Isolated upright gastroesophageal reflux is not a contraindication for antireflux surgery (original) (raw)
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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.
Patterns of Gastroesophageal Reflux in Health and Disease
Annals of Surgery, 1976
Twenty-four-hour pH monitoring of the distal esophagus quantitates gastroesophageal reflux in a near physiologic setting by measuring the frequency and duration of acid exposure to the esophageal mucosa. Fifteen asymptomatic volunteers were studied with 24-hour pH and esophageal manometry. The normal cardia was more competent supine than in the upright position. Physiologic reflux was unaffected by age, rarely occurred during slumber, and was the rule after alimentation. One hundred symptomatic patients with an abnormal 24-hour pH record (2 S.D. above the mean of controls) could be divided into three patterns of pathological reflux: those who refluxed only in the upright position (9), only in the supine position (37), and in both positions (54). Upright differed from supine refluxers by excessive aerophagia causing reflux episodes by repetitive belching. Compared to controls, they had excessive post-prandial reflux, lower DES pressure, and less DES exposed to the positive pressure of the abdomen. Supine differed from upright refluxers by having a higher incidence of esophagitis and an inability to clear the esophagus of acid after a supine reflux episode. Compared to controls, they had only a lower DES pressure. Combined refluxers had a higher incidence of esophagitis than supine refluxers. Stricture (15%) was seen only in this group. They were similar to supine refluxers in their inability to clear a supine reflux episode. Compared to controls, they had a lower DES pressure and less DES exposed to the positive pressure of the abdomen. Forty of the 100 patients had an antireflux procedure (4 upright, 8 supine, 28 combined). The most severe postoperative flatus and abdominal distention was seen in the upright refluxers. It is concluded that minimal reflux is physiological. Patients with pathological reflux all have lower DES pressure. Patients with upright reflux have less of their DES exposed to the positive pressure environment of the abdomen. Patients with supine reflux have an inability to clear the esophagus of reflux acid and are prone to develop esophagitis. Patients with both upright and supine reflux have the most severe disease and are at risk in developing strictures. In patients with only upright reflux, aerophagia and delayed gastric emptying may be an important etiological factor.
Review article: indications for anti-reflux surgery and endoscopic anti-reflux procedures
Alimentary Pharmacology and Therapeutics, 2004
Gastro-oesophageal reflux disease (GERD) is a complex multifactorial disorder whose treatment is based on knowledge of its pathophysiology, natural history and evolution. Recently the relationship between the severest degrees of cardial incontinence and hiatus hernia has been emphasized, which causes the impairment of the mechanical properties of the gastrooesophageal barrier and of oesophageal acid clearing. Among different types of hiatus hernia, those characterized by the permanent axial orad migration of the oesophago-gastric (EG) junction (nonreducible hiatus hernia) are correlated with severe GERD. Barium swallow may adequately differentiate hiatal insufficiency, concentric hiatus hernia and short oesophagus which are the steps of migration across or above the diaphragm. When associated with panmural oesophagitis and fibrosis of the oesophageal wall, these conditions may be the cause of recurrence of hiatus hernia and reflux after laparoscopic standard anti-reflux surgical procedures; in the presence of nonreducibility of the EG junction below the diaphragm without tension, dedicated surgical procedures are necessary. It is currently agreed that surgical therapy is indicated for patients affected by severe GERD who are not compliant with long-term medical therapy, require high dosages of drugs and are too young for lifetime medical treatment. While the existence of severe GERD correlated with an irreversible anatomical disorder represents an elective indication for surgery, warrants further investigation. Accurate identification of the functional and anatomical abnormalities underlying GERD is mandatory in order to decide whether medical or surgical therapy should be implemented, and to tailor the surgical technique, laparoscopic or open, to each patient.
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.
The Spectrum of Surgical Anti-reflux Procedures: Which Operations Work?
2017
Most of the underlying pathophysiology of gastro-oesophageal reflux (GER) has been elucidated in adults. The underlying mechanism giving rise to reflux is transient relaxation of the lower oesophageal sphincter (TRLES). This is combined with relaxation of the diaphragmatic crura and also with oesophageal shortening [1, 2].
2015
Introduction: Gastro-esophageal reflux (GER) is common among children of different ages and treatment is necessary since it could turn in to Gastroesophageal Reflux Disease (GERD) and cause complications. In patients that do not respond to medical treatment and patients that have complications such as repeated apnea, pneumonia, stricture caused by esophagitis and failure to thrive, surgical treatment is indicated. In this article the rates of clinical presentations of the disease particularly the respiratory manifestations after operation with the loose Nissen Fundoplication technique are studied. Material and Methods: In this descriptive retrospective study 76 cases of GERD underwent loose Nissen Fundoplication. Clinical presentations and diagnostic methods and the result of surgical treatment were studied. Results: During March 1997 till August 2010, 76 patients were studied. Male to female ratio was 1.6. The mean age of patients was 24.5 months (ranging between 17 days to 18 year...
Surgical Treatment of Gastroesophageal Reflux Disease
Background Gastroesophageal reflux disease (GERD) affects an estimated 20% of the population in the USA, and its prevalence is increasing worldwide. Lifestyle modifications and proton pump inhibitors (PPI) therapy are effective in the majority of patients and remain the mainstay of treatment of GERD. However, some patients will need surgical intervention because they have partial control of symptoms, do not want to be on long-term medical treatment, or suffer complications related to PPI therapy. Aims The aim of this study was to review the available evidence that supports laparoscopic antireflux surgery, and to study the effect of surgical therapy on the natural history of GERD. Results The key elements for the success of antireflux surgery are proper patient selection, careful analysis of the indications for surgery, complete pre-operative work-up, and proper execution of the surgical technique. Conclusions When the key elements are respected, antireflux surgery is very effective in controlling GERD, and it is associated to minimal morbidity and mortality.