EAES recommendations for the management of gastroesophageal reflux disease

Background

Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett’s esophagus, and enteroesophageal and duodenogastroesophageal reflux.

Methods

The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session.

Results

Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD.

Conclusions

Since the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.     

Refractory gastroesophageal reflux disease as diagnosed by impedance-pH monitoring can be cured by laparoscopic fundoplication

Background

Some patients with typical (heartburn/regurgitation) symptoms of gastroesophageal reflux disease (GERD) are refractory to proton pump inhibitor (PPI) therapy. Impedance-pH monitoring can identify PPI-refractory patients who could benefit from laparoscopic fundoplication, but outcome data are scarce. We aimed to assess whether PPI-refractory GERD as diagnosed by impedance-pH monitoring can be cured by laparoscopic fundoplication.

Methods

Forty-four consecutive GERD patients with heartburn/regurgitation refractory to high-dose PPI therapy entered a 3-year outcome assessment following robot-assisted laparoscopic fundoplication. Preoperative on-PPI impedance-pH diagnostic criteria consisted of positive symptom association probability (SAP)/symptom index (SI), and/or abnormal percentage esophageal acid exposure time (%EAET), and/or abnormal number of total refluxes. GERD cure was defined by 3-year postoperative off-PPI normal impedance-pH findings with persistent symptom remission.

Results

Preoperatively, 24 of 38 (63 %) patients who completed the outcome assessment had a positive SAP/SI, 20 of 38 (53 %) for weakly acidic refluxes; 3 of 38 (8 %) patients had an abnormal %EAET, 11 of 38 (29 %) an abnormal number of total refluxes only. Postoperatively, heartburn/regurgitation recurred in 3 patients; abnormal impedance-pH findings were found in two of them, and they responded to PPI therapy. GERD cure was achieved in 34 of 38 (89 %) patients, 11 of 11 with an abnormal number of total refluxes as the only preoperative abnormal impedance-pH finding. Postoperatively, there was a significant decrease of the %EAET (1 vs. 0.1 %, P = 0.002) and of the number of total refluxes (68 vs. 8, P = 0.001), with the latter finding mainly due to a decrease in the number of weakly acidic refluxes.

Conclusions

Normal reflux parameters and persistent symptom remission at 3-year follow-up can be achieved with laparoscopic fundoplication in the majority of patients with PPI-refractory GERD as diagnosed by impedance-pH monitoring. On-PPI impedance-pH diagnostic criteria should include SAP/SI positivity, an abnormal %EAET, and an abnormal number of total refluxes. Weakly acidic refluxes have a major role in the pathogenesis of PPI-refractory GERD.     

Idiopathic Pulmonary Fibrosis and Gastroesophageal Reflux. Implications for Treatment

Background

Even though the pathogenesis of idiopathic pulmonary fibrosis (IPF) is unknown, there is mounting evidence that abnormal reflux (GERD) and aspiration of gastric contents may play a role in the pathogenesis of this disease.

Aims

The aims of this study were to determine in patients with GERD and IPF: (a) the clinical presentation, (b) the esophageal function, and (c) the reflux profile.

Methods

We compared the clinical presentation, the esophageal function (as defined by high-resolution manometry), and the reflux profile (by dual sensor pH monitoring) in 80 patients with GERD (group A) and in 22 patients with GERD and IPF (group B).

Results

Heartburn was present in less than 60 % of patients with GERD and IPF. Lower esophageal sphincter pressure and peristalsis were normal in both groups, while the upper esophageal sphincter (UES) was more frequently hypotensive in IPF patients (p?=?0.008). In patients with GERD and IPF, the proximal esophageal acid exposure was higher (p?=?0.047) and the supine acid clearance was slower as compared with patients with GERD only (p?<?0.001).

Conclusions

The results of this study show that in patients with GERD and IPF: (a) reflux is frequently silent, (b) with the exception of a weaker UES, the esophageal function is preserved, and (c) proximal reflux is more common, and in the supine position, it is coupled with a slower acid clearance. Because these factors predisposing IPF patients to the risk of aspiration, antireflux surgery should be considered early after the diagnosis of IPF and GERD is established.     

Impact of Laparoscopic Sleeve Gastrectomy on Upper Gastrointestinal Symptoms

Background

Altered gastric anatomy following laparoscopic sleeve gastrectomy (LSG) is likely to induce upper gastrointestinal (GI) symptoms. Published studies, however, have focused mainly on gastroesophageal reflux disease (GERD). This study aims to evaluate LSG's impact on the prevalence of upper GI symptoms and to assess the effects of time from surgery, weight loss, and proton pump inhibitor (PPI) therapy.

Methods

The validated Rome III Criteria symptom questionnaire for upper GI symptoms, including quality of life items, has been self-administered to 97 patients who underwent LSG. Symptoms were analyzed either separately or altogether to classify patients in GERD or dyspepsia, subdivided in epigastric pain (EPS) and post-prandial distress (PDS) syndromes.

Results

Before LSG, 52.7 % of the patients were asymptomatic, 27.0 % had GERD, and 8.1 % had dyspepsia (2.7 % EPS, 5.4 % PDS). After a median follow-up of 13 months, 91.9 % of the patients complained of upper GI symptoms, the most prevalent being PDS (59.4 %). GERD prevalence did not differ before and after LSG. The only symptom strongly related to LSG was dysphagia (OR 4.7, 95 % CI 1.3–20.4, p?=?0.015), which was present in 19.7 % of the patients and mainly associated with PDS rather than GERD. GI symptoms, however, did not have a great impact on quality of life. Time from surgery, weight loss after surgery, as well as concomitant PPI, did not influence the symptoms.

Conclusions

After a median follow-up of 13 months, PDS-like dyspepsia, rather than GERD, was the main complaint, both poorly responding to PPI therapy. A longer follow-up will be necessary to evaluate their future persistency.     

Early referral for 24-h esophageal pH monitoring may prevent unnecessary treatment with acid-reducing medications

Background

Gastroesophageal reflux disease (GERD) affects nearly 25 % of adults; however, an objective diagnosis is rarely established. We hypothesized that patients’ symptoms and response to acid-reducing therapy are poor predictors of the outcome of 24-h esophageal pH monitoring.

Methods

A review of 24-h esophageal pH monitoring studies performed at an ambulatory tertiary care center between 2004 and 2011 was performed. Demographics, type of GERD symptoms, and duration and response to acid-reducing medications before referral for pH monitoring were collected. DeMeester score, symptom sensitivity index (SSI), and symptom index (SI) were tabulated and compared with the patients’ symptoms and response to medical therapy.

Results

One hundred patients were included. Of all reported symptoms, only heartburn was more common in patients with positive DeMeester scores, but there were no correlations between any symptoms and SSI or SI scores. Sixty-nine percent of patients with esophageal symptoms had a positive DeMeester score compared with only 29 % of patients with extraesophageal symptoms (P < 0.01). Esophageal symptoms and endoscopic evidence of GERD significantly increased the likelihood of having a positive DeMeester score, but they had no influence on SSI or SI scores. There was no correlation between response to acid-reducing medications and DeMeester, SSI, or SI scores. A total of 536 person-years of acid-reducing medications were prescribed to the study population, of which 151 (28 %) were prescribed to patients who had a negative pH study.

Conclusions

Extraesophageal symptoms and response to empiric trials of acid-reducing medications are poor predictors of the presence of GERD and the DeMeester score is more likely to identify GERD in patients who met other empiric diagnostic criteria than SSI or SI. Early referral for 24-h esophageal pH monitoring may avoid lengthy periods of unnecessary medical therapy.     

Laparoscopic Sleeve Gastrectomy: Symptoms of Gastroesophageal Reflux can be Reduced by Changes in Surgical Technique

Background

Bariatric surgery is the most effective treatment for gastro-esophageal reflux disease (GERD) in obese patients, with the Roux-en-Y gastric bypass being the technique preferred by many surgeons. Published data reporting the results of laparoscopic sleeve gastrectomy (LSG) in patients with GERD are contradictory. In a previous observational study, we found that relative narrowing of the distal sleeve, hiatal hernia (HH), and dilation of the fundus predispose to GERD after LSG. In this study, we evaluated the effects of standardization of our LSG technique on the incidence of postoperative symptoms of GERD.

Methods

This was a concurrent cohort study. Patients who underwent bariatric surgery at our center were followed prospectively. LSG was performed in all patients in this series.

Results

A total of 234 patients underwent surgery. There were no cases of death, fistula, or conversion to open surgery. All 134 patients who completed 6?C12?months of postoperative follow-up were evaluated. Excess weight loss at 1?year was 73.5?%. In the study group, 66 patients (49.2?%) were diagnosed with GERD preoperatively, and HH was detected in 34 patients (25.3?%) intraoperatively. HH was treated by reduction in three patients, anterior repair in 28, and posterior repair in three. Only two patients (1.5?%) had symptoms of GERD at 6?C12?months postoperatively.

Conclusions

Our results confirm that careful attention to surgical technique can result in significantly reduced occurrence of symptoms of GERD up to 12?months postoperatively, compared with previous reports of LSG in the literature.     

Fundoplication versus medical management of gastroesophageal reflux disease: systematic review and meta-analysis

Background

Medical, endoscopic, and open/laparoscopic surgical methods are used to treat gastroesophageal reflux disease (GERD). This study aimed to perform a systematic review of randomized controlled trials comparing medical and surgical treatments of GERD in adult patients.

Methods

For the study, MEDLINE and EMBASE (1980–2012) were searched. Two reviewers independently assessed methodologic aspects and extracted data from eligible studies, focusing on patient-relevant outcomes. The primary outcomes were health-related and GERD-specific quality-of-life aspects. Standardized mean differences (SMDs) between treatment groups were calculated and combined using random-effect meta-analysis.

Results

The study identified 11 publications reporting on 7 trials comparing surgical (open or laparoscopic) and medical treatment of GERD. Meta-analysis of both quality-of-life aspects showed a pooled-effect estimate in favor of fundoplication (SMD 0.18; 95 % confidence interval [CI] 0.01–0.35; SMD 0.33; 95 % CI 0.13–0.54). Heartburn and regurgitation were less frequent after surgical intervention. However, a considerable proportion of patients still needed antireflux medication after fundoplication. Nevertheless, the surgical patients were significantly more satisfied with their symptom control and showed higher satisfaction with the treatment received.

Conclusions

This systematic review showed that surgical management of GERD is more effective than medical management with respect to patient-relevant outcomes in the short and medium term. However, long-term studies still are needed to determine whether antireflux surgery is an equivalent alternative to lifelong medical treatment.     

Predicting patient dissatisfaction following laparoscopic Nissen fundoplication: an analysis of symptoms

Background

Nissen fundoplication is a well-established treatment for gastroesophageal reflux disease (GERD) with a high success rate and a long-lasting effect. However, the literature reports that a persistent, small group of patients is not fully satisfied with the outcome. Identifying this patient group preoperatively would prevent disappointment for both patients and surgeon. This has proven difficult since dissatisfaction was related to nondisease-related factors instead of typical symptoms of GERD or the objective findings of investigations. We studied our series of patients who underwent laparoscopic Nissen fundoplication to identify predictors of patient dissatisfaction and the impact of surgery on individual symptoms.

Methods

All consecutive private patients undergoing Nissen fundoplication were asked to complete a preoperative and postoperative questionnaire concerning symptoms, medication use, and satisfaction. Demographics, investigations, complications, and reinterventions were documented. A standard laparoscopic Nissen fundoplication was performed.

Results

Over an 11-year period 222 patients underwent surgery for GERD. The postoperative response rate to the questionnaire was 77.5 %, with dissatisfaction reported by 12.8 % of the patients. Of these dissatisfied patients, only 13.6 % had proven disease recurrence. Both satisfied and dissatisfied patients presented with an inconsistent pattern of symptoms. None of the preoperative symptoms and investigations or the patient’s age and gender was predictive of postoperative dissatisfaction. Only postoperative heartburn, regurgitation, and bloating significantly correlated with patient dissatisfaction.

Conclusion

Nissen fundoplication has a very high satisfaction rate overall. A small percentage of patients are not fully satisfied and dissatisfaction is associated with reported persistent symptoms and side effects of surgery rather than gender or preoperative symptom pattern, severity of esophagitis, or total 24 h esophageal acid exposure.     

Proton Pump Inhibitors in the Management of GERD

Introduction

Management of gastroesophageal reflux disease (GERD) is based on the concept that gastric contents, principally acid and pepsin, are responsible for symptoms of reflux and esophageal injury. Pharmacologic treatment is based on the principle that controlling intragastric pH will affect esophageal healing and subsequently symptom relief.

Results and Discussion

Control of pH can be accomplished with antisecretory agents, principally proton pump inhibitors (PPIs). The majority of patients respond to a single daily dose of a PPI; however, some will require higher doses, and a small percentage are “refractory” to twice daily dosing of these drugs. The success of these agents, and in fact the reasons for “failure,” is elucidated by understanding the mechanism of action of PPIs and the effect of dose timing and meals on their efficacy.

Conclusion

Awareness of new concerns regarding potential side effects of PPIs when used long-term require careful thought as GERD is a chronic disease with most needing some form of medical treatment over time. This article reviews the pharmacologic properties of PPIs and the impact on the treatment of GERD.

     

The diagnostic value of gastroesophageal reflux disease (GERD) symptoms and detection of pepsin and bile acids in bronchoalveolar lavage fluid and exhaled breath condensate for identifying lung transplantation patients with GERD-induced aspiration

Background

Gastroesophageal reflux disease (GERD) is thought to lead to aspiration and bronchiolitis obliterans syndrome after lung transplantation. Unfortunately, the identification of patients with GERD who aspirate still lacks clear diagnostic indicators. The authors hypothesized that symptoms of GERD and detection of pepsin and bile acids in the bronchoalveolar lavage fluid (BAL) and exhaled breath condensate (EBC) are effective for identifying lung transplantation patients with GERD-induced aspiration.

Methods

From November 2009 to November 2010, 85 lung transplantation patients undergoing surveillance bronchoscopy were prospectively enrolled. For these patients, self-reported symptoms of GERD were correlated with levels of pepsin and bile acids in BAL and EBC and with GERD status assessed by 24-h pH monitoring. The sensitivity and specificity of pepsin and bile acids in BAL and EBC also were compared with the presence of GERD in 24-h pH monitoring.

Results

The typical symptoms of GERD (heartburn and regurgitation) had modest sensitivity and specificity for detecting GERD and aspiration. The atypical symptoms of GERD (aspiration and bronchitis) showed better identification of aspiration as measured by detection of pepsin and bile acids in BAL. The sensitivity and specificity of pepsin in BAL compared with GERD by 24-h pH monitoring were respectively 60 and 45 %, whereas the sensitivity and specificity of bile acids in BAL were 67 and 80 %.

Conclusions

These data indicate that the measurement of pepsin and bile acids in BAL can provide additional data for identifying lung transplantation patients at risk for GERD-induced aspiration compared with symptoms or 24-h pH monitoring alone. These results support a diagnostic role for detecting markers of aspiration in BAL, but this must be validated in larger studies.     

The relationship between percutaneous endoscopic gastrostomy and gastro-oesophageal reflux disease in children: a systematic review

Background

The relationship between percutaneous endoscopic gastrostomy (PEG) insertion and gastro-oesophageal reflux disease (GERD) is widely disputed in the current literature. The aim of this systematic review is to examine the available evidence documenting the association between PEG and GERD.

Methods

The following databases were searched: MEDLINE (1950 to week 2, January 2011), PubMed, ISI Web of Knowledge (1898 to week 2, January, 2011), EMBASE (1980 to week 2, January 2011) and The Cochrane Central Register of Controlled Trials (CENTRAL) using the terms “gastroesophageal reflux”, “gastroesophageal disease”, “GERD”, “GERD”, “GER”, “GER” and “percutaneous endoscopic gastrostomy”, “PEG”, “gastrostomy”. In addition, the reference lists of all included studies were reviewed for relevant citations. Studies examining children pre and post insertion of PEG for GERD and written in English language were included. Data extraction was performed by two authors, and the methodology and statistical analysis of each study were assessed.

Results

Eight studies were included in this systematic review. Two reported increased incidence of GERD after PEG. However, neither was of high methodological quality. The remaining six reported no change or decreased GERD. Nonetheless, few demonstrated rigorous methodology.

Conclusions

The current evidence examining the effect of PEG insertion on GERD has been inconsistent and is not of high quality and therefore is unconvincing, preventing a definitive conclusion. Overall, the available literature on this topic does not demonstrate a causal effect of PEG insertion on GERD.     

Barrett’s oesophagus and nissen fundoplication. The significance of postoperative oesophageal pH measurement

Aim — Background

Barrett’s oesophagus is a condition caused by acid reflux from the stomach to the oesophagus for a prolonged period of time. Patients with Barrett’s oesophagus are at significant risk of developing oesophageal adenocarcinoma. This risk decreases with antireflux surgery. Treatment of gastroesophageal reflux disease (GERD) by Nissen fundoplication surgery has a success rate of 85–90%. The aim of this study is to highlight the significance of oesophageal pH measurement as part of the postoperative follow-up of patients diagnosed with Barrett’s oesophagus who undergo the Nissen fundoplication procedure.

Patients and methods

Between 2010 and 2012, eleven patients with Barrett’s oesophagus underwent Nissen fundoplication in our clinic, followed by 48h wireless oesophageal pH-metry monitoring.

Results

All patients reported relief of GERD typical symptoms. Mean DeMeester score of 1.5 was measured at the fifth postoperative month.

Conclusion

Prevention of oesophageal adenocarcinoma in patients with Barrett’s oesophagus is crucial. These patients are exposed to a great risk of adenocarcinoma development, not only owing to the potential progression of Barrett’s oesophagus to adenocarcinoma, but also because of the decreased capacity to experience typical GERD symptoms. Given the possibility of antireflux surgery failure and the fact that symptoms may be an unreliable indicator of GERD presence, postoperative oesophageal pHmetry is mandatory.     

Patient-centered care of de Quervain’s disease

Purpose

To test the hypothesis that most patients that elect symptomatic treatment of de Quervain’s disease experience symptom resolution.

Materials and methods

Eighty-three of 314 (26%) patients that elected initial symptomatic treatment of de Quervain’s disease responded to a mail survey inquiring about symptom resolution, symptom duration, subsequent opinions and treatments, final impressions and comments.

Results

Seventy-five respondents (90.4%) reported resolution of the pain, including 58 of the 61 (95%) respondents that elected neither corticosteroid injection nor surgery. Among patients with symptom resolution without injection or surgery 48 of 58 (83%) recalled symptoms for fewer than 12 months. The differences in reported average time to symptom resolution were not statistically significant between patients that elected or did not elect a corticosteroid injection.

Conclusions

Considered in the light of important limitations of this data including the reliance on patient recall and the limited response rate to the survey, the data are still intriguing. At least in one surgeon’s practice, most informed patients initially elect symptomatic treatment, and most experience symptom resolution within one year.     

Improvement of Gastroesophageal Reflux Symptoms After Standardized Laparoscopic Sleeve Gastrectomy

Background

Gastroesophageal reflux disease (GERD) is present in half of morbidly obese patients. Published data reporting the results of laparoscopic sleeve gastrectomy (LSG) in patients with GERD are contradictory. We have shown in a previous study that symptoms of GERD can be reduced for up to 12 months after LSG with careful attention to surgical technique. The present study prospectively evaluated the effect of a standardized LSG technique on the incidence of postoperative GERD symptoms in a larger sample, and followed patients for up to 22 months.

Methods

This was a concurrent cohort study. All patients who underwent LSG at our center completed a standard multidisciplinary preoperative evaluation and were followed prospectively.

Results

A total of 382 patients underwent surgery. There were no cases of death or fistula. GERD was diagnosed in 170 patients (44.5 %) preoperatively, and hiatal hernia (HH) was detected in 142 patients (37.2 %) intraoperatively. Between 6 and 22 months postoperatively, 373 patients were completely evaluated. Ten (2.6 %) had GERD symptoms 6–22 months postoperatively, and 94 % of patients with preoperative GERD symptoms were asymptomatic at follow-up 6–22 months after LSG. Only 1 patient (0.5 %) of a subgroup of 174 without HH or esophagitis at preoperative evaluation had GERD at follow-up.

Conclusions

Our results confirm that, contrary to previous reports of LSG in the literature, careful attention to surgical technique can result in significantly reduced GERD symptoms up to 22 months postoperatively suggesting that LSG does not predispose patients to GERD during that period.     

What is the role of the sleeve gastrectomy in the surgical treatment of morbid obesity?

Background

Laparoscopic sleeve gastrectomy (SG) is a relatively new procedure that is gaining wide acceptance and represents an innovative new approach to the surgical management of morbid obesity. Our purpose is to evaluate the SG as a surgical bariatric procedure.

Methods

We conducted a literature review on “PubMed” based on all publications related to SG since 2000 to July 30, 2014.

Results

The complication rate after SG varies in the literature, ranging from 0 to 29 %. The most feared complication after SG is leakage on the staple line, occurring in 0–7 % of cases. The mortality rate reported varies between 0 and 3.3 %. No consensus has developed on the types of stapling used or the methods of strengthening the staple line. SG may aggravate and be responsible for gastroesophageal reflux disease (GERD). SG improves comorbidities in more than 50 % after 5 years.

Conclusions

SG can be proposed as a surgical technique at first intension in patients not having GERD.     

Ratio Between Proximal/Distal Gastroesophageal Reflux Does Not Discriminate Abnormal Proximal Reflux

Introduction

The threshold for pathologic proximal acid reflux is a controversial topic. Most values previously published are based on absolute numbers. We hypothesized that a relative value representing the quantitative relation between the amount of acid reflux that reaches proximal levels and the amount of distal reflux would be a more adequate parameter for defining pathologic proximal reflux.

Methods

We studied 20 healthy volunteers (median age 30 years, 70 % women) without gastroesophageal reflux disease (GERD); 50 patients (median age 51 years, 60 % women) with esophageal symptoms of GERD (heartburn, regurgitation); and 50 patients (median age 49 years, 60 % women) with extra-esophageal symptoms of GERD. All individuals underwent manometry and dual-probe pH monitoring. GERD was defined as a DeMeester score >14.7. The proximal/distal reflux ratio was calculated for all six parameters that constitute the DeMeester score.

Results

Absolute numbers for proximal reflux were not different for the three groups except for the number of episodes of reflux, which was higher for patients with GERD and esophageal symptoms than for patients with GERD and extra-esophageal symptoms (p = 0.007). The number of episodes of distal reflux reaching proximal levels was significantly higher in volunteers than in all patients with GERD and significantly higher in patients with GERD and esophageal symptoms than in those with extra-esophageal symptoms.

Conclusions

Our results suggest that the proximal/distal reflux ratio is not a good normative value for defining proximal reflux.     

Hiatal hernia, Barrett’s esophagus, and long-term symptom control after laparoscopic fundoplication for gastroesophageal reflux

Background

The aim of this study was to determine the long-term symptom control after laparoscopic fundoplication for gastroesophageal reflux disease (GERD), and possible prognostic factors.

Methods

A cohort of 271 patients, operated on at a university hospital from 1996 through 2002, was eligible for evaluation after a median interval of 102?months (range?=?12–158). The time between surgery and recurrence of reflux symptoms (i.e., time to treatment failure) served as the end point for statistical analysis. Putative risk factors for symptom recurrence were analyzed by univariate analysis and by using Cox’s multiple-hazards regression.

Results

According to Kaplan–Meier estimates, the rate of reflux symptom recurrence was 15?% after 108?months, 11?% in cases without intestinal metaplasia, but 43?% in patients with long-segment (≥3?cm) Barrett’s esophagus (BE; p?<?0.0001). Reflux symptoms recurred in 22?% of cases with a hiatal hernia (HH)?≥3?cm before operation, but only in 7?% with smaller or absent HH (p?=?0.005). Multivariate analysis revealed a relative risk of 6.6 (CI?=?3.0–13.0) for long-segment BE and 3.0 (CI?=?1.7–10.1) for HH?≥?3?cm. A strong statistical interaction was found between HH?≥?3?cm and long-segment BE: the small group (n?=?18) of cases exhibiting both risk factors had an exaggerated recurrence rate of 72?% at 108?months.

Conclusions

Laparoscopic fundoplication for symptomatic GERD provided a long-lasting abolition of reflux symptoms in 231 of 271 (85?%) patients. HH?≥?3?cm and long-segment BE were shown as independent prognostic factors favoring recurrence.     

Evaluation of Gastroesophageal Reflux Disease

Introduction

Gastroesophageal reflux disease (GERD) may present with heartburn, regurgitation, dysphagia, chronic cough, laryngitis, or even asthma. The clinical presentation of GERD is therefore varied and poses certain challenges to the physician, especially given the limitations of the diagnostic testing.

Discussion

The evaluation of patients with suspected GERD might be challenging. It is based on the evaluation of clinical features, objective evidence of reflux on diagnostic testing, correlation of symptoms with episodes of reflux, evaluation of anatomical abnormalities, and excluding other causes that might account for the presence of the patient’s symptoms.

Conclusions

The diagnostic evaluation should include multiple tests, in addition to a thorough clinical examination.

     

A Novel Esophageal-preserving Approach to Treat High-grade Dysplasia and Superficial Adenocarcinoma in the Presence of Chronic Gastroesophageal Reflux Disease

Background

The optimal treatment strategy of esophageal high-grade dysplasia (HGD) and superficial adenocarcinoma remains controversial.

Methods

Here, we describe endoscopic, circumferential mucosal-submucosal en-bloc resection of the entire abnormal esophageal epithelium with extracellular matrix (ECM) placement to regenerate neoepithelium and minimize stricture. That procedure was then followed by a laparoscopic fundoplication as a novel esophageal-preserving approach to treat HGD and superficial adenocarcinoma in the face of chronic gastroesophageal reflux disease (GERD).

Conclusions

This approach could be an ideal option as an alternative to esophagectomy in selected patients.     

Overactive bladder in cervical spondylotic myelopathy

Background

Overactive bladder (OAB) is a new disease concept defined by the International Continence Society in 2002. There have been no reports of OAB among patients with cervical spondylotic myelopathy assessed on the basis of symptom questionnaires.

Methods

One-hundred-and-six patients diagnosed with cervical spondylotic myelopathy and treated by use of laminoplasty were examined. The patients were classified into two groups, those identified as having OAB (OAB group) and those identified as not having OAB (non-OAB group), by use of the Overactive Bladder Symptom Score collected before and 1 year after surgery. The clinical results for the two groups were assessed. OAB symptom prevalence and post-operative symptom improvement were investigated 1 year postoperatively.

Results

Of the 106 patients, 50 were identified as having OAB (symptom prevalence 47.2 %). Of these 50 patients, symptom improvement was observed for only 14 (28 %) 1 year after surgery. For both groups good improvement on the basis of the Japanese Orthopedic Association score was observed 1 year postoperatively, but there were no significant differences between them.

Conclusions

Post-operative improvement of OAB symptoms in cervical spondylotic myelopathy patients was low, which indicated that OAB was most frequently attributable to non-neurogenic and idiopathic, but not neurogenic, causes. It is considered necessary to tell patients with cervical spondylotic myelopathy that the possibility of post-operative OAB symptom improvement is not high when the explanation for informed consent is given before the operation.