes, and management of these patients after transplantation have been debated. The aim of this study was to evaluate the outcomes for CTD-ILD compared to those for idiopathic pulmonary fibrosis (IPF) after lung transplantation.

Methods

We performed a single-centre retrospective study of 62 patients with CTD-ILD or IPF who underwent lung transplantation at a tertiary hospital in South Korea between October 2012 and October 2016.

Results

Patients with CTD-ILD (n=15) were younger (46 vs. 60 years, P=0.001) and were less likely to be male (33.3% vs. 76.6%, P=0.004) than were patients with IPF (n=47). The 1-year cumulative survival rate was 80.0% for CTD-ILD and 59.6% for IPF (log-rank P=0.394). There was no difference in the cumulative survival rate (log-rank P=0.613) of age- and sex-matched patients with CTD-ILD (n=15) and IPF (n=15). The incidence of primary graft dysfunction was similar (P=0.154), and 2 (18.2%) patients developed possible CTD flare.

Conclusions

Patients with CTD-ILD and those with IPF who underwent lung transplantation had similar survival rates.

Evaluation of Gastroesophageal Reflux Disease

INTRODUCTION

Gastroesophageal reflux disease (GERD) may present with heartburn, regurgitation, dysphagia, chronic cough, laryngitis, or even asthma. The clinical presentation of GERD is therefore varied and poses certain challenges to the physician, especially given the limitations of the diagnostic testing.

DISCUSSION

The evaluation of patients with suspected GERD might be challenging. It is based on the evaluation of clinical features, objective evidence of reflux on diagnostic testing, correlation of symptoms with episodes of reflux, evaluation of anatomical abnormalities, and excluding other causes that might account for the presence of the patient's symptoms.

CONCLUSIONS

The diagnostic evaluation should include multiple tests, in addition to a thorough clinical examination.

Risk of lung cancer in patients with gastro-esophageal reflux disease: a population-based cohort study

This large-scale, controlled cohort study estimated the risks of lung cancer in patients with gastro-esophageal reflux disease (GERD) in Taiwan. We conducted this population-based study using data from the National Health Insurance Research Database of Taiwan during the period from 1997 to 2010. Patients with GERD were diagnosed using endoscopy, and controls were matched to patients with GERD at a ratio of 1:4. We identified 15,412 patients with GERD and 60,957 controls. Compared with the controls, the patients with GERD had higher rates of osteoporosis, diabetes mellitus, asthma, chronic obstructive pulmonary disease, pneumonia, bronchiectasis, depression, anxiety, hypertension, dyslipidemia, chronic liver disease, congestive heart failure, atrial fibrillation, stroke, chronic kidney disease, and coronary artery disease (all P < .05). A total of 85 patients had lung cancer among patients with GERD during the follow-up of 42,555 person-years, and the rate of lung cancer was 0.0020 per person-year. By contrast, 232 patients had lung cancer among patients without GERD during the follow-up of 175,319 person-years, and the rate of lung cancer was 0.0013 per person-year. By using stepwise Cox regression model, the overall incidence of lung cancer remained significantly higher in the patients with GERD than in the controls (hazard ratio, 1.53; 95% CI [1.19–1.98]). The cumulative incidence of lung cancer was higher in the patients with GERD than in the controls (P = .0012). In conclusion, our large population-based cohort study provides evidence that GERD may increase the risk of lung cancer in Asians.

Surgical Treatment of Paraesophageal Hernias: A Review

The management of paraesophageal hernia (PEH) can be challenging due to the lack of consensus regarding indications and principles of operative treatment. In addition, data about the pathophysiology of the hernias are scant. Therefore, the goal of this review is to shed light and describe the classification, pathophysiology, clinical presentation, and indications for treatment of PEHs, and provide an overview of the surgical management and a description of the technical principles of the repair.

Laparoscopic Antireflux Surgery: Importance of Patient's Selection and Preoperative Workup

BACKGROUND

Laparoscopic antireflux surgery (LARS) is an excellent option for patients with symptoms refractory to medical treatment, for patients who have complications secondary to the use of proton pump inhibitors, and for those who do not want to take medications for a long period of time.

HYPOTHESIS

We hypothesized that (1) LARS has excellent outcomes if a complete preoperative workup and proper patient selection are performed and (2) recurrent symptoms often are not due to failure of the fundoplication to control the pathologic reflux.

PATIENTS AND METHODS

Every patient referred for antireflux surgery underwent a detailed symptomatic evaluation, barium swallow, esophagogastroduodenoscopy (EGD), high-resolution manometry (HRM), and pH monitoring. A fundoplication was performed in all of them. Data were analyzed to determine outcomes across 8 years.

RESULTS

From 2008 to 2016, 176 patients with gastroesophageal reflux disease (GERD) underwent LARS. One hundred and thirty-four patients (76.1%) had a total fundoplication, 31 (17.6%) had an anterior partial fundoplication, and 11 (6.3%) had a posterior partial fundoplication. Thirty-nine patients (22.2%) referred persistent or recurrent symptoms after the procedure and underwent EGD, HRM, and pH monitoring. Abnormal reflux was documented in 5 patients (2.8%). Among these failures, 3 patients had a body mass index (BMI) ≥30 and 2 had ≥35.

CONCLUSIONS

The results of this study showed that (1) laparoscopic fundoplication is an effective procedure for GERD; (2) patient's BMI can affect the outcome of a fundoplication; and (3) pH monitoring is important to establish if recurrent symptoms are secondary to failure of the operation.

Laparoscopic Antireflux Surgery in Patients with Connective Tissue Diseases

Different connective tissue diseases (CTDs), such as dermatomyositis, mixed CTD, rheumatoid arthritis, polymyositis, lupus, and Behçet's, may affect the esophagus, impairing its motor function. The muscular atrophy and fibrosis caused by the autoimmune vasculitis and neuronal dysfunction affect the esophageal body and the lower esophageal sphincter, leading to a clinical presentation of dysphagia and gastroesophageal reflux disease (GERD). The belief that the impaired esophageal motility may negatively affect surgical outcome has led to the common recommendation of avoiding laparoscopic antireflux surgery (LARS) for fear of creating or worsening dysphagia. This review focuses on the evaluation of the outcome of LARS in patients with CTD. Specifically, this review shows that the literature on LARS and CTDs is scarce and most studies have a small number of patients and a short follow-up. Furthermore, a subanalysis of the outcome based on the type of CTD or the manometric profile is still elusive. In the setting of these limitations, it appears that results are good and comparable to those of patients with GERD and without a CTD. Morbidity and mortality are insignificant even considering the systemic manifestations of the CTD. LARS should not be denied to patients with CTD and GERD.

Gastroesophageal reflux disease and non-esophageal cancer

The association of gastroesophageal reflux disease (GERD) and esophageal cancer is well known. The carcinogenic properties of the gastroduodenal contents may also lead to cancer in target organs for GERD especially considering that they do not have intrinsic protective mechanisms as found in the esophagus. This review focuses on the putative relation between GERD and non-esophageal cancer. Most of the papers reviewed are far from ideal to prove the relationship of extra-esophageal cancer and GERD since a small number of patients is presented, most do not control cases based on tobacco usage and obesity, and the diagnosis of GERD is variable, not always from an objective measurement such as pH monitoring but relying on symptoms in most reports. Nevertheless, head and neck and lung cancer have a growing incidence parallel to GERD and a shift towards non-smoking, female gender and adenocarcinoma (compared to squamous cell carcinoma) is arising, similar to the example of esophageal cancer with the exception of the female gender.

GERD procedures: when and what?

BACKGROUND

The topic of "when and what" for gastroesophageal reflux disease (GERD) procedures centers on the correct indications for antireflux surgery gleaned from a thorough preoperative evaluation (the "when") and on the right antireflux operation to perform once the ideal candidate is identified (the "what").

AIMS

The goals of this evidence-based review are the following: (1) to identify the key indications for surgery and predictors of good outcomes in the initial evaluation of patients with symptoms of GERD; (2) to describe the operations for GERD in the armamentarium of the general surgeon and their indications, as well as the technical elements of the operation; and (3) to describe the optimal surgical treatment of GERD and obesity when the two diseases coexist.

Usefulness of pH monitoring in predicting the survival status of patients with scleroderma awaiting lung transplantation

BACKGROUND

Patients with scleroderma and end-stage lung disease (ESLD) have a very high prevalence of gastroesophageal reflux disease (GERD). Because GERD has been associated with aspiration in those with ESLD, and because those with scleroderma are particularly prone to develop severe GERD, there is some concern that GERD may contribute to shorten survival in patients with scleroderma awaiting lung transplantation. Therefore, we hypothesized that esophageal pH monitoring could predict survival of those with scleroderma and ESLD awaiting lung transplantation and that the severity of reflux can impact survival.

METHODS

We conducted a retrospective analysis of all scleroderma patients referred for lung transplantation who underwent esophageal manometry and pH monitoring since August 2008. We identified 10 patients in whom we calculated and compared the area under the curve for each receiver operating characteristic curve of the following variables: DeMeester score, forced expiratory volume in 1 s (FEV1), %predicted FEV1, forced vital capacity (FVC), %predicted FVC, diffusion capacity for carbon monoxide (DLco), and %predicted DLco.

RESULTS

The DeMeester score nominally outperformed FEV1, FVC, and DLco. Receiver operating characteristic curve analysis was also used to define the optimal DeMeester score (65.2) in differentiating survival status, as determined by maximizing sensitivity and specificity. Based on this value, we calculated the 1-y survival from the time of the esophageal function testing, which was 100% in seven patients with a DeMeester score of <65.2, and 33% in three patients with a score >65.2 (P = 0.01). The latter patients had greater total time pH < 4, greater time pH < 4 in the supine position, greater total episodes of reflux, and higher prevalence of absent peristalsis. The single survivor with a DeMeester score >70 had also proximal reflux, underwent antireflux surgery, and is alive 1201 d after transplant.

CONCLUSIONS

Our study shows that esophageal pH monitoring can predict survival status in patients with scleroderma awaiting lung transplantation and that the severity of reflux can impact the 1-y survival rate. Therefore, esophageal pH monitoring should be considered early in patients with scleroderma and ESLD, as this test could appropriately identify those in whom laparoscopic antireflux surgery should be performed quicker to prevent GERD and its detrimental effects in patients awaiting lung transplantation.

Survival after lung transplantation in systemic sclerosis. A systematic review

BACKGROUND

Lung transplantation is a life-saving option for systemic sclerosis (SSc)-associated pulmonary arterial hypertension (PAH) and interstitial lung disease (SSc-ILD) patients. However, some programs may be concerned about the possibility of excess post-transplantation mortality related to the extra-pulmonary manifestations of SSc. The objective of this study was to evaluate survival of SSc patients post-lung transplantation. We secondarily evaluated SSc lung transplant recipient characteristics (age, sex, and type of SSc lung disease), and discussed post-lung transplantation survival of SSc patients and non-SSc patients (idiopathic PAH, and ILD).

METHODS

A systematic review of MEDLINE, EMBASE, Cochrane Central Registry of Controlled Trials and CINAHL (all inception to 2012) was performed to identify studies evaluating post-lung transplant survival in SSc compared to PAH and ILD patients. Two reviewers independently abstracted study and survival data.

RESULTS

Two hundred twenty-six citations were screened to identify 7 observational studies reporting SSc patients who underwent single lung, double lung, or heart-lung transplantation. Mean age at transplantation ranged 46-53 years. SSc post-transplantation survival ranged 69%-91% at 30-days, 69%-85% at 6-months, 59%-93% at 1-year, 49%-80% at 2-years, and 46%-79% at 3-years. Causes of death included graft failure, infection, cardiac events, hemorrhagic stroke, respiratory failure, malignancy, pulmonary hypertension, complications of bronchiolitis obliterans syndrome, anesthetic complication, and scleroderma renal crisis. There were no reports of recurrence of SSc in the lung allograft.

CONCLUSION

The short-term and intermediate-term survival post-lung transplantation are similar to IPAH and ILD patients requiring lung transplantation.

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

INTRODUCTION

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

DISCUSSION

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

CONCLUSION

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

Gastroesophageal reflux in critically ill children: a review

Gastroesophageal reflux (GER) is very common in children due to immaturity of the antireflux barrier. In critically ill patients there is also a high incidence due to a partial or complete loss of pressure of the lower esophageal sphincter though other factors, such as the use of nasogastric tubes, treatment with adrenergic agonists, bronchodilators, or opiates and mechanical ventilation, can further increase the risk of GER. Vomiting and regurgitation are the most common manifestations in infants and are considered pathological when they have repercussions on the nutritional status. In critically ill children, damage to the esophageal mucosa predisposes to digestive tract hemorrhage and nosocomial pneumonia secondary to repeated microaspiration. GER is mainly alkaline in children, as is also the case in critically ill pediatric patients. pH-metry combined with multichannel intraluminal impedance is therefore the technique of choice for diagnosis. The proton pump inhibitors are the drugs of choice for the treatment of GER because they have a greater effect, longer duration of action, and a good safety profile.

Current trends in the management of gastroesophageal reflux disease: a review

Gastroesophageal reflux disease (GERD) is a chronic disorder of the upper gastrointestinal tract with global distribution. The incidence is on the increase in different parts of the world. In the last 30 to 40 years, research findings have given rise to a more robust understanding of its pathophysiology, clinical presentation, and management. The current definition of GERD (The Montreal definition, 2006) is not only symptom-based and patient-driven, but also encompasses esophageal and extraesophageal manifestations of the disease. The implication is that the disease can be confidently diagnosed based on symptoms alone. Nonerosive reflux disease (NERD) remains the predominant form of GERD. Current thinking is that NERD and erosive reflux disease (ERD) are distinct phenotypes of GERD rather than the old concept which regarded them as components of a disease spectrum. Non erosive reflux disease is a very heterogeneous group with significant overlap with other functional gastrointestinal disorders. There is no gold standard for the diagnosis of GERD. Esophageal pH monitoring and intraluminal impedance monitoring have thrown some light on the heterogeneity of NERD. A substantial proportion of GERD patients continue to have symptoms despite optimal PPI therapy, and this has necessitated research into the development of new drugs. Several safety concerns have been raised about chronic use of proton pump inhibitors but these are yet to be substantiated in controlled studies. The debate about efficacy of long-term medical treatment compared to surgery continues, however, recent data indicate that modern surgical techniques and long-term PPI therapy have comparable efficacy. These and other issues are subjects of further research.

Pre-dinner administration increases the efficacy of proton pump inhibitors on refractory GERD symptoms in connective tissue disease patients

BACKGROUND

A significant proportion of patients with connective tissue disease (CTD) have gastric esophageal reflux disease (GERD) symptoms despite receiving proton pump inhibitors (PPIs). Although pre-meal administration of PPIs is recommended in Western countries, the benefit of this administration timing in Japanese CTD patients with refractory GERD symptoms has not been proven.

OBJECTIVE

To determine whether pre-dinner administration of PPIs is more efficacious for refractory GERD symptoms in Japanese CTD patients.

METHODS

CTD patients receiving oral PPIs were instructed to take PPIs 1 h before dinner. Gastrointestinal symptoms were evaluated with frequency scale for the symptoms of GERD (FSSG) and gastrointestinal symptom rating scale (GSRS) before and after the intervention.

RESULTS

Pre-dinner administration of PPIs significantly improved FSSG total score, from a median of 8 to 6.5 (P = 0.005). Pre-dinner administration was more effective in patients with overt GERD symptoms (from median 18 to 10, P < 0.001) than in those with mild GERD symptoms (from median 2 to 2, P = 0.201). In addition to reflux syndrome, pre-dinner administration of PPIs significantly decreased abdominal pain syndrome and constipation syndrome of GSRS.

CONCLUSION

Pre-dinner administration of PPIs may increase their efficacy in Japanese CTD patients with GERD, especially those with overt symptoms.

Interstitial lung disease and gastroesophageal reflux disease: key role of esophageal function tests in the diagnosis and treatment

CONTEXT

Gastroesophageal reflux disease (GERD) is common in patients with respiratory disorders and interstitial lung fibrosis from diverse disease processes. However, a cause-effect relationship has not been well demonstrated. It is hypothesized that there might be more than a coincidental association between GERD and interstitial lung damage. There is still confusion about the diagnostic steps necessary to confirm the presence of GERD, and about the role of effective control of GERD in the natural history of these respiratory disorders.

OBJECTIVES

To determine the prevalence of GERD in patients with respiratory disorders and lung involvement; the sensitivity of symptoms in the diagnosis of GERD; and the role of esophageal function tests (manometry and 24- hour pH monitoring) in the diagnosis and treatment of these patients.

METHODS

Prospective study based on a database of 44 patients (29 females) with respiratory disorders: 16 patients had idiopathic pulmonary fibrosis, 11 patients had systemic sclerosis associated interstitial lung disease, 2 patients had polymyositis associated interstitial lung disease, 2 patients had Sjögren associated interstitial lung disease, 2 patients had rheumatoid artrithis associated interstitial lung disease, 1 patient had undifferentiated connective tissue diseases associated interstitial lung disease and 10 patients had sarcoidosis. The average forced vital capacity (% predicted) was 64.3%. All patients had esophageal function tests.

RESULTS

Thirty patients (68%) had pathologic reflux (average DeMeester score: 45, normal <14.7). The average number of reflux episodes recorded 20 cm above the lower esophageal sphincter was 24. Sensitivity and specificity of heartburn were 70% and 57%, of regurgitation 43% and 57%, and of dysphagia 33% and 64%. Twelve patients with GERD underwent a laparoscopic fundoplication which was tailored to the manometric profile: three patients in which peristalsis was normal had a total fundoplication (360°) and nine patients in which the peristalsis was absent had a partial anterior fundoplication (180°).

CONCLUSIONS

The results of our study show that: (a) abnormal reflux was present in about 2/3 of patients with respiratory disorders (idiophatic pulmonary fibrosis, connective tissue disorders and sarcoidosis), and it extended to the upper esophagus in most patients; (b) the sensitivity and specificity of reflux symptoms was very low; and (c) esophageal function tests were essential to establish the diagnosis of abnormal reflux, to characterize the esophageal function and guide therapy. Long term follow-up will be necessary to determine if control of reflux alters the natural history of these respiratory disorders.

The evolution and long-term results of laparoscopic antireflux surgery for the treatment of gastroesophageal reflux disease

BACKGROUND

For nearly 2 decades, the laparoscopic correction of gastroesophageal reflux disease (GERD) has demonstrated its utility. However, the surgical technique has evolved over time, with mixed long-term results. We briefly review the evolution of antireflux surgery for the treatment of GERD, provide an update specific to the long-term efficacy of laparoscopic antireflux surgery (LARS), and analyze the factors predictive of a desirable outcome.

MATERIALS AND METHODS

PubMed and Medline database searches were performed to identify articles regarding the laparoscopic treatment of GERD. Emphasis was placed on randomized control trials (RCTs) and reports with follow-up >1 year. Specific parameters addressed included operative technique, resolution of symptoms, complications, quality of life, division of short gastric vessels (SGVs), mesh repair, and approximation of the crura. Those studies specifically addressing follow-up of <1 year, the pediatric or elderly population, redo fundoplication, and repair of paraesophageal hernia and short esophagus were excluded.

RESULTS

LARS has varied in technical approach through the years. Not until recently have more long-term, objective studies become available to allow for evidenced-based appraisals. Our review of the literature found no long-term difference in the rates of heartburn, gas-bloat, antacid use, or patient satisfaction between laparoscopic Nissen and Toupet fundoplication. In addition, several studies have shown that more patients had an abnormal pH profile following laparoscopic partial as opposed to total fundoplication. Conversely, dysphagia was more common following laparoscopic total versus partial fundoplication in 50% of RCTs at 12-month follow-up, though this resolved over time, being present in only 20% with follow-up >24 months. We confirmed that preoperative factors, such as hiatal hernia, atypical symptoms, poor antacid response, body mass index (BMI), and postoperative vomiting, are potential predictors of an unsatisfactory long-term outcome. Last, no trial disfavored division of the short gastric vessels (SGVs), closure of the crura, or mesh repair for hiatal defects.

CONCLUSION

LARS has significantly evolved over time. The laparoscopic total fundoplication appears to provide more durable long-term results than the partial approach, as long as the technical elements of the operation are respected. Division of the SGVs, closure of the crura, and the use of mesh for large hiatal defects positively impacts long-term outcome. Hiatal hernia, atypical symptoms, poor antacid response, body mass index (BMI), and postoperative vomiting are potential predictors of failure in LARS.

Gastroesophageal reflux disease: From pathophysiology to treatment

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

Medical comorbidities should not deter the application of laparoscopic fundoplication

INTRODUCTION

Laparoscopic Nissen fundoplication offers significant improvement in gastroesophageal reflux disease (GERD) symptom severity and frequency. This study was undertaken to determine the impact of preoperative medical comorbidities on the outcome and satisfaction of patients undergoing fundoplication for GERD.

METHODS

Prior to fundoplication, patients underwent esophageal motility testing and 24-h pH monitoring. Before and after fundoplication, the frequency and severity of reflux symptoms were scored using a Likert scale. Medical comorbidities were classified by organ systems, and patients were assigned points corresponding to the number of medical comorbidities they had. In addition, all patients were assigned Charlson comorbidity index (CCI) scores according to the medical comorbidities they had. A medical comorbidity was defined as a preexisting medical condition, not related to GERD, for which the patient was receiving treatment. Analyses were then conducted to determine the impact of medical comorbidities as well as CCI score on overall outcome, symptom improvement, and satisfaction.

RESULTS

Six hundred and ninety-six patients underwent fundoplication: 538 patients had no medical comorbidities and 158 patients had one or more medical comorbidities. Preoperatively, there were no differences in symptom severity and frequency scores between patients with or without medical comorbidities. Postoperatively, all patients had improvement in their symptom severity and frequency scores. There were no differences in postoperative symptom scores between the patients with medical comorbidities and those without. The majority of patients were satisfied with their overall outcome; there was no relationship between the number of medical comorbidities and satisfaction scores. These findings were mirrored when patients' CCI scores were compared with satisfaction, overall outcome, and symptom improvement.

CONCLUSION

These results promote further application of laparoscopic Nissen fundoplication, even for patients with medical comorbidities.

Systemic sclerosis and bilateral lung transplantation: a single centre experience

Lung involvement is the leading cause of death in systemic sclerosis (SSc), but lung transplantation (LT) for systemic disease remains controversial. Our objective was to comprehensively evaluate post-LT outcomes for SSc compared to idiopathic pulmonary fibrosis (IPF). We retrospectively evaluated bilateral LT recipients (LTRs) with SSc or IPF at our centre between January 1, 2003 and December 31, 2007. The primary end-point was all-cause mortality at 1 yr post-LT. Secondary end-points included assessments of acute rejection (AR), pulmonary function, infection and chronic rejection. 14 patients with SSc and 38 patients with IPF underwent LT. Apart from a younger SSc cohort (53.2 versus 58.8 yrs; p = 0.02), the two groups were well matched. 1-yr all-cause mortality was no different between SSc (6.6%) and IPF (13.1%) groups, after adjusting for age (p = 0.62). Rates of (AR) ≥2 were significantly increased for the SSc compared with the IPF group (hazard ratio (HR) 2.91; p = 0.007). Other end-points, including chronic rejection, infection and pulmonary function, showed no differences. SSc LTRs experience similar survival 1 yr post-LT when compared to IPF. AR rates may be significantly higher in the SSc group. Longer follow-up is necessary to determine the effects of gastrointestinal dysfunction and AR on late allograft function in SSc LTR.