Medical or invasive therapy for GERD: an acidulous analysis

Positive effect of abdominal breathing exercise on gastroesophageal reflux disease: a randomized, controlled study

OBJECTIVES

The lower esophageal sphincter (LES), surrounded by diaphragmatic muscle, prevents gastroesophageal reflux. When these structures become incompetent, gastric contents may cause gastroesophageal reflux disease (GERD). For treatment, lifestyle interventions are always recommended. We hypothesized that by actively training the crura of the diaphragm as part of the LES using breathing training exercises, GERD can be positively influenced.

METHODS

A prospective randomized controlled study was performed. Patients with non-erosive GERD or healed esophagitis without large hernia and/or previous surgery were included. Patients were randomized and allocated either to active breathing training program or to a control group. Quality of life (QoL), pH-metry, and on-demand proton pump inhibitor (PPI) usage were assessed at baseline and after 4 weeks of training. For long-term follow-up, all patients were invited to continue active breathing training and were further assessed regarding QoL and PPI usage after 9 months. Paired and unpaired t-test was used for statistical analysis.

RESULTS

Nineteen patients with non-erosive GERD or healed esophagitis were randomized into two groups (10 training group and 9 control group). There was no difference in baseline patient characteristics between the groups and all patients finished the study. There was a significant decrease in time with a pH<4.0 in the training group (9.1±1.3 vs. 4.7±0.9%; P<0.05), but there was no change in the control group. QoL scores improved significantly in the training group (13.4±1.98 before and 10.8±1.86 after training; P<0.01), but no changes in QoL were seen in the control group. At long-term follow-up at 9 months, patients who continued breathing exercise (11/19) showed a significant decrease in QoL scores and PPI usage (15.1±2.2 vs. 9.7±1.6; 98±34 vs. 25±12 mg/week, respectively; P<0.05), whereas patients who did not train had no long-term effect.

CONCLUSIONS

We show that actively training the diaphragm by breathing exercise can improve GERD as assessed by pH-metry, QoL scores and PPI usage. This non-pharmacological lifestyle intervention could help to reduce the disease burden of GERD.

Evaluation of the gastro-oesophageal junction: defining the incompetent cardio-oeosophageal angle non-invasively with ultrasound and computerized tomography

This study aimed to demonstrate the presence of gastro-oesophageal reflux disease (GORD) non-invasively using ultrasound (US) and computerized tomography (CT). Intra-abdominal oesophageal length (IAOL) and cardio-oesophageal angle (COA) were measured by US in 25 patients with known reflux and in 25 healthy subjects (control group). CT images of 42 patients with reflux disease and 44 controls were reviewed retrospectively, and IAOL and COA were measured on curved multiplanar format images. Using a cut-off value for IAOL of 20.5 mm, the sensitivity to detect GORD with US was 96% and the specificity was 80% and, with CT, the sensitivity was 95% and the specificity was 78%. A cut-off value of 138.5° for COA yielded sensitivity and specificity values for GORD detection of 76% and 72% with US and 83% and 80% with CT, respectively. In conclusion, with equivocal diagnostic findings, IAOL and COA are useful parameters that can be determined non-invasively by US or CT and may aid diagnosis and treatment choices for patients with suspected GORD.

Long-term complications to reflux disease in community practice. A 17-year cohort study of 4706 patients

OBJECTIVE

To examine the risk of developing strictures in patients with erosive and non-erosive gastroesophageal reflux disease in a community-based setting, since controlled trials indicate that the use of proton pump inhibitors renders the risk of strictures insignificant.

MATERIAL AND METHODS

A 17-year cohort study of 4706 patients referred to endoscopy due to upper GI symptoms, with a population comparison cohort of 47,060 individuals. All patients were followed and treated according to prevailing guidelines by their usual care provider. Main outcomes were relative risks (RR) and 95% confidence intervals (CI) for incident strictures and dilatations.

RESULTS

776 (16.5%) patients were diagnosed with erosive esophagitis, particularly men (61.2%). Over a period of 1-17 years (mean 10.5), 20 patients (2.6%) in the esophagitis group developed a peptic stricture, necessitating one or more dilatations in 16 patients (2.1%). Among the non-esophagitis patients, the incidences for both outcomes were 1.2%. Male gender doubled the risk of developing strictures, and alcohol abuse raised the risk four folds. Erosive patients had a risk of developing strictures eight times (95% CI: 5.0-13.0) higher than controls, whereas non-erosive patients' risk was 4.0 (95% CI: 2.8-5.7). The majority of strictures developed within the first 10 years after a diagnosis of esophagitis.

CONCLUSION

Patients with esophagitis had eight times higher risk of strictures than population controls and two times higher than dyspeptic patients without esophagitis. This indicates that long-term outcomes in general practice are poorer than in controlled trials, most likely due to a lack of compliance with medication.

Surgical approach to gastroesophageal reflux disease: what the radiologist needs to know

Gastroesophageal reflux disease (GERD) is defined as gastroesophageal reflux resulting in symptoms or in injury to the esophageal epithelium. Although the medical management of GERD has improved, an increasing number of laparoscopic antireflux surgical procedures are being performed. Barium studies, endoscopy, manometry, and pH monitoring are all integral components of preoperative evaluation. Barium swallow examination must allow critical evaluation of esophageal peristalsis, the presence and extent of gastroesophageal reflux, and complications including esophagitis, stricture, and Barrett esophagus. It is crucial to identify and characterize hiatal hernia and longitudinal stricture, which can result in a shortened esophagus. In such cases, it becomes necessary for the surgeon to incorporate an esophageal lengthening procedure prior to fundoplication; otherwise, poor surgical outcome is likely. Normal postfundoplication radiographic findings as well as postoperative complications (eg, tight wrap, perforation, abscess, complete or partial dehiscence, recurrent stricture, recurrent hernia, intrathoracic migration of the wrap) must also be recognized and clearly understood by the radiologist. Given the chronic nature and prevalence of symptomatic GERD and the increasing number of patients undergoing surgical intervention, it is imperative that the radiologist understand the pre- and postsurgical evaluation of affected patients.

When fundoplication fails: redo?

OBJECTIVE

The largest series in the literature dealing with redo fundoplication was presented and published in 1999 and included 100 patients. Herein we update this initial series of 100, with 207 additional patients who have undergone redo fundoplication (n = 307).

SUMMARY BACKGROUND DATA

Increasing numbers of patients are failing esophagogastric fundoplication and requiring redo procedures. Data regarding the nature of these failures have been scant.

METHODS

Data on all patients undergoing foregut surgery are collected prospectively. Between 1991 and 2004, 307 patients underwent redo fundoplication for the management of anatomic complications or recurrent GERD. Statistical analysis was performed with multiple chi2 and Mann-Whitney U analyses, as well as ANOVA.

RESULTS

Between 1991 and 2004, 1892 patients underwent primary fundoplication for GERD (1734) or paraesophageal hernia (158). Of these, 54 required redo fundoplication (2.8%). The majority of failures (73%) were managed within 2 years of the initial operation (P = 0.0001). The mechanism of failure was transdiaphragmatic wrap herniation in 33 of 54 (61%). In the 231 patients who underwent fundoplication elsewhere, 109 had transdiaphragmatic herniation (47%, P = NS). In this group of 285 patients, 22 (8%) required another redo (P = NS). The majority of the procedures were initiated laparoscopically (240/307, 78%), with 20 converted (8%). Overall mortality was 0.3%.

CONCLUSIONS

Failure of fundoplication is unusual in experienced hands. Most are managed within 2 years of the initial operation. Wrap herniation has now become the most common mechanism of failure requiring redo. Redo fundoplication was successful in 93% of patients, and most could be safely handled laparoscopically.