Gastroesophageal disease and nausea: does fundoplication help or hurt?

HYPOTHESIS: Nausea associated with gastroesophageal reflux disease is cured by laparoscopic Nissen fundoplication (LNF). DESIGN: Prospective cohort study of unselected patients who underwent LNF from January 1, 1995, through March 31, 1999. Patients were followed up by a physician for 6 to 36 months. SETTING: A large community teaching hospital. PATIENTS: One hundred consecutive patients with gastroesophageal reflux disease who underwent LNF; all patients were followed up. Patients were grouped according to the presence (group A, n = 33) or absence (group B, n = 67) of preoperative nausea. Interventions were LNF, esophageal manometry, 24-hour pH monitoring, and nuclear gastric emptying studies. MAIN OUTCOME MEASURES: Resolution of symptoms after LNF. RESULTS: Nausea was the most common atypical symptom of gastroesophageal reflux disease, occurring in 33 patients (33%). There were no differences in esophageal manometry or 24-hour pH results between groups. There was a female preponderance in group A (55% vs 33%; P = .003). Patients in group A had a higher prevalence of preoperative dysphagia (P = .02). Patients with persistent postoperative nausea had a higher prevalence of cough (P = .003) and dysphagia (P = .009). The LNF was more effective in reducing heartburn (95% reduction) and regurgitation (95% reduction) than cough and dysphagia (60% reduction). There was a 79% reduction in the number of patients with nausea (33 to 7; P<.001). CONCLUSION: Laparoscopic Nissen fundoplication is effective in eliminating nausea associated with gastroesophageal reflux disease and is not contraindicated in these patients.     

Effect of Laparoscopic fundoplication on gastroesophageal reflux disease-induced respiratory symptoms

Laparoscopic fundoplication controls heartburn and regurgitation, but the effects on the respiratory symptoms of gastroesophageal reflux disease (GERD) are unclear. Confusion stems from difficulty preoperatively in determining whether cough or wheezing is actually caused by reflux when reflux is found on pH monitoring. To date, there is no proven way to pinpoint a cause-and-effect relationship. The goals of this study were to assess the following: (1) the value of pH monitoring in establishing a correlation between respiratory symptoms and reflux; (2) the predictive value of pH monitoring on the results of surgical treatment; and (3) the outcome of laparoscopic fundoplication on GERD-induced respiratory symptoms. Between October 1992 and October 1998, a total of 340 patients underwent laparoscopic fundoplication for GERD. From the clinical findings alone, respiratory symptoms were thought possibly to be caused by GERD in 39 patients (11 %). These 39 patients had been symptomatic for an average of 134 months. They were all taking H-blocking agents (21 %) or proton pump inhibitors (79%). Seven patients (18%) were also being treated with bronchodilators, alone (3 patients) or in combination with prednisonc (4 patients). Median length of postoperative follow-up was 28 months. In 23 patients (59%) a temporal correlation was found during 24-hour pH monitoring between respiratory symptoms and episodes of reflux. Postoperatively heartburn resolved in 91% of patients, regurgitation in 90% of patients, wheezing in 64% of patients, and cough in 74% of patients. Cough resolved in 19 (83%) of 23 patients in whom a correlation between cough and reflux was found during pH monitoring, but in only 8 (57%) of 14 of patients when this correlation was absent. Cough persisted postoperatively in the two patients who did not cough during the study. These data show that pH monitoring helped to establish a correlation between respiratory symptoms and reflux, and it helped to identify the patients most likely to benefit from antircflux surgery. Following laparoscopic surgery, respiratory symptoms resolved in 83% of patients when a temporal correlation between cough and reflux was found on pH monitoring; heartburn and regurgitation resolved in 90%. Presented at the Fortieth Annual Meeting ot The Society for Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999.     

Radiofrequency energy delivery to the lower esophageal sphincter (Stretta procedure) does not provide long-term symptom control

The Stretta procedure (radiofrequency energy application to the lower esophageal sphincter) is a unique endoluminal technique for the management of gastroesophageal reflux. This article reports on the long-term effectiveness of the Stretta procedure in patients with significant gastroesophageal reflux disease (GERD) referred to a surgical practice. Patients who underwent Stretta with a minimum of 36 months follow-up were included. Thirty-two patients with an average follow-up of 53 months were included; 19 proceeded to anti-reflux surgery. Those not undergoing surgery showed a significant improvement in their GERD satisfaction from 3.14 to 1.46 (P = .0006) but had significantly lower preprocedure heartburn scores (2.43) than those who proceeded to surgery (3.66, P = .0401). The Stretta procedure was effective in reducing symptoms in 40% of patients. Responders had less severe preoperative heartburn. Radiofrequency energy delivery to the lower esophageal sphincter may be effective in selected patients for the treatment of gastroesophageal reflux.     

Gastroesophageal reflux and pulmonary aspiration: incidence, functional abnormality, and results of surgical therapy.

The incidence of aspiration, the causative esophageal pathophysiology, and the results of surgical therapy were evaluated in 100 patients with abnormal gastroesophageal reflux documented by 24-hour esophageal pH monitoring. Based on historical evidence, 48 patients were suspected to be aspirators. Eight patients had documented episodes of aspiration (drop on esophagela pH, followed by acid taste in mouth and onset of cough or wheezing spell) during the monitoring period. Nine patients were considered to be potential aspirators because they presented oral acid regurgitation without development of pulmonary symptoms. In five patients a primary respiratory disorder (PRD) induced gastroesophageal reflux. The remaining 78 patients had abnormal reflux without aspiartion or regurgitation. Aspirators had a 75% incidence of esophageal motor abnormality on manometry, and the clearance of refluxed acid was significantly delayed in the supine position. A history of heartburn and endoscopic evidence of esophagitis were present in only half of the patients who were documented aspirators. Potential aspirators were spared from aspiration by rapid esophageal clearance of refluxed acid unaffected by changes in body position. Patients with a PRD had higher distal esophageal segment (DES) pressure and normal esophageal motility with minimal esophagitis. Nonaspirators significantly improved their clearance while in the supine position, emphasizing the protective effect of esophageal peristalsis against aspiration. An antireflux procedure in five aspirators raised the DES pressure significantly and returned the reflux status to normal by 24-hour pH-monitoring standards. The incidence of aspiration appears to be less than that suspected by history and is due to a motor disorder that interferes with the ability of the esophagus to clear reflex acid. Abnormal pulmonary symptoms can induce or result from gastroesophageal reflux and, when the latter occurs, an antireflex procedure stops both reflux and aspiration.     

Clinical outcomes of atypical extra-esophageal reflux symptoms following laparoscopic antireflux surgery

Introduction  

While it is well established that antireflux surgery is effective in relieving typical gastroesophageal reflux disease (GERD) symptoms such as heartburn and regurgitation, it is currently unclear whether atypical symptoms (cough, hoarseness, wheeze) foreshadow a less satisfactory outcome following laparoscopic antireflux surgery (LARS). The purpose of this study is to critically analyze the clinical outcomes of atypical symptoms in patients undergoing LARS.     

Alkaline gastroesophageal reflux.

Twenty-four hour monitoring provides a continuous record of the pH of the lower esophagus in a near physiologic setting. The upper level of physiologic reflux was determined from the percentage of time and the number of episodes that the pH was less than 4 or more than 7 and the mean duration of each episode in fifteen asymptomatic subjects. One hundred patients with symptoms of gastroesophageal reflux were divided into four groups on the basis of twenty-four hour pH monitoring: those with abnormal acid but normal alkaline reflux, termed acid refluxers (51 patients); those with both abnormal acid and alkaline reflux, termed acid-alkaline refluxers (25); those with normal acid and abnormal alkaline reflux, termed alkaline refluxers (6); and those with both normal acid and alkaline reflux, termed nonrefluxers (18).Nonrefluxers had a similar incidence of heartburn, regurgitation, and dysphagia as acid and acid-alkaline refluxers, proving the inaccuracy of symptoms for detecting reflux. Alkaline refluxers had a lesser incidence of heartburn but a greater incidence of regurgitation, and four alkaline reflux patients presented with severe pulmonary disease secondary to aspiration. Similar incidence and degree of esophagitis was seen in acid, acid-alkaline, and alkaline refluxers. All three groups of symptomatic refluxers had a mean distal esophageal sphincter pressure significantly lower than that of the control asymptomatic subjects. There was no difference in the distal esophageal sphincter pressure between controls and symptomatic nonrefluxers.Nine of the patients with acid-alkaline reflux and one of the patients with alkaline reflux underwent an antireflux procedure and were restudied three months postoperatively. All ten patients had a 24 hour pH acid score within normal limits, but two had an abnormal 24 hour pH alkaline score. In both patients, reflux was demonstrated after placing an acid load in the stomach.It is concluded that symptomatic gastroesophageal reflux in patients with an intact gastrointestinal tract is a mixture of both acid and alkaline secretions, with one or both abnormal due to different degrees of acid production and pyloric regurgitation. Patients with alkaline reflux may develop serious complications of reflux in the absence of typical symptoms of heartburn. Twenty-four hour pH monitoring of the esophagus is useful in the identification of these patients and in evaluating the ability of an antireflux procedure to control both abnormal acid and alkaline reflux.     

Laparoscopic Nissen fundoplication improves quality of life in patients with atypical symptoms of gastroesophageal reflux

Laparoscopic Nissen fundoplication has been shown to improve overall quality of life (QOL) in patients with gastroesophageal reflux, but most studies have not addressed patients with atypical symptoms. We investigated the effect of laparoscopic Nissen fundoplication on QOL using the Gastrointestinal Quality of Life Index (GIQLI) survey modified to address both typical (heartburn, regurgitation, dysphagia) and atypical (hoarse voice, chronic cough, adult-onset asthma, vocal cord polyps) symptoms. One-hundred forty-eight patients underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease (GERD) at UCLA Medical Center from January 1, 1995 to May 1, 2002. Surveys evaluating pre- and postoperative QOL were administered after surgery: 55 per cent of patients responded (82/148). Forty-eight per cent of all patients (72/148) had atypical symptoms. Perioperative morbidity and mortality were 8.8 per cent and 0.7 per cent, respectively. Mean length of postoperative stay was 2.96 +/- 1.5 days. Mean follow-up for the entire cohort was 18.5 months. Postoperative dysphagia not present before surgery occurred in 4.7 per cent of patients. Eighty per cent of patients were medication-free following surgery. QOL scores for all participants increased significantly from 52.5 +/- 15.3 preoperatively to 72.0 +/- 14.9 postoperatively (P < 0.0001). Patients with atypical symptoms or typical symptoms alone showed significant mean QOL score increases from 48.3 +/- 17.6 preoperatively to 71 +/- 15.7 postoperatively (P < 0.0001) and from 55.7 +/- 12.6 to 72.8 +/- 14.4 (P < 0.0001), respectively. Laparoscopic Nissen fundoplication can effectively improve overall QOL for patients with GERD. Patients with atypical GERD symptoms can experience increases in QOL similar to those with only typical gastrointestinal symptoms.     

A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease.

OBJECTIVE: The authors examined indications, evaluations, and outcomes after laparoscopic fundoplication in patients with gastroesophageal reflux through this single-institution study. SUMMARY OF BACKGROUND DATA: Laparoscopic fundoplication has been performed for less than 5 years, yet the early and intermediate results suggest that this operation is safe and equivalent in efficacy to open techniques of antireflux surgery. METHODS: Over a 4-year period, 300 patients underwent laparoscopic Nissen fundoplication (252) or laparoscopic Toupet fundoplication (48) for gastroesophageal reflux refractory to medical therapy or requiring daily therapy with omeprazole or high-dose H2 antagonists. Preoperative evaluation included symptom assessment, esophagogastroduodenoscopy, 24-hour pH evaluation, and esophageal motility study. Physiologic follow-up included 24-hour pH study and esophageal motility study performed 6 weeks and 1 to 3 years after operation. RESULTS: The most frequent indication for surgery was the presence of residual typical and atypical gastroesophageal reflux symptoms (64%) despite standard doses of proton pump inhibitors. At preoperative evaluation, 51% of patients had erosive esophagitis, stricture, or Barrett's metaplasia. Ninety-eight percent of patients had an abnormal 24-hour pH study. Seventeen percent had impaired esophageal motility and 2% had aperistalsis. There were four conversions to open fundoplication (adhesions, three; large liver, one). Intraoperative technical difficulties occurred in 19(6%) patients and were dealt with intraoperatively in all but 1 patient (bleeding from enlarged left liver lobe). Minor complications occurred in 6% and major complications in 2%. There was no mortality. Median follow-up was 17 months. One year after operation, heartburn was absent in 93%. Four percent took occasional H2 antagonists, and 3% were back on daily therapy. Atypical reflux symptoms (e.g., asthma, hoarseness, chest pain, or cough) were eliminated or improved in 87% and no better in 13%. Overall patient satisfaction was 97%. Four patients have subsequently undergone laparotomy for repair of gastric perforation (1 year after operation), severe dumping, "slipped" Nissen, and repair of acute paraesophageal herniation. Two patients had laparoscopic revision of herniated fundoplications. Results of follow-up 24-hour pH studies were normal in 91% of patients more than 1 year after operation. In patients with poor esophageal motility, esophageal body pressure improved 1 year after operation in 75% and worsened in 10%. CONCLUSIONS: Although long-term efficacy data are lacking, intermediate follow-up shows laparoscopic fundoplication to be safe and effective. A physiologic approach to evaluation and follow-up of patients with gastroesophageal disease allows the surgeon to tailor antireflux surgery to esophageal body function and follow the function of the fundoplication and esophagus after operation.     

Surgical repair of recurrent hiatal hernia

The surgical management results of recurrent hiatal hernia repair are unknown in the laparoscopic era. The experience of the senior authors (CJF) and (SKM) is reported herein. From 1993 to 2004, 52 patients underwent re-operative hiatal hernia surgery at our center. Preoperative symptoms were heartburn, chest pain, dysphagia, regurgitation and pulmonary manifestations of gastroesophageal reflux disease. Patients had preoperative evaluation by upper endoscopy, pH-monitoring, esophagogram and manometry to assess the mechanism of failure. Pre- and postoperative symptoms were assessed utilizing a standardized questionnaire. Patients underwent laparoscopic repair (n=18), open laparotomy (n=6) and transthoracic surgery (n=28). Ninety-five percent follow-up was achieved with a mean follow-up of 34 months. Thirty-seven percent of patients encountered para-operative complications one of them died due to respiratory insufficiency. Five patients experienced a re-recurrent hernia. The symptom resolution was 65% for dysphagia, 68% for heartburn, 95% for chest pain and 79% for regurgitation. The overall patient satisfaction was 6.94 on a scale of 1–10. There was no significant difference in patient outcome when comparing the operative approaches or disease process. Surgical repair of recurrent hiatal hernias is safe and effective. Laparoscopic surgery is an appropriate alternative approach for recurrent hiatal hernia repair in selected patients.     

Evaluation of gastroesophageal reflux disease

Patients with gastroesophageal reflux disease (GERD) may present with a variety of symptoms, including heartburn, regurgitation, dysphagia, chronic cough, laryngitis, or even asthma. Therefore, the clinical presentation of GERD varies among individuals and conversely symptoms not always correspond to the presence of actual reflux. For that reason, the diagnosis poses certain challenges to the physician. To overcome these challenges, a thorough clinical examination followed by objective functional testing could improve diagnostic accuracy. In addition, a proper evaluation of patients with GERD can help in identifying those who will likely benefit the most from an antireflux procedure. The diagnostic work-up of these patients should include: symptomatic evaluation, upper endoscopy, barium swallow, high-resolution manometry, and ambulatory pH monitoring. Once a proper diagnosis of GERD is achieved, antireflux surgery is an excellent option for patients with partial control of symptoms with medication, for patients who do not want to be on long-term medical treatment (compliance/cost), or when complications of medical treatment occur.     

Preoperative symptom evaluation and esophageal acid infusion predict response to laparoscopic Nissen fundoplication in gastroesophageal reflux patients who present with cough

BACKGROUND: Most patients with cough and gastroesophageal reflux disease (GERD) improve on medical treatment with proton pump inhibitors (PPI). Nonresponders may be considered for antireflux surgery, but the selection of patients is difficult. METHODS: We have performed laparoscopic Nissen fundoplications (LNF) in 677 patients. Of these patients, 81% have undergone 6-month follow-up assessment with 24-h pH testing, esophageal manometry, symptom scores, and quality-of-life scores. RESULTS: LNF controlled heartburn in 93% and improved cough in 81%. Stepwise multiple regression showed that the preoperative cough score (r = 0.620, p <0.0001) and change in cough on and off PPI (r = 0.296, p = 0.0002) predicted improvement after surgery. A positive result on a randomized acid infusion test was associated with a greater improvement in cough after surgery (p = 0.0243). CONCLUSION: An acid infusion test and assessment of cough on and off PPI may be useful preoperative tools for the selection of patients with cough for LNF.     

Diagnosis of gastroesophageal reflux and Barrett esophagus

Gastroesophageal reflux is a very common disorder. Typical symptoms are heartburn, regurgitation and chest pain. Recently, it has been demonstrated that gastroesophageal reflux may generate or worse extraesophageal symptoms such as asthma, chronic bronchitis, posterior laryngitis, and chronic cough. The diagnosis of gastroesophageal reflux is suggested by typical symptoms which improve under a therapy with proton pump inhibitors. pH-monitoring over 24 hours is able to establish directly the diagnosis by measuring acid reflux into the esophagus. Manometry detects the two most common causes of gastroesophageal reflux: insufficiency of the lower esophageal sphincter or esophageal motility abnormalities. Gastroesophageal reflux can lead to reflux esophagitis, which is diagnosed endoscopically. An endoscopy should routinely be performed in case of dysphagia, anemia, or loss of weight. A long-term sequela of gastroesophageal reflux is the development of Barrett's-esophagus, a condition which has to be verified by endoscopy and biopsy. This premalignant lesion is defined by a metaplastic change from the normal squamous mucosa to a specialized intestinal epithelium characterized by goblet cells. Because dysplasia in these metaplastic areas can lead to esophageal adenocarcinoma, regular endoscopic surveillance with biopsies is recommended. Gastroesophageal reflux can significantly impair the quality of life and can cause complications that include the neoplastic progression from Barrett's esophagus to carcinoma. Therefore, appropriate diagnostic procedures and adequate therapy are required. This article summarizes the diagnostic approach to patients with gastroesophageal reflux, reflux esophagitis and Barrett's-esophagus. The impact of endoscopy, pH-monitoring, esophageal manometry, radiology and scintigraphy are reviewed.     

LAPAROSCOPIC ANTIREFLUX SURGERY IN PATIENTS WITH EXTRA ESOPHAGEAL SYMPTOMS RELATED TO ASTHMA

Background

Asthma, laryngitis and chronic cough are atypical symptoms of the gastroesophageal reflux disease.

Aim

To analyze the efficacy of laparoscopic surgery in the remission of extra-esophageal symptoms in patients with gastroesophageal reflux, related to asthma.

Methods

Were reviewed the medical records of 400 patients with gastroesophageal reflux disease submitted to laparoscopic Nissen fundoplication from 1994 to 2006, and identified 30 patients with extra-esophageal symptoms related to asthma. The variables considered were: gender, age, gastroesophageal symptoms (heartburn, acid reflux and dysphagia), time of reflux disease, treatment with proton pump inhibitor, use of specific medications, treatment and evolution, number of attacks and degree of esophagitis. Data were subjected to statistical analysis, comparing the pre- and post-surgical findings.

Results

The comparative analysis before surgery (T1) and six months after surgery (T2) showed a significant reduction on heartburn and reflux symptoms. Apart from that, there was a significant difference between the patients with daily crises of asthma (T1 versus T2, 45.83% to 16.67%, p=0.0002) and continuous crises (T1, 41.67% versus T2, 8.33%, p=0.0002).

Conclusion

Laparoscopic Nissen fundoplication was effective in improving symptoms that are typical of reflux disease and clinical manifestations of asthma.     

Outcome after laparoscopic fundoplication is not dependent on a structurally defective lower esophageal sphincter

With the advent of laparoscopic surgery and the recognition that gastroesophageal reflux disease often requires lifelong medication, patients with normal resting sphincter characteristics are now being considered for surgery. The outcome of these patients after fundoplication is unknown and formed the basis of this study. The study population consisted of 123 patients undergoing laparoscopic Nissen fundoplication between 1992 and 1996. All patients had increased esophageal acid exposure on 24-hour esophageal pH monitoring. Patients were divided into those with a normal (n = 36) and those with a structurally defective (n = 87) lower esophageal sphincter (LES), based on LES resting pressure (normal >6 mm Hg), overall length (normal >2 cm), and abdominal length (normal > 1 cm), and their outcomes were assessed. Each group was subsequently divided into patients presenting with a primary symptom that was "typical" (heartburn, regurgitation, or dysphagia) or "atypical" (gastric, respiratory, or chest pain) of gastroesophageal reflux, and outcome was assessed. Median duration of follow-up was 18 months after surgery. Overall, laparoscopic fundoplication was successful in relieving symptoms of gastroesophageal reflux in 90% of patients. Patients with a typical primary symptom had an excellent outcome irrespective of the resting status of the LES (95% and 97%, respectively). Atypical primary symptoms were significantly more common in patients with a normal LES (29%) than in those with a structurally defective LES (10%; P <0.05), and these symptoms were less likely (50%) to be relieved by antireflux surgery. Laparoscopic antireflux surgery is highly successful and not dependent on the status of the resting LES in patients with increased esophageal acid exposure and primary symptoms "typical" of gastroesophageal reflux. Antireflux surgery should be applied cautiously in patients with atypical primary symptoms. Presented in part at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14,1997.     

Heartburn is more likely to recur after Toupet fundoplication than Nissen fundoplication

Toupet (270 degrees) fundoplication is commonly recommended for patients with gastroesophageal reflux (GER) and esophageal dysmotility. However, Toupet fundoplication may be less effective at protecting against reflux than Nissen (360 degrees) fundoplication. We therefore compared the effectiveness and durability of both types of fundoplication as a function of preoperative esophageal motility. From January 1992 through January 1998, 669 patients with GER underwent laparoscopic fundoplication (78 Toupet, 591 Nissen). Patients scored heartburn, regurgitation, and dysphagia preoperatively, and at 6 weeks and 1 year postoperatively, using a 0 ("none") to 3 ("severe") scale. We compared symptom scores (Wilcoxon rank sum test) and redo fundoplication rates (Fisher exact test) in Toupet and Nissen patients. We also performed subgroup analyses on 81 patients with impaired esophageal motility (mean peristaltic amplitude, <30 mm Hg or peristalsis <70% of wet swallows) and 588 patients with normal esophageal motility. Toupet and Nissen patients reported similar preoperative heartburn, regurgitation, and dysphagia. At 6 weeks after operation, heartburn and regurgitation were similarly improved in both groups, but dysphagia was more prevalent among Nissen patients. After 1 year, heartburn and regurgitation were re-emerging in Toupet patients, and dysphagia was again similar between groups. Patients with impaired motility who have Nissen fundoplication are no more likely to suffer persistent dysphagia than their counterparts who have Toupet fundoplication. In addition, patients with normal motility are more likely to develop symptom recurrence after Toupet fundoplication than Nissen fundoplication, with no distinction in dysphagia rates. We conclude that since Toupet patients suffer more heartburn recurrence than Nissen patients, with similar dysphagia, selective use of Toupet fundoplication requires further study.     

Gastroesophageal scintigraphy to assess the severity of gastroesophageal reflux disease.

Thirty-six (36) patients with symptomatic gastroesophageal reflux were studied. Symptoms of heartburn, regurgitation and dysphagia were scored as to their severity and compared to quantitative tests of gastroesophageal reflux. Patients were studied with the acid reflux test, fiberoptic endoscopy, esophageal mucosal biopsy with a pinch forceps, esophageal manometry and radioisotopic gastroesophageal scintigraphy. Symptoms were scored according to an arbitrary grading system as mild, moderate, or severe. There were significant correlations between symptoms scores and both the degree of endoscopic esophagitis and the gastroesophageal reflux indices as measured by the radioisotopic scintiscan, but not with the degree of histologic esophagitis or lower esophageal sphincter pressure. Review of the findings suggests the following profile for patients who might require antireflux surgery: severe symptoms, presence of endoscopic esophagitis; resting lower esophageal sphincter pressure below 10 mmHg; and gastroesophageal reflux index above 10%.     

Prospective study of laparoscopic nissen fundoplication in a community hospital and its effect on typical, atypical, and nonspecific gastrointestinal symptoms.

BACKGROUND: Laparoscopic Nissen fundoplication (LNF) provides long-term improvement in the typical symptoms of gastroesophageal reflux disease. Few studies have prospectively addressed LNF in the community hospital or the effect of LNF on specific atypical symptoms, other related gastrointestinal symptoms, and weight change. METHODS: Data were collected prospectively on consecutive patients having LNF. Three typical, 6 atypical, and 3 other gastrointestinal symptoms were studied. RESULTS: Short-term data on 91 patients and long-term data on 84 patients were studied. Overall long-term improvement was 98%. Regarding typical symptoms, the greatest improvement occurred in heartburn and regurgitation. Regarding atypical symptoms, the greatest improvement occurred in cough and sore throat, but chest pain, hoarseness, and throat clearing also showed significant durable improvement. Bloating, nausea, and diarrhea showed no significant change from preoperative to postoperative surveys. Mild weight loss was common. CONCLUSION: LNF can be safely performed in a community hospital with results equal to those of university hospitals. Improvement in typical symptoms was greater than improvement in atypical symptoms, but results for both were significant and durable. Nonspecific gastrointestinal symptoms, such as nausea, bloating, and diarrhea, may be unrelated to Nissen fundoplication.     

The Influence of Laparoscopic Adjustable Gastric Banding on Gastroesophageal Reflux

Background: Laparoscopic adjustable gastric banding (LAGB) influences gastroesophageal reflux. Methods: 26 patients undergoing gastric banding were assessed by a questionnaire for symptom analysis, 24-hour pH monitoring, endoscopy and barium swallows, preoperatively, at 6 weeks and at 6 months after operation. Results: Gastric banding had minimal effect on heartburn scores, but regurgitation and belching scores increased significantly during follow-up. Use of acid-reducing drugs decreased significantly at 6 weeks and increased significantly at 6 months. Pathological reflux was present in 13 of the 26 patients preoperatively. At 6 months pathological reflux was found in only 6 of these 13 patients, but 4 of the 13 patients with preoperative normal reflux patterns had developed pathological reflux. 6 months after the operation esophagitis had disappeared in 6 patients and was increased in 9 patients. In 9 patients, a pouch was found at 6 months. Pouch formation was significantly correlated with the presence of pathological reflux, esophagitis and the use of acid-reducing medication. Preoperative presence of a hiatal hernia did not influence pouch formation or pathological reflux. Conclusion: LAGB decreases gastroesophageal reflux if there is no pouch formation during follow-up.     

Chronic respiratory symptoms and occult gastroesophageal reflux. A prospective clinical study and results of surgical therapy.

Seventy-seven patients with a primary complaint of persistent cough, wheezing, and/or recurrent pneumonia were evaluated for the presence of occult gastroesophageal reflux disease. Fifty-four patients (70%) had increased esophageal acid exposure on 24-hour pH monitoring of the distal esophagus. In 28% of these patients the respiratory symptoms were thought to be due to aspiration because they occurred during or within 3 minutes after a reflux episode. In the other patients, the respiratory symptoms were either induced by or were unrelated to reflux episodes. The number of respiratory symptoms reported by the patients with increased esophageal acid exposure was directly related to the presence of a nonspecific esophageal motility abnormality (p less than 0.05). This suggested that a motility disorder contributes to aspiration by promoting the aboral flow of refluxed gastric juice. Seventeen patients with increased esophageal acid exposure had an antireflux operation to relieve their respiratory complaints. Patients whose respiratory symptoms induced reflux episodes were not helped by the procedure. Of the other patients, symptoms were abolished by the procedure only in those with normal esophageal motility. It is concluded that the majority of patients suffering from chronic unexplained respiratory symptoms have occult gastroesophageal reflux disease, but only a minority of them are helped by surgery. Carefully performed esophageal function studies are needed to select those patients who will benefit from a surgical antireflux procedure.     

Gastroesophageal reflux disease: A review of surgical decision making

Gastroesophageal reflux disease(GERD) is a very common disorder with increasing prevalence. It is estimated that up to 20%-25% of Americans experience symptoms of GERD weekly. Excessive reflux of acidic often with alkaline bile salt gastric and duodenal contents results in a multitude of symptoms for the patient including heartburn, regurgitation, cough, and dysphagia. There are also associated complications of GERD including erosive esophagitis, Barrett's esophagus, stricture and adenocarcinoma of the esophagus. While first line treatments for GERD involve mainly lifestyle and non-surgical therapies, surgical interventions have proven to be effective in appropriate circumstances. Anti-reflux operations are aimed at creating an effective barrier to reflux at the gastroesophageal junction and thus attempt to improve physiologic and mechanical issues that may be involved in the pathogenesis of GERD. The decision for surgical intervention in the treatment of GERD, moreover, requires an objective confirmation of the diagnosis. Confirmation is achieved using various preoperative evaluations including: ambulatory p H monitoring, esophageal manometry, upper endoscopy(esophagogastroduodenoscopy) and barium swallow. Upon confirmation of the diagnosis and with appropriate patient criteria met, an antireflux operation is a good alternative to prolonged medical therapy. Currently, minimally invasive gastroesophageal fundoplication is the gold standard for surgical intervention of GERD. Our review outlines the many factors that are involved in surgical decisionmaking. We will review the prominent features that reflect appropriate anti-reflux surgery and present suggestions that are pertinent to surgical practices, based on evidence-based studies.