Utilization of Antireflux Mucosectomy and Resection and Plication: A Novel Approach for the Management of Recurrent Gastroesophageal Reflux Disease after Prior Nissen Fundoplication or Transoral Incisionless Fundoplication (original) (raw)
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Endoscopy International Open
Background and study aims Antireflux mucosectomy (ARMS) and antireflux mucosal ablation (ARMA) are new endoscopic procedures for patients with gastroesophageal reflux disease (GERD). We conducted a meta-analysis to systematically assess the feasibility, clinical success, and safety of these procedures. Patients and methods We searched Embase, PubMed, and Cochrane Central from inception to October 2020. Overlapping reports, animal studies, and case reports were excluded. Our primary outcomes were clinical success and adverse events (AEs). Secondary outcomes included technical success, endoscopic esophagitis, 24-hour pH monitoring, and proton pump inhibitor (PPI) use. A random effects model was used to pool data. Results In total, 15 nonrandomized studies (12 ARMS, n = 331; 3 ARMA, n = 130) were included; 10 were conducted in patients with refractory GERD. The technical success rate was 100 %. The pooled short-term (first assessment within the first 6 months), 1-year, and 3-year clini...
The Treatment of Gastroesophageal Reflux Disease With Laparoscopic Nissen Fundoplication
Annals of Surgery, 1998
Gastroesophageal reflux disease (GERD), typically presenting as heartburn, regurgitation, or dysphagia, may lead to esophagitis, Barrett's metaplasia, and esophageal adenocarcinoma. It occurs when the antireflux barrier between the stomach and esophagus is impaired. In tertiary-care centers, approximately 50% of patients with reflux symptoms have erosive esophagitis, whereas nonerosive disease is encountered in 50-70% of patients in community-based practices. Though almost never lifethreatening, GERD impairs the quality of life and work productivity. The goals of management in GERD are to relieve symptoms, heal esophagitis (if present), and prevent complications. In view of the costs, lifelong medical therapy and limitations of surgery, a variety of endoscopic techniques have been developed for the treatment of this condition. The principle of this approach is to provide an option for patients who are unsatisfied with protracted pharmacologic therapy yet wish to avoid antireflux (laparoscopic) surgery with results adversely affected by morbidity and mortality, which are unacceptable for what is essentially a benign condition. Moreover, a remarkable proportion of surgically treated patients still require daily antisecretory drugs, and a third of patients suffer from new symptoms after surgery, such as dysphagia, belching, diarrhea, and nausea. The best candidates for surgery are patients with effective relief of symptoms with medical treatment who experience frequent relapses, those with large hiatal hernia, those requiring high doses of proton pump inhibitors (PPIs), and patients unwilling to stay on continuous medical treatment.
Gastroesophageal Reflux Disease and Antireflux Surgery—What Is the Proper Preoperative Work-up?
Journal of Gastrointestinal Surgery, 2012
Background Many surgeons feel comfortable performing antireflux surgery (ARS) on the basis of symptomatic evaluation, endoscopy, and barium esophagography. While esophageal manometry is often obtained to assess esophageal peristalsis, pH monitoring is rarely considered necessary to confirm the diagnosis of gastroesophageal reflux disease (GERD). Aims The aim of this study was to analyze the sensitivity and specificity of symptoms, endoscopy, barium esophagography, and manometry as compared to pH monitoring in the preoperative evaluation of patients for ARS. Patients and Methods One hundred and thirty-eight patients were referred for ARS with a diagnosis of GERD based on symptoms, endoscopy, and/or barium esophagography. Barium esophagography, esophageal manometry, and ambulatory 24h pH monitoring were performed preoperatively in every patient. Results Four patients were found to have achalasia and were excluded from the analysis. Based on the presence or absence of gastroesophageal reflux on pH monitoring, the remaining 134 patients were divided into two groups: GERD+ (n078, 58 %) and GERD− (n056, 42 %). The groups were compared with respect to the incidence of symptoms, presence of reflux and hiatal hernia on esophagogram, endoscopic findings, and esophageal motility. There was no difference in the incidence of symptoms between the two groups. Within the GERD+ group, 37 patients (47 %) had reflux at the esophagogram and 41 (53 %) had no reflux. Among the GERD− patients, 17 (30 %) had reflux and 39 (70 %) had no reflux. A hiatal hernia was present in 40 and 32 % of patients, respectively. Esophagitis was found at endoscopy in 16 % of GERD+ patients and in 20 % of GERD− patients. Esophageal manometry showed no difference in the pressure of the lower esophageal sphincter or quality of peristalsis between the two groups. Conclusions The results of this study showed that (a) symptoms were unreliable in diagnosing GERD, (b) the presence of reflux or hiatal hernia on esophagogram did not correlate with reflux on pH monitoring, (c) esophagitis on endoscopy had low sensitivity and specificity, and (d) manometry was mostly useful for positioning the pH probe and rule out achalasia. Ambulatory 24-h pH monitoring should be routinely performed in the preoperative work-up of patients suspected of having GERD in order to avoid unnecessary ARS.
Antireflux Surgery and Laryngopharyngeal Reflux
Current Otorhinolaryngology Reports, 2016
Surgical fundoplication, the recreation of the lower esophageal sphincter mechanism by wrapping the fundus of the stomach around the gastroesophageal junction, is a well-established treatment option in the management of gastroesophageal reflux disease. By decreasing the incidence of both acid and non-acid reflux, fundoplication results in a measureable decrease in symptoms and additional sequela of gastric reflux. Laryngopharyngeal reflux (LPR), a compliment of symptoms, resulting from the reflux of gastric contents into the larynx and pharynx, may also benefit from fundoplication. This review of the recent literature will explore the indications, benefits, and response of LPR to surgical fundoplication. Additionally, the use of novel endoscopic techniques for fundoplication will be reviewed. Keywords Nissen fundoplication Á Laryngopharyngeal reflux (LPR) Á Gastroesophageal reflux disease (GERD) Á Reflux Á Transoral incisionless fundoplication (TIF) Á EsophyX This article is part of the Topical Collection on Laryngopharyngeal Reflux.
Severe ineffective esophageal motility: results of antireflux surgery
Gastroenterology, 2000
Esophageal pH monitoring identifies some patients who have physiologic amounts of esophageal acid exposure but have a strong correlation between symptoms of esophageal reflux and esophageal reflux events. These patients with symptomatic physiologic reflux (SPR) probably have enhanced sensory perception of reflux events, and may be difficult to control with acid suppressive therapy. Little is known about the role of antireflux surgery in this group. Methods: Patients with no endoscopic evidence of GERD and a normal 24-hour pH composite score « 22.4 in our lab), but a symptom index (SI = # of symptoms/# of acid reflux events) of > 50% were offered laparoscopic fundoplication if acid suppressive therapy was unsatisfactory. This group comprised 18 (4%) of 459 patients undergoing fundoplication in our institution. Heartburn, dysphagia, and reflux symptoms were scored on a scale of 0-10 on and off medicine preoperatively, and at a mean of 7.2 months (1-32) postoperatively. Results: The 18 patients with SPR (6 M, 12 F) had heartburn as a major complaint. Preoperative response to proton pump inhibitors for heartburn symptoms was 72%, and for all symptoms was 60%. The group had a mean pH composite score of 14 (range, 4-22). The symptom used to calculate the SI was heartburn in 12, regurgitation in 3, chest pain in 2, and cough in 1 patient. An average of 18 symptoms (2-56) were recorded.The mean SI was 82% (range, 50%-100%). A Nissen was performed in 9 cases and a Toupet in 9. Surgery was successful in alleviating reflux symptoms in 14 patients and partially successful (> 75%) in the remaining 3(Table). Gas-bloat and dysphagia were seen in I patient each. Conclusions: Antireflux surgery is effective at relieving reflux symptoms in carefully selected patients with symptomatic physiologic reflux, with minimal side effects.
Isolated upright gastroesophageal reflux is not a contraindication for antireflux surgery
Surgery, 1997
Background. Patients with gastroesophageal rejlux disease who rejlux only in the ,upright position are thought to have a less severe abnormality. Controvers) exists over whether these patients should be considered candidates for antireflux surgery Methods. A total of 224 consecutive patients with increased esophageal acid exposztre on 24-hour PH monitoring were classified as having upright (n = 54), supine (n = 72), or bzpositional (n = 98) rejlux and were evaluated by manometrJ and endoscopy Of these, 116 patients had a laparoscopic Nissen fundoplication. Their clinical outcome at a median of 12 months (range 4 to 44 mon.ths) was compared. Results. Patients with upright reflux had a lower prevalence of a structuralQ defective lower esophageal sphilzcter; fewer hiatal hernia,s, and less esophageal injury when compared to those with bipositional reJux (p < 0.005). Excellent (asymptomaticj or good outcome (minor symptoms not requiring acid suppression therapy) was achieved in 86% of the patien ts with upright rejlux, 90% of those with sup&e rejlux, avzd 89% of those with bipositiorzal rejlux. Conclusions. Patients with upright rejlux have less complicated, earlier disease and have results equivalent to those patients with supine and bipositional reflux after antirejlux su'rgery (Surgery 1997;122:829-35.
Does Nissen Fundoplication Provide Lifelong Reflux Control? Symptomatic Outcome After 31–33 Years
World Journal of Surgery, 2017
Background A substantial number of people are suffering from gastroesophageal reflux disease (GERD). The indication for surgical treatment is the failure of medical treatment in patients with objectively verified GERD. The use of PPIs has been noted to increase with the length of follow-up after fundoplication, raising questions concerning the durability of surgical results. The aim of the study was to investigate the results of open Nissen fundoplication (ONF) over a follow-up of more than 31 years. Methods ONF was performed for 38 consecutive patients. Questionnaires concerning long-term outcome were sent on December 14, 2015, to the 24 patients still living. Long-term symptom evaluation was carried out using the Gastrointestinal Symptom Rating Scale (GSRS), Visick grading, a Visual Analog Scale (VAS), the DeMeester-Johnson reflux scale, and the 15D tool. Results Seventeen (70.8%) of the 24 patients still living participated in the study. The typical symptoms of GERD had resolved significantly. Dysphagia was graded as none or minimal by 13 (81.3%) patients. The mean 15D score of the patient group was clinically and statistically the same (0.896 vs. 0.899) as that of the age-and sex-standardized general population (p = 0.912). Six (15.8%) patients had used antireflux medication after the operation and 4 of them (10.6%) continuously. Conclusions Patients in the present study used PPIs less frequently than what has been reported in previous longterm follow-up studies. Our results indicate that successful surgery may provide lifelong relief of GERD symptoms and normalize the health-related quality of life in GERD patients.