Anti-reflux surgery for controlling respiratory symptoms of gastro-esophageal reflux disease: A systematic review and meta-analysis

Treatable Traits in Asthma: The Importance of Extrapulmonary Traits-GERD, CRSwNP, Atopic Dermatitis, and Depression/Anxiety

Treatable traits is a personalized medicine approach to the management of airway disease. Assessing traits within the 3 domains of pulmonary, extrapulmonary, and behavioral/lifestyle/risk factor traits, and applying targeted treatments to effectively manage these traits, enables a holistic and personalized approach to care. Asthma is a heterogeneous and complex airway disease that is frequently complicated by several extrapulmonary traits that impact asthma outcomes and predict future outcomes. We propose that the identification of extrapulmonary and behavioral risk factor traits and the implementation of targeted therapy will lead to improved management of people with asthma. Furthermore, many extrapulmonary traits present as "connected comorbidities"; that is, they coexist with asthma, have an impact on asthma, and effective treatment improves both asthma and the comorbidity or the comorbidities may share a similar mechanism. In this review, we explore this concept and look at atopic dermatitis, chronic rhinosinusitis with nasal polyps, gastroesophageal reflux disease, anxiety, and depression as treatable traits of asthma and how these can be managed using this approach.

Laparoscopic fundoplication in treating refractory gastroesophageal reflux-related chronic cough: A meta-analysis

BACKGROUND

Gastroesophageal reflux-related chronic cough (GERC), is one common type of chronic cough. Drug treatment is effective for some GERC patients. But, there is refractory GERC (rGERC). For rGERC, fundoplication may be the only effective method. However, there were very few studies about laparoscopic fundoplication in treating rGERC, and the cure rate of fundoplication in treating rGERC was unknown. So there is a question, what is the cure rate of fundoplication in treating rGERC? To solve this question, we performed this meta-analysis.

METHODS

The PRISMA strategy and Cochrane collaboration method were used for this study. Our study was registered with PROSPERO (ID: CRD42021251072). We searched PubMed, Medline, Web of Science, and the Cochrane databases from 1990 to December 2022. The meta-analysis was performed with Review Manager 5.4 and Stata 14.

RESULTS

After selection and exclusion, 8 articles out of 672 were included. The meta-analysis showed the cure rate of laparoscopic fundoplication in treating rGERC was 62% (95% confidence interval: 53-71%), with no deaths in 503 patients. There was no significant heterogeneity or bias in the meta-analysis.

CONCLUSIONS

In terms of safety, laparoscopic fundoplication is quite reliable offered by skilled surgeons. In terms of cure rate, laparoscopic fundoplication could completely heal two-thirds of rGERC patients; however, there are still some patients who can not be completely cured by fundoplication.

Exploring objective factors to predict successful outcomes after laparoscopic Nissen fundoplication

BACKGROUND

Currently, the reported parameters that predict the resolution of symptoms after surgery are largely subjective and unreliable. Considering that fundoplication rebuilds the structural integrity of the lower esophageal sphincter (LES), the authors focused on searching for objective and quantitative predictors for the resolution of symptoms based on the anatomical issues and whether an antireflux barrier can be well established or not.

MATERIALS AND METHODS

The authors reviewed the prospectively collected data of 266 patients with gastroesophageal reflux disease (GERD) who had undergone laparoscopic Nissen fundoplication (LNF). All patients were diagnosed with GERD using preoperative esophagogastroduodenoscopy, 24-h ambulatory esophageal pH monitoring, and high-resolution esophageal manometry. The patients received GERD symptom surveys using the validated Korean Antireflux Surgery Group questionnaire twice: preoperatively and 3 months after the surgery.

RESULTS

After excluding patients with insufficient follow-up data, 152 patients were included in the analysis. Multivariate logistic regression analyses revealed that a longer length of the LES and lower BMI determined better resolution of typical symptoms after LNF (all P <0.05). Regarding atypical symptoms, higher resting pressure of LES and DeMeester score greater than or equal to 14.7 were associated with better resolution after the surgery (all P <0.05). After LNF, typical symptoms improved in 34 out of 37 patients (91.9%) with a length of LES >greater than .05 cm, BMI less than 23.67 kg/m 2 , and atypical symptoms were resolved in 16 out of 19 patients (84.2%) with resting pressure of LES greater than or equal to 19.65 mm Hg, DeMeester score greater than or equal to 14.7.

CONCLUSION

These results show that the preoperative length and resting pressure of LES is important in the objective prediction of symptom improvement after LNF.

Efficacy of laparoscopic fundoplication in patients with chronic cough and gastro-oesophageal reflux

BACKGROUND

The outcome of anti-reflux surgery in patients with suspected gastro-oesophageal reflux-induced cough is frequently uncertain. The aims of this study were to assess the efficacy of laparoscopic fundoplication for controlling cough in patients with chronic cough without asthma, who have pathologic gastro-oesophageal reflux, and to identify predictors of response.

METHODS

From a prospective database of 1598 patients who have undergone laparoscopic fundoplication, 66 (4%) with proven gastro-oesophageal reflux disease (GORD) and chronic cough without asthma were studied. All patients underwent gastroscopy and 24-h pH monitoring before operation. Heartburn and regurgitation were assessed using a modified DeMeester score. Severity of cough before and after surgery was self-assessed by the patient using a visual analog scale at a minimum of 12 months post-operatively (median 43 mo; range: 14-104 mo). Patients were considered to have responded to fundoplication if they had no cough or the cough had improved by 50% or more after operation.

RESULTS

Cough and heartburn/regurgitation were relieved in 61% (40/66) and 90% (44/49) of the patients, respectively. The presence of typical GORD symptoms or oesophagitis, and pH study variables did not predict the response of the cough to fundoplication.

CONCLUSION

Refinement in the aetiological diagnosis of chronic cough due to GORD is necessary for improved outcome. Patients diagnosed with GORD-related chronic cough need to be counseled regarding their expectations from anti-reflux surgery.

Laparoscopic total fundoplication is superior to medical treatment for reducing the cancer risk in Barrett's esophagus: a long-term analysis

The present study aims to compare the effectiveness of surgical and medical therapy in reducing the risk of cancer in Barrett's esophagus in a long-term evaluation. A prospective cohort was designed that compared Barrett's esophagus patients submitted to medical treatment with omeprazole or laparoscopic Nissen fundoplication. The groups were compared using propensity score matching paired by Barrett's esophagus length. A total of 398 patients met inclusion criteria. There were 207 patients in the omeprazole group (Group A) and 191 in the total fundoplication group (Group B). After applying the propensity score matching paired by Barrett's esophagus length, the groups were 180 (Group A) and 190 (Group B). Median follow-up was 80 months. Group B was significantly superior for controlling GERD symptoms. Group B was more efficient than Group A in promoting Barrett's esophagus regression or blocking its progression. Group B was more efficient than Group A in preventing the development of dysplasia and cancer. Logistic regression was performed for the outcomes of adenocarcinoma and dysplasia. Age and body mass index were used as covariates in the logistic regression models. Even after regression analysis, Group B was still superior to Group A to prevent esophageal adenocarcinoma or dysplasia transformation (odds ratio [OR]: 0.51; 95% confidence interval [CI]: 0.27-0.97, for adenocarcinoma or any dysplasia; and OR: 0.26; 95% CI: 0.08-0.81, for adenocarcinoma or high-grade dysplasia). Surgical treatment is superior to medical management, allowing for better symptom control, less need for reflux medication use, higher regression rate of the columnar epithelium and intestinal metaplasia, and lower risk for progression to dysplasia and cancer.

GERD-related chronic cough: Possible mechanism, diagnosis and treatment

GERD, or gastroesophageal reflux disease, is a prevalent medical condition that affects millions of individuals throughout the world. Chronic cough is often caused by GERD, and chronic cough caused by GER is defined as GERD-related chronic cough (GERC). It is still unclear what the underlying molecular mechanism behind GERC is. Reflux theory, reflex theory, airway allergies, and the novel mechanism of esophageal motility disorders are all assumed to be linked to GERC. Multichannel intraluminal impedance combined with pH monitoring remains the gold standard for the diagnosis of GERC, but is not well tolerated by patients due to its invasive nature. Recent discoveries of new impedance markers and new techniques (mucosal impedance testing, salivary pepsin, real-time MRI and narrow band imaging) show promises in the diagnosis of GERD, but the role in GERC needs further investigation. Advances in pharmacological treatment include potassium-competitive acid blockers and neuromodulators (such as Baclofen and Gabapentin), prokinetics and herbal medicines, as well as non-pharmacological treatments (such as lifestyle changes and respiratory exercises). More options have been provided for the treatment of GERC other than acid suppression therapy and anti-reflux surgery. In this review, we attempt to review recent advances in GERC mechanism, diagnosis, and subsequent treatment options, so as to provide guidance for management of GERC.

Evaluating the Non-conventional Achalasia Treatment Modalities

Introduction

Achalasia is a primary esophageal dysmotility disorder. Despite the high volume of studies addressing the conventional treatments for achalasia, few are debated regarding the non-conventional treatments, such as cardiectomy, cardioplasty, endoluminal substances injection (ethanolamine oleate, polidocanol, botulinum toxin), stents, and certain drugs (beta-agonists, anticholinergic, nitrates, calcium channel blockers, and phosphodiesterase inhibitors).

Methods

A critical review was performed.

Results

Endoscopic, surgical, and pharmacological treatments were included. A qualitative synthesis was presented.

Conclusion

Non-conventional therapeutic options for treating achalasia encompass medical, endoscopic, and surgical procedures. Clinicians and patients need to know all the tools for the management of achalasia. However, several currently available studies of non-conventional treatments lack high-quality evidence, and future randomized trials are still needed.

Can subjective symptoms predict objective findings in gastroesophageal reflux disease patients?

INTRODUCTION

Medical therapy is the first-line treatment for gastroesophageal reflux disease, but surgical options are available and shown to be effective when medical management fails. There is no consensus for when a surgical evaluation is indicated. We set out to determine if the GERD-HRQL questionnaire scores correlate to objective findings found in patients undergoing anti-reflux surgery to predict when surgical consultation could be warranted.

METHODS

A prospectively gathered database was used for patients undergoing anti-reflux surgery from January 2014 to September 2020. Inclusion criteria required a diagnosis of GERD and comprehensive esophageal workup with the GERD-HRQL questionnaire, EGD, esophageal manometry, and ambulatory pH monitoring. Analysis of the GERD-HRQL scores was compared to objective endpoints to see correlation and predictability. Logistic regression analysis was used to assess relationship between the presence of objective findings and GERD-HRQL questionnaire scores.

RESULTS

There were 246 patients meeting inclusion criteria. There was no significant correlation between GERD-HRQL score and DeMeester score (correlation coefficient = 0.23), or presence of a hiatal hernia, regardless of size (p = 0.89). Patients with esophagitis had significantly higher average GERD-HRQL scores compared to those without esophagitis (40.1 ± 18.9 vs 30.4 ± 19.1, p < 0.0001). Patients with a score of 40 or greater had a 42% to 65% probability of having esophagitis versus a score of 30 or less, lowering the chances of having esophagitis to less than 35%.

CONCLUSION

Usage of a GERD-HRQL questionnaire score can potentially show the correlation between subjective and objective findings in the workup of a patient for anti-reflux surgery. Specifically, patients with a GERD-HRQL score of 40 or greater have an increased probability of esophagitis compared to those with a score of 30 or less. Using these scores can help referring clinicians identify those patients failing medical therapy and allow for prompt referral for surgical evaluation.

Long-Term Outcomes of Chronic Cough Reduction after Laparoscopic Nissen Fundoplication—A Single-Center Study

Background and Objectives: Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases. It affects 20% of the adult population and is the third most common cause of chronic cough in adults. This study describes the results of LNF for the relief of GERD-related cough. Materials and Methods: The prospectively collected data on 135 laparoscopic LNF in our department from 2014 to 2018 were reviewed. During consultations, patients were asked about the frequency of symptoms using the GERD Impact Scale (GERD-IS), their satisfaction and recommendation to others, and their general condition after the procedure. Results: We analyzed 23 of 111 patients (20.7%) reporting chronic cough. The mean age was 47 years (range 27–76 years, ±13.9 years) and the mean follow-up time was 48.3 months (range 22.6–76.3 ± 18.05 months). Most patients reported relief from cough after the surgery (78.3%, p < 0.001). Five patients (22%) reported the recurrence of symptoms after a mean of 10.8 months (6–18 months). Seventeen patients (74%) would undergo the surgery again and 18 patients (78%) would recommend the surgery to their relatives. There was a statistically significant improvement in all symptoms from the GERD-IS (p < 0.05). Conclusions: LNF may play an important role in the management of GERD patients with extraesophageal symptoms. After LNF, most of the operated patients reported complete resolution of chronic cough and would recommend the procedure to their relatives.

Fundoplication versus oral proton pump inhibitors for gastroesophageal reflux disease: a systematic review and meta-analysis of randomized clinical trials

Gastroesophageal reflux disease (GERD) is a widely studied and highly prevalent condition. However, few are reported about the exact efficacy and safety of fundoplication (FPT) compared to oral intake proton-pump inhibitors (PPI). This systematic review and meta-analysis of randomized clinical trials (RCT) aims to compare PPI and FPT in relation to the efficacy, as well as the adverse events associated with these therapies. Search carried out in June 2020 was conducted on Medline, Cochrane, EMBASE and LILACS. Selection was restricted to RCT comparing PPI and FPT (open or laparoscopic) in GERD patients. Certainty of evidence and risk of bias were assessed with GRADE Pro and with Review Manager Version 5.4 bias assessment tool. Ten RCT were included. Meta-analysis showed that heartburn (RD =  - 0.19; 95% CI =  - 0.29, - 0.09) was less frequently reported by patients that underwent FPT. Furthermore, patients undergoing surgery had greater pressure on the lower esophageal sphincter than those who used PPI (MD = 7.81; 95% CI 4.79, 10.83). Finally, FPT did not increase significantly the risk for adverse events such as postoperative dysphagia and impaired belching. FPT is a more effective therapy than PPI treatment for GERD, without significantly increasing the risk for adverse events. However, before indicating a possible surgical approach, it is extremely important to correctly assess and select the patients who would benefit from FPT to ensure better results.