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Hiatal hernias in patients with GERD-like symptoms: evaluation of dynamic real-time MRI vs endoscopy. Eur Radiol 2019; 29:6653-6661. [DOI: 10.1007/s00330-019-06284-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/17/2019] [Accepted: 05/24/2019] [Indexed: 12/11/2022]
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Philpott H, Garg M, Tomic D, Balasubramanian S, Sweis R. Dysphagia: Thinking outside the box. World J Gastroenterol 2017; 23:6942-6951. [PMID: 29097867 PMCID: PMC5658312 DOI: 10.3748/wjg.v23.i38.6942] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 08/29/2017] [Accepted: 09/26/2017] [Indexed: 02/07/2023] Open
Abstract
Dysphagia is a common symptom that is important to recognise and appropriately manage, given that causes include life threatening oesophageal neoplasia, oropharyngeal dysfunction, the risk of aspiration, as well as chronic disabling gastroesophageal reflux (GORD). The predominant causes of dysphagia varies between cohorts depending on the interplay between genetic predisposition and environmental risk factors, and is changing with time. Currently in white Caucasian societies adopting a western lifestyle, obesity is common and thus associated gastroesophageal reflux disease is increasingly diagnosed. Similarly, food allergies are increasing in the west, and eosinophilic oesophagitis is increasingly found as a cause. Other regions where cigarette smoking is still prevalent, or where access to medical care and antisecretory agents such as proton pump inhibitors are less available, benign oesophageal peptic strictures, Barrett's oesophagus, adeno- as well as squamous cell carcinoma are endemic. The evaluation should consider the severity of symptoms, as well as the pre-test probability of a given condition. In young white Caucasian males who are atopic or describe heartburn, eosinophilic esophagitis and gastroesophageal reflux disease will predominate and a proton pump inhibitor could be commenced prior to further investigation. Upper gastrointestinal endoscopy remains a valid first line investigation for patients with suspected oesophageal dysphagia. Barium swallow is particularly useful for oropharyngeal dysphagia, and oesophageal manometry mandatory to diagnose motility disorders.
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Affiliation(s)
- Hamish Philpott
- Department of Gastroenterology, Eastern Health Clinical School Monash University, Melbourne 3128, Australia
| | - Mayur Garg
- Department of Gastroenterology, Eastern Health Clinical School Monash University, Melbourne 3128, Australia
| | - Dunya Tomic
- Department of Gastroenterology, Eastern Health Clinical School Monash University, Melbourne 3128, Australia
| | - Smrithya Balasubramanian
- Department of Gastroenterology, Eastern Health Clinical School Monash University, Melbourne 3128, Australia
| | - Rami Sweis
- University College London, London NW1 2BU, United Kingdom
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Abstract
PURPOSE OF REVIEW This review aims to discuss the putative relationship between hiatus hernia and dysphagia. RECENT FINDINGS Proposed mechanisms of dysphagia in patients with hiatus hernia are usually difficult to identify, but recent advances in technology (high-resolution manometry with or without concomitant impedance, ambulatory pH with impedance, videofluoroscopy, and the endoluminal functional lumen imaging probe (EndoFLIP)) and methodology (inclusion of swallows of various consistencies and volumes or shifting position during the manometry protocol) can help induce symptoms and identify the underlying disorder. Chronic reflux disease is often associated with hiatus hernia and is the most common underlying etiology. Dysmotility because of impaired contractility and vigor can occur as a consequence of repeated acid exposure from the acid pocket within the hernia, and the resultant poor clearance subsequently worsens this insult. As such, dysphagia appears to be more common with increasing hiatus hernia size. Furthermore, mucosal inflammation can lead to fibrotic stricture formation and in turn obstruction. On the other hand, there appears to be a difference in the pathophysiology of smaller sliding hernias, in that those with dysphagia are more likely to have extrinsic compression at the crural diaphragm as compared to those with reflux symptoms only. Sliding hiatus hernia, especially when small, does not commonly lead to dysmotility and dysphagia; however, in those patients with symptoms, the underlying etiology can be sought with new technologies and, in particular, the reproduction of normal eating and drinking during testing.
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Affiliation(s)
- Hamish Philpott
- Department of Gastroenterology, Eastern Health, Melbourne, Australia.
- Department of Gastroenterology, Box Hill Hospital, 3 Arnold St Box Hill, Melbourne, 3128, Australia.
| | - Rami Sweis
- Department of Gastroenterology, University College London, London, UK
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Abstract
PURPOSE OF REVIEW This review aims to shed light on subtleties of achalasia diagnosis, including potential pitfalls that may lead to errors. Optimal methods for assessment of disease severity and the relationship between achalasia and other motility disorders will also be reviewed with an emphasis on recent findings from the literature. RECENT FINDINGS Adjunctive testing with viscous substances or larger water volumes should be used routinely as it improves the accuracy of achalasia diagnosis. Chronic opiate use can mimic achalasia. The timed barium swallow remains the best test for assessments of disease severity and prognostication, but the functional lumen-imaging probe, a newer tool which measures esophagogastric junction distensibility using impedance planimetry, is emerging as a potentially more powerful tool for these purposes. Functional esophagogastric junction outflow obstruction is possibly part of the achalasia spectrum. By addressing the potential pitfalls described, and through routine and standardized use of the diagnostic tools mentioned herein, the accuracy of diagnosis, severity assessment, and prognostication of achalasia can be improved.
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Affiliation(s)
- Santosh Sanagapalli
- GI Physiology Unit, Elizabeth Garrett Anderson Wing, University College Hospital, 235 Euston Rd, London, NW1 2BU, UK.
- St. Vincent's Hospital Sydney, Department Gastroenterology, 235 Euston Rd, 390 Victoria St, NSW, 2010, Australia.
| | - Rami Sweis
- GI Physiology Unit, Elizabeth Garrett Anderson Wing, University College Hospital, 235 Euston Rd, London, NW1 2BU, UK
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Promberger R, Lenglinger J, Riedl O, Seebacher G, Eilenberg W, Ott J, Riegler F, Gadenstätter M, Neumayer C. Gastro-oesophageal reflux disease in type 2 diabetics: symptom load and pathophysiologic aspects - a retro-pro study. BMC Gastroenterol 2013; 13:132. [PMID: 23972125 PMCID: PMC3765380 DOI: 10.1186/1471-230x-13-132] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 08/14/2013] [Indexed: 12/15/2022] Open
Abstract
Background Information about gastro-oesophageal reflux disease (GERD) in patients with Diabetes mellitus type 2 (T2D) is scarce, although the incidence of both disorders is increasing. We aimed to determine GERD symptoms and their underlying pathophysiologic characteristics in T2D patients. Methods This “retro-pro” study compared 65 T2D patients to a control group of 130 age- and sex-matched non-diabetics. GERD was confirmed by gastroscopy, manometry, pH-metry and barium swallow. Results In patients with T2D compared to controls, dysphagia (32.3% vs. 13.1%; p = 0.001) and globus sensation (27.7% vs. 13.8%; p = 0.021) were found more frequently, whereas heartburn (76.9% vs. 88.5%; p = 0.046) and regurgitation (47.7% vs. 72.3%; p = 0.001) were predominant in non-diabetics. Despite higher body mass indices (31.1 ± 5.2 vs. 27.7 ± 3.7 kg/m2; p < 0.001), hiatal hernia was less frequent in T2D patients compared to controls (60.0% vs. 90.8%, p < 0.001). Lower oesophageal sphincter (LES) pressure was higher in patients with T2D (median 10.0 vs. 7.2 mmHg, p = 0.016). DeMeester scores did not differ between the groups. Helicobacter pylori infections were more common in T2D patients (26.2% vs. 7.7%, p = 0.001). Barrett metaplasia (21.5% vs. 17.7%), as well as low- (10.8% vs. 3.8%) and high-grade dysplasia (1.5% vs. 0%) were predominant in T2D patients. Conclusions T2D patients exhibit different GERD symptoms, higher LES pressures and a decreased prevalence of hiatal hernia than non-diabetics, which may be related to worse oesophageal motility and, thus, a more functional rather than anatomical cause of GERD. Low-grade dysplasia was more than twice as high in T2D than in non-diabetics patients. Trial registration Ethics committee of the Medical University of Vienna, IRB number 720/2011.
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Lee SB, Jeon KM, Kim BS, Kim KC, Jung HY, Choi YB. Early experiences of minimally invasive surgery to treat gastroesophageal reflux disease. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2013; 84:330-7. [PMID: 23741690 PMCID: PMC3671001 DOI: 10.4174/jkss.2013.84.6.330] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 03/19/2013] [Accepted: 04/05/2013] [Indexed: 12/23/2022]
Abstract
Purpose There are fewer patients with gastroesophageal reflux disease (GERD) in Korea compared with Western countries. The incidence of GERD has increased in recent years however, concerning many physicians. Here, we report our early experiences of using a recently introduced method of laparoscopic antireflux surgery for the treatment of GERD in Korean patients. Methods Fifteen patients with GERD were treated using antireflux surgery between May 2009 and February 2012 at the University of Ulsan College of Medicine and Asan Medical Center. Laparoscopic Nissen fundoplication with 360° wrapping was performed on all patients. Results Eleven male and four female patients were evaluated and treated with an average age of 58.1 ± 14.1 years. The average surgical time was 118.9 ± 45.1 minutes, and no complications presented during surgery. After surgery, the reflux symptoms of each patient were resolved; only two patients developed transient dysphagia, which resolved within one month. One patient developed a 6-cm hiatal hernia that had to be repaired and reinforced using mesh. Conclusion The use of laparoscopic surgery for the treatment of GERD is safe and feasible. It is also an efficacious method for controlling the symptoms of GERD in Korean patients. However, the use of this surgery still needs to be standardized (e.g., type of surgery, bougienage size, wrap length) and the long-term outcomes need to be evaluated.
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Affiliation(s)
- Sae Byul Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Khajanchee YS, Cassera MA, Swanström LL, Dunst CM. Diagnosis of Type-I hiatal hernia: a comparison of high-resolution manometry and endoscopy. Dis Esophagus 2013; 26:1-6. [PMID: 22320417 DOI: 10.1111/j.1442-2050.2011.01314.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Sliding Type-I hiatal hernia is commonly diagnosed using upper endoscopy, barium swallow or less commonly, esophageal manometry. Current data suggest that endoscopy is superior to barium swallow or esophageal manometry. Recently, high-resolution manometry has become available for the assessment of esophageal motility. This novel technology is capable of displaying spatial and topographic pressure profiles of gastroesophageal junction and crural diaphragm in real time. The objective of the current study was to compare the specificity and sensitivity of high-resolution manometry and endoscopy in the diagnosis of sliding hiatal hernia in patients with gastroesophageal reflux disease. Data were analyzed retrospectively for 83 consecutive patients (61% females, mean age 52 ± 13.2 years) with objective gastroesophageal reflux disease who were considered for laparoscopic antireflux surgery between January 2006 and January 2009 and had preoperative high-resolution manometry and endoscopy. Manometrically, hiatal hernia was defined as separation of the gastroesophageal junction >2.0 cm from the crural diaphragm. Intraoperative diagnosis of hiatal hernia was used as the gold standard. Sensitivity, specificity and likelihood ratios of a positive test and a negative test were used to compare the performance of the two diagnostic modalities. Forty-two patients were found to have a Type-I sliding hiatal hernia (>2 cm) during surgery. Twenty-two patients had manometric criteria for a hiatal hernia by high-resolution manometry, and 36 patients were described as having a hiatal hernia by preoperative endoscopy. False positive results were significantly fewer (higher specificity) with high-resolution manometry as compared with endoscopy (4.88% vs. 31.71%, P= 0.01). There were no significant differences in the false negative results (sensitivity) between the two diagnostic modalities (47.62% vs. 45.24%, P= 0.62). Analysis of likelihood ratios of a positive and negative test demonstrated that high-resolution manometry is better than endoscopy both to rule out and rule in a hiatal hernia. A significant discordance was also observed between the two tests (P= 0.033). High-resolution manometry has better specificity and ability to rule out an overt Type-I sliding hiatal hernia (greater likelihood ratio of a positive test) in patients with GERD. Because of high false negative results, both high-resolution manometry and endoscopy are unreliable for ruling in a hiatal hernia. Negative result for a hiatal hernia by either modality mandates additional testing.
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Affiliation(s)
- Y S Khajanchee
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 4805 NE Glisan Street, Portland,OR 97213, USA
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Pandolfino JE, Kwiatek MA, Ho K, Scherer JR, Kahrilas PJ. Unique features of esophagogastric junction pressure topography in hiatus hernia patients with dysphagia. Surgery 2009; 147:57-64. [PMID: 19744454 DOI: 10.1016/j.surg.2009.05.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2008] [Accepted: 05/01/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND Our aim was to assess pressure dynamics within the esophagogastric junction (EGJ) in sliding hiatus hernia (HH) during normal peristalsis and to compare the pressure profiles of HH patients with gastroesophageal reflux disease (GERD) symptoms (HH-GERD) to HH patients with dysphagia (HH-dysphagia). METHODS High-resolution manometry studies in 230 consecutive patients and 68 controls were reviewed. HH patients were defined by a >or=1.5 cm separation between the lower esophageal sphincter (LES) and crural diaphragm (CD) on pressure topography plots. The HH population was further culled to eliminate those patients with motor disorders or stricture. The study groups were composed of 18 HH patients with only reflux symptoms and 10 HH patients with only dysphagia. Analysis of the pressure dynamics within the EGJ was performed at rest and after swallowing to independently quantify the LES and CD contributions to residual EGJ pressure, as well as the magnitude and genesis of distal esophageal intrabolus pressure (IBP). Differences among study groups were analyzed with analysis of variance. RESULTS After swallows, HH-dysphagia patients had greater residual CD pressure (9 mmHg; standard deviation [SD], 4) and IBP pressure (19 mmHg; SD, 4) compared to HH-GERD patients (5 mmHg; SD, 2; and 12 mmHg; SD, 2, respectively; P<.001) or normal subjects (NA; 11 mmHg; SD, 3; P<.001). CONCLUSION Sliding HH alters the pressure dynamics through the EGJ and can lead to a functional obstruction. Patients with HH and dysphagia have greater pressures through the CD compared to HH patients with GERD symptoms, supporting the hypothesis that sliding HH in and of itself may be responsible for dysphagia.
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Affiliation(s)
- John E Pandolfino
- Department of Medicine, Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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Ciovica R, Riedl O, Neumayer C, Lechner W, Schwab GP, Gadenstätter M. The use of medication after laparoscopic antireflux surgery. Surg Endosc 2009; 23:1938-46. [PMID: 19169748 DOI: 10.1007/s00464-008-0271-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Accepted: 11/05/2008] [Indexed: 12/20/2022]
Abstract
BACKGROUND Laparoscopic antireflux surgery (LARS) significantly improves symptoms of gastro-esophageal reflux disease (GERD) and quality of life. Nevertheless, 14-62% of patients report using antisecretory medication after surgery, although only a tiny percentage has proven recurrence of GERD. We sought to determine symptoms of GERD, quality of life, and use of medication before and after LARS, and to compare our findings with those from previous studies. METHODS Five hundred fifty-three patients with GERD who underwent LARS were evaluated before and at 1 year after surgery. After surgery, multidisciplinary follow-up care was provided for all patients by surgeons, psychologists, dieticians, and speech therapists. RESULTS Symptoms of GERD and quality of life improved significantly and only 4.2% of patients still required medication after surgery [proton pump inhibitors (PPI) (98.4 vs. 2.2%; p < 0.01), prokinetics (9.6 vs. 1.1%; p < 0.01), and psychiatric medication (8 vs. 1.6%; p < 0.01)]. CONCLUSION LARS significantly reduced medication use at 1-year follow-up. However, these effects might be attributed, in part, to the multidisciplinary follow-up care. Further studies are therefore required to investigate which patients may benefit from multidisciplinary follow-up care and whether its selective application may reduce the need for medication after LARS.
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Affiliation(s)
- Ruxandra Ciovica
- Department of Surgery, General Hospital of Krems, Mitterweg 10, 3500, Krems, Austria
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Ciovica R, Gadenstätter M, Klingler A, Lechner W, Riedl O, Schwab GP. Quality of life in GERD patients: medical treatment versus antireflux surgery. J Gastrointest Surg 2006; 10:934-9. [PMID: 16843863 DOI: 10.1016/j.gassur.2006.04.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2005] [Revised: 03/15/2006] [Accepted: 04/05/2006] [Indexed: 02/07/2023]
Abstract
Medical and surgical treatments are able to improve symptoms in patients with gastroesophageal reflux disease (GERD). The aim of this study was to evaluate the outcome in GERD patients without therapy, under continuous medical treatment, and after laparoscopic antireflux surgery. Five hundred seventy-nine consecutive patients underwent medical or surgical treatment for GERD-induced symptoms. Patients were studied in detail before and after treatment by means of a symptom questionnaire, endoscopy, esophageal manometry, 24-hour esophageal pH monitoring, and a barium esophagogram. In addition, quality of life was measured by the means of the Gastrointestinal Quality of Life Index (GIQLI) and the Health-Related Quality of Life (HRQL) questionnaire. Surgery was indicated and performed in 351 patients with persistent or recurrent GERD symptoms and/or complications, and in patients preferring surgery to medical treatment, despite the use of an adequate medication. The remaining 228 patients were treated with proton pump inhibitors (PPI) in the standard dose, or if required, the double dose. The outcome was assessed 3 and 12 months after treatment. While symptoms and quality of life were highly impaired in GERD patients without therapy compared with normal people, a significant improvement was obtained by PPI therapy. Following surgery, quality of life was normalized in all subsections and was significantly higher compared with the medically treated group. These results stayed constant in short-term and intermediate follow-up. Medical and surgical therapies are both able to improve symptoms and quality of life in GERD patients. Nevertheless, the outcome is significantly better following surgery. It can be suggested that surgical treatment may be the more successful therapy in the long-term.
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Abstract
Antireflux surgery has become well established as an effective and durable therapy for gastroesophageal reflux disease and its complications. The outcome of antireflux surgery, however, is only as good as the evaluation to document the association between pathologic esophageal acid exposure and the patient's symptoms. This article discusses the well-established diagnostic modalities used to assess foregut structure and function and includes several more sophisticated secondary studies that may aid the clinician in elucidating the cause of the problem in patients in whom standard testing is inadequate.
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Affiliation(s)
- Thomas J Watson
- Department of Surgery, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box Surgery, Rochester, NY 14642, USA.
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Wykypiel H, Wetscher GJ. Präoperative Diagnostik bei der gastroösophagealen Refluxkrankheit – was ist notwendig, was ist verzichtbar? Visc Med 2005. [DOI: 10.1159/000083353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Abstract
Gastroesophageal reflux disease is one of the most common disorders affecting western civilization. Historically, surgical antireflux therapy was reserved for patients who had failed medical therapy, typically in the presence of refractory ulcers or difficult-to-manage strictures. More recently, with improvements in acid control, these acid-pepsin-related complications of reflux have been replaced by the malignant complications of reflux disease, with emphasis now on total control of reflux. Recent developments in surgical technique and the demonstrated effectiveness of a variety of minimally invasive treatment options have changed our approach to these patients. This article summarizes the recommended diagnostic evaluation of patients with reflux symptoms and the current indications for antireflux surgery. The techniques of commonly performed minimally invasive antireflux procedures are described along with a review of the results to be expected. Future prospects for improving the management of reflux are discussed; these include recently described nonsurgical methods for restoring competency to the lower esophageal sphincter.
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Affiliation(s)
- J A Hagen
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
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Gadenstätter M, Klingler A, Prommegger R, Hinder RA, Wetscher GJ. Laparoscopic partial posterior fundoplication provides excellent intermediate results in GERD patients with impaired esophageal peristalsis. Surgery 1999. [DOI: 10.1016/s0039-6060(99)70097-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Franzén T, Boström J, Tibbling Grahn L, Johansson K. Prospective study of symptoms and gastro-oesophageal reflux 10 years after posterior partial fundoplication. Br J Surg 1999; 86:956-60. [PMID: 10417573 DOI: 10.1046/j.1365-2168.1999.01183.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND This was a prospective study of symptoms, and short-term and long-term reflux competence after partial fundoplication. METHODS Some 101 patients were operated consecutively with posterior partial (270 degrees ) fundoplication. Indications for surgery were reflux disease without erosive oesophagitis in 25 patients, moderate oesophagitis in 43, severe oesophagitis in 25 and paraoesophageal hernia in eight. Symptom score, manometry and pH tests were performed before operation, 6 months after operation and after 6-14 years. RESULTS All patients (n = 101) were free from heartburn and regurgitation at early follow-up. There was evidence of clinical recurrence at late follow-up (n = 87) in two of 22 patients without oesophagitis before operation, two of 39 with moderate oesophagitis before operation and three of 19 patients with severe oesophagitis before operation; 92 per cent had good reflux control at late follow-up. CONCLUSION Posterior partial fundoplication shows excellent reflux control at early follow-up. Ten years later fewer than 10 per cent of patients have recurrence, which is more common in patients who had severe oesophagitis before operation.
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Affiliation(s)
- T Franzén
- Department of Surgery, University Hospital, Linköping, Sweden
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Wetscher GJ, Glaser K, Gadenstaetter M, Profanter C, Hinder RA. The effect of medical therapy and antireflux surgery on dysphagia in patients with gastroesophageal reflux disease without esophageal stricture. Am J Surg 1999; 177:189-92. [PMID: 10219852 DOI: 10.1016/s0002-9610(99)00011-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Poor esophageal body motility and trapping of the hernial sac by the hiatal crura are the major pathomechanisms of gastroesophageal reflux disease (GERD)-induced dysphagia. There is only little knowledge of the effect of medical therapy or antireflux surgery in reflux-induced dysphagia. METHODS Fifty-nine consecutive GERD patients with dysphagia were studied by means of a symptom questionnaire, endoscopy, barium swallow, esophageal manometry, and 24-hour pH monitoring of the esophagus. Patients had proton pump inhibitor therapy and cisapride for 6 months. After GERD relapsed following withdrawal of medical therapy, 41 patients decided to have antireflux surgery performed. The laparoscopic Nissen fundoplication was chosen in 12 patients with normal esophageal body motility and the laparoscopic Toupet fundoplication in 29 patients with impaired peristalsis. Dysphagia was assessed prior to treatment, at 6 months of medical therapy, and at 6 months after surgery. RESULTS Heartburn and esophagitis were effectively treated by medical and surgical therapy. Only surgery improved regurgitation. Dysphagia improved in all patients following surgery but only in 16 patients (27.1%) following medical therapy. Esophageal peristalsis was strengthened following antireflux surgery. CONCLUSIONS Medical therapy fails to control gastroesophageal reflux as it does not inhibit regurgitation. Thus, it has little effect on reflux-induced dysphagia. Surgery controls reflux and improves esophageal peristalsis. This may contribute to its superiority over medical therapy in the treatment of GERD-induced dysphagia.
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Affiliation(s)
- G J Wetscher
- Department of Surgery, University of Innsbruck, Austria
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Dickerman RD, McConathy WJ, Smith AB. Can pressure overload cause sliding hiatal hernia? A case report and review of the literature. J Clin Gastroenterol 1997; 25:352-3. [PMID: 9412919 DOI: 10.1097/00004836-199707000-00012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We describe a hiatal hernia of moderate size in a 31-year-old competitive bodybuilder to raise the question of whether such hernias are more likely in young elite resistance-trained athletes as a consequence of attempts to increase intra-abdominal pressure and thus decrease the strain on the lumbar spine.
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Affiliation(s)
- R D Dickerman
- Department of Medicine, University of North Texas Health Science Center, Fort Worth 76107-2699, USA
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Wetscher GJ, Glaser K, Gadenstätter M, Perdikis G, Lund R, Bodner E, Hinder RA. Gastroesophageal reflux disease associated with poor esophageal body motility is effectively treated by laparoscopic toupet fundoplication. ACTA ACUST UNITED AC 1996. [DOI: 10.1007/bf02625960] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Stein HJ, DeMeester TR. Outpatient physiologic testing and surgical management of foregut motility disorders. Curr Probl Surg 1992; 29:413-555. [PMID: 1606845 DOI: 10.1016/0011-3840(92)90036-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- H J Stein
- Department of Surgery, University of Southern California Medical School, Los Angeles
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Abstract
Prior to any rational therapy of gastro-esophageal reflux disease, an objective diagnosis of the presence and the cause of the disease are necessary. Gastro-esophageal reflux disease, i.e., increased esophageal exposure to gastric juice, can be due to a mechanically defective lower esophageal sphincter, inefficient esophageal clearance of refluxed gastric contents, and abnormalities of the gastric reservoir that augment physiologic reflux. Antireflux surgery is designed to correct a mechanically defective sphincter, i.e., a sphincter with a mean pressure below 6 mm Hg, a mean length exposed to the positive pressure environment of the abdomen of less than 1 cm, or a mean overall length of less than 2 cm. In our experience, this is found in approximately 50% to 60% of patients with gastro-esophageal reflux disease. Antireflux surgery is not indicated in patients with increased esophageal exposure to gastric juice secondary to ineffective clearance or gastric abnormalities. Consequently, the indications to proceed with an antireflux procedure are persistent or recurrent symptoms and/or complications of gastro-esophageal reflux disease after 8 to 12 weeks of intensive acid suppression therapy, the objective documentation of increased esophageal exposure to gastric juice with 24 hour esophageal pH monitoring, and the presence of a mechanically defective lower esophageal sphincter on manometry. In patients selected according to these criteria, Nissen fundoplication provides effective relief of reflux symptoms in 91% of patients with more than 10 year follow-up.
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Affiliation(s)
- H J Stein
- Department of Surgery, University of Southern California Medical Center, Los Angeles 90033
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