Gastro-oesophageal reflux and respiratory disease: the place of the surgeon

Surgery for reflux induced airway disease: a systematic review

OBJECTIVES

1. Evaluate the current evidence regarding the efficacy and safety of anti-reflux surgery for the treatment of severe gastroesophageal reflux-related airway disease in children. 2. Provide evidence based recommendations regarding indications and outcomes of anti-reflux surgery for airway disease in children.

METHODS

An a priori protocol was defined to identify all articles addressing anti-reflux surgery for the treatment of reflux-related airway disease in children where details regarding the diagnosis, treatment, and outcomes were clearly presented. The search was inclusive of all references available through August 30, 2013 and included electronic databases to identify candidate articles as well as a comprehensive series of crosschecks. The two authors independently determined which references met inclusion criteria, extracted data, and assigned levels of evidence. Data were pooled using a random effects model due to significant study heterogeneity.

RESULTS

Fourteen articles met inclusion criteria. The overall level of evidence was grade C. There was significant heterogeneity among the studies (I(2)=82.7%; p<0.001). However, each article uniformly presented cases suggesting that anti-reflux surgery is efficacious and safe in treating children with severe reflux-related respiratory disease. The pooled success rate for complete or partial resolution of symptoms after anti-reflux surgery was 0.91 (95% CI: 0.88, 0.94). The pooled success rate for complete symptom resolution after surgery was 0.72 (95% CI: 0.62, 0.83).

CONCLUSION

The current literature suggests that anti-reflux surgery is an effective and safe treatment for severe reflux-related airway disease. However, the level of evidence lacks strength and further investigation is warranted.

The spectrum of pulmonary symptoms due to gastroesophageal reflux

Most asthmatics have GER, and the evidence is strong that GER plays an important role in some patients who have asthma. Despite sophisticated study methods and technologically advanced diagnostic tests, the results of published studies on mechanisms have failed to provide a diagnostic test with a degree of certainty great enough to identify which patients have GER-induced or GER-exacerbated asthma and which patients will respond to antireflux therapy. The difficulties involved in establishing a definite cause-and-effect relationship between GER and asthma are real. Even positive results on such direct tests as sputum inspection and scintigraphic monitoring, both of which establish reflux into the tracheobronchial tree, do not necessarily establish cause or effect and cannot be used to predict outcomes. Ambulatory esophageal pH testing can suggest, but cannot prove, the diagnosis of GER-induced asthma, and pH testing cannot be relied on safely to make clinical decisions. A trial of a proton pump inhibitor (PPI) is indicated to assess if asthma improves subjectively and objectively, but the dose must be high enough to prevent even silent esophageal acid exposure, and the duration must be long enough to allow for detection of even subtle trends in subjective and objective respiratory improvement. Antireflux surgery remains a therapeutic option and should not be withheld if GER is a reasonable suspect in asthma exacerbations. Although strong opinions have been voiced as to whether or not a good response to PPI therapy predicts a good response to antireflux surgery, the opinions, although logical, are based on personal experience and gut feelings; a good PPI response may not necessarily predict a good surgery response. Opinions suggesting that a poor response to PPI predicts a poor response to antireflux surgery also may seem logical but are not based on clinical data; a poor PPI response may not necessarily predict a poor antireflux surgery response. When the method is found that predicts which patients who have GER and asthma will respond to antireflux treatment, the results could be profound: fewer hospitalizations for respiratory complications, less pulmonary morbidity and mortality, less need for pulmonary medications, less time lost from work, fewer visits to physicians' offices, and less illness associated with corticosteroid therapy. For the present, however, clinical judgment and good sense still are our best friends. It is not unreasonable to urge patients to alter their lifestyle: the huge volume, calorie-dense, high-fat meals eaten before bedtime are not likely to prevent GER or add to their life expectancy.

Gastroesophageal reflux disease in asthma: effects of medical and surgical antireflux therapy on asthma control

OBJECTIVE

To critique the English-language reports describing the effects of medical and surgical antireflux therapy on respiratory symptoms and function in patients with asthma.

METHODS

The Medline computerized database (1959-1999) was searched, and all publications relating to both asthma and gastroesophageal reflux disease were retrieved.

RESULTS

Seven of nine trials of histamine-receptor antagonists showed a treatment-related improvement in asthma symptoms, with half of the patients benefiting. Only one study identified a beneficial effect on objective measures of pulmonary function. Three of six trials of proton pump inhibitors documented improvement in asthma symptoms with treatment; benefit was seen in 25% of patients. Half of the studies reported improvement in pulmonary function, but the effect occurred in fewer than 15% of patients. In the one study that used optimal antisecretory therapy, asthma symptoms were improved in 67% of patients and pulmonary function was improved in 20%. Combined data from 5 pediatric and 14 adult studies of anti-reflux surgery indicated that almost 90% of children and 70% of adults had improvement in respiratory symptoms, with approximately one third experiencing improvements in objective measures of pulmonary function.

CONCLUSIONS

Fundoplication has been consistently shown to ameliorate reflux-induced asthma; results are superior to the published results of antisecretory therapy. Optimal medical therapy may offer similar results, but large studies providing support for this assertion are lacking.

Gastroesophageal reflux and asthma: are they related?

The relationship between asthma and gastroesophageal reflux (GER) is controversial. This paper reviews the evidence for an association between them, the effect of asthma on GER, and the effects of GER and antireflux therapy on asthma. The association between the two conditions seems firm but studies of the effects of GER on asthma and asthma on GER are contradictory. Critical review suggests that GER affects asthma symptoms but not pulmonary function. Antireflux therapy improves asthma symptoms and reduces medication requirements but does not improve pulmonary function. The paradox of GER causing asthma symptoms but not changing pulmonary function may be explained by its increasing minute ventilation rather than triggering bronchospasm.

The effects of antireflux surgery on asthmatics with gastroesophageal reflux

BACKGROUND

Antireflux therapy, including surgery, has been advocated for asthma patients with gastroesophageal reflux (GER). A recent review of medical antireflux therapy reported improvements in asthma symptoms and medication requirements but no improvement in pulmonary function. The purpose of this article is to review the available literature on the effects of antireflux surgery in asthma.

METHOD

Using the Medline 1966 to August 1998 database, lung disease, asthma, and pulmonary function were combined with GER and different antireflux surgeries, including fundoplication. Reference lists of identified articles were also reviewed.

RESULTS

Combining the terms asthma and GER identified 271 articles, including 193 in English. Searching the term fundoplication identified 497 articles, including 413 in English. Twenty-four reports addressed the effects of antireflux surgery in asthma. Only two studies were controlled. Asthmatic data could not be distinguished from that of other subjects in five articles. The remainder were case series, retrospective reviews, or uncontrolled studies. Ten reports included data on < or = 10 patients. Two studies were only published as abstracts. A total of 417 asthma patients were included in the identified reports. Antireflux surgery improved GER symptoms, asthma symptoms, asthma medication use, and pulmonary function in 90%, 79%, 88%, and 27%, respectively.

CONCLUSIONS

Antireflux surgery may improve GER and asthma symptoms and decrease medication requirements, but it has little effect on pulmonary function. The effects of antireflux surgery on asthma are similar to those of medical antireflux therapy.

Gastroesophageal reflux and asthma

The medical literature has been deluged with articles on the relation between gastroesophageal reflux (GER) and asthma. In an effort to piece together the complex puzzle, investigators from all disciplines have gathered their patients with wheezing and heartburn and studied the epidemiology, the possible cause or effect mechanisms and the therapeutic response to GER treatment. Indeed, since humans first began to hunker down and work together to discuss interesting observations, the world has begun to breathe easier. Epidemiological evidence for a GER/asthma association suggests that about three-fourths of asthmatics, independent of the use of bronchodilators, have acid GER, increased frequency of reflux episodes, or heartburn; and 40% have reflux esophagitis. Physiological studies suggest that 2 separate mechanisms are involved in the GER/asthma relationship: (1) a vagally mediated pathway and (2) microaspiration. In any given patient, however, there is no acceptable diagnostic method available to confirm the presence or absence of GER-induced asthma. Clinical trials, using antireflux medical therapy and antireflux surgery have begun to provide some clues about GER-related pulmonary symptoms. The trials of medical therapy using acid suppressing drugs (e.g. histamine-2 receptor antagonists) have ranged from no benefit to modest improvement of only nocturnal asthma symptoms. Studies with proton-pump inhibitors are underway. In uncontrolled surgical studies, antireflux surgery has resulted in partial or complete remission of asthma symptoms in a large proportion of patients. Despite the uncontrolled nature of these studies, many patients have had dramatic subjective improvement in pulmonary symptoms. It appears for now that clinical trials are the only available means to assess whether medical or surgical treatment of GER in patients with both GER and asthma improves the symptoms of asthma and decreases the need for pulmonary medications. One conclusion is certain: We no longer can ignore the important co-existent nature of these 2 afflictions.

Gastro-oesophageal reflux disease and asthma

Gastro-oesophageal reflux disease (GOR) and asthma are both common medical conditions that often co-exist. Studies using oesophageal manometry and 24 h ambulatory pH monitoring have shown that up to 80% of asthmatics have abnormal GOR. A number of mechanisms whereby GOR may trigger asthma have been proposed, and it is believed that acid reflux may stimulate vagal receptors in the lower oesophagus causing reflex bronchoconstriction. However, GOR may be worsened by asthma causing abnormal diaphragm mechanics and by its treatment. Formal evaluation of GOR should be considered a part of asthma assessment, particularly if asthmatic symptoms are precipitated by factors known to trigger GOR such as reclining, alcohol ingestion, and the use of theophylline. Twenty-four hour ambulatory intra-oesophageal pH monitoring remains the gold standard for the diagnosis of GOR. Medical therapy with anti-reflux medications, such as acid suppressive agents and prokinetic agents may improve both GOR and asthma control. In those who fail medical therapy, anti-reflux surgery may be warranted in some.

Simultaneous tracheal and esophageal pH monitoring: investigating reflux-associated asthma

Aspiration of gastric acid into the trachea may cause asthma in some patients who have gastroesophageal reflux. Antireflux surgery has been advocated for such patients, but lack of an objective test for acid aspiration makes patient selection difficult. We report a new technique for demonstrating acid aspiration, simultaneous tracheal and esophageal pH monitoring. Tracheal pH was measured with a 1.0-mm pH electrode introduced through the cricothyroid membrane under bronchoscopic vision. A standard esophageal pH electrode was placed in the usual position. Tracheal and esophageal pH were monitored over a 24-hour period. Peak expiratory flow rate was measured hourly while the patient was awake. We present data obtained in 3 patients with severe asthma and symptomatic gastroesophageal reflux. All 3 patients demonstrated a decrease in tracheal pH to less than 5.5, coinciding with a decrease in esophageal pH to less than 4.0. The test was repeated after antireflux operation and showed that significant decreases in esophageal pH no longer lowered tracheal pH. Asthmatic symptoms were improved, and medication was reduced in 2 of the 3 patients.

Predicting preoperatively the outcome of respiratory symptoms of gastroesophageal reflux

The fact that bronchopulmonary symptoms remain unchanged in about 15% of patients after successful operation for gastroesophageal reflux (GER) with respiratory tract disease (RTD) makes surgical indications uncertain and warrants further research into preoperative prognostic predictors. This problem has been addressed in infants by demonstrating that those most likely to be cured by antireflux procedures have long nocturnal episodes of GER and/or temporal coincidence between drops in pH levels and respiratory episodes. In an attempt to validate these predictors and, at the same time, to search for other reliable ones, we have retrospectively studied the charts, manometric studies, pH tracings, and pathology reports of 55 patients aged 48 +/- 36 months (range, 2 to 170) who had Nissen funduplication for GER with RTD in the last 10 years. Forty-five children were cured or improved of their RTD symptoms after operation, but in 10 (18%) they were unchanged in spite of the control of GER. Patients with a former history of vomiting (n = 38) had better results than those (n = 17) without it (95% of RTD cure v 53%, P less than .001). The success rate in children with recurrent obstructive airway disease (n = 20) was definitely lower than in those without it (n = 35) (70% v 89%, P less than .05). Neither esophageal manometry nor mucosal biopsy provided any predictive clue, but pH studies confirmed that the mean duration of nocturnal episodes of reflux (ZMD) was definitely longer in patients responding favourably to surgical cure of GER than in those in whom this failed (12.2 +/- 9.6 v 3.9 +/- 2.8 minutes, P less than .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Medical and surgical treatment of nonallergic asthma associated with gastroesophageal reflux

Patients presenting to a chest clinic because of adult-onset wheezing with no history of allergy had a 90 percent prevalence of gastroesophageal reflux, even though reflux symptoms were mild or absent. Ninety patients were randomly assigned to receive cimetidine or an identical placebo or to undergo antireflux surgery. During a six-month period, all groups improved clinically; the cimetidine and surgical groups improved more than the placebo group. The intake of pulmonary medication decreased significantly in both cimetidine and surgical groups. Pulmonary function test results improved in the cimetidine- and surgically treated patients; improvement was not statistically significant. At long-term follow-up, the surgical group maintained clinical improvement and decreased pulmonary medication intake, whereas the placebo group worsened. We conclude that gastroesophageal reflux can play a significant role in some patients with nonallergic pulmonary disease and that its treatment can improve pulmonary symptoms and objective measurements of pulmonary function.

Diagnosis and treatment of gastroesophageal reflux in 500 children with respiratory symptoms: the value of pH monitoring

Gastroesophageal reflux (GER) usually presents with digestive symptoms, failure to thrive, and/or respiratory symptoms. During the 8-year period from 1981 to 1989, 1,153 children underwent 20-hour pH monitoring to assess GER. All patients were graded using the scoring system of Euler and Byrne. Patients were classified as severe (score greater than 50), moderate (score 25 to 50), and normal (score less than 25). Five hundred (43.3%) of these patients presented with respiratory symptoms including apnea, cyanosis, or "near miss" sudden infant death syndrome (36%), poorly controlled asthma (28%), recurrent bronchopneumonia (13%), bronchiolitis (9%), and miscellaneous symptoms such as intermittent dyspnea, chronic cough, and stridor (12%). Eight patients (2%) had cystic fibrosis. The ages ranged from 1 month to 20 years (mean, 19.5 months). Twelve patients had technically inadequate studies and were excluded. Severe reflux was present in 156 patients (31%) and moderate reflux in 159 patients (31%). All patients were treated initially by medical therapy for a minimum of 8 weeks. The majority of patients (81%) had resolution of their symptoms with change in position, thickened feedings, and, when indicated, additional therapy with metoclopramide, cisapride, or domperidone. Most of these patients were found to have a specific position, usually prone, which decreased reflux. The remaining 57 patients had documentation of persistent reflux by pH monitoring and underwent an antireflux procedure. Of those patients undergoing surgery 51 had severe reflux and 6 had moderate reflux. Forty-four patients had a posterior 270 degrees wrap (Toupet), 10 had a 360 degrees wrap (Nissen), and 3 had an anterior 180 degrees wrap (Boix-Ochoa).(ABSTRACT TRUNCATED AT 250 WORDS)