The Spectrum of Surgical Anti-reflux Procedures: Which Operations Work? (original) (raw)
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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.
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.
CLINICAL TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE: WHAT DO THE LATEST STUDIES AVOID? (Atena Editora), 2022
INTRODUCTION: Gastroesophageal reflux is a physiological response of the body. When, for any reason, this reflux is associated with diseases, complications and impairment of quality of life, the condition is called gastroesophageal reflux disease (GERD). The clinical diagnosis of GERD is very sensitive, as most patients have the classic symptoms of the disease. The treatment can be clinical or surgical, depending on its dominant form of presentation and its main etiology. Surgery will rarely be a first option, as it must be reserved for cases that are refractory to medical treatment or for life-threatening situations. For this reason, the current discussion aims to investigate what the latest studies point out in the clinical treatment of GERD. METHODOLOGY: This is a bibliographic review whose secondary data were obtained through articles from Google Scholar, Scielo and PubMed databases. The descriptors were defined by the Decs BVS in “Gastroesophageal Reflux Disease”, “Clinical treatment” and “Non-pharmacological measures”, and hundreds of articles from national and international literature were identified. For the purpose of this literature review, only articles published in the last 2 years were included to discuss the clinical treatment of the disease. RESULTS: The therapeutic approach to GERD includes two modalities, clinical and surgical treatment, the choice of which depends on the patient's characteristics, in addition to other factors such as response to treatment, presence of erosions in the esophageal mucosa, atypical symptoms and complications. Clinical treatment aims to relieve symptoms, heal esophageal mucosal lesions and prevent the development of complications. It is based on non-pharmacological and pharmacological measures. Anti-reflux surgery must be reserved for patients who do not respond to medical treatment and/or who have life-threatening conditions. After the emergence of more potent prokinetic agents and acid secretion inhibitors, the role of surgery as a definitive therapeutic weapon for complicated reflux has been questioned. CONCLUSIONS: Surgical treatment, when properly indicated, tends to be a definitive way to resolve the typical and atypical symptoms of GERD. On the other hand, considering the multidimensional etiopathogenesis of the disease, clinical treatment is still the best alternative to start with. It is understandable that the adjustment of doses, the association of classes, the combination with behavioral measures and the due adherence by the patient are presented as determinant measures for the therapeutic success, being able to avoid a surgical approach in most cases.
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.
Long-term effects of anti-reflux surgery on the physiology of the esophagogastric junction
Surgical endoscopy, 2015
Studies performed shortly after anti-reflux surgery have demonstrated that the reduction of reflux episodes is caused by a decrease in the rate of transient lower esophageal sphincter relaxations (TLESRs) and a decrease in the distensibility of the esophagogastric junction (EGJ). We aimed to assess the long-term effects of surgical fundoplication on the physiology of the EGJ. We included 18 patients who underwent surgical fundoplication >5 years before and 10 GERD patients who did not have surgery. Patients underwent 90-min combined high-resolution manometry and pH-impedance monitoring, and EGJ distensibility was assessed. Post-fundoplication patients exhibited a lower frequency of reflux events than GERD patients (2.0 ± 0.5 vs 15.1 ± 4.3, p < 0.05). The rate of TLESRs (6.1 ± 0.9 vs 12.6 ± 1.0, p < 0.05) and their association with reflux (28.3 ± 9.0 vs 74.9 ± 6.9 %, p < 0.05) was lower in post-fundoplication patients than in GERD patients. EGJ distensibility was signific...
The Physiologic Basis for the Medical Management of Gastroesophageal Reflux
Surgical Clinics of North America, 1983
Gastroesophageal reflux is a normal physiologic event, although this has been established only in man. 12 • 33 It is difficult to see how such reflux could have brought any adaptive advantage to an animal in an evolutionary sense. Therefore, reflux is probably best thought of as a physical consequence of other physiologic events that have provided adaptive advantages (such as negative intrathoracic pressure). In the normal person, reflux occurs more frequently after meals and during the waking hours, and it occurs infrequently, if at all, during sleep. Once physiologic reflux occurs, swallowing rapidly empties the esophagus of the refluxed content within minutes. 12 Gastroesophageal reflux may progress to a clinical disorder if the defense mechanisms against physiologic reflux fail (1) when the esophagus fails to empty the normal refluxate, so that there is prolonged contact with the esophageal mucosa; (2) when there is breakdown in the normal esophageal mucosal resistance to various materials within its lumen; and (3) when the nature of the refluxate includes particularly noxious materials to the esophageal mucosa. Gastroesophageal reflux disease may also result if abnormal amounts of reflux occur because of (1) a breakdown in anatomic barriers to reflux, (2) a breakdown in physiologic barriers to reflux, and (3) increased amounts of gastric contents being available to reflux.