The outcome of laparoscopic antireflux surgery in relation to patients' subjective degree of compliance with former antireflux medication

Untangling Nonerosive Reflux Disease From Functional Heartburn

Heartburn is a common symptom in clinical practice, but as many as 70% of patients have normal findings from upper endoscopy. Most of these patients have nonerosive reflux disease (NERD) or functional esophageal disorders. NERD is the most common phenotype of gastroesophageal reflux disease, and functional heartburn is the most common cause for refractory heartburn. In patients with NERD, symptoms arise from gastroesophageal reflux and esophageal hypersensitivity, whereas in patients with functional heartburn, symptoms result from esophageal hypersensitivity. A diagnosis of NERD requires endoscopy and reflux testing, whereas a diagnosis of functional heartburn also requires esophageal manometry. NERD is treated most commonly with medical, endoscopic, and surgical antireflux approaches, whereas functional heartburn as well as NERD can be treated with neuromodulators, psychological intervention, and complementary medicine options.

Pre-operative clinical and instrumental factors as antireflux surgery outcome predictors

Gastroesophageal reflux disease (GERD) is nowadays a highly prevalent, chronic condition, with 10% to 30% of Western populations affected by weekly symptoms. Many patients with mild reflux symptoms are treated adequately with lifestyle modifications, dietary changes, and low-dose proton pump inhibitors (PPIs). For those with refractory GERD poorly controlled with daily PPIs, numerous treatment options exist. Fundoplication is currently the most commonly performed antireflux operation for management of GERD. Outcomes described in current literature following laparoscopic fundoplication indicate that it is highly effective for treatment of GERD; early clinical studies demonstrate relief of symptoms in approximately 85%-90% of patients. However it is still unclear which factors, clinical or instrumental, are able to predict a good outcome after surgery. Virtually all demographic, esophagogastric junction anatomic conditions, as well as instrumental (such as presence of esophagitis at endoscopy, or motility patterns determined by esophageal high resolution manometry or reflux patterns determined by means of pH/impedance-pH monitoring) and clinical features (such as typical or atypical symptoms presence) of patients undergoing laparoscopic fundoplication for GERD can be factors associated with symptomatic relief. With this in mind, we sought to review studies that identified the factors that predict outcome after laparoscopic total fundoplication.

Use of acid-suppressive therapy before anti-reflux surgery in 2922 patients: a nationwide register-based study in Denmark

BACKGROUND

Guidelines recommend that patients with gastro-oesophageal reflux disease are adequately treated with acid-suppressive therapy before undergoing anti-reflux surgery. Little is known of the use of acid-suppressive drugs before anti-reflux surgery.

AIM

To determine the use of proton pump inhibitors and H2 -receptor antagonists in the year before anti-reflux surgery.

METHODS

A nationwide retrospective study of all patients aged ≥18 undergoing first-time anti-reflux surgery in Denmark during 2000-2012 using data from three different sources: the Danish National Register of Patients, the Danish National Prescription Register, and the Danish Person Register.

RESULTS

The study population thus included 2922 patients (median age: 48 years, 55.7% male). The annual proportion of patients redeeming ≥180 DDD of acid-suppressive therapy increased from 17.0% 5 years before anti-reflux surgery to 64.9% 1 year before. The probability for inadequate dosing 1 year before surgery (<180 DDD) was significantly increased for younger patients, patients operated in the period 2000-2003, patients who had not undergone pre-surgical manometry, pH- or impedance monitoring, and patients who had not redeemed prescriptions on NSAID or anti-platelet drugs.

CONCLUSION

Compliance with medical therapy should be evaluated thoroughly before planning anti-reflux surgery, as a high proportion of patients receive inadequate dosing of acid-suppressive therapy prior to the operation.

The use of medication after laparoscopic antireflux surgery

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.

Optimization of outcome after laparoscopic antireflux surgery

Laparoscopic fundoplication has emerged as an effective treatment for gastro-oesophageal reflux disease. The majority of patients who have undergone antireflux surgery report an improvement in reflux symptoms and in quality of life. However, some patients are dissatisfied with the outcome of antireflux surgery, and attempts have been made by surgeons to improve the results of this surgery. Careful case selection based on objective evidence of acid reflux, refinement of the surgical technique and 'tailoring' the wrap to suit the patient by selective use of a partial fundoplication may help to optimize the outcome from laparoscopic antireflux surgery.