The influence of psychological factors on the outcomes of laparoscopic Nissen fundoplication

Postoperative Gastrointestinal Complaints After Laparoscopic Nissen Fundoplication

PURPOSE

To investigate the postoperative gastrointestinal complaints and their effects on the satisfaction level of patients after laparoscopic Nissen fundoplication (LNF).

MATERIALS AND METHODS

Over a 7-year period, 553 patients who underwent "floppy" LNF were evaluated for preoperative and postoperative complaints. For this purpose, a set of questions derived from gastroesophageal reflux disease-health-related quality-of-life questionnaire (GERD-HRQL) was used. A P-value of <0.05 was considered to show a statistically significant result.

RESULTS

The present study included 215 patients with a mean follow-up of 60 months. Reflux-related symptoms [regurgitation (17.7%), heartburn (17.2%), and vomiting (3.7%)] and nonspecific symptoms [bloating (50.2%), abdominal pain (15.3%), and belching (27%)] showed a significant decrease (P<0.001) after the surgery. Inability to belch (25.1%) and early satiety (29.3%) were the newly emerged symptoms. The percentage of patients with flatulence increased from 23.3% to 38.1% after LNF. There was no significant difference for dysphagia (25.6%) and diarrhea (15.3%) in the postoperative period. Of the patients, 15.3% had recurrent preoperative complaints and 9.8% were using drugs for that condition. Satisfaction level and preference for surgery were 82.8% and 91.6%, respectively. There was no significant difference in GERD-HRQL score according to body mass index.

CONCLUSIONS

This is the first study in which postoperative reflux-related and nonspecific gastrointestinal complaints are analyzed together for a long follow-up period. We found a significant decrease in many reflux-related and nonspecific symptoms. Although some disturbing complaints like inability to belch, early satiety, and flatulence emerged, the preference for surgery did not change.

Proton pump inhibitor-refractory gastroesophageal reflux disease: challenges and solutions

A significant percentage of patients with gastroesophageal reflux disease (GERD) will not respond to proton pump inhibitor (PPI) therapy. The causes of PPI-refractory GERD are numerous and diverse, and include adherence, persistent acid, functional disorders, nonacid reflux, and PPI bioavailability. The evaluation should start with a symptom assessment and may progress to imaging, endoscopy, and monitoring of esophageal pH, impedance, and bilirubin. There are a variety of pharmacologic and procedural interventions that should be selected based on the underlying mechanism of PPI failure. Pharmacologic treatments can include antacids, prokinetics, alginates, bile acid binders, reflux inhibitors, and antidepressants. Procedural options include laparoscopic fundoplication and LINX as well as endoscopic procedures, such as transoral incisionless fundoplication and Stretta. Several alternative and complementary treatments of possible benefit also exist.

Do preoperative depressive symptoms predict quality of life after laparoscopic cholecystectomy: A longitudinal prospective study

OBJECTIVE

The impact of preoperative depressive symptoms on quality of life (QOL) after laparoscopic cholecystectomy (LC) remains unclear. The purpose of this study was to develop a benchmark for capturing the burden of depressive symptoms on QOL after LC and for supporting evidence-based clinical interventions for remediating these effects.

METHODS

Patients diagnosed with depressive symptoms (Beck Depression Inventory score > 13) after LC (n = 336) were classified into a depressive symptoms group. Propensity score matching was then used to match them with 336 patients in a non-depressive symptoms group for all potential confounding factors. All patients completed the 36-item Short Form Health Survey (SF-36) and the Gastrointestinal Quality of Life Index (GIQLI) at baseline and at 2 years postoperatively. The 95% confidence intervals (CIs) for differences in responsiveness estimates were derived by bootstrap estimation.

RESULTS

The GIQLI results revealed that the non-depressive symptoms group had relatively stronger responses for emotional impairment (4.10, 95% CI 2.81 to 5.39) and social impairment (4.06, 95% CI 2.65 to 5.46) in comparison with the depressive symptoms group. In the SF-36, the non-depressive symptoms group also had stronger responses for role emotional (12.63, 95% CI 10.73 to 14.54), social functioning (11.25, 95% CI 9.85 to 12.65), vitality (3.81, 95% CI 2.82 to 4.81), mental health (11.97, 95% CI 10.36 to 13.56) and general health (3.84, 95% CI 2.95 to 4.75).

CONCLUSIONS

Depressive symptoms complicate the management of LC patients and are associated with poorer outcomes. Because depressive symptoms are very common, further studies are needed to evaluate integrated and comprehensive approaches for assessing and treating these symptoms.

Psychological modulation in patients surgically intervened for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) has been related with certain psychological dimensions. The influence of mood, emotional intelligence, and perceived quality of life on clinical symptoms and outcome of antireflux surgery was evaluated in GERD patients with and without hiatal hernia. The study included 61 patients who were diagnosed with GERD between 2003 and 2008: 16 of them without hiatal hernia (group A) and 45 of them with hiatal hernia (group B). All of these patients had undergone laparoscopic antireflux surgery. Patients were clinically examined and evaluated with the following instruments: Short Form (SF)-36 Health Survey, Gastrointestinal Quality of Life Index, Hospital Anxiety and Depression (HAD) Scale, and Trait Meta-Mood Scale (TMMS)-24. Proportions were compared by using the chi-squared test; averages were compared by using the Student's t-test (with Bonferroni's correction). In general, our patients intervened for GERD showed results lower than normal or close to the lower limit of normal in the administered tests. Patients in the group without hernia were younger (P < 0.001) and with lower American Society of Anaesthesiologists risk. They showed higher scores in the SF-36 dimensions: Physical Functioning, Physical Role and Emotional Role, and lower scores in the Social Role (P < 0.001). They showed lower scores in the Emotional dimension of Gastrointestinal Quality of Life Index (P = 0.0068) and worse results in the Hospital Anxiety and Depression subscales of Anxiety (P < 0.001) and Depression (not significant). Men in the group without hernia showed higher scores than men in the group with hernia in the TMMS subscales corresponding to Emotional Clarity and Emotional Repair (P < 0.001). Women in the group with hernia showed higher scores than women in the group without hernia regarding Emotional Clarity (P = 0.0012). GERD patients showed poor results in all the tests, and patients without hiatal hernia compared with patients with hernia showed higher levels of anxiety, which interfered with their social life. Moreover, they showed lower tolerance to stress and higher frustration, fear, and worry. On the basis of such unfavorable phychoemotional results observed with GERD patients (especially those without hernia) in the different tests, we propose that improving our knowledge of the psychological profile of GERD patients - particularly those without hiatal hernia - could help in designing individualized medical and psychological therapies and increase success rates.

Somatization and somatic symptom presentation in cancer: a neglected area

Abstract The recognition of somatization process in cancer patients is a challenging and neglected area, for the extreme difficulty in differentiating and assessing the psycho(patho)logical components from those biologically determined and related to cancer and cancer treatment, as well as for the scarce usefulness of rigid categorical DSM criteria. However, several dimensions of somatization (and the interconnected concept of abnormal illness behaviour) have been shown to be diagnosable in cancer patients and to negatively influence coping and quality of life outcomes. An integration of the formal DSM-ICD nosology with a system specifically taking into account the patients' emotional responses to cancer and cancer treatment, such as the Diagnostic Criteria for Psychosomatic Research (DCPR), is suggested. More data on some specific symptom dimensions, including pain, fatigue and sexual disorders, are needed to examine their possible psychological components. More research is also needed regarding the association of somatization with personality traits (e.g. type D distressed personality, alexithymia), developmental dimensions (e.g. attachment), and cultural issues (e.g. culturally mediated attributional styles to somatic symptoms). Also, the impact and effectiveness of specific therapeutic intervention in 'somatizing' cancer patients is necessary.

Partial response to proton pump inhibitor therapy for GERD: observational study of patient characteristics, burden of disease, and costs in the USA

Background

Disease burden and associated costs are not well understood among patients with gastroesophageal reflux disease (GERD) who have persistent symptoms despite optimized proton pump inhibitor (PPI) therapy. The aim of this study was to investigate disease burden and costs of GERD in partial responders to PPI therapy.

Methods

The Partial Response to PPI treatment: the Cost to Society and the Burden to the Patient in the US (REMAIN US) study was a 12-month, multicenter, noninterventional, observational study of 552 partial PPI responders in the USA. Participating sites were comprised of family practice (n = 30), internal medicine (n = 8), and specialist (gastroenterologist) centers (n = 15). GERD symptoms, health-related quality of life (HRQL), and impact on productivity were evaluated from patient-reported outcome instruments. Resource utilization data were also collected.

Results

Patients had a high symptom burden, impaired HRQL, and reduced productivity while at work and in daily activities, despite optimized PPI therapy. Mean annual GERD-related costs were US$9944 per patient, comprising total direct costs and mean productivity loss costs of US$4068 and US$5876 per patient, respectively.

Conclusion

Patients with GERD and a partial response to PPI therapy have considerable direct and indirect costs, along with substantial impairments in HRQL and productivity.

The relationship between existence of typical symptoms and psychological factors in patients with erosive esophagitis

Background/Aims

In Asian countries including Korea, the prevalence of gastroesophageal reflux disease (GERD) is on the rise and its clinical impact has been emphasized. The purpose of this study was to investigate the clinical characteristics of esophagitis patients with or without symptoms, and their association with psychological factors.

Methods

Subjects diagnosed as erosive esophagitis of Los Angeles-A or more in screening by upper gastrointestinal endoscopy were enrolled. Questionnaires regarding GERD symptoms and Symptom Checklist-90-Revision were used to identify the presence of psychological symptoms.

Results

There was no difference between the subjects' general characteristics (gender, age, body mass index, smoking and alcohol intake) according to the existence of typical symptoms in these patients with erosive esophagitis. Patients with typical GERD symptoms were more likely to have atypical symptoms, dyspepsia and higher scores on psychological symptoms (somatization, obsessive-compulsiveness and phobic anxiety) than those without.

Conclusions

Psychological symptoms and other gastrointestinal symptoms should be considered in the patients with erosive esophagitis.

Differences in cerebral response to esophageal acid stimuli and psychological anticipation in GERD subtypes--an fMRI study

Background

To evaluate whether there are differences in the cerebral response to intraesophageal acid and psychological anticipation stimuli among subtypes of gastroesophageal reflux disease (GERD).

Methods

Thirty nine patients with GERD and 11 healthy controls were enrolled in this study after gastroscopy and 24 hr pH monitoring. GERD subjects were divided into four subgroups: RE (reflux esophagitis), NERD+ (non-erosive reflux disease with excessive acid reflux), NERD-SI+ (normal acid exposure and positive symptom index) and NERD-SI+ (normal acid exposure and negative symptom index, but responded to proton pump inhibitor trial). Cerebral responses to intraesophageal acid and psychological anticipation were evaluated with fMRI.

Results

During intraesophageal acid stimulation, the prefrontal cortex (PFC) region was significantly activated in all subgroups of GERD; the insular cortex (IC) region was also activated in RE, NERD+ and NERD-SI- groups; the anterior cingulated cortex (ACC) region was activated only in RE and NERD-SI- groups. The RE subgroup had the shortest peak time in the PFC region after acid was infused, and presented the greatest change in fMRI signals in the PFC and ACC region (P = 0.008 and P = 0.001, respectively). During psychological anticipation, the PFC was significantly activated in both the control and GERD groups. Activation of the IC region was found in the RE, NERD-SI+ and NERD-SI- subgroups. The ACC was activated only in the NERD-SI+ and NERD-SI- subgroups. In the PFC region, the NERD-SI- subgroup had the shortest onset time (P = 0.008) and peak time (P < 0.001). Compared with actual acid infusion, ACC in RE and IC in NERD+ were deactivated while additional areas including the IC and ACC were activated in the NERD-SI+ group; and in NERD-SI- group, onset-time and peak time in the PFC and IC areas were obviously shorter in induced anticipation than in actual acid infusion.

Conclusions

The four subgroups of GERD patients and controls showed distinctly different activation patterns and we therefore conclude GERD patients have different patterns of visceral perception and psychological anticipation. Psychological factors play a more important role in NERD-SI+ and NERD-SI- groups than in RE and NERD+ groups.

Review article: gastro-oesophageal reflux disease and psychological comorbidity

BACKGROUND

A growing number of studies have shown the impact of psychological comorbidities on gastro-oesophageal reflux disease (GERD) patients' symptom reports and healthcare-seeking behaviour.

AIM

To review the reported relationship between GERD and psychological comorbidity.

METHODS

Review of the literature on GERD and psychological comorbidity.

RESULTS

Psychological comorbidity is common among GERD patients and appears to afflict all GERD phenotypes. Sexual and physical abuse is also common in GERD patients. Stress enhances perception of oesophageal acid exposure. Treatment for GERD, especially in those who are not responsive to antireflux treatment, may require further evaluation for psychological comorbidity.

CONCLUSIONS

Psychological comorbidity is very common in GERD patients and is likely to play an important role in response, or failure of response, to proton pump inhibitor treatment.

Psychological factors in gastroesophageal reflux disease measured by scl-90-R questionnaire

BACKGROUND

An association between psychological factors and gastroesophageal reflux disease has been recognized. Psychological distress can influence the outcomes of the disease.

AIMS

To determine the existence of psychological factors in our gastroesophageal reflux disease sample, as well as determine their influence on the outcome of the disease and treatment response.

METHODS

A cross-sectional study was performed from February 2006 to December 2007. Patients referred to gastrointestinal specialists who reported symptoms of gastroesophageal reflux were asked to fill out the SCL-90-R questionnaire. All underwent endoscopy and pH-metry studies.

RESULTS

Fifty-five patients with gastroesophageal reflux disease were analyzed. Subjects with reflux symptoms had higher scores compared to healthy controls on sommatization, obsessiveness, interpersonal sensitivity, being phobic, being psychotic, and the global index (P < 0.05). Patients with high frequency of symptoms and long duration of disease have increased psychological distress. There was no relationship among pH-metry results, endoscopy findings, and SCL-90-R scores.

CONCLUSIONS

Psychosocial factors can predispose to gastroesophageal reflux disease. The SCL-90-R questionnaire can be useful in investigating psychological factors in those patients with unsuccessful outcome of the symptoms despite correct management.

Clinical trial design in adult reflux disease: a methodological workshop

BACKGROUND

The development of well-tolerated acid suppressant drugs has stimulated substantial growth in the number of trials assessing therapy options for gastro-oesophageal reflux disease (GERD).

AIM

To develop consensus statements to inform clinical trial design in adult patients with GERD.

METHODS

Draft statements were developed employing a systematic literature review. A modified Delphi process including three rounds of voting was used to reach consensus. Between voting, statements were revised based on feedback from the Working Group and additional literature reviews. The final vote was at a face-to-face meeting that included discussion time. Voting was conducted using a six-point scale.

RESULTS

At the last vote, 93% of the final 102 statements achieved consensus (defined a priori as being supported by >or=75% of the votes). The Working Group strongly supported the development of validated patient-reported outcome instruments. Symptom assessments carried out by the investigator were considered unacceptable. There was agreement that exclusion from clinical trials should be minimized to improve generalizability, that prospective evaluation ideally requires electronic timed/dated methods and that endoscopists should be blinded to patient symptom status.

CONCLUSIONS

Implementation of the consensus statements will improve the quality and comparability of trials, and make them compatible with regulatory requirements.