Understanding gastro-oesophageal reflux disease: a patient-cluster analysis

The Economic Impact of Introducing RefluxStop for Refractory Gastroesophageal Reflux Disease on the Italian Healthcare System

INTRODUCTION

Gastroesophageal reflux disease (GERD) is a common ailment associated with troublesome symptoms. The standard of care in Italy involves initial treatment with proton pump inhibitor (PPI)-based medical management or laparoscopic Nissen fundoplication (LNF) for patients unwilling to continue or intolerant of long-term PPI therapy. RefluxStop is a novel medical device, intended for laparoscopic implantation, that has recently proven to be an efficacious and cost-effective treatment option for patients with GERD. This analysis aims to describe the short-term budget impact of introducing RefluxStop as a GERD treatment option within the Italian National Health Service (SSN).

METHODS

A model adherent to international best practice recommendations was developed to estimate the budget impact of introducing RefluxStop over a 5-year time horizon. Two scenarios were considered: one without RefluxStop (i.e., comprising PPI therapy, LNF, and magnetic sphincter augmentation using the LINX system); and one with RefluxStop (i.e., addition of RefluxStop to the three treatment options previously mentioned). Clinical benefits and costs associated with each intervention were included in the analysis.

RESULTS

Over 5 years, the introduction of RefluxStop resulted in avoidance of 95 surgical failures, 11 reoperations, and 64 endoscopic esophageal dilations. Introduction of RefluxStop resulted in an almost neutral impact on the existing budget with a 0.316% increase in the annual Italian SSN spending on GERD treatment.

CONCLUSION

Introduction of RefluxStop as a GERD treatment option in Italy is likely to be associated with substantial clinical benefits and a marginal budget impact.

Gas and Bloat in Female Patients after Antireflux Procedures: Analysis of 934 Cases

BACKGROUND

Antireflux procedures (ARPs) are effective treatments for GERD. However, variation in objective and patient-reported outcomes persists. Limited evidence and anecdotal experience suggest that patient sex may play a role. The objective of this study was to compare outcomes after ARPs between male and female patients.

STUDY DESIGN

We performed a retrospective review of a prospectively maintained database at a single institution. All patients who underwent an ARP for GERD were included. Demographic, clinical, and patient-reported outcomes data (GERD health-related quality of life [HRQL] and reflux symptom index), and radiographic hernia recurrence were collected and stratified by sex. Univariable and multivariable logistic and mixed-effects linear regression were used to control for confounding effects.

RESULTS

Between 2009 and 2022, 934 patients (291 men and 643 women) underwent an ARP. Reflux symptom index, GERD-HRQL, and gas and bloat scores improved uniformly for both sexes, though female patients were more likely to have higher gas and bloat scores 1 year postprocedure (mean ± SD 1.7 ± 1.4 vs 1.4 ± 1.3, p = 0.03) and higher GERD-HRQL scores 2 years postprocedure (6.3 ± 8.1 vs 4.7 ± 6.8, p = 0.04). Higher gas and bloat scores in women persisted on regression controlling for confounders. Hernia recurrence rate was low (85 patients, 9%) and was similar for both sexes. A final intraprocedural distensibility index 3 mm 2 /mmHg or more was significantly associated with a 7 times higher rate of recurrence (95% CI 1.62 to 31.22, p = 0.01).

CONCLUSIONS

Although patients of either sex experience symptom improvement and low rate of recurrence after ARPs, women are more likely to endorse gas and bloat compared with men. Final distensibility index 3 mm 2 /mmHg or more carries a high risk of recurrence. These results may augment how physicians prognosticate during consultation and tailor their treatment in patients with GERD.

Personalized anti-reflux surgery: connecting GERD phenotypes in 690 patients to outcomes

BACKGROUND

Anti-reflux operations are effective treatments for GERD. Despite standardized surgical techniques, variability in post-operative outcomes persists. Most patients with GERD possess one or more characteristics that augment their disease and may affect post-operative outcomes-a GERD "phenotype". We sought to define these phenotypes and to compare their post-operative outcomes.

METHODS

We performed a retrospective review of a prospective gastroesophageal database at our institution, selecting all patients who underwent an anti-reflux procedure for GERD. Patients were grouped into different phenotypes based on the presence of four characteristics known to play a role in GERD: hiatal or paraesophageal hernia (PEH), hypotensive LES, esophageal dysmotility, delayed gastric emptying (DGE), and obesity. Patient-reported outcomes (GERD-HRQL, dysphagia, and reflux symptom index (RSI) scores) were compared across phenotypes using the Wilcoxon rank-sum test.

RESULTS

690 patients underwent an anti-reflux procedure between 2008 and 2022. Most patients underwent a Nissen fundoplication (302, 54%), followed by a Toupet or Dor fundoplication (205, 37%). Twelve distinct phenotypes emerged. Non-obese patients with normal esophageal motility, normotensive LES, no DGE, with a PEH represented the most common phenotype (134, 24%). The phenotype with the best post-operative GERD-HRQL scores at one year was defined by obesity, hypotensive LES, and PEH, while the phenotype with the worst scores was defined by obesity, ineffective motility, and PEH (1.5 ± 2.4 vs 9.8 ± 11.4, p = 0.010). There was no statistically significant difference in GERD-HRQL, dysphagia, or RSI scores between phenotypes after five years.

CONCLUSIONS

We have identified distinct phenotypes based on common GERD-associated patient characteristics. With further study these phenotypes may aid surgeons in prognosticating outcomes to individual patients considering an anti-reflux procedure.

Endoscopic and Surgical Management of Gastroesophageal Reflux Disease

Approximately, 10% to 15% of patients in the United States experience gastroesophageal reflux symptoms on a weekly basis, negatively affecting the quality of life and increasing the risk of reflux-related complications. For patients with symptoms recalcitrant to proton pump inhibitor (PPI) therapy or those who cannot take PPIs, surgical fundoplication is the gold standard. The preoperative workup is complex but vital for operative planning and ensuring good postoperative outcomes. Most patients are highly satisfied after fundoplication, though transient dysphagia, gas bloating, and resumption of PPI use are common postoperatively. Multiple newer technologies offer safe alternatives to fundoplication with similar outcomes.

Epidemiology of Barrett's esophagus and esophageal adenocarcinoma in Spain. A unicentric study

INTRODUCTION

Barrett's esophagus (BE) is an acquired disease defined by the presence of intestinal metaplasia with goblet cells in the distal esophagus. The prevalence of BE has increased dramatically over the last years.

AIMS

The primary aims of the study were to analyze the characteristics of BE and esophageal adenocarcinoma (EAC) in a Spanish health district during a follow-up period.

METHODOLOGY

Sociodemographic factors, alcohol consumption and cigarette smoking were analyzed. We also studied the histological behavior and cause of death in each group.

RESULTS

In the present study 430 patients were included, 338 with BE and 92 with EAC. Incidence rates have risen from 2.25 and 1.25 per 100,000 inhabitants in 1996 to 6.5 and 4.75 per 100,000 in 2011, respectively. In the EAC group, male gender, age and alcohol consumption were higher in comparison to the BE group, and the overall survival was 23 months. In the BE group, the main causes of death were non-esophageal cancer and cardiovascular disease.

CONCLUSIONS

The incidence and prevalence rates of AEC and BE have risen over the past years. Risk factors for these conditions were male gender, age and alcohol consumption. Long BE (> 3 cm) is involved in dysplasia progression. AEC diagnosis mainly occurs after neoplasia is detected and, in a few cases, due to a previous BE. Cardiovascular diseases and non-esophageal cancers have been found to be the main cause of death in BE patients.

Systematic review: the burden of disruptive gastro-oesophageal reflux disease on health-related quality of life

BACKGROUND

About one-third of patients with gastro-oesophageal reflux disease (GERD) have frequent and/or severe reflux symptoms ('disruptive GERD'). The relative burden of disruptive GERD on health-related quality of life (HRQL) has not been systematically investigated.

AIM

To assess the burden of disruptive vs. nondisruptive GERD on HRQL.

METHODS

Systematic searches were conducted in PubMed and Embase. To be included, studies had to have used validated questionnaires to assess HRQL.

RESULTS

Nineteen studies were included. Data on the comparative burden of frequent (ranging from daily to ≥weekly) and severe reflux symptoms were provided in eight and 13 studies respectively; six reported on the additional burden of nocturnal symptoms. Compared with individuals with nondisruptive GERD, those with disruptive GERD had 2.4-times and 1.5-times higher mean rates of absenteeism and presenteeism respectively (five studies), 1.5-times lower sleep quality scores (three studies), 1.1-times lower mean summary scores for physical and mental health (five studies) and 1.3-times lower mean scores for psychological and general well-being (four studies). Increasing symptom frequency and severity both increased the burden of disease to a similar extent. The presence of nocturnal symptoms in addition to daytime symptoms led to worsening of physical health, but their effect on mental health and work productivity was less clear.

CONCLUSIONS

Disruptive GERD is associated with a high burden of disease compared with occasional or mild reflux symptoms. Disease management needs to vary across the GERD spectrum and should be tailored to patients' requirements for optimal therapeutic outcomes.

Management of gastro-oesophageal reflux disease in primary care: a European observational study

OBJECTIVE

To describe the management of gastro-oesophageal reflux disease (GERD) in primary care, as part of the RANGE (Retrospective ANalysis of GERD) study.

METHODS

Over 4 months, at 134 primary care practices in six European countries, 12 815 patients consulted for GERD-related reasons. A random selection of these patients was invited to enter the study. Data were then collected retrospectively (from the initial consultation) and prospectively (from a follow-up visit). This included information on GERD diagnosis, symptoms and complications, medication use and healthcare resource utilisation.

RESULTS

Of 12 815 patients who underwent consultation for GERD-related reasons, 2678 were randomly selected and accepted the invitation to participate in the study. Across countries, 28-47% of patients reported a significant GERD symptom load at initial consultation. Thereafter, 30-100% of patients were prescribed a proton pump inhibitor (PPI), but a significant GERD symptom load was still experienced by 15-30% (all patients combined) at follow-up (median 5.0-7.5 months after initial consultation). In the majority of patients (65-88%), no diagnostic procedures were performed between initial consultation and follow-up. During the follow-up period, the most common form of healthcare utilisation comprised additional GERD-related consultations with a physician.

CONCLUSIONS

The findings of this pan-European study indicate that current management of primary care patients with GERD is far from optimal, and accounts for a marked burden on patients and healthcare systems alike. A more structured approach to GERD management, by tailoring treatment according to the impact of the disease, may reduce this burden.