Laparoscopic fundoplication for gastroesophageal reflux disease

Gastroesophageal reflux disease(GERD) is a condition that develops when the reflux of gastric contents into the esophagus leads to troublesome symptoms and/or complications. Heartburn is the cardinal symptom, often associated with regurgitation. In patients with endoscopy-negative heartburn refractory to proton pump inhibitor(PPI) therapy and when the diagnosis of GERD is in question, direct reflux testing by impedance-pH monitoring is warranted. Laparoscopic fundoplication is the standard surgical treatment for GERD. It is highly effective in curing GERD with a 80% success rate at 20-year follow-up. The Nissen fundoplication, consisting of a total(360°) wrap, is the most commonly performed antireflux operation. To reduce postoperative dysphagia and gas bloating, partial fundoplications are also used, including the posterior(Toupet) fundoplication, and the anterior(Dor) fundoplication. Currently, there is consensus to advise laparoscopic fundoplication in PPI-responsive GERD only for those patients who develop untoward side-effects or complications from PPI therapy. PPI resistance is the real challenge in GERD. There is consensus that carefully selected GERD patients refractory to PPI therapy are eligible for laparoscopic fundoplication, provided that objective evidence of reflux as the cause of ongoing symptoms has been obtained. For this purpose, impedance-pH monitoring is regarded as the diagnostic gold standard.     

Surgical fundoplication in laryngopharyngeal reflux unresponsive to aggressive acid suppression: a controlled study.

BACKGROUND & AIMS: In patients with persistent laryngeal symptoms despite aggressive proton pump inhibitor therapy, gastroesophageal reflux disease (GERD) continues to be implicated. The role of surgical fundoplication as the definitive therapy for these patients is uncertain. METHODS: In this prospective concurrent controlled study, 72 patients with suspected GERD-related laryngeal symptoms received aggressive acid-suppressive therapy. Four-month symptomatic nonresponders (<50% improvement) with continued laryngeal inflammation and normalized esophageal acid exposure were offered laparoscopic Nissen fundoplication. The primary outcome was symptom improvement/resolution at 1 year after surgery. RESULTS: Twenty-five of 72 (35%) patients remained unresponsive after 4 months of acid-suppressive therapy. Ten patients (40%) underwent surgical fundoplication (median age, 54 y; men, 4) and 15 patients (60%) continued medical therapy (median age, 52; men, 4). The most common laryngeal symptoms were sore throat, hoarseness, and cough. pH studies at 3 and 12 months were normal in all patients after fundoplication (median % time pH < 4, .0% and .3%; respectively). One of 10 (10%) patients in the surgery group reported improvement of laryngeal symptoms at 1 year compared with 1 of 15 in the control group (6.7%) (P = 1.0). Treatment of causes other than GERD improved symptoms in an additional 2 of 10 (20%) patients in the surgical group, and 10 of 15 (66%) patients in the nonsurgical cohort. CONCLUSIONS: Surgical fundoplication does not improve laryngeal symptoms reliably in patients unresponsive to aggressive proton pump inhibitor therapy. The argument of low volume or intermittent reflux as the cause of persistent laryngeal symptoms needs to be replaced with evaluation and therapy for other potential non-GERD causes.     

Objective assessment of gastroesophageal reflux after extended Heller myotomy and total fundoplication for achalasia with the use of 24‐hour combined multichannel intraluminal impedance and pH monitoring (MII‐pH)

SUMMARY. This study aims to evaluate by the use of 24‐hour combined multichannel intraluminal impedance and pH monitoring (MII‐pH) the efficacy of the Nissen fundoplication in controlling both acid and nonacid gastroesophageal reflux (GER) in patients that underwent Heller myotomy for achalasia. It has been demonstrated that fundoplication prevents the pathologic acid GER after Heller myotomy, but no objective data exists on the efficacy of this antireflux surgery in controlling all types of reflux events. The study population consisted of 20 patients that underwent laparoscopic Heller myotomy and Nissen fundoplication for achalasia. All patients were investigated with manometry and MII‐pH. MII‐pH showed no evidence of postoperative pathologic GER. The overall number of GER episodes was normal in both the upright and recumbent position. This reduction was obtained because of the postoperative control of both the acid and nonacid reflux episodes. The Nissen fundoplication adequately controls both acid and nonacid GER after extended Heller myotomy. Further controls with MII‐pH are warranted to check at a longer follow‐up for the efficacy of this antireflux procedure in achalasic patients.     

Short-term symptom and quality-of-life comparison between laparoscopic Nissen and Toupet fundoplications

Laparoscopic antireflux surgery is an established method of treatment of gastroesophageal reflux disease (GERD). This study evaluates the efficacy of Nissen versus Toupet fundoplication in alleviating the symptoms of GERD and compares the two techniques for the development of post-fundoplication symptoms and quality of life (QOL) at 12 months post-surgery. In this prospective consecutive cohort study, 94 patients presenting for laparoscopic antireflux surgery underwent either laparoscopic Nissen fundoplication (LN) ( n  = 51) from February 2002 to February 2004 or a laparoscopic Toupet fundoplication (LT) ( n  = 43) from March 2004 to March 2006, performed by a single surgeon (G. S. S.). Symptom assessment, a QOL scoring instrument, and dysphagia questionnaires were applied pre- and postoperatively. At 12 months post-surgery, patient satisfaction levels in both groups were high and similar (LT: 98%, LN: 90%; P  = 0.21). The proportion of patients reporting improvement in their reflux symptoms was similar in both groups (LT: 95%, LN: 92%; P  = 0.68), as were post-fundoplication symptoms (LT: 30%, LN: 37%; P  = 0.52). Six patients in the Nissen group required dilatation for dysphagia compared with one in the Toupet group (LT: 2%, LN: 12%; P  = 0.12). One patient in the Nissen group required conversion to Toupet for persistent dysphagia ( P  = 0.54). In this series, overall symptom improvement, QOL, and patient satisfaction were equivalent 12 months following laparoscopic Nissen or Toupet fundoplication. There was no difference in post-fundoplication symptoms between the two groups, although there was a trend toward a higher dilatation requirement and reoperation after Nissen fundoplication.     

Laparoscopic fundoplication in mentally normal children with gastroesophageal reflux disease

Laparoscopic antireflux surgery has been performed in neurologically impaired and scoliotic children. We aimed to assess the effectiveness of laparoscopic fundoplication in mentally normal children with gastroesophageal reflux disease that failed to respond to medical therapy. Data were prospectively collected (symptoms, medical therapy, endoscopies' findings) on 12 children (nine boys, three girls) aged 9-15 years with gastroesophageal reflux disease. Pre- and postoperative ambulatory 24-h pH and DeMeester and Johnson scores were also recorded. Effectiveness of surgery was assessed by comparison of pre- and postoperative total acid exposure time, Visick grade, need for antireflux medication and symptom scores. In total, 11 children underwent a laparoscopic Nissen fundoplication and one underwent a Toupet procedure. Median length of stay was 2 (2-3) nights. The median preoperative pH acid exposure time (AET) was 4.7 (0.8-16.4) percent compared with postoperative AET of 0.4 (0-3) percent. Early postoperative dysphagia occurred in four out of 12 patients, requiring a total of six dilatations. Postoperative Visick scores were: grade I=7 and grade II=5. Laparoscopic fundoplication can be safely performed and is effective in children with GERD who have failed to respond to medical therapy.     

Minimally invasive surgery for gastroesophageal reflux disease]

Gastroesophageal reflux disease (GERD) is a chronic disease deteriorating patient's quality of life. With the advent of proton pump inhibitors, treatment failures have decreased considerably. However, surgical therapy offers the potential for cure in more than 90% of patients with GERD. Specific indications for antireflux surgery are: incomplete response to medical therapy, frequent recurrences despite the medical treatment, laryngopharyngeal, and/or respiratory symptoms, and complications of GERD, such as esophageal stricture, erosive esophagitis, esophageal ulcer, and/or Barrett's esophagus. The introduction of laparoscopic surgery in early ninties had a profound impact on many surgical fields, including the treatment of GERD. In this review, laparoscopic Nissen fundoplication is described and controversial topics, such as total vs. partial fundoplication, and the natural history of Barrett's esophagus after antireflux surgery are addressed.     

Management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a chronic condition requiring long-term treatment. Simple lifestyle modifications are the first methods employed by patients and, because of their low cost and simplicity, should be continued even when more potent therapies are initiated. Potent acid-suppressive therapy is currently the most important and successful medical therapy. Whereas healing of the esophageal mucosa is achieved with a single dose of any proton pump inhibitor (PPI) in more than 80% of cases, symptoms are more difficult to control. Patients with persistent symptoms on therapy should be tested (preferably with combined multichannel intraluminal impedance and pH) for association of symptoms with acid, nonacid, or no GER. Long-term follow-up studies indicate that PPIs are efficacious, tolerable, and safe medication. So far, promotility agents have shown limited efficacy, and their side-effect profile outweighs their benefits. Antireflux surgery in carefully selected patients (ie, young, typical GERD symptoms, abnormal pH study, and good response to PPI) is as effective as PPI therapy and should be offered to these patients as an alternative to medication. Still, patients should be informed about the risks of antireflux surgery (ie, risk of postoperative dysphagia; decreased ability to belch, possibly leading to bloating; increased flatulence). Endoscopic antireflux procedures are recommended only in selected patients and given the relative short experience with these techniques, patients treated with endoscopic procedures should be enrolled in a rigorous follow-up program.     

Duodenogastroesophageal reflux: results of medical treatment and antireflux surgery

BACKGROUND/AIMS: Recent studies have shown that reflux of the duodenal content to the esophagus plays an important role in esophageal mucosal damage. The aim of the study is to compare the duodenogastroesophageal (DGER) reflux with the severity of reflux esophagitis and evaluate its response to either medical and/or antireflux surgery. METHODOLOGY: Ninety-six patients with DGER were subjected to thorough history, upper GI endoscopy, barium study, esophageal manometry and 24-hr esophageal pH metry combined with Bilitec 2000. Medical treatment was given for all, while Nissen fundoplication was done for 28 patients. All patients were evaluated after Nissen fundoplication and treatment. RESULTS: The age of studied patients was 36.26+/-12.7 years with male to female ratio 2:1. The chief symptom was heartburn in 73 (76%) patients. Upper GI endoscopy revealed, 30 (31.2%) patients had grade I reflux, 30 (31.2%) patients had grade II reflux, 7 patients had grade III reflux, 5 patients had grade VI reflux, Barrett's esophagus in 14 patients (14.5%), hiatus hernia (HH) in 26 (27%) patients. Barium study revealed that, 40 (41.6%) patients had evidence of reflux, while 34 (35.4%) patients had reflux with HH. Esophageal motility revealed the mean LESP (12.7+/-7.6), 68 patients (70.8%) had normotensive body while ineffective esophageal body motility was encountered in 28 (29.1%) patients. Esophageal 24-hr pH study and Bilitec 2000 revealed that 54 (56.2%) patients had bile reflux with pathological acid reflux, while 42 (43.7%) patients had bile reflux in alkaline pH. Medical treatment gave excellent to good response in 68 (70.8%) patients, while Nissen fundoplication was done for 28 (29.2%) patients. Endoscopic examination 6 months after Nissen fundoplication showed marked improvement in endoscopic injury. Barium study after Nissen fundoplication revealed repair of HH and control of GERD in all patients except one. Esophageal motility, 24 hr pH study and Bilitec 2000, after 6 months of Nissen shows high significant increase in LESP, decrease in acid and bile reflux. No significant difference between open or laparoscopic fundoplication in LESP, acid and bile reflux. CONCLUSIONS: DGER in acid medium is more injurious to the esophagus than DGER in alkaline pH. The severity of esophageal injury does not correlate with the severity of acid or bile reflux but has a direct correlation with impaired distal esophageal motility. Medical treatment gives satisfactory control of symptoms and healing of esophageal lesion in 70% of DGER. The response to medical treatment does not depend on the severity of esophageal injury but depends on the severity of bile and acid reflux. Nissen fundoplication in refractory patients, either open or laparoscopic, was effective in control of heartburn in 95% of patients contrary to 50% in mixed symptoms.     

腹腔镜Nissen胃底折叠术与腹腔镜前180°部分胃底折叠术后5年临床效果的比较

目的:随机对照研究腹腔镜Nissen胃底折叠术及镜前180°部分胃底折叠术2种手术方式在术后5年的临床效果.方法:2006-03/12共有107例接受腹腔镜抗反流手术的患者随机分入腹腔镜Nissen胃底折叠术组和腹腔镜前180°部分胃底折叠术组,各组均采用标准手术操作.术后定期随访,对随访记录包括有无烧心反酸、吞咽困难、胀气症状、嗳气、是否排气过多等症状及手术满意度等进行主观评分.临床数据进行统计分析.结果:两组之间烧心症状以及服用质子泵抑制剂的比例没有显著性差异.出现吞咽困难的比例无明显差异,但是前胃底折叠术组患者吞咽困难的程度比Nissen组患者明显较轻.Nissen组的患者出现上腹胀气、无法有效嗳气及排气过多的比例较高.两组的总体临床效果满意度基本相同.术后5年大多数患者没有或只有轻微的反流症状.结论:腹腔镜前180°部分胃底折叠术抗反流效果持久,术后出现并发症及不良反应的比例明显低于Nissen胃底折叠术.腹腔镜前180°部分胃底折叠术可以作为临床治疗胃食管反流性疾病的常规手术方式.     

Gas-related symptoms after laparoscopic 360° Nissen or 270° Toupet fundoplication in gastrooesophageal reflux disease patients with aerophagia as comorbidity

BACKGROUND: Aerophagia is a rare but well-known comorbidity in patients with gastrooesophageal reflux disease. Particularly after laparoscopic Nissen fundoplication, it has proven to result in worse symptomatic outcome and a lower postoperative quality of life in comparison to patients without preoperative gas-related symptoms. AIMS: Aim of the study was to compare the postoperative outcome in gastrooesophageal reflux disease patients with aerophagia as comorbidity after either laparoscopic 360 degrees 'floppy' Nissen fundoplication or 270 degrees Toupet fundoplication with main focus on the frequency and subjective impairment of gas-related symptoms. PATIENTS AND METHODS: In 56 gastrooesophageal reflux disease patients, the comorbidity of aerophagia was diagnosed prior to laparoscopic antireflux surgery. Irrespective of their preoperative manometric findings, the patients were either scheduled to a laparoscopic 360 degrees 'floppy' Nissen (n=28) or a laparoscopic 270 degrees Toupet fundoplication (n=28). All patients have been analysed concerning the presence of gas-related symptoms preoperatively as well as 3 months after surgery. Additionally, the subjective degree of impairment was evaluated using a numerous rating scale (0=no perception/impairment, 100=most severe perception/impairment). The following symptoms have been analysed: ability/inability to belch, 'gas bloat', flatulence, postprandial fullness and epigastric pain. RESULTS: Before surgery, there were no significant differences between both surgical groups. Three months after surgery, significant differences (p<0.05-0.01) were found: patients who underwent a laparoscopic 270 degrees Toupet fundoplication suffered from less impairing gas bloat, flatulence and postprandial fullness when compared with patients with a 360 degrees 'floppy' Nissen fundoplication. The majority of these patients were able to belch postoperatively but felt no impairment due to this symptom. In contrast, patients of the Nissen group felt a significant impairment due to the inability to belch. CONCLUSION: Gas-related symptoms are very common in gastrooesophageal reflux disease patients with aerophagia as a comorbidity. Patients who undergo a laparoscopic Toupet fundoplication show less impairment in relation to gas-related problems compared with patients treated with a Nissen fundoplication for a follow-up period of at least 3 months. In the Toupet group, the ability to belch postoperatively seems to be a positive aspect from the patients' view which also improves the percentage of gas-related problems. However, long-term results are necessary.     

Yield of 24-Hour Esophageal pH and Bilitec Monitoring in Patients with Persisting Symptoms on PPI Therapy

Current management algorithms propose pH monitoring under proton pump inhibitors (PPIs) in suspected gastroesophageal reflux disease (GERD) with insufficient treatment response, but recent observations challenge this approach because of its low yield. AIM: To perform an audit of the outcomes of pH monitoring under PPI therapy in our unit, and to study the yield of additional nonacid reflux monitoring. METHODS: All pH monitoring studies under antireflux therapy since 1997, with or without simultaneous Bilitec monitoring, were analyzed. RESULTS: From 1997 to 2003, 347 patients (157 men, mean age 49.4 +/- 0.8 years) underwent pH studies on PPI therapy (28% half-, 67% full-, and 5% double-dose PPI) for persisting typical (53%) or atypical (75%) symptoms. In 184 patients, simultaneous Bilitec monitoring was performed. Esophageal pH monitoring on PPI was pathological in 105 (30%) patients. Pathological pH monitoring on PPI was associated with typical reflux symptoms (64 versus 52%, P = 0.03), and a higher prevalence of persisting esophagitis (54 versus 36%, P < 0.005) and of hiatal hernia (58 versus 27%, P < 0.005). Bilitec monitoring on PPI therapy was pathological in 114 (62%) patients, of which 74 (40%) had normal pH monitoring. Adding Bilitec increased the rate of abnormal results over pH monitoring alone, from 38% to 69% on half-dose, from 27% to 69% on full-dose, and from 0% to 38% on double-dose PPI. CONCLUSIONS: The rate of abnormal pH monitoring in symptomatic GERD patients while on PPI therapy is relatively low, especially in those on double-dose PPI. Combined pH and Bilitec monitoring significantly increased the rate of ongoing pathological reflux compared to pH alone in refractory to PPI therapy GERD patients.     

Endoscopic therapies for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) accounts for a substantial degree of medical resource utilization and is a common indication for outpatient physician visits. The primary therapy for GERD has been proton pump inhibitors (PPIs). Equally effective and reasonably safe for GERD is surgical therapy, specifically, laparoscopic Nissen fundoplication. Medical therapy is used initially, with surgery reserved for patients with refractory symptoms despite optimal medical management, to avoid the added risks of abdominal surgery. As such, there has been considerable investigation into minimally invasive, endoscopic therapies for patients who respond to PPI, but would prefer to avoid long-term medication use. Here, we discuss the anatomical and physiological barriers that must be overcome by such devices. We further review the data on currently available endoscopic devices. Despite considerable interest and resources in developing an effective endoscopic therapy for GERD, none of the currently available technologies have demonstrated an ability to overcome the pathophysiological hurdles present in most patients with GERD. Furthermore, well-designed trials have not demonstrated adequate clinical efficacy for these endoscopic devices. As such, despite a growing need for an intermediate therapy between PPI and fundoplication, at present there is not adequate evidence to recommend endoscopic therapy for patients with GERD.     

Revision of failed transoral incisionless fundoplication by subsequent laparoscopic Nissen fundoplication

AIM:To evaluate the feasibility and outcomes of laparoscopic Nissen fundoplication after failed transoral incisionless fundoplication(TIF).METHODS:TIF is a new endoscopic approach for treating gastroesophageal reflux disease(GERD).In cases of TIF failure,subsequent laparoscopic fundoplication may be required.All patients from 2010 to 2013 who had persistence and objective evidence of recurrent GERD after TIF underwent laparoscopic Nissen fundoplication.Primary outcome measures included operative time,blood loss,length of hospital stay and complications encountered.RESULTS:A total of 5 patients underwent revisional laparoscopic Nissen fundoplication(LNF)or gastrojejunostomy for recurrent GERD at a median interval of 24mo(range:16-34 mo)after TIF.Patients had recurrent reflux symptoms at an average of 1 mo following TIF(range:1-9 mo).Average operative time for revisionalsurgical intervention was 127 min(range:65-240 min)and all surgeries were performed with a minimal blood loss(<50 m L).There were no cases of gastric or esophageal perforation.Three patients had additional finding of a significant hiatal hernia that was fixed simultaneously.Median length of hospitalization was 2 d(range:1-3 d).All patients had resolution of symptoms at the last follow up.CONCLUSION:LNF is a feasible and safe option in a patient who has persistent GERD after a TIF.Previous TIF did not result in additional operative morbidity.     

Update on Fundoplication for the Treatment of GERD

Rudolph Nissen firstly implemented the idea of surgical treatment of gastroesophageal reflux more than 55 years ago. Today, laparoscopic fundoplication has become the surgical “golden standard” for the treatment of GERD. However, the initial enthusiasm and increasing number of performed procedures in the early 1990s declined dramatically between 2000 and 2006. Despite its excellent outcome, laparoscopic fundoplication is only offered to a minority of patients who are suffering from GERD. In this article we review the current indications for antireflux surgery, technical and intraoperative aspects of fundoplication, perioperative complications as well as short and long-term outcome. The focus is on the laparoscopic approach as the current surgical procedure of choice.     

Positive predictors for gastroesophageal reflux disease and the therapeutic response to proton-pump inhibitors

AIM:To identify objective and subjective predictors for the reliable diagnosis of gastroesophageal reflux disease(GERD)and the response to proton pump inhibitor(PPI)therapy.METHODS:Retrospectively,683 consecutive patients suspected for GERD who underwent pH-metry/impedance measurement(pH/MII)were analyzed.All patients had previously undergone standard PPI treatment(e.g.,pantoprazole 40 mg/d or comparable).Four hundred sixty patients were at least 10 d off PPIs(group A),whereas 223 patients were analyzed during their ongoing PPI therapy(group B).In addition,all patients completed a standardized symptom-and lifestyle-based questionnaire,including the therapeutic response to previous PPI trials on a 10-point scale.Uniand multivariance analyses were performed to identify criteria associated with positive therapeutic response to PPIs.RESULTS:In group A,positive predictors(PPs)for response in empirical PPI trials were typical GERD symptoms(heartburn and regurgitation),a positive symptom index(SI)and pathological results in pH/MII,along with atypical symptoms,including hoarseness and fullness.In group B,regular alcohol consumption was associated with the therapeutic response.The PPs for pathological results in pH/MII in group A included positive SI,male gender,obesity,heartburn and regurgitation.In group B,the PPs were positive SI and vomiting.Analyzing for positive SI,the PPs were pathological pH and/or MII,heartburn regurgitation,fullness,nausea and vomiting in group A and pathological pH and/or MII in group B.CONCLUSION:Anamnestic parameters(gender,obesity,alcohol)can predict PPI responses.In non-obese,female patients with non-typical reflux symptoms,pH/MII should be considered instead of empirical PPIs.     

Reflux-induced laryngitis (laryngopharyngeal reflux)

Opinion statement Gastroesophageal reflux disease (GERD) has been increasingly associated with ear, nose, and throat (ENT) signs and symptoms. This condition, often referred to as laryngopharyngeal reflux (LPR) has become increasingly prevalent. However, the cause and effect relationship between GERD and laryngeal signs or symptoms is far from established. Many patients diagnosed initially with GERD as the cause of laryngeal signs do not symptomatically or laryngoscopically respond to aggressive acid suppression and do not have abnormal esophageal acid exposure by pH monitoring. This has resulted in frustration on the part of both gastroenterologists and ENT physicians and confusion on the part of patients. The current recommendations for the management of LPR patients call for initial empiric therapy with twice daily proton-pump inhibitors (PPIs) for 2 to 4 months. In those unresponsive to such therapy, diagnostic testing with prolonged pH monitoring may be indicated. However, in the majority of such patients, the reason for lack of response to PPI therapy may be irritation of the larynx by causes other than GERD. Surgical fundoplication in this group of patients has lower efficacy than in those with typical symptoms of GERD and is reserved for those with improvement on acid-suppressive therapy.     

Functional heartburn

Opinion statement Functional heartburn (FH) is a common disorder that accounts for 30% to 50% of the patients with nonerosive reflux disease. FH is composed from a heterogeneous group of patients. They primarily include the hypersensitive and the nonacid sensitive esophagus. The mechanisms responsible for pain, clinical characteristics, and the optimal therapeutic approach of FH remain to be fully elucidated. Symptom response rate to potent antireflux treatment is significantly lower in FH patients as compared with any other gastroesophageal reflux disease (GERD) group, suggesting that in proton pump inhibitor (PPI) non-responders mechanisms other than acid reflux are likely the cause of symptoms. Patients with FH should be approached therapeutically as patients with GERD and should initially receive antireflux medications. Due to the need for profound acid suppression in this group of patients, PPIs should be considered relatively early in their care. Failure to respond to standard dosage of PPI is common and will require doubling the dose. If patients continue to report heartburn symptoms while receiving PPI twice daily, adding or switching to pain modulators/visceral analgesics is an appropriate therapeutic approach. Data about the usage of other therapeutic modalities in FH such as antireflux surgery, endoscopic treatment for GERD, and psychotherapy are still unavailable. Emerging treatment will likely include novel pain modulators and more effective antireflux medications.     

Evaluation of Patients with Suspected Laryngopharyngeal Reflux: A Practical Approach

Laryngopharyngeal reflux (LPR) is associated with symptoms of laryngeal irritation such as throat pain, cough, and voice change. Currently, the two main diagnostic tools are laryngoscopy and reflux monitoring. On laryngoscopy, the signs most commonly used to diagnose LPR are erythema and edema of the larynx; however, these signs are not specific for LPR, may be associated with other causes, and may even be found in healthy individuals. In addition, pH testing has low sensitivity in diagnosing gastroesophageal reflux disease-related laryngeal findings. Proton pump inhibitor (PPI) therapy remains the cornerstone of treatment. The current management recommendation for this group of patients is empiric therapy with twice-daily PPIs for 1 to 2 months. In the majority of those who are unresponsive to such therapy, other causes of laryngeal irritation are considered. Surgical fundoplication is most effective in those who are responsive to acid-suppressive therapy.     

Esophageal pH-impedance monitoring and symptom analysis in GERD: a study in patients off and on therapy

INTRODUCTION: Combined esophageal pH-impedance monitoring allows detection of nearly all gastroesophageal reflux episodes, acid as well as nonacid. However, the role of nonacid reflux in the pathogenesis of symptoms is poorly known. The aim of this study was to evaluate the diagnostic yield of this technique in patients with suspected reflux symptoms while on or off PPI therapy. PATIENTS AND METHODS: The recordings of 150 patients recruited at seven academic centers with symptoms possibly related to gastroesophageal reflux were analyzed. Reflux events were detected visually using impedance (Sandhill, CO) and then characterized by pHmetry as acid or nonacid reflux. The temporal relationship between symptoms and reflux episodes was analyzed: a symptom association probability (SAP) > or =95% was considered indicative of a positive association. RESULTS: One hundred fifty patients were included, 102 women (mean age 52 +/- 14 yr, range 16-84). Among the 79 patients off PPI, five did not report any symptom during the recording period. A positive SAP was found in 41 of the 74 symptomatic patients (55.4%), including acid reflux in 23 (31.1%), nonacid reflux in three (4.1%), and acid and nonacid in 15 (20.3%). In the group of patients on PPI (N = 71, 46 women, mean age 51 +/- 15 yr), 11 were asymptomatic during the study, SAP was positive in 22 of the 60 symptomatic patients (36.7%), including acid reflux in three (5.0%), nonacid reflux in 10 (16.7%), and acid and nonacid in nine (15.0%). The symptoms most frequently associated with nonacid reflux were regurgitation and cough. CONCLUSION: Adding impedance to pH monitoring improves the diagnostic yield and allows better symptom analysis than pHmetry alone, mainly in patients on PPI therapy. The impact of this improved diagnostic value on gastroesophageal reflux disease management remains to be investigated by outcome studies.