Incidence of Antireflux Surgery in Finland 1988-1993: Influence of Proton-Pump Inhibitors and Laparoscopic Technique

Background: The advent of proton-pump inhibitors, and subsequently of the laparoscopic technique, can be assumed to have influenced the use of antireflux surgery in gastro-oesophageal reflux disease. Methods: Data on antireflux operations carried out in Finland in 1988-93 were obtained from national statistics, and the number of operations performed laparoscopically in 1993 was ascertained by a questionnaire to all relevant units. The rates per 100,000 population in the catchment areas were calculated. Results: Antireflux surgery almost always implied fundoplication. During 1993, 784 fundoplications and 43 other antireflux procedures were performed in Finland (total population around 5 million). The fundoplication rate per 100,000 population rose from 8.8 to 15.4 between 1988 and 1993. The increase was minimal (8.1-8.2) in 1990-91 when the first proton-pump inhibitor, omeprazole, was introduced, but remarkably greater (12.8-15.4) in 1992-93, when the laparoscopic technique became popular. Differences in fundoplication rates were six to tenfold between health service districts and even larger between hospitals. Conclusions: The numbers of antireflux operations in Finland were almost static when proton-pump inhibitors were introduced, but rapidly increased after the advent of the laparoscopic technique. Remarkable discrepancies were found in the incidence of fundoplication between different areas and hospitals.     

Quality of Life and Surgical Outcome after Laparoscopic Antireflux Surgery in the Elderly Gastroesophageal Reflux Disease Patient

Background: Generally, treatment of gastroesophageal reflux disease (GERD) in the elderly follows the same principles as for any adult patient. Currently laparoscopic antireflux surgery (LARS) has not been clearly established in the elderly patient. The aim of this prospective study was to evaluate the surgical outcome including quality of life after LARS in patients older than 65 years. Methods: Since 1993 more than 500 patients underwent LARS in our institute. A total of 72 patients, older than 65 years, has been treated with laparoscopic 'floppy' Nissen (n = 51) or Toupet (n = 21) fundoplication. The patients included 23 women and 49 men, with a mean age of 71 years (range, 66-79 years). Quality of life was evaluated using the Gastrointestinal Quality of Life Index (GIQLI). The GIQLI was evaluated prior to surgery, and 3 months and 1 year after surgery, with 24-h pH monitoring and esophageal manometry being performed. Results:     

Do patients with gastroesophageal reflux disease and somatoform tendencies benefit from antireflux surgery?

BACKGROUND The clinical presentation of gastroesophageal reflux disease(GERD) shows a large symptom variation also in different intensities among patients. As several studies have shown, there is a large overlap in the symptomatic spectrum between proven GERD and other disorders such as dyspepsia, functional heartburn and/or somatoform disorders.AIM To prospectively evaluate the GERD patients with and without somatoform disorders before and after laparoscopic antireflux surgery.METHODS In a tertiary referral center for foregut surgery over a period of 3 years patients with GERD, qualifying for the indication of laparoscopic antireflux surgery, were investigated prospectively regarding their symptomatic spectrum in order to identify GERD and associated somatoform disorders. Assessment of symptoms was performed by an instrument for the evaluation of somatoform disorders[Somatoform Symptom Index(SSI) > 17]. Quality of life was evaluated by Gastrointestinal Quality of Life Index(GIQLI).RESULTS In 123 patients an indication for laparoscopic antireflux surgery was established and in 43 patients further medical therapy was suggested. The portion of somatoform tendencies in the total patient population was 20.48%(34 patients).Patients with a positive SSI had a preoperative GIQLI of 77(32-111). Patients with a normal SSI had a GIQLI of 105(29-140)(P < 0.0001). In patients with GERD the quality of life could be normalized from preoperative reduced values of GIQLI102(47-140) to postoperative values of 117(44-144). In patients with GERD and somatoform disorders, the GIQLI was improved from preoperative GIQLI 75(47-111) to postoperative 95(44-122)(P < 0.0043).CONCLUSION Patients with GERD and associated somatoform disorders have significantly worse levels of quality of life. The latter patients can also benefit from laparoscopic fundoplication, however they will not reach a normal level.     

Psychological Intervention Influences the Outcome of Laparoscopic Antireflux Surgery in Patients with Stress-related Symptoms of Gastroesophageal Reflux Disease

Background: Psychological aspects such as stress, emotions, illness behaviour or personality are known to affect the severity of symptoms of gastroesophageal reflux disease (GERD) and can influence medical outcome in some patients. The aim of the present study was to evaluate the efficacy of psychological intervention within routine surgical care on the surgical outcome of laparoscopic antireflux surgery (LARS) in patients with stress-ralated GERD symptoms during a 1-year follow-up. Methods: Out of a sample of 196 consecutive patients who required LARS (Nissen fundoplication), a group of 89 (45%) believed that stress was a factor in the cause of their symptoms (stress-related versus stress-unrelated GERD patients). Patients with stress-related symptoms were randomly assigned to the psychological intervention (PI group; n = 42) or control group with routine surgical care (RC group; n = 42). Five patients were excluded from the study. Assessments of surgical outcome were: objective clinical data such as DeMeester score or lower oesophageal sphincter pressure, Gastrointestinal Quality-of-Life Index (GIQLI), evaluation of potential side effects such as subjective degree of dysphagia, general impairment as a result of LARS, and patient satisfaction with surgery. Results: There were no significant differences in objective clinical data between the different treatment groups before and after surgery. Before surgery, patients with stress-related symptoms had a lower GIQLI and an increased spectrum of gastrointestinal (GI) symptoms compared with patients without stress-related symptoms. A significant impact (P &lt; 0.05-0.01) of psychological intervention on quality-of-life data, especially in GI symptoms, degree of dysphagia and general impairment, could be calculated after surgery. No differences in satisfaction with therapy were detectable. Comparing outcome, no significant differences between patients without stress-related GERD symptoms and the PI group were found. Generally, quality-of-life data in all patients improved significantly and patient satisfaction was excellent or good in 98.9% one year after surgery. In two patients a laparoscopic refundoplication was neccessary because of a 'slipping Nissen'. Conclusions: These findings indicate that there is no impact of psychological intervention on objective clinical data. Patients with stress-related GERD symptoms profit significantly from psychological intervention in patient-related factors of surgical outcome such as quality of life or degree of several aspects such as dysphagia and general impairment. Generally, LARS in patients with stress-related GERD symptoms is an effective and safe procedure which improves quality of life with fewer side effects. Psychological intervention reduces non GERD-related GI symptoms and makes the outcome comparable to the outcome of patients without stress-related symptoms. We therefore suggest that surgical treatment alone in patients with stress-related GERD symptoms is incomplete and that psychological intervention can optimize surgical outcome in these patients.     

Prevalence of gastroesophageal reflux symptoms in a large unselected general population in Japan

AIM：To examine the prevalence of gastroesophageal reflux disease （GERD） symptoms in a large unselected general population in Japan.
METHODS： In Japan, mature adults are offered regular check-ups for the prevention of gastric cancer. A notice was sent by mail to all inhabitants aged 〉 40 years. A total of 160 983 Japanese （60 774 male, 100 209 female; mean age 61.9 years） who underwent a stomach check up were enrolled in this study. In addition, from these 160 983 subjects, we randomly selected a total of 82 894 （34 275 male, 48 619 female; mean age 62.4 years） to evaluate the prevalence of abdominal pain. The respective subjects were prospectively asked to complete questionnaires concerning the symptoms of heartburn, dysphagia, and abdominal pain for a 1 mo period.
RESULTS： The respective prevalences of the symptoms in males and females were： heartburn, 15.8% vs 20.7%; dysphagia, 5.4% vs 7.8%; and abdominal pain, 6.6% vs 9.6%. Among these symptoms, heartburn was significantly high compared with the other symptoms, and the prevalence of heartburn was significantly more frequent in females than in males in the 60-89-year agegroup. Dysphagia was also significantly more frequent in female patients.
CONCLUSION： The prevalence of typical GERD symptoms （heartburn） was high, at about 20% of the Japan population, and the frequency was especially high in females in the 60-89 year age group.     

Antireflux surgery for Barrett''s esophagus: comparative results of the Nissen and Collis-Nissen operations

Using a Collis-Nissen repair instead of a standard Nissen fundoplication to treat the reflux disease of Barrett's esophagus is controversial. This paper compares the Nissen and Collis-Nissen operations when treating Barrett's esophagus. Thirty-three patients with documented Barrett's esophagus (male : female, 26 : 7, median age, 48.8 years) had a Nissen fundoplication during 1976-1989. Fifty-one patients (male : female = 41 : 10, median age = 53.2 years) underwent a Collis-Nissen operation between 1990 and 1999. Clinical assessments, esophagogram, radionuclide emptying, manometry, 24-h pH study, and endoscopy were obtained pre- and postoperatively. There was no operative death in either group. Median follow-up was 8.0 years for the Nissen group and 6.5 years for the Collis group. Postoperative reflux symptoms were more frequent in the Nissen group (52%) when compared to the Collis group (7%, P < 0.001). These symptoms correlated with the 24-h pH recordings revealing an increased acid exposure in the Nissen group (3.4%) as opposed to 1% in the Collis group (P = 0.003). Endoscopy revealed mucosal erosions and ulcers in 39% of patients receiving a standard Nissen repair while these damages were seen in 7% of patients who were offered an elongation gastroplasty with a total fundoplication (P = 0.007). The cumulative success rate was 83% for the Nissen group and 100% for the Collis group at 5 years, and 63% versus 90% at 10 years (Log-rank test, P = 0.004). The Collis-Nissen fundoplication provides better reflux protection for Barrett's patients than a standard Nissen repair. It lowers the risk of fundoplication failure.     

Canadian Digestive Health Foundation Public Impact Series: Gastroesophageal reflux disease in Canada: Incidence, prevalence, and direct and indirect economic impact

The Canadian Digestive Health Foundation initiated a scientific program to assess the incidence, prevalence, mortality and economic impact of digestive disorders across Canada. The current article presents the updated findings from the study concerning gastroesophageal reflux disease – a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications (Montreal definition).     

Laparoscopic Heller myotomy with or without partial fundoplication： A matter of debate

AIM: To present our experience of laparoscopic Heller stretching myotomy followed by His angle reconstruction as surgical approach to esophageal achalasia. METHODS: Thirty-two patients underwent laparoscopic Heller myotomy; an anterior partial fundoplication in 17, and angle of His reconstruction in 15 cases represented the antireflux procedure of choice. RESULTS: There were no morbidity and mortality recorded in both anterior funduplication and angle of His reconstruction groups. No differences were detected in terms of recurrent dysphagia, p.o. reflux or medical therapy. CONCLUSION: To reduce the incidence of recurrent achalasia after laparoscopic Heller myotomy, we believe that His' angle reconstruction is a safe and effective alternative to the anterior fundoplication.     

Gastroesophageal reflux disease: Update on inflammation and symptom perception

Although gastroesophageal reflux disease(GERD)is a common disorder in Western countries,with a significant impact on quality of life and healthcare costs,the mechanisms involved in the pathogenesis of symptoms remain to be fully elucidated.GERD symptoms and complications may result from a multifactorial mechanism,in which acid and acid-pepsin are the important noxious factors involved.Prolonged contact of the esophageal mucosa with the refluxed content,probably caused by a defective anti-reflux barrier and luminal clearance mechanisms,would appear to be responsible for macroscopically detectable injury to the esophageal squamous epithelium.Receptors on acid-sensitive nerve endings may play a role in nociception and esophageal sensitivity,as suggested in animal models of chronic acid exposure.Meanwhile,specific cytokine and chemokine profiles would appear to underlie the various esophageal phenotypes of GERD,explaining,in part,the genesis of esophagitis in a subset of patients.Despite these findings,which show a significant production of inflammatory mediators and neurotransmitters in the pathogenesis of GERD,the relationship between the hypersensitivity and esophageal inflammation is not clear.Moreover,the large majority of GERD patients(up to 70%)do not develop esophageal erosions,a variant of the condition called non-erosive reflux disease.This summary aims to explore the inflammatory pathway involved in GERD pathogenesis,to better understand the possible distinction between erosive and non-erosive reflux disease patients and to provide new therapeutic approaches.     

小儿食管裂孔疝反流和手术抗反流机制的研究

目的了解小儿食管裂孔疝（ＨＨ）发生反流和手术抗反流的作用机制。方法２０例经钡餐造影确诊的ＨＨ患儿进行手术前后食管２４小时ｐＨ监测和食管动力功能检查。结果２０例患儿均有病理性胃酸反流；术后各项反流指标除了平均反流周期外均显著改善，下食管括约肌长度（ＬＥＳＬ）显著增加（从１．１７ｃｍ增加到１．９４ｃｍ．Ｐ＜０．０１）．主要是腹内食管段增加明显（从０．５４ｃｍ增加到１．３０ｃｍ，Ｐ＜０．０５）。胃内压降低（从２．８６ｍｍＨｇ降到１．７８ｍｍＨｇ，Ｐ＜０．０１）：术后腹内食管段长度影响治疗效果，长度长则疗效好（Ｐ＜０，０５）；手术前后下食管括约肌压力（ＬＥＳＰ）无显著差别（Ｐ＞０．０５）。结论小儿ＨＨ发生反流的机制是由于ＬＥＳ长度不足，主要是腹内食管段长度不足甚至消失及胃内压增高引起；手术抗反流的机制定增加了ＬＥＳ的长度，主要是增加了腹内食管段的长度。     

腹腔镜抗反流手术术后并发症的处理

目的探讨腹腔镜抗反流手术术后并发症的评估及处理方法。 方法回顾性分析2005年9月至2014年4月,新疆维吾尔自治区人民医院施行腹腔镜抗反流手术725例患者的临床资料,并对并发症患者进行治疗分析。 结果725例患者均成功完成食管裂孔疝修补＋胃底折叠术。术后并发症患者45例,其中吞咽困难21例,食管裂孔疝复发(折叠的胃底疝入胸腔)4例,症状复发14例,胃肠胀气综合征6例。随访6个月至9年,平均36.6个月。 结论腹腔镜抗反流手术并发症的发生率及其后果主要与术前评估、术者经验、围手术期饮食指导和患者的依从性相关。     

Outcomes of pediatric laparoscopic fundoplication: A critical review of the literature

BACKGROUND/OBJECTIVE:

Laparoscopic fundoplication for gastroesophageal reflux disease (GERD) is one of the most common procedures performed in children. A critical literature review was performed to evaluate the level and quality of evidence supporting the efficacy of this procedure.

METHODS:

Systematic reviews of the EMBASE, PubMed and CENTRAL databases were conducted to retrieve all articles published over a 15-year period (1996 to 2010) reporting medium- to long-term outcomes (minimum six months follow-up) of laparoscopic fundoplication for the treatment of pediatric GERD. Articles were critically appraised using the Newcastle-Ottawa quality assessment scale and the Cochrane risk of bias assessment tool. Extracted outcomes included GERD recurrence, need for reoperation, postoperative morbidity and mortality.

RESULTS:

A total of 5302 articles were retrieved. Thirty-six studies met inclusion and exclusion criteria, including five prospective (level 2b), four retrospective comparative (level 3b) and 27 case series (level 4). No studies compared laparoscopic fundoplication with medical treatment. Thirty-six per cent of studies did not describe the symptoms used to suspect GERD; 11% did not disclose the diagnostic modalities used; and 41% did not report the findings of diagnostic modalities. Only 17% of studies provided a definition of recurrence, and only 14% attempted to control for confounding variables. The follow-up intervals were inconsistently reported, ranging between two months and nine years. Significant heterogeneity among studies limited the ability to pool outcomes. Mean (± SD) recurrence rates varied between 0% and 48±19.6% of patients. Reoperation was required in 0.69±0.95% to 17.7±8.4% of patients. Mortality ranged between 0% and 24±16.7%.

CONCLUSION:

The level and quality of the evidence supporting laparoscopic fundoplication are extremely poor. Higher-quality data are required before the procedure can be considered to be an effective intervention in the treatment of pediatric GERD.     

Systematic review:Laparoscopic fundoplication for gastroesophageal reflux disease in partial responders to proton pump inhibitors

AIM:To assess laparoscopic fundoplication(LF)in partial responders to proton pump inhibitors(PPIs)for gastroesophageal reflux disease(GERD).METHODS:We systematically searched PubMed and Embase(1966-Dec 2011)for articles reporting data on LF efficacy in partial responders.Due to a lack of randomized controlled trials,observational studies were included.Of 558 articles screened,17 were eligible for inclusion.Prevalence data for individual symptoms were collated across studies according to mutually compatible time points(before and/or after LF).Where suitable,prevalence data were presented as percentage of patients reporting symptoms of any frequency or severity.RESULTS:Due to a lack of standardized reporting of symptoms,the proportion of patients experiencing symptoms was recorded across studies where possible.After LF,the proportion of partial responders with heartburn was reduced from 93.1%(5 studies)to 3.8%(5 studies),with similar results observed for regurgitation[from 78.4%(4 studies)to 1.9%(4 studies)].However,10 years after LF,35.8%(2 studies)of partial responders reported heartburn and 29.1%(1 study)reported regurgitation.The proportion using acidsuppressive medication also increased,from 8.8%(4studies)in the year after LF to 18.2%(2 studies)at 10years.In the only study comparing partial responders to PPI therapy with complete responders,higher symptom scores and more frequent acid-suppressive medication use were seen in partial responders after LF.CONCLUSION:GERD symptoms improve after LF,but subsequently recur,and acid-suppressive medication use increases.LF may be less effective in partial responders than in complete responders.     

Lansoprazole for Long-Term Maintenance Therapy of Erosive Esophagitis: Double-Blind Comparison with Ranitidine

In a study evaluating the efficacy and safety of lansoprazole to prevent the relapse of erosive esophagitis (EE), 206 of 241 patients (85%) healed after open-label treatment with lansoprazole 30 mg once daily for 8 weeks and received double-blind maintenance treatment with lansoprazole 15 mg once daily or ranitidine 150 mg twice daily for up to 1 year. At 1 year, 67% of lansoprazole-treated and 13% of ranitidine-treated patients remained healed (P < 0.001). Lansoprazole-treated patients experienced significantly greater symptom relief (P < 0.001), and, if asymptomatic at entry into the maintenance phase, remained asymptomatic for significantly longer than ranitidine-treated patients (P < 0.001). Symptom status correlated with healing (P = 0.001), supporting the symptom-directed management of EE. Both treatments were well tolerated and no unexpected events occurred. Daily therapy with lansoprazole to prevent the relapse of EE is effective, well tolerated, and superior to ranitidine in the maintenance of healing and symptom relief.     

Impact of body mass index and gender on quality of life in patients with gastroesophageal reflux disease

AIM: To investigate the symptom presentation and quality of life in obese Chinese patients with gastroesophageal reflux disease (GERD).METHODS: Data from patients diagnosed with GERD according to the Montreal definition, were collected between January 2009 to March 2010. The enrolled patients were assigned to the normal [body mass index (BMI) < 25 kg/m²], overweight (25-30 kg/m²), and obese (BMI > 30 kg/m²) groups. General demographic data, endoscopic findings, and quality of life of the three groups of patients were analyzed and compared.RESULTS: Among the 173 enrolled patients, 102, 56 and 15 patients were classified in the normal, overweight, and obese, respectively. There was significantly more erosive esophagitis (73.3% vs 64.3% vs 39.2%, P = 0.002), hiatal hernia (60% vs 33.9% vs 16.7%, P = 0.001), and males (73.3% vs 73.2% vs 32.4%, P = 0.001) in the obese cases. The severity and frequency of heartburn, not acid regurgitation, was positively correlated with BMI, with a significant association in men, but not in women. Obese patients were prone to have low quality of life scores, with obese women having the lowest scores for mental health.CONCLUSION: In patients with GERD, obese men had the most severe endoscopic and clinical presentation. Obese women had the poorest mental health.     

胃食管反流病误诊为咽喉疾病48例临床分析

目的探讨胃食管反流病误诊原因,提出防范误诊措施。方法对48例胃食管反流病误诊资料进行回顾性分析。结果48例患者主要表现为咽痛、清咽、咽部阻塞感、咽不适感等胃肠外症状。喉镜检查均见咽喉部黏膜充血、水肿、咽后壁有淋巴小结增生。经胃镜检查、诊断性治疗诊断胃食管反流病。给予质子泵抑制剂及促胃动力药。结论部分胃食管反流病以咽喉症状为主要表现,易误诊为咽喉疾病,应仔细鉴别胃食管反流病,行胃镜检查或24h食管PH值测定及其他寻找胃食管反流证据的检查、给予质子泵抑制剂诊断性治疗,有助于正确诊断。     

Laparoscopic Surgery in Rectal Cancer: A Prospective Analysis of Patient Survival and Outcomes

Purpose The role of laparoscopic resection in the management of rectal cancer is still controversial. We prospectively evaluated patient survival and outcomes in patients undergoing laparoscopic rectal resection for rectal cancer at a single institution. Methods From November 1999 to November 2005, 107 patients with rectal cancer were treated by laparoscopy. Exclusion criteria were: metastatic disease, advanced disease with invasion of adjacent structures, clinical or radiologic involvement of the external anal sphincter, previous colonic resection, synchronous colonic adenocarcinoma, and contraindications to laparoscopy. All patients were followed prospectively for survival and complications. Survival was calculated by the Kaplan-Meier method. Results A laparoscopic sphincter-saving procedure was performed in 104 patients, 2 patients had a laparoscopic Miles operation, and 1 underwent a laparoscopic Hartmann’s procedure. Mean operating time was 278 (range, 135–430) minutes. Conversion to open surgery was required in 20 of 107 patients (18.7 percent). Overall morbidity was 27 percent, anastomotic leakage occurred in 14 of 104 patients (13.5 percent). There was no postoperative mortality. A mean of 18 (range, 1–49) lymph nodes was removed. Mean distance of distal margin from tumor was 2.6 (range, 0.5–10) cm; in two patients there was microscopic invasion of the distal margin. Mean hospital stay was nine (range, 4–43) days. Mean follow-up was 35.8 months. There was local recurrence in 1 of 107 patients (0.95 percent); there were no port site metastases. Actuarial five-year and disease-free survival rates are 81.4 and 79.8 percent, respectively. Conclusions Laparoscopic rectal surgery is feasible and oncologically radical but also technically demanding (conversion rate, 18.7 percent), time-consuming (mean operating time, 278 minutes), and associated with specific intraoperative complications. At present, the technique should only be performed in specialist centers by teams experienced in laparoscopic surgery. Presented at the meeting of The Society for Surgery of the Alimentary Tract, Los Angeles, California, May 20 to 24, 2006.