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1.
Gastro-Esophageal Reflux and Esophageal Motility Disorders in Morbidly Obese Patients before and after Bariatric Surgery 总被引:6,自引:6,他引:0
Merrouche M Sabaté JM Jouet P Harnois F Scaringi S Coffin B Msika S 《Obesity surgery》2007,17(7):894-900
Background Obesity is a predisposing factor to gastro- esophageal reflux disease (GERD), but esophageal function remains poorly studied
in morbidly obese patients and could be modified by bariatric surgery.
Methods Every morbidly obese patient (BMI ≥40 kg/m2 or ≥35 in association with co-morbidity) was prospectively included with an evaluation of GERD symptoms, endoscopy, 24-hour
pH monitoring and esophageal manometry before and after adjustable gastric banding (AGB) or Roux-en-Y gastric bypass (RYGBP).
Results Before surgery, 100 patients were included (84 F, age 38.4 ± 10.9 years, BMI 45.1 ± 6.02 kg/m2), of whom 73% reported GERD
symptoms. Endoscopy evidenced hiatus hernia in 39.4% and esophagitis in 6.4%. The DeMeester score was pathological in 53.3%;
69% of patients had lower esophageal sphincter (LES) pressure <15 mmHg and 7 had esophageal dyskinesia. BMI was significantly
related to the DeMeester score (P = 0.018) but not to LES tone or esophageal dyskinesia. Postoperative data were available in 27 patients (AGB n = 12/60, RYGBP
n = 15/36). The DeMeester score (normal <14.72) was significantly decreased after RYGBP (24.8 ± 13.7 before vs 5.8 ± 4.9 after;
P < 0.001) but tended to increase after AGB (11.5 ± 5.1 before vs 51.7 ± 70.7 after; P = 0.09), with severe dyskinesia in 2 cases. Conclusion: GERD and LES incompetence are highly prevalent in morbidly obese
patients. Preliminary postoperative data show different effects of RYGBP and AGB on esophageal function, with worsening of
pH-metric data with occasional severe dyskinesia after AGB. 相似文献
2.
Koppman JS Poggi L Szomstein S Ukleja A Botoman A Rosenthal R 《Surgical endoscopy》2007,21(5):761-764
Background Most studies investigating esophageal motility among the morbidly obese have focused on the relationship between lower esophageal
sphincter (LES) pressure and gastroesophageal reflux disease (GERD). Very few studies in the literature have examined motility
disorders among the morbidly obese population in general outside the context of GERD. This study aimed to determine the prevalence
of esophageal motility disorders in obese patients selected for bariatric surgery.
Methods A total of 116 obese patients (81 women and 35 men) selected for laparoscopic gastric banding underwent manometric evaluation
of their esophagus from January to March 2003. Tracings were retrospectively reviewed for the end points of LES resting pressure,
LES relaxation, and esophageal peristalsis.
Results The study patients had a body mass index (BMI) of 42.9 kg/m2, and a mean age of 48.6 years. The following abnormal manometric findings were demonstrated in 41% of the patients: nonspecific
esophageal motility disorders (23%), nutcracker esophagus (peristaltic amplitude >180 mmHg) (11%), isolated hypertensive LES
pressure (>35 mmHg) (3%), isolated hypotensive LES pressure (<12 mmHg) (3%), diffuse esophageal spasm (1%), and achalasia
(1%). Only one patient with abnormal esophageal motility reported noncardiac chest pain.
Conclusions Despite a high prevalence of esophageal dysmotility in our morbidly obese study population, there was a conspicuous absence
of symptoms. Although the patients in this study were not directly questioned with regard to esophageal symptoms, several
studies in the literature support our conclusion.
Podium presentation at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), 26–29 April
2006, Dallas, TX, USA 相似文献
3.
Hong D Khajanchee YS Pereira N Lockhart B Patterson EJ Swanstrom LL 《Obesity surgery》2004,14(6):744-749
Background: Obesity is an epidemic in the USA. Many disorders are associated with obesity including gastroesophageal reflux
disease (GERD). However, the prevalence of GERD and esophageal motility disorders in the morbidly obese population is unclear.
Methods: During evaluation for bariatric surgery, 61 morbidly obese patients underwent preoperative 24-hr pH and esophageal
manometry. A single reviewer evaluated all 24-hr pH and manometric tracings. Johnson-DeMeester score >14.7 was considered
diagnostic of GERD. Manometric criteria for motility disorders were from published values. All values are given as mean ±
SD. Results: Mean age was 44.4 + 10.3 years. 55 of the patients (90%) were female. Mean BMI was 50.1 ± 7.2 kg/m2. 23 patients (38%) complained of GERD symptoms (reflux and/or heartburn). 1 patient (2%) complained of noncardiac chest pain.
Mean Johnson-DeMeester score was 19.6 ± 17.8. Mean intragastric and intrabolus pressures were both elevated (8.3 ± 1.6 mmHg
and 15 ± 9 mmHg). 33 patients (54%) had abnormal manometric findings: 10 had a mechanically defective LES, 11 had a hypertensive
LES, 2 had diffuse esophageal spasm, 3 had nutcracker esopha gus,1 had ineffective esophageal disorder and 14 had nonspecific
esophageal motility disorder. Some patients had more than one disorder. 20 patients (33%) had significantly elevated (>180
mmHg) contraction amplitudes at the most distal channel (210.0 ± 28.7 mmHg). Conclusions: Prevalence of manometric abnormalities
in the morbidly obese is high. Presence of a nut cracker-like distal esophagus in the morbidly obese is significant and warrants
further evaluation. 相似文献
4.
Gastroesophageal reflux disease (GERD) is highly prevalent in morbidly obese patients, and a high body mass index (BMI) is
a risk factor for the development of GERD. However, the mechanism by which the BMI affects esophageal acid exposure is not
completely understood. Although many advances have been made in the understanding of the pathophysiology of GERD, many aspects
of the pathophysiology of this disease in morbidly obese patients remain unclear. The following review describes the current
evidence linking esophageal reflux to obesity, covering the pathophysiology of the disease and the implications for treatment
of GERD in the obese patient. 相似文献
5.
Background To date, few studies have examined the effect of morbid obesity on the outcome of laparoscopic antireflux surgery and results
have been conflicting. The aim of this work was to study the outcome of laparoscopic Nissen fundoplication (LNF) in patients
with body mass index (BMI) ≥ 35.
Methods We prospectively followed 70 patients (15 men, 55 women) with a proven diagnosis of gastroesophageal reflux disease (GERD)
and a mean BMI of 38.4 ± 0.5 (range, 35–51) who underwent LNF. All patients underwent 24-h pH study, esophageal manometry,
upper gastrointestinal (GI) endoscopy, and GERD symptom score before and 6 months after LNF. Surgical outcomes were compared
to those of 70 sequential nonobese patients (BMI < 30) who also underwent LNF.
Results LNF was completed laparoscopically in 69 of 70 patients in the morbidly obese (MO) group and in all 70 patients in the normal-weight
(NW) group. The mean operative time for the MO group was not significantly longer than that for the NW group (55.9 ± 2.3 min
vs 50.0 ± 2.1 min), but the mean length of stay was significantly longer (3.17 ± 0.2 days vs 2.2 ± 0.1 days, p < 0.0001) in the MO group. There was one postoperative complication (a transhiatal herniation of the stomach) in the morbidly
obese group. In both patient groups, LNF resulted in a significant increase in lower esophageal sphincter (LES) pressures.
This was associated with a significant decrease in percent acid reflux in 24-h testing and a significant improvement in GERD
symptom score in both groups, although patients in the MO group had a significantly higher mean reflux symptom score after
surgery than did those in the NW group. After a mean follow-up of 41.6 ± 2.9 months, one patient in the MO group required
reoperation and one proton pump inhibitor therapy (PRN PPI), as required.
Conclusions Morbid obesity does not adversely affect the outcome of LNF. The conversion rate is low when performed by an experienced surgeon.
Presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting, Los Angeles, CA, USA, 12–15
March 2003 相似文献
6.
Shahin Ayazi Jeffrey A. Hagen Linda S. Chan Steven R. DeMeester Molly W. Lin Ali Ayazi Jessica M. Leers Arzu Oezcelik Farzaneh Banki John C. Lipham Tom R. DeMeester Peter F. Crookes 《Journal of gastrointestinal surgery》2009,13(8):1440-1447
Introduction Obesity and gastroesophageal reflux disease (GERD) are increasingly important health problems. Previous studies of the relationship
between obesity and GERD focus on indirect manifestations of GERD. Little is known about the association between obesity and
objectively measured esophageal acid exposure. The aim of this study is to quantify the relationship between body mass index
(BMI) and 24-h esophageal pH measurements and the status of the lower esophageal sphincter (LES) in patients with reflux symptoms.
Methods Data of 1,659 patients (50% male, mean age 51 ± 14) referred for assessment of GERD symptoms between 1998 and 2008 were analyzed.
These subjects underwent 24-h pH monitoring off medication and esophageal manometry. The relationship of BMI to 24-h esophageal
pH measurements and LES status was studied using linear regression and multiple regression analysis. The difference of each
acid exposure component was also assessed among four BMI subgroups (underweight, normal weight, overweight, and obese) using
analysis of variance and covariance.
Results Increasing BMI was positively correlated with increasing esophageal acid exposure (adjusted R
2 = 0.13 for the composite pH score). The prevalence of a defective LES was higher in patients with higher BMI (p < 0.0001). Compared to patients with normal weight, obese patients are more than twice as likely to have a mechanically defective
LES [OR = 2.12(1.63–2.75)].
Conclusion An increase in body mass index is associated with an increase in esophageal acid exposure, whether BMI was examined as a continuous
or as a categorical variable; 13% of the variation in esophageal acid exposure may be attributable to variation in BMI.
An erratum to this article can be found at 相似文献
7.
8.
Gastroesophageal Reflux in Patients with Morbid Obesity: A Role of Obstructive Sleep Apnea Syndrome?
Sabaté JM Jouët P Merrouche M Pouzoulet J Maillard D Harnois F Msika S Coffin B 《Obesity surgery》2008,18(11):1479-1484
Background Obesity is a risk factor for gastroesophageal reflux disease (GERD) and for obstructive sleep apnea (OSA). Our aim was to
evaluate in morbidly obese patients the prevalence of OSA and GERD and their possible relationship.
Methods Morbidly obese patients [body mass index (BMI) >40 or >35 kg/m2 in association with comorbidities] selected for bariatric surgery were prospectively included. Every patient underwent a
24-h pH monitoring, esophageal manometry, and nocturnal polysomnographic recording.
Results Sixty-eight patients [59 women and 9 men, age 39.1 ± 11.1 years; BMI 46.5 ± 6.4 kg/m2 (mean ± SD)] were included. Fifty-six percent of patients had an abnormal Demester score, 44% had abnormal time spent at
pH <4, and 80.9% had OSA [apnea hypopnea index (AHI) >10] and 39.7% had both conditions. The lower esophageal sphincter (LES)
pressure was lower in patients with GERD (11.6 ± 3.4 vs 13.4 ± 3.6 mm Hg, respectively; P = 0.039). There was a relationship between AHI and BMI (r = 0.337; P = 0.005). Patients with OSA were older (40.5 ± 10.9 vs 33.5 ± 10.4 years; P = 0.039). GERD tended to be more frequent in patients with OSA (49.1% vs 23.1%, respectively; P = 0.089). There was no significant relationship between pH-metric data and AHI in either the 24-h total recording time or
the nocturnal recording time. In multivariate analysis, GERD was significantly associated with a low LES pressure (P = 0.031) and with OSA (P = 0.045) but not with gender, age, and BMI.
Conclusion In this population of morbidly obese patients, OSA and GERD were frequent, associated in about 40% of patients. GERD was significantly
associated with LES hypotonia and OSA independently of BMI. 相似文献
9.
Background: Heartburn and gastroesophageal reflux disease (GERD) affects approximately 25–50% of morbidly obese patients. Although objective physiologic testing has been reported extensively in patients following Nissen fundoplication, there are no previous reports of such testing in morbidly obese patients. A life-saving surgical alternative for the morbidly obese patient is gastric bypass surgery, which usually improves heartburn symptoms in addition to many serious health conditions such as diabetes, hypertension, and sleep apnea. We hypothesized that, in morbidly obese patients, gastric bypass surgery would be as effective as Nissen fundoplication in reducing both heartburn symptoms and esophageal acid exposure, as reflected by the DeMeester score. Methods: Between 1995 and 2000, all patients undergoing laparoscopic Nissen fundoplication (LN) and laparoscopic gastric bypass (LGB) in our practice underwent preoperative and postoperative esophageal physiologic testing. Patients were included in this study that were morbidly obese and had significant heartburn symptoms or objective evidence of acid reflux, and had repeat esophageal physiologic testing after either LN or LGB. Data were obtained through retrospective review of prospectively collected data. Results: Twelve patients met the inclusion criteria: six patients who had LN and six who had LGB. The mean body mass index (BMI) was 55 kg/m2 in the LGB group and 39.8 in the LN group. After surgery, the mean DeMeester score decreased from 64.3 to 2.8 in the LN group (p = 0.01) and from 34.7 to 5.7 in the LGB group (p = 0.1). Both groups mean postoperative DeMeester scores were normal after surgery, and there was no significant difference between the two groups (p = 0.3). Both groups experienced a significant improvement in heartburn symptoms postoperatively. The mean preoperative symptom score improved from 3.5 to 0.5 in the LN group (p = 0.01) and from 2.2 to 0.2 in the LGB group (p = 0.003). There was no difference in the mean postoperative symptom scores between the groups (p = 0.35). After surgery, mean LES resting pressures increased from 12.9 to 35.5 (p = 0.003) in the LN group and from 23.6 to 29.7 (p = 0.45) in the LGB group. There were no complications in either group. Conclusion: Results of this study show that laparoscopic gastric bypass and laparoscopic Nissen fundoplication are both effective in treating heartburn symptoms and objective acid reflux in morbidly obese patients. The health benefits of weight loss after laparoscopic gastric bypass should make this operation the procedure of choice in the morbidly obese patient with heartburn. 相似文献
10.
Gabor Varga Agnes Kiraly Laszlo Cseke Katalin Kalmar Ors Peter Horvath 《Journal of gastrointestinal surgery》2008,12(2):304-307
For hypertensive lower esophageal sphincter with dysphagia and chest pain, a laparoscopic cardiomyotomy is recommended. Recently,
the role of gastroesophageal reflux in this abnormality has been recognized. A prospective study on six patients with manometrically
proven hypertensive lower esophageal sphincter was performed. Laparoscopic floppy Nissen fundoplication was performed in all
cases. The first follow up was performed 6 weeks after the operation. The mean follow up time was 56 months (range 50–61).
Before the operation, all patients had abnormal esophageal acid exposure. Mean DeMeester score was 41.7 (range 16.7–86). Average
LES pressure before the operation was 50.5 mmHg (range 35.6–81.3). Six weeks after operation, all patients were symptom free.
DeMeester score returned to a normal level of 2.9. Furthermore, a marked decrease in the lower esophageal sphincter pressure
(24.7 mmHg) was detected. At late follow up, all patients were symptom-free, and only two patients agreed to undergo functional
testing. The mean DeMeester score of this two patients was 1.2. The pressure remained at normal value (15.7 mmHg). In our
study, an antireflux operation normalized lower esophageal sphincter pressure suggesting that abnormal esophageal acid exposure
may be an etiologic factor in the development of hypertensive lower esophageal sphincter. 相似文献
11.
Sarah M. Cowgill Mark Bloomston Sam Al-Saadi Desiree Villadolid Alexander S. RosemurgyII 《Journal of gastrointestinal surgery》2007,11(6):701-707
Intuitively, a manometrically normal lower esophageal sphincter (LES) will promote dysphagia after laparoscopic Nissen fundoplication.
This study was undertaken to compare outcomes after laparoscopic Nissen fundoplication for patients who had normal and manometrically
inadequate LES preoperatively. Before fundoplication, the length and resting pressures of LES were determined manometrically
in 59 patients with documented gastroesophageal reflux disease (GERD). Twenty-nine patients had a manometrically normal LES,
with resting pressures >10 mm Hg and length >2 cm. Thirty patients had resting pressures of ≤10 mm Hg and length of ≤2 cm.
Before and after fundoplication, patients graded the frequency and severity of symptoms of GERD utilizing a Likert scale (0
= never/not bothersome to 10 = always/very bothersome). DeMeester scores and symptom scores before and after fundoplication
were compared. Before fundoplication, the manometric character of the LES did not impact the elevation of DeMeester scores
or the frequency/severity of reflux symptoms. All symptoms improved significantly with fundoplication independent of LES pressure/length.
Prefundoplication, manometric character of the LES did not impact the frequency or severity of reflux symptoms after fundoplication.
Preoperative manometric character of the LES does not impact the presentation of GERD or the outcome after fundoplication.
Symptoms globally and significantly improve after fundoplication, independent of manometric LES character. Normal LES manometry
does not impact outcome and, specifically, does not promote dysphagia, after laparoscopic Nissen fundoplication.
Presented at the 47th Annual Meeting for the Society of Surgery of the Alimentary Tract, Los Angeles, CA May 20 to 24 2006 相似文献
12.
Michel Gagner 《Obesity surgery》2016,26(4):715-717
The incidence of esophageal adenocarcinoma is not rising at the same rate as severe obesity, and incidence-based mortality is marginally going down since 2000. Laparoscopic sleeve gastrectomy (LSG) is now the preferred operation for weight loss in several countries including the USA. Recent objective studies of reflux before and 2 years after LSG show improvement by GERD Symptom Assessment Scale score, DeMeester score, total acid exposure, as well as unchanged lower esophageal sphincter pressure measurements. Therefore, sleeve gastrectomy improves symptoms and reduces reflux in most morbidly obese patients with preoperative reflux. At the last LSG consensus conference, 94.5 % of experts mentioned Barrett’s esophagus to be a major contraindication for the performance of LSG, a change from 2011 (81 %). But the actual incidence of Barrett’s is only 1 % in the severely obese. Therefore, 99 % of patients should be able to get a LSG. Further, after 25 years of duodenal switch operations (which includes a sleeve gastrectomy, there are still no reports of esophageal adenocarcinoma. Hence, LSG is not a contraindication in GERD patients without Barrett’s. 相似文献
13.
High Prevalence of Asymptomatic Esophageal Motility Disorders among Morbidly Obese Patients 总被引:4,自引:1,他引:3
Background: Morbid obesity is becoming more prevalent in the industrialized world. Few data exist regarding the resting lower
esophageal sphincter pressure (LESP) and esophageal motility in relationship to body mass index (BMI). Methods: During a 3-year
period, 111 of 152 morbidly obese patients seeking bariatric surgery completed esophageal manometric testing and questionnaire
regarding esophageal symptoms. Manometric parameters included wave amplitude and duration of esophageal contractions, percentage
of peristaltic function, and resting LESP. Questionnaire data included age, sex, medications, prior medical conditions, and
esophageal symptoms. Results: 88 (79%) of the patients were female; 23 (21%) were male. The mean age was 39.8 years (± 9.9),
the mean BMI was 50.7 kg/m2 (± 9.4). There was a lack of correlation between BMI and LESP (r = 0.04). Abnormal manometric
findings were observed in 68/111 (61%) patients: 28 (25%) had only hypotensive lower esophageal sphincter (LESP < 10 mm Hg);
16 (14%) had nutcracker esophagus (amplitude >180 mm Hg), 15 (14%) had nonspecific esophageal motility disorders, 8 (7%) had
diffuse esophageal spasm (DES), and 1 (1%) had achalasia. Patients with DES had a significantly higher BMI than those with
other motility disorders (P < 0.05). Dysphagia was reported in 7 (6%) patients and chest pain in 1 patient. Heartburn and/or
regurgitation (gastroesophageal reflux disease, GERD) was noted in 35 patients (32%), of whom 18 (51%) had a hypotensive resting
LES. 40 of 68 patients (59%) with abnormal motility tracings did not report any esophageal symptoms. Conclusion: Morbid obesity
per se does not imply an abnormality of LESP. In addition, a majority of morbidly obese patients who were considering bariatric
surgery had no esophageal symptoms but were found to have abnormal esophageal manometric patterns. These findings add support
to the suggestion that morbidly obese patients may have abnormal visceral sensation. 相似文献
14.
H Weiss MD B Labeck MD J Klocker MD H Nehoda MD R Mittermair MD F Aigner MD M Gadenstätter MD G Wetscher MD H Schwelberger PhD 《Obesity surgery》2001,11(6):735-739
Background: Patients with gastroesophageal reflux disease (GERD) have alterations of gut neuropeptides, such as neurotensin
(N) and motilin (M), which are resolved following antireflux surgery. Obesity is associated with GERD. Since the adjustable
gastric band prevents gastroesophageal reflux in morbidly obese patients, this study was performed to investigate plasma levels
of N and M before and after adjustable gastric banding (AGB). Methods: 47 morbidly obese patients were operated laparoscopically
using the Swedish AGB. Preand postoperatively basal plasma levels of N and M were investigated. Symptoms such as heartburn,
regurgitation and dysphagia were documented, and esophageal manometry as well as 24-hour pH-monitoring were performed pre-
and postoperatively. 11 non-obese, asymptomatic, age-matched volunteers served as controls. Results: After a median postoperative
follow-up period of 268 days, a significant weight reduction was observed. Preoperatively, 14 patients suffered from reflux
symptoms. An insufficient lower esophageal sphincter (LES) was found in 8 patients, and 2 patients had impaired esophageal
body motility. Pathologic pH-testing was found in 6 patients. Postoperatively, reflux symptoms were present in 4 patients;
LES findings and pH-testing were normalized in all patients. However, there was significant impairment of esophageal peristalsis.
Preoperatively, levels of N were significantly decreased and levels of M increased compared with control subjects. Postoperatively,
there was a significant increase of N and levels of M were normalized. Alterations in gut neuropeptides did not correlate
with reflux symptoms, impaired gastroesophageal motility, age, gender or BMI. Conclusion: Morbid obesity alters gut neuropeparetides,
which are resolved by AGB. This may be caused by reduction of hypercaloric nutrition post-operatively rather than by improvement
of gastroesophageal reflux. 相似文献
15.
目的 探讨腹腔镜胃底折叠术联合胃袖状切除术(LFDSG)治疗肥胖合并胃食管反流病(GERD)的临床疗效。方法 前瞻性分析自2017年5月至2018年5月在新疆维吾尔自治区人民医院腹腔镜、腹壁疝外科收治的60例符合减重手术适应证的肥胖病人的临床资料。依据手术方式分为LSG组(30例)和LFDSG组(30例)。两组术后随访12个月,观察病人术后减重和抗反流效果。结果 两组术后12个月的BMI和多余体重减少百分比(%EWL)与术前比较差异有统计学意义(P<0.05)。与LSG组相比,LFDSG组GERD症状缓解评分(8~13分及14~18分)分布以及术后12个月酸反流(pH≤4)次数、食管近端酸反流(%)、DeMeester评分、食管下段括约肌残余压、食管远端收缩积分的差异均有统计学意义(P<0.05)。LFDSG组治疗后抗反流有效率显著高于LSG组[28例(93.3%) vs. 21例(70.0%),P<0.05]。LFDSG组病人无并发症发生,LSG组病人住院期间1例发生并发症,出院后3例发生并发症。两组均无死亡病例。结论 LFDSG治疗肥胖合并GERD的效果较好,可达到抗反流与减重的双重目的,有效防治GERD的发生与发展。 相似文献
16.
W. O. Richards R. H. Clements P. C. Wang C. D. Lind H. Mertz J. K. Ladipo M. D. Holzman K. W. Sharp 《Surgical endoscopy》1999,13(10):1010-1014
Background: There is still some controversy over the need for antireflux procedures with Heller myotomy in the treatment of achalasia.
This study was undertaken in an effort to clarify this question.
Methods: To determine whether Heller myotomy alone would cause significant gastroesophageal reflux (GER), we studied 16 patients who
had undergone laparoscopic Heller myotomy without concomitant antireflux procedures. Patients were asked to return for esophageal
manometry and 24-h pH studies after giving informed consent for the Institutional Review Board (IRB)-approved study at a median
follow-up time of 8.3 months (range, 3–51). Results are expressed as the mean ± SEM.
Results: Fourteen of the 16 patients reported good to excellent relief of dysphagia after myotomy. They were subsequently studied
with a 24-h pH probe and esophageal manometry. These 14 patients had a significant fall in lower esophageal sphincter (LES)
pressure from 41.4 ± 4.2 mmHg to 14.2 ± 1.3 mmHg, after the myotomy (p < 0.01, Student's t-test). The two patients who reported more dysphagia postoperatively had LES pressures of 20 and 25 mmHg, respectively. Two
of 14 patients had DeMeester scores of >22 (scores = 61.8, 29.4), while only one patient had a pathologic total time of reflux
(percent time of reflux, 8%). The mean percent time of reflux in the other 13 patients was 1.9 ± 0.6% (range, 0.1–4%), and
the mean DeMeester score was 11.7 ± 4.6 (range, 0.48–19.7).
Conclusions: Laparoscopic Heller myotomy is effective for the relief of dysphagia in achalasia if the myotomy lowers the LES pressure
to <17 mmHg. If performed without dissection of the entire esophagus, the laparoscopic Heller myotomy does not create significant
GER in the postoperative period. Clearance of acid refluxate from the aperistaltic esophagus is an important component of
the pathologic gastroesophageal reflux disease (GERD) seen after Heller myotomy for achalasia. Furthermore, GERD symptoms
do not correlate with objective measurement of GE reflux in patients with achalasia. Objective measurement of GERD with 24
h pH probes may be indicated to identify those patients with pathologic acid reflux who need additional medical treatment.
Received: 12 May 1998/Accepted: 15 December 1998 相似文献
17.
Madalosso CA Fornari F Callegari-Jacques SM Madalosso CA Gurski RR 《Obesity surgery》2008,18(6):668-674
Background Gastroesophageal reflux disease (GERD) has been increasingly recognized in patients with morbid obesity. A recent global evidence-based
consensus on GERD has been proposed, but its performance in patients with morbid obesity is unknown. The aim of this study
was to assess the performance of the Montreal Consensus in the diagnosis of GERD in morbidly obese patients.
Methods Seventy-five consecutive morbidly obese patients underwent GERD symptoms assessment, upper gastrointestinal endoscopy, and
ambulatory esophageal pH monitoring “off PPI”. The performance of the Montreal Consensus was determined by comparing two diagnostic
algorithms: 1. a gold standard approach in which any GERD symptom and findings from both endoscopy and pH monitoring were
taken into account, and 2. the approach with the Montreal Consensus, in which troublesome GERD symptoms and endoscopic findings
were considered.
Results GERD was found present in 57 patients by applying the gold standard approach. The Montreal Consensus identified 41 of these
patients, whereas the remaining 34 patients were classified as “no GERD”. Of these, 16 (47%) showed reflux esophagitis and/or
abnormal pH-metry. The Montreal Consensus had an accuracy of 78.7%, sensitivity of 72% (95% CI 59–82%), specificity of 100%
(95% CI 82–100%) and negative predictive value of 47% (95% CI 37–57%).
Conclusions In morbidly obese patients, the approach with the Montreal Consensus has high specificity and suboptimal sensitivity in the
diagnosis of GERD. Its intermediate negative predictive value suggests that complementary investigation might be routine in
these patients, particularly in those who do not present with troublesome GERD symptoms.
Madalosso and Fornari contributed equally to the study. 相似文献
18.
Background
The purpose of this study was to assess the effect of body position on lower esophageal sphincter (LES) structure and function.Methods
Symptomatic patients underwent high-resolution manometry in the supine and upright positions followed by pH testing. Regardless of whether there was a positive DeMeester score, isolated upright reflux patterns were considered present when the supine fraction of time pH <4?=?0%. Predominant-upright and predominant-supine bipositional reflux (SBR) patterns were considered present when the supine fraction of time wasResults
Of 128 patients, 35 isolated upright, 55 predominant-upright bipositional, and 27 SBR patients were identified. When supine, LES pressure/length was higher in upright compared to bipositional reflux patients. When upright, there was no difference in LES pressure/length between groups. The LES in isolated upright reflux patients became defective when moved from supine to upright position compared to bipositional patients, where the LES was defective regardless of position. Although the incidence of laryngopharyngeal reflux (LPR) events was comparable between groups, isolated upright patients commonly had a normal DeMeester score.Conclusion
Position impacts LES competency in those with upright reflux and would not be detected with supine manometry. Upright reflux can be associated with GERD and LPR despite negative pH testing. 相似文献19.
Anand P. Tamhankar M.D. Gideon Almogy M.D. Mustafa A. Arain M.D. Giuseppe Portale M.D. Jeffrey A. Hagen M.D. Jeffrey H. Peters M.D. Peter F. Crookes M.D. Lelan F. Sillin M.D. Steven R. DeMeester M.D. Cedric G. Bremner M.D. Tom R. DeMeester M.D. 《Journal of gastrointestinal surgery》2003,7(8):990-996
Hypertensive lower esophageal sphincter (LES) is an uncommon manometric abnormality found in patients with dysphagia and chest
pain, and is sometimes associated with gastroesophageal reflux disease (GERD). Preventing reflux by performing a fundoplication
raises concerns about inducing or increasing dysphagia. The role of myotomy in isolated hypertensive LES is also unclear.
The aim of this study was to determine the outcome of surgical therapy for isolated hypertensive LES and for hypertensive
LES associated with GERD. Sixteen patients (5 males and 11 females), ranging in age from 39 to 89 years, with hypertensive
LES (>26 mm Hg; i.e., >95th percentile of our control population) who had surgical therapy between 1996 and 1999 were reviewed.
Patients with a diagnosis of achalasia and diffuse esophageal spasm were excluded. All patients had dysphagia or chest pain.
Eight of 16 patients had symptoms of GERD, four had a type III hiatal hernia, and four had isolated hypertensive LES pain.
Patients with hypertensive LES and GERD or type III hiatal hernia had a Nissen fundoplication, and those with isolated hypertensive
LES had a myotomy of the LES with partial fundoplication. Outcome was assessed as follows: excellent if the patient was asymptomatic; good if symptoms were present but no treatment was required; fair if symptoms were present and required treatment; and poor if symptoms were unimproved or worsened. All patients were contacted by telephone for symptom assessment at a median of 3.6
years (range 3 to 6.1 years) after surgery. Patients with hypertensive LES and GERD or type III hiatal hernia had significantly
lower LES pressure than those with isolated hypertensive LES (29.9 vs. 47.4 mm Hg; P = 0.013). Dysphagia and chest pain were relieved in all patients at long-term follow up. Outcome was excellent in 10 of 16,
good in 3 of 16, and fair in 3 of 16. All patients but one were satisfied with their outcome. Patients with hypertensive LES
are a heterogeneous group in regard to symptoms and etiology. Treatment of patients with hypertensive LES should be individualized.
A Nissen fundoplication for hypertensive LES with GERD or type III hiatal hernia relieves dysphagia and chest pain suggesting
reflux as an etiology. A myotomy with partial fundoplication for isolated hypertensive LES relieves dysphagia and chest pain
suggesting a primary sphincter dysfunction.
Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 17–22,
2003. 相似文献
20.
Alberto Zalar Baya Haddouche Michel Antonietti Raied Alhameedi Isabelle Iwanicki-Caron Stéphane Lecleire Philippe Ducrotté 《Obesity surgery》2013,23(11):1939-1941
The relationship between obesity and gastroesophageal reflux disease (GERD) is a subject of debate. In this large series of 250 morbidly obese patients, all candidates for bariatric surgery, we have shown the very low prevalence of severe GERD and neither Barrett’s esophagus nor esophageal adenocarcinoma was detected. Moreover, no relationship was found between GERD and not only BMI but also abdominal diameter. 相似文献