Pharmacologic management of gastroesophageal reflux disease

Laparoscopic fundoplication with double sided posterior gastropexy: a different surgical technique

BACKGROUND

Laparoscopic Nissen Fundoplication has become the gold standard surgical procedure for management of gastroesophageal reflux disease. Nissen fundoplication provides an effective barrier against reflux. The aim of this study was to evaluate early postoperative outcomes of a different surgical technique, laparoscopic fundoplication with double sided posterior gastropexy.

METHODS

Data of 46 patients who underwent laparoscopic fundoplication with double sided posterior gastropexy between February 2010 and December 2011 were collected. Surgically, after Nissen fundoplication was completed, 2-4 sutures were passed through the uppermost parts of the posterior and anterior wall of the gastric wrap and then passed gently 1 cm above the celiac artery from the denser fibers of uppermost part of the arcuate ligament. Demographic data, preoperative and postoperative assesments of sympthomatic and functional outcomes of patients were recorded. Length of hospital stay, operative time, early postoperative complications and complications at 1 year follow up, early recurrence rate were also recorded.

RESULTS

This technique resulted in good symptomatic and clinical outcomes. Only one patient out of 45 patients was reoperated. The early recurrence rate was 2.2%.

CONCLUSION

Laparoscopic Nissen fundoplication with double sided posterior gastropexy may prevent paraesophageal herniation. It is a reasonably feasible and effective method in surgical management of GERD.

Novel surgical concept in antireflux surgery: long-term outcomes comparing 3 different laparoscopic approaches

BACKGROUND

The Nissen fundoplication procedure is the most widely used type of antireflux surgery. The results are not always as good as expected, and several modifications to the original technique have been proposed. Long-term effectiveness studies comparing different techniques of antireflux surgery are limited. Our group developed a new concept in antireflux surgery (complete fixed "nondeformable" fundoplication) in order to improve its outcome; we present the long-term comparative results of this novel concept/technique.

METHODS

Overall, 512 patients were included in the study and assigned into 1 of 3 fundoplications groups: partial (131), Nissen (133), and fixed "nondeformable" (121). We compared the groups with each other and with a group who chose to receive medical treatment (MT) (127). All patients underwent clinical evaluation, upper gastrointestinal endoscopy, esophageal manometry, 24-hour esophageal pH monitoring, and the SF-36 health status survey prior to operation and at 1, 5, 10, and 15 years of follow-up.

RESULTS

At the 15-year follow-up, we were able to complete the protocol in 319 patients: 103 patients from the partial group, 102 patients from the Nissen group, 97 patients from the fixed "nondeformable" group, and 17 patients from the medical treatment group. A lower prevalence of erosive gastroesophageal reflux disease (GERD) was observed in the fixed "nondeformable" group (7.20%) versus 21.56% for Nissen, 39.80% for partial, and 47.05% for MT (P < .01). Lower esophageal sphincter (LES) pressure and LES length were more constant in the fixed "nondeformable" group (14.7 mm Hg/2.2 cm) compared with the Nissen (9 mm Hg/0.7 cm), partial (7 mm Hg/2 cm), and MT (5.64 mm Hg/1.3 cm) groups (P < .01). Reflux recurrence was observed in 168 patients (13 in fixed "nondeformable," 41 in Nissen, and 98 in partial (P < .01).

CONCLUSION

The complete fixed "nondeformable" fundoplication showed best results in studied parameters and had a lower long-term recurrence compared with Nissen and partial techniques.

Oxidative damage in an experimentally induced gastric and gastroduodenal reflux model

The exact pathophysiologic mechanisms of esophageal cell damage and carcinogenesis by gastroesophageal reflux are not clearly understood. The aim of this study was to evaluate the damage to the esophageal epithelium that occurs after acid reflex and mixed acid and bile reflux by assessing histopathology, reactive oxygen species, and DNA damage. Eighty 10-week-old male Sprague-Dawley rats were divided into two groups, an acid reflux group and a mixed (acid/bile) reflux group. Acid reflux was achieved by esophagogastroplasty in which mixed reflux was encouraged via esophagoduodenal anastomosis. Each group contained a control subgroup that underwent sham laparotomy alone. The rats were killed 3, 6, 9, and 12 months after surgery. Malondialdehyde, protein carbonyl content, and DNA damage were determined in lymphocytes. Histopathologic analysis was performed according to the histologic activity index. Inflammation, ulcer, and regeneration in both reflux groups were significantly increased in the esophagus at 3, 6, 9, and 12 months compared with the control group. Mucosal damage was greater in the mixed reflux group compared with the gastric reflux group. Malondialdehyde and carbonyl content in the serum, and DNA damage in lymphocytes, were significantly increased in both reflux groups. At 9 and 12 months, oxidative damage was increased in the mixed reflux group compared with the acid reflux group. Oxygen-derived free radicals seem to be one of the important mediators in the evaluation and generation of reflux esophagitis. The impact of oxygen free radicals, as demonstrated in this study, can be evaluated by assessing the damage that they incur to lipid membranes, serum proteins, and circulating lymphocyte DNA. Serum malondialdehyde and carbonyl content as well as lymphocyte DNA damage were significantly increased in the setting of acid and mixed acid/bile reflux in these rodent models. Further, these serum and lymphocytic changes were associated with esophageal ulceration, inflammation, and regeneration. Evaluation of such markers as serum malondialdehyde and carbonyl content as well as evaluation of lymphocyte DNA might prove to be useful investigations in patients with precancerous and cancerous conditions in addition to conventional methods of diagnosis. Further studies, both animal and human are warranted.

Maintenance Therapy in Gastro-oesophageal Reflux Disease

Gastro-oesophageal reflux disease (GORD) is a chronic condition. Symptom control and the maintenance of healing of erosive oesophagitis, if present, are important topics. In patients responding to a proton pump inhibitor (PPI) and showing no treatment symptoms it is appropriate to consider long-term treatment strategies, whether continuous, intermittent or on demand. Maintenance PPI therapy is well tolerated for up to 10 years of continuous use. Furthermore, tachyphylaxis does not occur during long-term maintenance PPI therapy. Previous concerns about risks of long-term PPI therapy in Heliobacter pylori-negative or H. pylori-positive patients have not materialized, while no cases of intestinal metaplasia with dysplasia or adenocarcinoma were found. The choice between medical and surgical therapy should depend upon informed patient preference. The optimal candidate for antireflux surgery is a young patient, with typical GORD symptoms, with erosive oesophagitis, with previous complete symptom resolution on acid-suppression therapy and unable to undergo continuous therapy, or alternatively in patients with regurgitation predominating over heartburn as long as the surgical procedures are conducted by an expert surgical team. Endoscopic therapy for erosive GORD should currently be regarded as experimental. The endoscopic procedures are safe, although they remain untested in patients with severe erosive oesophagitis and/or significant hiatal hernia.