Antireflux surgery for Barrett's oesophagus

Barrett's oesophagus is usually the result of severe reflux disease. Relief of reflux symptoms is the primary aim of treatment in patients with Barrett's oesophagus who do not have high-grade dysplasia. Some studies with medium-term (2-5 years) follow up show that antireflux surgery can provide good or excellent symptom control, with normal oesophageal acid exposure, in more than 90% of patients with Barrett's oesophagus. Antireflux surgery, but not medical therapy, can also reduce duodenal nonacid reflux to normal levels. There is no conclusive evidence that antireflux surgery can prevent the development of dysplasia or cancer, or that it can reliably induce regression of dysplasia, and patients with Barrett's oesophagus should therefore remain in a surveillance programme after operation. Some data suggest that antireflux surgery can prevent the development of intestinal metaplasia (IM) in patients with reflux disease but no IM. The combination of antireflux surgery plus an endoscopic ablation procedure is a promising treatment for patients with Barrett's oesophagus with low-grade dysplasia.     

Antireflux surgery in infants with vesicoureteral reflux

Febrile urinary tract infections (UTI) resulted in the admission of five infants (four boys, one girl) to Okinawa Prefectural Hospital in Miyako. The first febrile episode developed at an average age of 1.3 months. All patients underwent cystoscopy and X-ray studies to role out secondary causes for vesicoureteral reflux (VUR). All patients had high grade reflux and underwent antireflux surgery using a modification of the Amar-Paquin method or the Politano-Leadbetter method. They tolerated the procedures without any complications. No UTI recurred and VUR disappeared in one year following surgery. Early surgical intervention seems beneficial for selected infants with high grade VUR, but the surgical procedure and methods for infants, especially those with severe dilated ureter, are still controversial.     

Antireflux surgery does not change ongoing renal functional deterioration

Aim Treatment modalities of vesicoureteral reflux (VUR) consist of antimicrobial prophylaxis and antireflux surgery. In this study, we aimed to determine if antireflux surgery changes the course of renal functional deterioration in children with VUR and urinary tract infections (UTI). Methods Medical files of patients with VUR diagnosed during evaluation for UTI were evaluated retrospectively for gender, age, follow-up period, and renal ultrasonography (US) and serial 99mTc-dimercaptosuccinic acid (99mTc-DMSA) scintigraphy findings. Estimated glomerular filtration rate and urinary protein levels were determined at the initial and last visits, and before the operation in children who had antireflux surgery. The patients were divided into two groups as solely medically treated (Group 1) and both medically and surgically treated (Group 2). Group 2 was further divided as those with stable renal function (Group 2a) and with progressive renal injury (Group 2b). Results There were 140 patients (77 female; mean age 51.6?±?51.9 months). Group 1 and Group 2 included 82 and 58 patients, respectively. In Group 2, the number of patients with the abnormal US, DMSA scintigraphy, and renal function was higher than in Group 1. Recurrent UTI rate was similar, but progressive scarring was more prominent in the antireflux surgery group. In Group 2, 31 patients had a stable renal function (Group 2a) while 27 had progressive deterioration of renal functions (Group 2b). These subgroups were not different with respect to the rate of high-grade VUR, the presence of a renal scar in DMSA, and UTI recurrence. However, the bilateral renal scar was more common in Group 2b. Conclusion Antireflux surgery does not change the course of ongoing renal injury and renal functional deterioration.     

Antireflux surgery in children under 3 months of age

PURPOSE: The aim of this study was to analyze the indications and results of fundoplication in 110 infants under 3 months of age. METHODS: A retrospective review was conducted on the charts of all infants operated on for gastroesophageal reflux disease (GERD) at the UCLA Medical Center from January 1980 to December 1997. There were 59 boys and 51 girls. Recurrent emesis was the indication for operation in 62 of 110 infants, and respiratory symptoms in 85 of 110, with 54 of 110 having both. Neurological impairment was present in 32%. Prematurity was present in 21%; 35% had associated anomalies. Overall, 81 of 110 infants (73.6%) had one or more associated major malformations or disorders. Reflux was confirmed by upper gastrointestinal series findings in 63 of 78, esophageal pH monitoring in 60 of 62, and endoscopy in five of seven. RESULTS: Mean age at operation was 1.8+/-0.1 months and mean weight was 3,686+/-90.2 g. A Nissen fundoplication was performed on 104 children, and six underwent a Thal procedure. Thirty-one had a gastric emptying procedure for delayed gastric emptying. Complications occurred in 7 infants. Emesis was controlled in 57 of 62 patients, aspiration in 38 of 48, and apneic spells in 54 of 57. Follow-up greater than 6 months was available for 73 patients. There were nine late deaths, all related to severe associated malformations. Seven patients required a redo fundoplication for recurrent reflux. CONCLUSIONS: Nissen fundoplication can be performed safely in symptomatic infants under 3 months of age with low mortality and morbidity rates and with resolution of the presenting symptoms in 79% of infants.     

Use of Antireflux Medication After Antireflux Surgery

Introduction It is claimed that a substantial number of patients who undergo antireflux surgery use antireflux medication postoperatively. This study was aimed to determine the prevalence and underlying reasons for antireflux medication usage in patients after surgery. Materials and Methods A questionnaire on the usage of antireflux medication was sent to 1,008 patients identified from a prospective database of patients who had undergone a laparoscopic antireflux procedure. Results A total of 844 patients (84%) returned the questionnaire. Mean follow-up was 5.9 years after surgery. A single or combination of medications was being taken by 312 patients (37%): 82% proton pump inhibitors, 9% H₂-blockers and 34% antacids. Fifty-two patients (17%) had never stopped taking medication, whereas 260 patients (83%) restarted medication at a mean of 2.5 years after surgery. Return of the same (31%) or different (49%) symptoms were the commonest reasons for taking medication, whereas 20% were asymptomatic or had other reasons for medication use. Postoperative 24-hour pH studies were abnormal in 16/61 patients (26%) on medication and in 5/78 patients (6%) not taking medication. Conclusions Antireflux medication is frequently taken by many patients for various symptoms after antireflux surgery. Symptomatic patients should be properly investigated before antireflux medications are prescribed.     

Antireflux surgery for patients with end-stage lung disease before and after lung transplantation

Background Gastroesophageal reflux disease (GERD) is prevalent among patients with end-stage lung disease (ESLD). This disease can lead to microaspiration and may be a risk factor for lung damage before and after transplantation. A fundoplication is the best way to stop reflux, but little is known about the safety of elective antireflux surgery for patients with ESLD. This study aimed to report the safety of laparoscopic fundoplication for patients with ESLD and GERD before or after lung transplantation. Methods Between January 1997 and January 2007, 305 patients were listed for lung transplantation, and 189 patients underwent the procedure. In 2003, routine esophageal studies were added to the pretransplantation evaluation. After the authors’ initial experience, gastric emptying studies were added as well. Results A total of 35 patients with GERD or delayed gastric emptying were referred for surgical intervention. A laparoscopic fundoplication was performed for 32 patients (27 total and 5 partial). For three patients, a pyloroplasty also was performed. Two patients had a pyloroplasty without fundoplication. Of the 35 operations, 15 were performed before and 20 after transplantation. Gastric emptying of solids or liquids was delayed in 12 (92%) of 13 posttransplantation studies and 3 (60%) of 5 pretransplantation studies. All operations were completed laparoscopically, and 33 patients recovered uneventfully (94%). The median hospital length of stay was 2 days (range, 1–34 days) for the patients admitted to undergo elective operations. Hospitalization was not prolonged for the three patients who had fundoplications immediately after transplantation. Conclusions The results of this study show that laparoscopic antireflux surgery can be performed safely by an experienced multidisciplinary team for selected patients with ESLD before or after lung transplantation, and that gastric emptying is frequently abnormal and should be objectively measured in ESLD patients. Presented as a Poster of Distinction at the Spring 2007 Meeting of the Society of Gastrointestinal and Endoscopic Surgeons (SAGES) at Las Vegas, Nevada, 18–22 April 2007     

Antireflux operations without catheter

Forty-three patients are presented in whom 80 ureters were transplanted by Cohen's method without leaving a catheter in the bladder. No complications were observed and the incidence of urinary tract infection and dysuria was lower. The late results of the operation were good in every case.     

Antireflux anastomosis following oesophagectomy

BACKGROUND: Reflux of duodeno-gastric fluid is a significant problem after oesophagectomy with gastric conduit reconstruction. It can impact considerably upon the patient's quality of life and can induce oesophagitis and Barrett's metaplasia in the remnant oesophagus. AIM: The aim of the present study was to describe the use of a modified fundoplication in controlling reflux after oesophagectomy. METHODS: Patients undergoing subtotal oesophagectomy at the Royal Adelaide Hospital were identified. Clinical and operative details were obtained from hospital records. All patients had an end oesophagus to side stomach anastomosis. Two cohorts were identified - one with a standard anastomosis only and the other in whom a modified fundoplication had been added. A structured phone interview was used to assess reflux in the two groups with a minimum of 6 months follow up. The interviewer was blinded to the operative details. RESULTS: The operative technique is described. A total of 44 patients were assessed, 33 having the fundoplication type anastomosis and 11 the standard anastomosis. Operative morbidity was not different between the groups. Symptoms of reflux were better controlled in patients with the fundoplication anastomosis than in patients with a standard anastomosis. Of those with a fundoplication, 14 of 33 patients (42%) were asymptomatic with respect to reflux compared to only one of 11 patients (9%) in the standard anastomosis group. Only four of the 33 patients (12%) with a fundoplication anastomosis had symptoms of severe reflux while seven of the 11 patients (63%) with a standard anastomosis had severe reflux symptoms. CONCLUSIONS: This initial evaluation of a modified fundoplication as an antireflux manoeuvre after oesophagectomy suggests that the technique is effective in controlling post-oesophagectomy reflux in the majority of patients. It is simple to perform and may have benefits in improving quality of life and preventing oesophagitis and metaplastic changes in the remnant oesophagus. A more detailed prospective study of the technique is warranted.     

Antireflux valves in patient-controlled analgesia

Antireflux valves are widely used in conjunction with patient-controlled analgesia devices. It is important to appreciate the limitations and dangers of these systems. They can achieve a potential 'stored volume' if occluded and they may, as part of the administration set, retard fluid administration. Seven antireflux systems currently available were tested in conjunction with three patient-controlled analgesia pumps. The systems' volume, time to occlusion alarm and flow rates were measured. Results showed that the sets with low stored volumes were less efficient as administration sets. A potentially dangerous bolus could result after release of occlusion if sets with large stored volumes were used in conjunction with pumps that utilised concentrated solutions of opioid. This study has identified the ideal antireflux valve system.