1
|
Puri A, Steven S, Markar SR, Boyle N. Longer-term outcomes of gastroesophageal reflux disease treated with magnetic sphincter augmentation. Dis Esophagus 2023; 36:doad014. [PMID: 36942526 PMCID: PMC10789235 DOI: 10.1093/dote/doad014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 02/14/2023] [Accepted: 02/28/2023] [Indexed: 03/23/2023]
Abstract
Surgical intervention for gastroesophageal reflux disease (GERD) has historically been limited to fundoplication. Magnetic sphincter augmentation (MSA) is a less invasive alternative that was introduced 15 years ago, and it may have a superior side-effect profile. To date, however, there has been just a single published study reporting outcomes in a UK population. This study reports quality-of-life (QOL) outcomes and antacid use in patients undergoing MSA, with a particular focus on postoperative symptoms and those with severe reflux. A single-center cohort study was carried out to assess the QOL outcomes and report long-term safety outcomes in patients undergoing MSA. GERD-health-related quality of life (GERD-HRQL) and Reflux Symptom Index (RSI) scores were collected preoperatively, and immediately postoperatively, at 1-, 2-, 3-, and 5-year follow-up time points. All patients underwent preoperative esophagogastroduodenoscopy, impedance, and manometry. Two hundred and two patients underwent laparoscopic MSA over 9 years. The median preoperative GERD-HRQL score was 31, and the median RSI score was 17. There was a reduction in all scores from preoperative values to each time point, which was sustained at 5-year follow-up; 13% of patients had a preoperative DeMeester score of >50, and their median preoperative GERD-HRQL and RSI scores were 32 and 15.5, respectively. These were reduced to 0 at the most recent follow-up. There was a significant reduction in antacid use at all postoperative time points. Postoperative dilatation was necessary in 7.4% of patients, and the device was removed in 1.4%. Erosion occurred in no patients. MSA is safe and effective at reducing symptom burden and improving QOL scores in patients with both esophageal and laryngopharyngeal symptoms, including those with severe reflux.
Collapse
Affiliation(s)
- Aiysha Puri
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sue Steven
- Department of Surgery, Reflux UK, London, UK
| | - Sheraz R Markar
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
| | | |
Collapse
|
2
|
Frazzoni M, Frazzoni L, Ribolsi M, Russo S, Conigliaro R, De Bortoli N, Savarino E. On-therapy impedance-pH monitoring can efficiently characterize PPI-refractory GERD and support treatment escalation. Neurogastroenterol Motil 2023; 35:e14547. [PMID: 36780512 DOI: 10.1111/nmo.14547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/10/2023] [Accepted: 01/26/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND On-therapy impedance-pH monitoring is recommended in patients with documented GERD and PPI-refractory heartburn in order to establish whether the unremitting symptom is reflux-related or not. AIMS To define on-PPI cut-offs of impedance-pH metrics allowing proper interpretation of on-therapy impedance-pH monitoring. METHODS Blinded expert review of impedance-pH tracings performed during double-dosage PPI, prospectively collected from 150 GERD patients with PPI-refractory heartburn and 45 GERD patients with PPI-responsive heartburn but persisting extra-esophageal symptoms. Acid exposure time (AET), number of total refluxes (TRs), post-reflux swallow-induced peristaltic wave (PSPW) index, and mean nocturnal baseline impedance (MNBI) were assessed. On-PPI cut-offs were defined and evaluated with ROC analysis and the area under curve (AUC). RESULTS All the four impedance-pH metrics significantly differed between PPI-refractory and PPI-responsive heartburn cases. At ROC analysis, AUC was 0.73 for AET, 0.75 for TRs, 0.81 for PSPW index, and 0.71 for MNBI; best cut-offs were ≥1.7% for AET, ≥45 for TRs, ≤36% for PSPW index, and ≤ 1847 Ω for MNBI; AUC of such cut-offs was 0.66, 0.71, 0.73, and 0.68, respectively. Analysis of PSPW index and MNBI added to assessment of AET and TRs significantly increased the yield of on-therapy impedance-pH monitoring in the PPI-refractory cohort (97% vs. 83%, p < 0.0001). Notably, suboptimal acid suppression as shown by AET ≥1.7% was detected in 43% of 150 PPI-refractory cases. CONCLUSIONS We have defined on-PPI cut-offs of impedance-pH metrics by which comprehensive assessment of impedance-pH tracings, including analysis of PSPW index and MNBI can efficiently characterize PPI-refractory GERD and support treatment escalation.
Collapse
Affiliation(s)
- Marzio Frazzoni
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Ospedale Civile di Baggiovara, Modena, Italy
| | - Leonardo Frazzoni
- Gastroenterology Unit, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S Orsola-Malpighi, Bologna, Italy
| | - Mentore Ribolsi
- Dipartimento di Medicina e Chirurgia, Digestive Disease, Università Campus Bio-Medico di Roma, Roma, Italy
| | - Salvatore Russo
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Ospedale Civile di Baggiovara, Modena, Italy
| | - Rita Conigliaro
- Digestive Pathophysiology Unit and Digestive Endoscopy Unit, Azienda Ospedaliero Universitaria di Modena, Ospedale Civile di Baggiovara, Modena, Italy
| | - Nicola De Bortoli
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| |
Collapse
|
3
|
Rettura F, Bronzini F, Campigotto M, Lambiase C, Pancetti A, Berti G, Marchi S, de Bortoli N, Zerbib F, Savarino E, Bellini M. Refractory Gastroesophageal Reflux Disease: A Management Update. Front Med (Lausanne) 2021; 8:765061. [PMID: 34790683 PMCID: PMC8591082 DOI: 10.3389/fmed.2021.765061] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/04/2021] [Indexed: 12/12/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is one of the most frequent gastrointestinal disorders. Proton pump inhibitors (PPIs) are effective in healing lesions and improving symptoms in most cases, although up to 40% of GERD patients do not respond adequately to PPI therapy. Refractory GERD (rGERD) is one of the most challenging problems, given its impact on the quality of life and consumption of health care resources. The definition of rGERD is a controversial topic as it has not been unequivocally established. Indeed, some patients unresponsive to PPIs who experience symptoms potentially related to GERD may not have GERD; in this case the definition could be replaced with “reflux-like PPI-refractory symptoms.” Patients with persistent reflux-like symptoms should undergo a diagnostic workup aimed at finding objective evidence of GERD through endoscopic and pH-impedance investigations. The management strategies regarding rGERD, apart from a careful check of patient's compliance with PPIs, a possible change in the timing of their administration and the choice of a PPI with a different metabolic pathway, include other pharmacologic treatments. These include histamine-2 receptor antagonists (H2RAs), alginates, antacids and mucosal protective agents, potassium competitive acid blockers (PCABs), prokinetics, gamma aminobutyric acid-B (GABA-B) receptor agonists and metabotropic glutamate receptor-5 (mGluR5) antagonists, and pain modulators. If there is no benefit from medical therapy, but there is objective evidence of GERD, invasive antireflux options should be evaluated after having carefully explained the risks and benefits to the patient. The most widely performed invasive antireflux option remains laparoscopic antireflux surgery (LARS), even if other, less invasive, interventions have been suggested in the last few decades, including endoscopic transoral incisionless fundoplication (TIF), magnetic sphincter augmentation (LINX) or radiofrequency therapy (Stretta). Due to the different mechanisms underlying rGERD, the most effective strategy can vary, and it should be tailored to each patient. The aim of this paper is to review the different management options available to successfully deal with rGERD.
Collapse
Affiliation(s)
- Francesco Rettura
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Francesco Bronzini
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Michele Campigotto
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Christian Lambiase
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Andrea Pancetti
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Ginevra Berti
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Santino Marchi
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Nicola de Bortoli
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Frank Zerbib
- CHU de Bordeaux, Centre Medico-Chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Massimo Bellini
- Division of Gastroenterology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| |
Collapse
|
4
|
Lundell L. Reflux Symptoms: Functional and Structural Diseases and the Approach from the GI Specialist. Dig Dis 2021; 39:590-597. [PMID: 33561854 PMCID: PMC8686707 DOI: 10.1159/000515109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/22/2021] [Indexed: 02/02/2023]
Abstract
The GI specialist has an important role to play in the long-term management of gastroesophageal reflux disease (GERD) patients to secure a proper diagnosis and the selection of best possible therapeutic strategy. Through intensified information and education, the implementation of national and international guidelines can be more effectively processed, whereupon a significant improvement in cost-effectiveness of the current management will be fostered. Regarding the more specific group of GERD patients, as represented by the so-called PPI-refractory patients, data have now emerged to guide us into the future. Noteworthy is that the majority of the alleged PPI-refractory GERD patients do not, after careful investigations, have GERD. Based on recently published RCT data, a clinically highly relevant difference in treatment success was noted in favor of laparoscopic antireflux surgery as compared to a variety of medical treatment alternatives. Likewise, it can be concluded that it seems as if the latter can only offer a limited effect. Whenever a corresponding powerful clinical difference in therapeutic outcome between different strategies and treatment alternatives is detected, this will have a huge impact on treatment algorithms and clinical management.
Collapse
Affiliation(s)
- Lars Lundell
- Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden,Department of Surgery, University of Southern Denmark, Odense University Hospital, Odense, Denmark,*Lars Lundell,
| |
Collapse
|
5
|
Naik RD, Meyers MH, Vaezi MF. Treatment of Refractory Gastroesophageal Reflux Disease. Gastroenterol Hepatol (N Y) 2020; 16:196-205. [PMID: 34035721 PMCID: PMC8132683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Gastroesophageal reflux disease (GERD) is a common disorder that is treated with lifestyle modification, weight loss, and medications, such as proton pump inhibitors (PPIs). An empiric course of PPI therapy is an effective and cost-effective strategy for the management of GERD. However, in some patients, PPI therapy and lifestyle changes are inadequate to control symptoms. When there is persistence of symptoms despite empiric therapy, patients are labeled as having refractory GERD. This label underestimates the wide differential diagnosis of foregut pathology that can mimic symptoms of GERD. A careful history of symptoms, response to PPI therapy, adherence, compliance, and timing helps elucidate if medication has been helping. When patients are refractory, alternative etiologies of GERD must be considered. Many of these alternatives can be determined on an upper endoscopy or with complementary testing, such as high-resolution esophageal manometry or gastric emptying testing as symptoms dictate. When an alternative cause is not found and index endoscopy is normal, additional testing with either traditional pH or impedance testing can be completed based on prior examination results and response to therapy. Further therapy, including medical, endoscopic, or surgical, can then be targeted at the etiology.
Collapse
Affiliation(s)
- Rishi D Naik
- Dr Naik is an assistant professor of medicine and Dr Vaezi is a professor of medicine, clinical director, and director of the Center for Swallowing and Esophageal Disorders in the Department of Gastroenterology, Hepatology, and Nutrition at Vanderbilt University Medical Center in Nashville, Tennessee
- Dr Meyers is an internal medicine resident in the Department of Internal Medicine at Vanderbilt University Medical Center
| | - Matthew H Meyers
- Dr Naik is an assistant professor of medicine and Dr Vaezi is a professor of medicine, clinical director, and director of the Center for Swallowing and Esophageal Disorders in the Department of Gastroenterology, Hepatology, and Nutrition at Vanderbilt University Medical Center in Nashville, Tennessee
- Dr Meyers is an internal medicine resident in the Department of Internal Medicine at Vanderbilt University Medical Center
| | - Michael F Vaezi
- Dr Naik is an assistant professor of medicine and Dr Vaezi is a professor of medicine, clinical director, and director of the Center for Swallowing and Esophageal Disorders in the Department of Gastroenterology, Hepatology, and Nutrition at Vanderbilt University Medical Center in Nashville, Tennessee
- Dr Meyers is an internal medicine resident in the Department of Internal Medicine at Vanderbilt University Medical Center
| |
Collapse
|
6
|
Ayazi S, Zaidi AH, Zheng P, Chovanec K, Chowdhury N, Salvitti M, Newhams K, Levy J, Hoppo T, Jobe BA. Comparison of surgical payer costs and implication on the healthcare expenses between laparoscopic magnetic sphincter augmentation (MSA) and laparoscopic Nissen fundoplication (LNF) in a large healthcare system. Surg Endosc 2019; 34:2279-2286. [PMID: 31376004 PMCID: PMC7113225 DOI: 10.1007/s00464-019-07021-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/19/2019] [Indexed: 12/26/2022]
Abstract
Introduction Magnetic sphincter augmentation (MSA) is a promising antireflux surgical treatment. The cost associated with the device may be perceived as a drawback by payers, which may limit the adoption of this technique. There are limited data regarding the cost of MSA in the management of reflux disease. The aims of the study were to report the clinical outcome and quality of life measures in patients after MSA and to compare the pharmaceutical and procedure payer costs and the disease-related and overall expense of MSA compared to laparoscopic Nissen fundoplication (LNF) from a payer perspective. Methods and procedures This prospective observational study was performed in conjunction with the region’s largest health insurance company. Data were collected on patients who underwent MSA over a 2-year period beginning in September 2015 at the study network hospitals. The LNF comparison group was procured from members’ claims data of the payer. Inclusion was predicated by patients having continuous coverage during study period. The total procedural reimbursement and the disease-related and overall medical claims submitted up to 12 months prior to surgery and up to 12 months following surgery were obtained. The payer reimbursement data are presented as allowed cost per member per month (PMPM). These values were then compared between groups. Results There were 195 patients who underwent MSA and 1131 that had LNF. MSA results in comparable symptom control, PPI elimination rate, and quality of life measures compared to values reported for LNF in the literature. The median (IQR) reimbursement of surgery was $13,522 (13,195–14,439) for those who underwent MSA and $13,388 (9951–16,261) for patients with LNF, p = 0.02. In patients who underwent MSA, the median reimbursement related to the upper gastrointestinal disease was $ 305 PMPM, at 12 months prior to surgery and $ 104 at 12 months after surgery, representing 66% decrease in cost. These values were $ 233 PMPM and $126 PMPM for patients who underwent LNF, representing a 46% decrease (p = 0.0001). At 12 months following surgery, the reimbursement for overall medical expenses had decreased by 10.7% in the MSA group and 1.4% in the LNF group when compared to the preoperative baseline reimbursement. The reimbursement for PPI use after surgery showed a 95% decrease in the MSA group and 90% among LNF group when compared to the preoperative baseline (p = 0.10). Conclusion When compared with LNF, MSA results in a reduction of disease-related expenses for the payer in the year following surgery. While MSA is associated with a higher procedural payer cost compared to LNF, payer costs may offset due to reduction in the expenses after surgery.
Collapse
Affiliation(s)
- Shahin Ayazi
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Ali H Zaidi
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Ping Zheng
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Kristy Chovanec
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Nobel Chowdhury
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Madison Salvitti
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Kirsten Newhams
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Jonathan Levy
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Toshitaka Hoppo
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Blair A Jobe
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA.
| |
Collapse
|
7
|
Magnetic sphincter augmentation (MSA) in patients with hiatal hernia: clinical outcome and patterns of recurrence. Surg Endosc 2019; 34:1835-1846. [PMID: 31286251 PMCID: PMC7093380 DOI: 10.1007/s00464-019-06950-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/26/2019] [Indexed: 12/16/2022]
Abstract
Introduction Magnetic sphincter augmentation (MSA) is an effective treatment for patients with gastroesophageal reflux disease. In early studies, patients with a hiatal hernia (HH) ≥ 3 cm were excluded from consideration for implantation and initially the FDA considered its use as “precautionary” in this context. This early approach has led to an attitude of hesitance among some surgeons to offer this therapy to patients with HH. This study was designed to evaluate the impact of HH status on the outcome of MSA and to report the rate of HH recurrence after MSA. Methods and procedures This is a retrospective review of prospectively collected data of patients who underwent MSA between June 2013 and August 2017. Baseline clinical and objective data were collected. Patients were divided into four groups based on HH status: no HH, small HH (< 3 cm), large HH (≥ 3 cm), and paraesophageal hernia (PEH). Patient satisfaction, GERD–HRQL and RSI data, freedom from PPI, need for postoperative dilation, length of hospitalization, 90-day readmission rate, need for device removal, and HH recurrence was compared between groups. Results There were 350 patients [60% female, mean (SD) age: 53.5 (13.8)] who underwent MSA. There were 65 (18.6%) with no HH, 205 (58.6%) with small HH (< 3 cm), 58 (16.6%) with large HH (≥ 3 cm) and 22 (6.2%) with PEH. At a mean follow-up of 13.6 (10.4) months, the rate of outcome satisfaction was similar between the groups (86%, 87.9%, 92.2% and 93.8%, p = 0.72). This was also true for GERD–HRQL total score clinical improvement (79.1%, 77.8%, 82% and 87.5%, p = 0.77). The rate of postoperative dysphagia (p = 0.33) and freedom from PPIs (p = 0.96) were similar among the four groups. Duration of hospitalization was higher among those with a large HH or PEH, and only PEH patients had a higher 90-day readmission rate (p = 0.0004). There was no difference between the need for dilation among groups (p = 0.13). The need for device removal (5% overall) was similar between the four groups (p = 0.28). HH recurrence was 10% in all groups combined, and only 7 of 240 (2.9%) patients required reoperation; the majority of these patients underwent a minimal dissection approach (no hernia repair) at the index operation. The incidence of recurrent HH increased in direct correlation with the preoperative HH size (0%, 10.1%, 16.6 and 20%, p = 0.032). Conclusion In the largest series of MSA implantation, we demonstrate that the excellent outcomes and high degree of satisfaction after MSA are independent of the presence or size of HH. Despite higher rates of hernia recurrence in large HH and PEH patients, the rates of postoperative endoscopic intervention, and device removal is similar to those with no or small HH. The minimal dissection approach to MSA should be abandoned.
Collapse
|
8
|
Abdul-Hussein M, Khalaf M, Castell D. Throat Clearing, Frequently Reported, But is it GERD Related? J Clin Gastroenterol 2018; 52:869-872. [PMID: 29356788 DOI: 10.1097/mcg.0000000000000985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
GOALS To identify the association of throat clearing (TC) with gastroesophageal reflux disease (GERD) during objective reflux monitoring in a large number of patients studied in our esophageal testing laboratory. BACKGROUND TC is frequently reported and considered to be an atypical symptom of GERD. Atypical GERD symptoms have been widely investigated and empirically treated with proton pump inhibitors. STUDY We reviewed ambulatory impedance-pH studies of 186 patients referred for evaluation of possible GERD from January 2011 to December 2015 to evaluate the symptom association (SA) of TC with both an abnormal number of reflux episodes and also abnormal esophageal acid exposure (EAE). Patients were divided into 2 groups; group 1: TC is the only reported symptom, group 2: TC is one of the symptoms. All patients were studied off proton pump inhibitors therapy. RESULTS Group 1 where TC was the only symptom in 27/186 (14.5%) patients. There was no significant difference in positive SA between this group (6/27; 22%) and group 2 (43/159; 27%) (Z score P=0.59). There was also no significant association between SA and abnormal EAE whether TC was the only presenting symptom (χ, P=0.7) or one of the reported symptoms (χ, P=0.10). None of the 6/27 had abnormal EAE. CONCLUSION Although TC is often considered a possible GERD-related symptom, we found a low probability of objective association. TC is not likely to be the only presenting symptom, and if it happens, it is unlikely to be associated with GERD. Perhaps, TC should not be considered as a GERD symptom, even as an atypical one.
Collapse
|
9
|
Bognár L, Vereczkei A, Papp A, Jancsó G, Horváth ÖP. Gastroesophageal Reflux Disease Might Induce Certain-Supposedly Adaptive-Changes in the Esophagus: A Hypothesis. Dig Dis Sci 2018; 63:2529-2535. [PMID: 29995182 DOI: 10.1007/s10620-018-5184-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 06/25/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND The increasing prevalence of GERD has become a major concern due to its major health and economic impacts. Beyond the typical unpleasant symptoms, reflux can also be the source of severe, potentially life-threatening complications, such as aspiration. AIM Our aim was to support our hypothesis that the human body may in some cases develop various protective mechanisms to prevent these conditions. METHODS Based on our experiences and review of the literature, we investigated the potential adaptive nature of seven reflux complications (hypertensive lower esophageal sphincter, achalasia, hypertensive upper esophageal sphincter, Zenker's diverticulum, Schatzki's ring, esophageal web, and Barrett's esophagus). RESULTS Patients with progressive GERD may develop diverse structural and functional esophageal changes that narrow the lumen of the esophagus and therefore reduce the risk of regurgitation and protect the upper aerodigestive tract from aspiration. The functional changes (hypertensive lower esophageal sphincter, achalasia, hypertensive upper esophageal sphincter) seem to be adaptive reactions aimed at easing the unpleasant symptoms and reducing acid regurgitation. The structural changes (Schatzki's ring, esophageal web) result in very similar outcomes, but we consider these are rather secondary consequences and not real adaptive mechanisms. Barrett's esophagus is a special form of adaptive protection. In these cases, patients report significant relief of their previous heartburn as Barrett's esophagus develops because of the replacement of the normal squamous epithelium of the esophagus by acid-resistant metaplastic epithelium. CONCLUSION We believe that GERD may induce different self-protective reactions in the esophagus that result in reduced acid regurgitation or decreased reflux symptoms.
Collapse
Affiliation(s)
- Laura Bognár
- Department of Surgery, Clinical Center, University of Pécs, Medical School, 13 Ifjúság útja, Pecs, 7624, Hungary. .,Department of Surgical Research and Techniques, University of Pécs, Medical School, 12 Szigeti út, Pecs, 7624, Hungary.
| | - András Vereczkei
- Department of Surgery, Clinical Center, University of Pécs, Medical School, 13 Ifjúság útja, Pecs, 7624, Hungary
| | - András Papp
- Department of Surgery, Clinical Center, University of Pécs, Medical School, 13 Ifjúság útja, Pecs, 7624, Hungary
| | - Gábor Jancsó
- Department of Surgical Research and Techniques, University of Pécs, Medical School, 12 Szigeti út, Pecs, 7624, Hungary
| | - Örs Péter Horváth
- Department of Surgery, Clinical Center, University of Pécs, Medical School, 13 Ifjúság útja, Pecs, 7624, Hungary
| |
Collapse
|
10
|
Frazzoni L, Frazzoni M, de Bortoli N, Tolone S, Martinucci I, Fuccio L, Savarino V, Savarino E. Critical appraisal of Rome IV criteria: hypersensitive esophagus does belong to gastroesophageal reflux disease spectrum. Ann Gastroenterol 2018; 31:1-7. [PMID: 29333061 PMCID: PMC5759602 DOI: 10.20524/aog.2017.0199] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 09/17/2017] [Indexed: 12/12/2022] Open
Abstract
The Rome IV Committee introduced a major change in the classification of functional gastrointestinal disorders, proposing a more restrictive definition of gastroesophageal reflux disease (GERD). It was suggested that hypersensitive esophagus (HE) may sit more firmly within the functional realm. It was suggested that GERD diagnosis should be based upon abnormal acid exposure time (AET) only, implying no advantage of impedance-pH over pH monitoring. Symptom association probability (SAP), symptom index (SI) and heartburn relief with proton pump inhibitor (PPI) therapy were regarded as unreliable, whereas a lack of response to PPI was considered as evidence of functional heartburn. These assumptions are contradicted by numerous studies showing the clinical relevance of weakly acidic refluxes and the diagnostic utility of SAP, SI and new impedance parameters, namely the post-reflux swallow-induced peristaltic wave (PSPW) index and the mean nocturnal baseline impedance (MNBI). The PSPW index and MNBI provide significant diagnostic advantage, particularly in patients with normal AET who can be classified as HE when both parameters are abnormal, even though SAP and SI are negative. Visceral pain modulators are recommended by the Rome IV Committee despite scanty evidence of efficacy, but a positive outcome with medical or surgical anti-reflux treatment has been reported by several studies of HE patients. Therefore, we believe that patients with endoscopy-negative heartburn should be investigated by means of impedance-pH monitoring with analysis of PSPW index and MNBI: such an approach provides accurate identification of HE cases, who remain, in our opinion, within the realm of GERD and should be treated accordingly.
Collapse
Affiliation(s)
- Leonardo Frazzoni
- Department of Medical and Surgical Sciences, University of Bologna (Leonardo Frazzoni, Lorenzo Fuccio), Italy
| | - Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Modena (Marzio Frazzoni), Italy
| | - Nicola de Bortoli
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa (Nicola de Bortoli, Irene Martinucci), Italy
| | - Salvatore Tolone
- General and Bariatric Surgery Unit, Department of Surgery, 2 University of Napoli (Salvatore Tolone), Italy
| | - Irene Martinucci
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa (Nicola de Bortoli, Irene Martinucci), Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, University of Bologna (Leonardo Frazzoni, Lorenzo Fuccio), Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genova (Vincenzo Savarino), Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova (Edoardo Savarino), Italy
| |
Collapse
|
11
|
Roman S, Gyawali CP, Savarino E, Yadlapati R, Zerbib F, Wu J, Vela M, Tutuian R, Tatum R, Sifrim D, Keller J, Fox M, Pandolfino JE, Bredenoord AJ. Ambulatory reflux monitoring for diagnosis of gastro-esophageal reflux disease: Update of the Porto consensus and recommendations from an international consensus group. Neurogastroenterol Motil 2017; 29:1-15. [PMID: 28370768 DOI: 10.1111/nmo.13067] [Citation(s) in RCA: 204] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 02/20/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND An international group of experts evaluated and revised recommendations for ambulatory reflux monitoring for the diagnosis of gastro-esophageal reflux disease (GERD). METHODS Literature search was focused on indications and technical recommendations for GERD testing and phenotypes definitions. Statements were proposed and discussed during several structured meetings. KEY RESULTS Reflux testing should be performed after cessation of acid suppressive medication in patients with a low likelihood of GERD. In this setting, testing can be either catheter-based or wireless pH-monitoring or pH-impedance monitoring. In patients with a high probability of GERD (esophagitis grade C and D, histology proven Barrett's mucosa >1 cm, peptic stricture, previous positive pH monitoring) and persistent symptoms, pH-impedance monitoring should be performed on treatment. Recommendations are provided for data acquisition and analysis. Esophageal acid exposure is considered as pathological if acid exposure time (AET) is greater than 6% on pH testing. Number of reflux episodes and baseline impedance are exploratory metrics that may complement AET. Positive symptom reflux association is defined as symptom index (SI) >50% or symptom association probability (SAP) >95%. A positive symptom-reflux association in the absence of pathological AET defines hypersensitivity to reflux. CONCLUSIONS AND INFERENCES The consensus group determined that grade C or D esophagitis, peptic stricture, histology proven Barrett's mucosa >1 cm, and esophageal acid exposure greater >6% are sufficient to define pathological GERD. Further testing should be considered when none of these criteria are fulfilled.
Collapse
Affiliation(s)
- S Roman
- Digestive Physiology, Hospices Civils de Lyon and Lyon I University, Inserm U1032, LabTAU, Lyon, France
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - E Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, Padua, Italy
| | - R Yadlapati
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - F Zerbib
- Department of Gastroenterology, Bordeaux University Hospital, and Université de Bordeaux, Bordeaux, France
| | - J Wu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - M Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - R Tutuian
- Division of Gastroenterology, University Clinics for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - R Tatum
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - D Sifrim
- Center for Digestive Diseases, Bart's and the London School and Dentistry, London, UK
| | - J Keller
- Department of Internal Medicine, Israelitic Hospital, University of Hamburg, Hamburg, Germany
| | - M Fox
- Department of Gastroenterology, Abdominal Center, St. Claraspital, Basel, Switzerland
| | - J E Pandolfino
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - A J Bredenoord
- Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | | |
Collapse
|
12
|
Frazzoni M, de Bortoli N, Frazzoni L, Tolone S, Savarino V, Savarino E. Impedance-pH Monitoring for Diagnosis of Reflux Disease: New Perspectives. Dig Dis Sci 2017; 62:1881-1889. [PMID: 28550489 DOI: 10.1007/s10620-017-4625-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 05/19/2017] [Indexed: 12/17/2022]
Abstract
Heartburn is the most specific symptom of gastroesophageal reflux disease (GERD). In clinical practice, heartburn relief by a proton pump inhibitor (PPI) trial does suffice to confirm GERD. However, an objective diagnosis of GERD is required before anti-reflux endoscopic or surgical interventions, independently from PPI response. Thus, since normal findings at upper endoscopy are detected in the majority of patients with heartburn, reflux monitoring is often required. When traditional catheter-based or wireless pH tests are used, reflux episodes are conventionally identified by pH drops below 4.0 units. Combined impedance-pH monitoring has the advantage to provide a comprehensive assessment of both physical and chemical properties of refluxate and the distinction between acid and weakly acidic refluxes, both proven to cause heartburn. Unfortunately, the conventional impedance-pH parameters, namely acid exposure time and number of reflux events, are characterized by suboptimal diagnostic sensitivity, and the reliability of symptom-reflux association indexes remains questionable. Therefore, novel impedance parameters, namely the post-reflux swallow-induced peristaltic wave (PSPW) index and the mean nocturnal baseline impedance (MNBI), have recently been proposed in order to achieve a better diagnostic yield. In fact, they proved to be highly accurate in distinguishing reflux-related from reflux-unrelated heartburn, off- as well as on-PPI therapy. Currently, manual review of impedance-pH tracings is needed because of the modest accuracy of available software tools for automated analysis. PSPW index and MNBI are highly applicable and reproducible, and their calculation requires a few additional minutes during the manual review of impedance-pH tracings. So far, we believe that PSPW index and MNBI are ready for prime time and should become part of the standard analysis of impedance-pH tracings for GERD diagnosis in patients with endoscopy-negative heartburn.
Collapse
Affiliation(s)
- Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Viale Giardini 1355, 41100, Modena, Italy.
| | - Nicola de Bortoli
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Leonardo Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Viale Giardini 1355, 41100, Modena, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Salvatore Tolone
- General and Bariatric Surgery Unit, Department of Surgery, 2nd University of Napoli, Naples, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padua, Italy
| |
Collapse
|
13
|
Naik RD, Vaezi MF. Recent advances in diagnostic testing for gastroesophageal reflux disease. Expert Rev Gastroenterol Hepatol 2017; 11:531-537. [PMID: 28317452 DOI: 10.1080/17474124.2017.1309286] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Gastroesophageal reflux disease (GERD) has a large economic burden with important complications that include esophagitis, Barrett's esophagus, and adenocarcinoma. Despite endoscopy, validated patient questionnaires, and traditional ambulatory pH monitoring, the diagnosis of GERD continues to be challenging. Areas covered: This review will explore the difficulties in diagnosing GERD with a focus on new developments, ranging from basic fundamental changes (histology and immunohistochemistry) to direct patient care (narrow-band imaging, impedance, and response to anti-reflux surgery). We searched PubMed using the noted keywords. We included data from full-text articles published in English. Further relevant articles were identified from the reference lists of review articles. Expert commentary: Important advances in novel parameters in intraluminal impedance monitoring such as baseline impedance monitoring has created some insight into alternative diagnostic strategies in GERD. Recent advances in endoscopic assessment of esophageal epithelial integrity via mucosal impedance measurement is questioning the paradigm of prolonged ambulatory testing for GERD. The future of reflux diagnosis may very well be without the need for currently employed technologies and could be as simple as assessing changes in epithelia integrity as a surrogate marker for GERD. However, future studies must validate such an approach.
Collapse
Affiliation(s)
- Rishi D Naik
- a Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Michael F Vaezi
- a Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders , Vanderbilt University Medical Center , Nashville , TN , USA
| |
Collapse
|
14
|
Frazzoni M, de Bortoli N, Frazzoni L, Furnari M, Martinucci I, Tolone S, Farioli A, Marchi S, Fuccio L, Savarino V, Savarino E. Impairment of chemical clearance and mucosal integrity distinguishes hypersensitive esophagus from functional heartburn. J Gastroenterol 2017; 52:444-451. [PMID: 27241210 DOI: 10.1007/s00535-016-1226-9] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 05/15/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hypersensitive esophagus (HE) is defined by endoscopy-negative heartburn with a normal acid exposure time but positive symptom association probability (SAP) and/or symptom index (SI) on impedance-pH monitoring, and proton pump inhibitor (PPI) responsiveness. Functional heartburn (FH) is distinguished by negative SAP/SI and PPI refractoriness. The clinical value of SAP and SI has been questioned. We aimed to investigate whether impairment of chemical clearance and of mucosal integrity, expressed by the postreflux swallow-induced peristaltic wave (PSPW) index and the mean nocturnal baseline impedance (MNBI), characterize HE independently of SAP and SI. METHODS Impedance-pH tracings from PPI-responsive endoscopy-negative patients, 125 with nonerosive reflux disease and 108 with HE, distinguished by an abnormal and a normal acid exposure time, and from 70 patients with FH were retrospectively selected and blindly reviewed. RESULTS The mean PSPW index and MNBI were significantly lower in nonerosive reflux disease (30 %, 1378 Ω) than in HE (51 %; 2274 Ω) and in both of them as compared with FH (76 %; 3445 Ω) (P = 0.0001). Both the PSPW index (adjusted odds ratio 0.863, P = 0.001) and the MNBI (adjusted odds ratio 0.998, P = 0.001) were independent predictors of HE; with their combined assessment, the area under the curve on receiver operating characteristic analysis was 0.957. SAP and/or SI was positive in 67 of the 108 HE patients (62 %), whereas the PSPW index and/or MNBI was abnormal in 99 of the 108 HE patients (92 %; P < 0.0001). CONCLUSIONS HE is characterized by impairment of chemical clearance and mucosal integrity, which explains the increased reflux perception. When SAP and SI afford uncertain results, the PSPW index and MNBI should be analyzed.
Collapse
Affiliation(s)
- Marzio Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Viale Giardini, 1355, 41100, Modena, Italy.
| | - Nicola de Bortoli
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Manuele Furnari
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Irene Martinucci
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Salvatore Tolone
- General and Bariatric Surgery Unit, Department of Surgery, 2nd University of Napoli, Naples, Italy
| | - Andrea Farioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Santino Marchi
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| |
Collapse
|
15
|
Frazzoni M, de Bortoli N, Frazzoni L, Tolone S, Furnari M, Martinucci I, Mirante VG, Marchi S, Savarino V, Savarino E. The added diagnostic value of postreflux swallow-induced peristaltic wave index and nocturnal baseline impedance in refractory reflux disease studied with on-therapy impedance-pH monitoring. Neurogastroenterol Motil 2017; 29. [PMID: 27620303 DOI: 10.1111/nmo.12947] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 08/23/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND On-therapy impedance-pH monitoring in proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD) yielded conflicting results. We aimed to assess the diagnostic value of postreflux swallow-induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI) in PPI-refractory heartburn. METHODS On-therapy impedance-pH tracings from 189 consecutive patients with PPI-refractory heartburn were blindly reviewed. Patients were subdivided into refractory reflux esophagitis (RRE), healed reflux esophagitis (HRE), non-erosive reflux disease (NERD), and functional heartburn (FH) according to endoscopic and conventional impedance-pH findings. The diagnostic accuracy of PSPW index and MNBI in separating NERD from FH was assessed with receiver-operating-characteristic (ROC) analysis. Objectively documented persistent reflux remission at 3-year follow-up in 53 patients who underwent laparoscopic fundoplication served to evaluate PSPW index and MNBI as independent predictors of PPI-refractory GERD confirmed by positive surgical outcome. KEY RESULTS Median PSPW index and MNBI values were significantly lower in 39 RRE (16%; 1145 Ω) than in 41 HRE (25%; 1741 Ω) and in 68 NERD (29%; 2374 Ω) patients, and in all three GERD subgroups compared to 41 FH cases (67%; 3488 Ω) (P<.008). At ROC analysis, comparing NERD to FH the area under the curve was 0.886 with PSPW index and 0.677 with MNBI (P=.005). PSPW index was an independent predictor of PPI-refractory GERD (odds ratio 0.6983, P=.012). CONCLUSIONS & INFERENCES At on-therapy impedance-pH monitoring, PSPW index and MNBI efficiently distinguish PPI-refractory NERD from FH. The PSPW index represents an independent predictor of PPI-refractory GERD.
Collapse
Affiliation(s)
- M Frazzoni
- Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - N de Bortoli
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - L Frazzoni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - S Tolone
- General and Bariatric Surgery Unit, Department of Surgery, 2nd University of Napoli, Naples, Italy
| | - M Furnari
- Gastroenterology Unit, Department of Internal Medicine, University of Genova, Genova, Italy
| | - I Martinucci
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - V G Mirante
- Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - S Marchi
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - V Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genova, Genova, Italy
| | - E Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| |
Collapse
|
16
|
Dulery C, Lechot A, Roman S, Bastier PL, Stoll D, de Gabory L, Zerbib F. A study with pharyngeal and esophageal 24-hour pH-impedance monitoring in patients with laryngopharyngeal symptoms refractory to proton pump inhibitors. Neurogastroenterol Motil 2017; 29. [PMID: 27424517 DOI: 10.1111/nmo.12909] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/22/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND The role of gastroesophageal reflux in chronic laryngeal symptoms is difficult to establish. The aim of this study was to characterize pharyngeal and esophageal pH-impedance reflux patterns in a group of patients with suspected laryngopharyngeal reflux and to determine predictive factors of response to proton pump inhibitors. METHODS Patients with chronic pharyngolaryngeal symptoms were evaluated with a symptom score questionnaire, laryngoscopy, and 24-hour pharyngeal and esophageal pH-impedance monitoring at baseline and after 8-week treatment with esomeprazole 40 mg b.i.d. Response to treatment was defined by a diminution of more than 50% of the score for the primary symptom. Reflux patterns and baseline impedance values were compared to those obtained in 46 healthy subjects. KEY RESULTS Twenty-four patients were included (17 women, median age 54 years), all previously refractory to antisecretory therapy. Symptom scores were 46 (32-62) and 40 (27-76) off and on therapy, respectively (P=.1). There was no significant difference between patients and controls for pH-impedance reflux parameters and baseline values off and on therapy in distal and proximal esophagus and in the pharynx. Median numbers of pharyngeal reflux were 0 and 0 off and on therapy, respectively. Only two patients were responders to treatment, both with excessive distal reflux but no pharyngeal reflux. Only one patient had abnormal pharyngeal reflux but did not respond to proton pump inhibitors. CONCLUSIONS Patients with suspected laryngopharyngeal reflux refractory to therapy do not exhibit abnormal pharyngeal or esophageal pH-impedance reflux. In these patients, laryngopharyngeal reflux is unlikely.
Collapse
Affiliation(s)
- C Dulery
- Gastroenterology Department, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - A Lechot
- ENT Department, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - S Roman
- LabTAU, Inserm U1032, Univ Lyon, Lyon, France.,Digestive Physiology Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - P-L Bastier
- ENT Department, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - D Stoll
- ENT Department, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - L de Gabory
- ENT Department, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - F Zerbib
- Gastroenterology Department, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| |
Collapse
|
17
|
Emilsson ÖI, Benediktsdóttir B, Ólafsson Í, Cook E, Júlíusson S, Berg S, Nordang L, Björnsson ES, Guðlaugsdóttir S, Guðmundsdóttir AS, Janson C, Gislason T. Definition of nocturnal gastroesophageal reflux for studies on respiratory diseases. Scand J Gastroenterol 2016; 51:524-30. [PMID: 26825677 DOI: 10.3109/00365521.2015.1124284] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Nocturnal gastroesophageal reflux (nGER) has been associated with respiratory diseases. Our aim was to study a questionnaire method to identify nGER subjects with respiratory involvement in a general population. MATERIAL AND METHODS A subgroup of Icelandic participants in the European Community Respiratory Health Survey III (ECRHS III) reporting symptoms of nGER (n = 48) as well as age and gender paired controls (n = 42) were studied further by a structured interview, questionnaires, laryngeal fibrescopy, and exhaled breath condensate. A subgroup underwent 24-h oesophageal pH impedance (24-h MII-pH) measurements. Symptoms of nGER were assessed with a modified version of the reflux disease questionnaire (RDQ), where symptoms were divided into daytime and nocturnal. A report of nGER both at baseline and at follow-up was defined as persistent nGER. RESULTS Participants reporting persistent nGER had significantly more signs of laryngopharyngeal reflux according to the reflux finding score than those without nGER (Mean ± SD: 5.1 ± 2.3 vs. 3.9 ± 2.2, p = 0.02). Of the 16 persistent nGER subjects that underwent 24-h MII-pH, 11 had abnormal gastroesophageal reflux, but none of three control subjects (69% vs. 0%). Pepsin was more commonly found in exhaled breath condensate in the nGER group (67% vs. 45%, p = 0.04). CONCLUSIONS Participants with nGER symptoms at least once a month, reported on two occasions, had a high level of positive 24-h MII-pH measurements, laryngeal inflammation and pepsin in exhaled breath condensate. This nGER definition identified a representable group for studies on nGER and respiratory diseases in a general population.
Collapse
Affiliation(s)
- Össur Ingi Emilsson
- a Faculty of Medicine, University of Iceland , Reykjavik , Iceland ;,b Department of Respiratory Medicine and Sleep , Landspitali University Hospital , Reykjavik , Iceland ;,c Department of Respiratory , Allergy and Sleep Research, Uppsala University , Uppsala , Sweden
| | - Bryndís Benediktsdóttir
- a Faculty of Medicine, University of Iceland , Reykjavik , Iceland ;,b Department of Respiratory Medicine and Sleep , Landspitali University Hospital , Reykjavik , Iceland
| | - Ísleifur Ólafsson
- d Department of Clinical Biochemistry , Landspitali University Hospital , Reykjavik , Iceland
| | - Elizabeth Cook
- d Department of Clinical Biochemistry , Landspitali University Hospital , Reykjavik , Iceland
| | - Sigurður Júlíusson
- a Faculty of Medicine, University of Iceland , Reykjavik , Iceland ;,e Department of Ear, Nose and Throat , Landspitali University Hospital , Reykjavik , Iceland
| | - Sören Berg
- f Department of Otolaryngology and Head and Neck Surgery , Lund University , Lund , Sweden
| | - Leif Nordang
- g Department of Surgical Sciences , Otorhinolaryngology and Head and Neck Surgery, Uppsala University , Uppsala , Sweden
| | - Einar Stefán Björnsson
- a Faculty of Medicine, University of Iceland , Reykjavik , Iceland ;,h Department of Gastroenterology , Landspitali University Hospital , Reykjavik , Iceland
| | - Sunna Guðlaugsdóttir
- h Department of Gastroenterology , Landspitali University Hospital , Reykjavik , Iceland
| | | | - Christer Janson
- c Department of Respiratory , Allergy and Sleep Research, Uppsala University , Uppsala , Sweden
| | - Thorarinn Gislason
- a Faculty of Medicine, University of Iceland , Reykjavik , Iceland ;,b Department of Respiratory Medicine and Sleep , Landspitali University Hospital , Reykjavik , Iceland
| |
Collapse
|
18
|
Sakin YS, Vardar R, Sezgin B, Cetin ZE, Alev Y, Yildirim E, Kirazli T, Bor S. The diagnostic value of 24-hour ambulatory intraesophageal pH-impedance in patients with laryngopharyngeal reflux symptoms comparable with typical symptoms. United European Gastroenterol J 2016; 5:632-640. [PMID: 28815026 DOI: 10.1177/2050640616675040] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 09/25/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The diagnosis of laryngopharyngeal reflux is currently based on a combination of the patient history of multichannel intraluminal impedance and ambulatory pH (MII-pH); however, none of these findings alone is specific for the diagnosis of laryngopharyngeal reflux. We aimed to compare the baseline characteristics and esophageal baseline impedance values between patients with and without laryngopharyngeal reflux symptoms. METHODS We retrospectively analyzed data from two groups of patients with laryngopharyngeal reflux according to their reflux finding score (RFS) as scored by ENTs. Control patients were nonerosive reflux disease patients without laryngopharyngeal reflux. All MII-pH parameters and baseline impedance were analyzed from six levels and the proximal and distal baseline impedance and the ratio of the proximal to distal baseline impedance levels was calculated. RESULTS Altogether 123 patients with laryngopharyngeal reflux and 49 control patients were included. A total of 81 of 123 patients had RFS ≥ 7, and 42 of 123 patients had RFS < 7. Baseline impedance analysis showed that patients with laryngopharyngeal reflux symptoms had significantly lower proximal baseline impedance values (1997 ± 51 vs 2245 ± 109, p < 0.05) than the control group. Additionally, patients with laryngopharyngeal reflux symptoms had a significantly lower proximal-to-distal ratio (1.28 ± 0.05 vs 1.53 ± 0.09, p < 0.05). In the subgroup analysis, patients with RFS < 7 were found to have a significantly lower acid exposure time than either the patients with RFS ≥ 7 (3.85 ± 0.65 vs 8.2 ± 1.52, p < 0.05) or the control group (3.85 ± 0.65 vs 6.1 ± 0.81, p < 0.05). Additionally, patients with RFS ≥ 7 had significantly lower proximal baseline impedance levels than the control group (1970 ± 63 vs 2245 ± 109, p < 0.05). CONCLUSIONS Patients with pathologic laryngopharyngeal reflux symptom scores had lower proximal baseline impedance levels and lower proximal-to-distal ratios, which may reflect the proximal mucosal noxious effect of the refluxate. These results may indicate that laryngopharyngeal reflux symptoms may be due to chronic acid exposure in the proximal segments of the esophagus, and the proximal-to-distal ratio may be used as a new metric for diagnosis.
Collapse
Affiliation(s)
- Yusuf S Sakin
- Department of Gastroenterology, Gulhane Training and Research Hospital, Ankara, Turkey
| | - Rukiye Vardar
- Department of Gastroenterology, Ege University, Izmir, Turkey
| | - Baha Sezgin
- Department of Ear-Nose-Throat (ENT), Ege University, Izmir, Turkey
| | | | - Yasemin Alev
- Department of Gastroenterology, Ege University, Izmir, Turkey
| | - Esra Yildirim
- Department of Gastroenterology, Ege University, Izmir, Turkey
| | - Tayfun Kirazli
- Department of Ear-Nose-Throat (ENT), Ege University, Izmir, Turkey
| | - Serhat Bor
- Department of Gastroenterology, Ege University, Izmir, Turkey
| |
Collapse
|
19
|
Ang D, How CH, Ang TL. Persistent gastro-oesophageal reflux symptoms despite proton pump inhibitor therapy. Singapore Med J 2016; 57:546-551. [PMID: 27779277 PMCID: PMC5075954 DOI: 10.11622/smedj.2016167] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
About one-third of patients with suspected gastro-oesophageal reflux disease (GERD) do not respond symptomatically to proton pump inhibitors (PPIs). Many of these patients do not suffer from GERD, but may have underlying functional heartburn or atypical chest pain. Other causes of failure to respond to PPIs include inadequate acid suppression, non-acid reflux, oesophageal hypersensitivity, oesophageal dysmotility and psychological comorbidities. Functional oesophageal tests can exclude cardiac and structural causes, as well as help to confi rm or exclude GERD. The use of PPIs should only be continued in the presence of acid reflux or oesophageal hypersensitivity for acid reflux-related events that is proven on functional oesophageal tests.
Collapse
Affiliation(s)
- Daphne Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Choon How How
- Care and Health Integration, Changi General Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| |
Collapse
|
20
|
Abstract
For patients with gastroesophageal reflux disease (GERD) who suffer from severe symptoms despite adequate medical therapy, interventional procedures are the only option for improving symptoms and thus the quality of life. In the clinical practice it is decisive if a hiatal hernia (HH) is present or not and whether it is larger or smaller than 2-3 cm. Patients who have a HH > 2-3 cm should undergo laparoscopic fundoplication with hiatal hernia repair. Patients with a larger HH are no longer eligible for endoscopic therapy as closure of the HH is not endoscopically possible. With the new laparoscopic methods (e.g. LINX and electrical stimulation) HH closure is theoretically possible but sufficient data is lacking. Furthermore, if a hiatal closure is additionally carried out the actual advantages of these methods are partly lost. Currently, outside of clinical trials only laparoscopic fundoplication can be recommended for patients with GERD and HH, because convincing long-term data are only available for this method. It seems that in clinical practice it is not so important what type of fundoplication is performed, more important seems to be the experience of the surgeon with the technique.
Collapse
|
21
|
|
22
|
Scarpellini E, Ang D, Pauwels A, De Santis A, Vanuytsel T, Tack J. Management of refractory typical GERD symptoms. Nat Rev Gastroenterol Hepatol 2016; 13:281-94. [PMID: 27075264 DOI: 10.1038/nrgastro.2016.50] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The management of patients with refractory GERD (rGERD) is a major clinical challenge for gastroenterologists. In up to 30% of patients with typical GERD symptoms (heartburn and/or regurgitation), acid-suppressive therapy does not provide clinical benefit. In this Review, we discuss the current management algorithm for GERD and the features and management of patients who do not respond to treatment (such as those individuals with an incorrect diagnosis of GERD, inadequate PPI intake, persisting acid reflux and persisting weakly acidic reflux). Symptom response to existing surgical techniques, novel antireflux procedures, and the value of add-on medical therapies (including prokinetics and reflux inhibitors) for rGERD symptoms are discussed. Pharmaceutical agents targeting oesophageal sensitivity, a condition that can contribute to symptom generation in rGERD, are also discussed. Finally, on the basis of available published data and our expert opinion, we present an outline of a current, usable algorithm for management of patients with rGERD that considers the timing and diagnostic use of pH-impedance monitoring on or off PPI, additional diagnostic tests, the clinical use of baclofen and the use of add-on neuromodulators (tricyclic agents and selective serotonin reuptake inhibitors).
Collapse
Affiliation(s)
- Emidio Scarpellini
- Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium.,Division Gastroenterology, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Daphne Ang
- Division of Gastroenterology, Changi General Hospital, 2 Simei Street 3, Singapore 529889
| | - Ans Pauwels
- Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Adriano De Santis
- Division of Gastroenterology, Changi General Hospital, 2 Simei Street 3, Singapore 529889
| | - Tim Vanuytsel
- Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Jan Tack
- Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| |
Collapse
|
23
|
|
24
|
Pauwels A. Dental erosions and other extra-oesophageal symptoms of gastro-oesophageal reflux disease: Evidence, treatment response and areas of uncertainty. United European Gastroenterol J 2015; 3:166-70. [PMID: 25922676 DOI: 10.1177/2050640615575972] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 02/11/2015] [Indexed: 12/19/2022] Open
Abstract
Extra-oesophageal symptoms of gastro-oesophageal reflux disease (GORD) are often studied, but remain a subject of debate. It has been clearly shown that there is a relationship between the extra-oesophageal symptoms chronic cough, asthma, laryngitis and dental erosion and GORD. Literature is abundant concerning reflux-related cough and reflux-related asthma, but much less is known about reflux-related dental erosions. The prevalence of dental erosion in GORD and vice versa, the prevalence of GORD in patients with dental erosion is high but the exact mechanism of reflux-induced tooth wear erosion is still under review.
Collapse
|
25
|
Perry KA, Pham TH, Spechler SJ, Hunter JG, Melvin WS, Velanovich V. 2014 SSAT State-of-the-Art Conference: advances in diagnosis and management of gastroesophageal reflux disease. J Gastrointest Surg 2015; 19:458-66. [PMID: 25519085 DOI: 10.1007/s11605-014-2724-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 12/04/2014] [Indexed: 01/31/2023]
Abstract
Gastroesophageal reflux disease affects at least 10 % of people in Western societies and produces troublesome symptoms and impairs patients' quality of life. The effective management of GERD is imperative as the diagnosis places a significant cost burden on the United States healthcare system with annual direct cost estimates exceeding 9 billion dollars annually. While effective for many patients, 30-40 % of patients receiving medical therapy with proton pump inhibitors experience troublesome breakthrough symptoms, and recent evidence suggests that this therapy subjects patients to increased risk of complications. Given the high cost of PPI therapy, patients are showing a decrease in willingness to continue with a therapy that provides incomplete relief; however, due to inconsistent outcomes and concern for procedure-related side effects following surgery, only 1 % of the GERD population undergoes anti-reflux surgery annually. The discrepancy between the number of patients who experience suboptimal medical treatment and the number considered for anti-reflux surgery indicates a large therapeutic gap in the management of GERD. The objective of the SSAT State-of-the-Art Conference was to examine technologic advances in the diagnosis and treatment of GERD and to evaluate the ways in which we assess the outcomes of these therapies to provide optimal patient care.
Collapse
Affiliation(s)
- Kyle A Perry
- Division of General and Gastrointestinal Surgery, The Ohio State University Medical Center, N729 Doan Hall, 410 W. 10th Avenue, Columbus, OH, 43210, USA,
| | | | | | | | | | | |
Collapse
|
26
|
Desjardin M, Roman S, des Varannes SB, Gourcerol G, Coffin B, Ropert A, Mion F, Zerbib F. Pharyngeal pH alone is not reliable for the detection of pharyngeal reflux events: A study with oesophageal and pharyngeal pH-impedance monitoring. United European Gastroenterol J 2014; 1:438-44. [PMID: 24917995 DOI: 10.1177/2050640613513016] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 10/16/2013] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Pharyngeal pH probes and pH-impedance catheters have been developed for the diagnosis of laryngo-pharyngeal reflux. OBJECTIVE To determine the reliability of pharyngeal pH alone for the detection of pharyngeal reflux events. METHODS 24-h pH-impedance recordings performed in 45 healthy subjects with a bifurcated probe for detection of pharyngeal and oesophageal reflux events were reviewed. Pharyngeal pH drops to below 4 and 5 were analysed for the simultaneous occurrence of pharyngeal reflux, gastro-oesophageal reflux, and swallows, according to impedance patterns. RESULTS Only 7.0% of pharyngeal pH drops to below 5 identified with impedance corresponded to pharyngeal reflux, while 92.6% were related to swallows and 10.2 and 13.3% were associated with proximal and distal gastro-oesophageal reflux events, respectively. Of pharyngeal pH drops to below 4, 13.2% were related to pharyngeal reflux, 87.5% were related to swallows, and 18.1 and 21.5% were associated with proximal and distal gastro-oesophageal reflux events, respectively. CONCLUSIONS This study demonstrates that pharyngeal pH alone is not reliable for the detection of pharyngeal reflux and that adding distal oesophageal pH analysis is not helpful. The only reliable analysis should take into account impedance patterns demonstrating the presence of pharyngeal reflux event preceded by a distal and proximal reflux event within the oesophagus.
Collapse
Affiliation(s)
- Marie Desjardin
- CHU Bordeaux, Bordeaux, France ; Bordeaux Segalen University, Bordeaux, France
| | - Sabine Roman
- Hospices Civils de Lyon, Lyon, France ; Claude Bernard Lyon 1 University, Lyon, France
| | | | | | - Benoit Coffin
- Assistance Publique-Hôpitaux de Paris, Colombes, France ; INSERM U987, Boulogne Billancourt, France
| | | | - François Mion
- Hospices Civils de Lyon, Lyon, France ; Claude Bernard Lyon 1 University, Lyon, France
| | - Frank Zerbib
- CHU Bordeaux, Bordeaux, France ; Bordeaux Segalen University, Bordeaux, France
| |
Collapse
|
27
|
Martinucci I, de Bortoli N, Savarino E, Piaggi P, Bellini M, Antonelli A, Savarino V, Frazzoni M, Marchi S. Esophageal baseline impedance levels in patients with pathophysiological characteristics of functional heartburn. Neurogastroenterol Motil 2014; 26:546-55. [PMID: 24433456 DOI: 10.1111/nmo.12299] [Citation(s) in RCA: 155] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 12/06/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recently, it has been suggested that low esophageal basal impedance may reflect impaired mucosal integrity and increased acid sensitivity. We aimed to compare baseline impedance levels in patients with heartburn and pathophysiological characteristics related to functional heartburn (FH) divided into two groups on the basis of symptom relief after proton pump inhibitors (PPIs). METHODS Patients with heartburn and negative endoscopy were treated with esomeprazole or pantoprazole 40 mg daily for 8 weeks. According to MII-pH (off therapy) analysis, patients with normal acid exposure time (AET), normal reflux number, and lack of association between symptoms and refluxes were selected; of whom 30 patients with a symptom relief higher than 50% after PPIs composed Group A, and 30 patients, matched for sex and age, without symptom relief composed Group B. A group of 20 healthy volunteers (HVs) was enrolled. For each patient and HV, we evaluated the baseline impedance levels at channel 3, during the overnight rest, at three different times. KEY RESULTS Group A (vs Group B) showed an increase in the following parameters: mean AET (1.4 ± 0.8% vs 0.5 ± 0.6%), mean reflux number (30.4 ± 8.7 vs 24 ± 6.9), proximal reflux number (11.1 ± 5.2 vs 8.2 ± 3.6), acid reflux number (17.9 ± 6.1 vs 10.7 ± 6.9). Baseline impedance levels were lower in Group A than in Group B and in HVs (p < 0.001). CONCLUSIONS & INFERENCES Evaluating baseline impedance levels in patients with heartburn and normal AET could achieve a better understanding of pathophysiology in reflux disease patients, and could improve the distinction between FH and hypersensitive esophagus.
Collapse
Affiliation(s)
- I Martinucci
- Division of Gastroenterology, University of Pisa, Pisa, Italy
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Puesta al día en el reflujo gastroesofágico. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 37:73-82. [DOI: 10.1016/j.gastrohep.2013.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 11/17/2013] [Accepted: 11/18/2013] [Indexed: 02/08/2023]
|
29
|
Martinucci I, de Bortoli N, Savarino E, Nacci A, Romeo SO, Bellini M, Savarino V, Fattori B, Marchi S. Optimal treatment of laryngopharyngeal reflux disease. Ther Adv Chronic Dis 2013; 4:287-301. [PMID: 24179671 DOI: 10.1177/2040622313503485] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Laryngopharyngeal reflux is defined as the reflux of gastric content into larynx and pharynx. A large number of data suggest the growing prevalence of laryngopharyngeal symptoms in patients with gastroesophageal reflux disease. However, laryngopharyngeal reflux is a multifactorial syndrome and gastroesophageal reflux disease is not the only cause involved in its pathogenesis. Current critical issues in diagnosing laryngopharyngeal reflux are many nonspecific laryngeal symptoms and signs, and poor sensitivity and specificity of all currently available diagnostic tests. Although it is a pragmatic clinical strategy to start with empiric trials of proton pump inhibitors, many patients with suspected laryngopharyngeal reflux have persistent symptoms despite maximal acid suppression therapy. Overall, there are scant conflicting results to assess the effect of reflux treatments (including dietary and lifestyle modification, medical treatment, antireflux surgery) on laryngopharyngeal reflux. The present review is aimed at critically discussing the current treatment options in patients with laryngopharyngeal reflux, and provides a perspective on the development of new therapies.
Collapse
|
30
|
Bonavina L, Saino G, Lipham JC, Demeester TR. LINX(®) Reflux Management System in chronic gastroesophageal reflux: a novel effective technology for restoring the natural barrier to reflux. Therap Adv Gastroenterol 2013; 6:261-8. [PMID: 23814607 PMCID: PMC3667475 DOI: 10.1177/1756283x13486311] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) results from incompetency of the lower esophageal sphincter that allows the contents of the stomach to reflux into the esophagus, the airways, and the mouth. The disease affects about 10% of the western population and has a profound negative impact on quality of life. The majority of patients are successfully treated with proton-pump inhibitors, but up to 40% have incomplete relief of symptoms even after dose adjustment. The laparoscopic Nissen fundoplication represents the surgical gold standard, but is largely underused because of the level of technical difficulty and the prevalence of side effects. These factors have contributed to the propensity of patients to continue with medical therapy despite inadequate symptom control and complications of the disease. As a consequence, a significant 'therapy gap' in the treatment of GERD remains evident in current clinical practice. The LINX(®) Reflux Management System (Torax Medical, St. Paul, MN, USA) is designed to provide a permanent solution to GERD by augmenting the sphincter barrier with a standardized, reproducible laparoscopic procedure that does not alter gastric anatomy and is easily reversible. Two single-group trials confirmed that a magnetic device designed to augment the lower esophageal sphincter can be safely and effectively implanted using a standard laparoscopic approach. The device decreased esophageal acid exposure, improved reflux symptoms and quality of life, and allowed cessation of proton-pump inhibitors in the majority of patients.
Collapse
Affiliation(s)
- Luigi Bonavina
- Division of General Surgery, Department of Biomedical Sciences for Health, University of Milano School of Medicine, via Morandi 30, 20097 San Donato Milanese, Milan, Italy
| | | | | | | |
Collapse
|