Bipositional Reflux Research Articles

ESOPHAGEAL FUNCTIONAL DISORDERS IN THE PRE-OPERATORY EVALUATION OF BARIATRIC SURGERY.

Obesity is an independent risk factor for esophageal symptoms, gastroesophageal reflux disease (GERD), and motor abnormalities. When contemplating bariatric surgery, patients with obesity type III undergo esophagogastroduodenoscopy (EGD) and also esophageal manometry (EMN), and prolonged pHmetry (PHM) as part of their pre-operative evaluation. Description of endoscopy, manometry and pHmetry findings in patients with obesity type III preparing for bariatric surgery, and correlation of these findings with the presence of typical GERD symptoms. Retrospective study in which clinical symptoms of GERD were assessed, focusing on the presence of heartburn and regurgitation. All patients underwent EMN, PHM and most of them EGD. 114 patients (93 females-81%), average age 36 years old, average BMI of 45.3, were studied. Typical GERD symptoms were referred by 43 (38%) patients while 71 (62%) were asymptomatic. Eighty two patients (72% of total) underwent EGD and 36 (42%) evidenced esophageal abnormalities. Among the abnormal findings, hiatal hernia was seen in 36%, erosive esophagitis (EE) in 36%, and HH+EE in 28%. An abnormal EMN was recorded in 51/114 patients (45%). The main abnormality was a hypotensive lower esophageal sphincter (LES) in 32%, followed by ineffective esophageal motility in 25%, nutcracker esophagus in 19%, IEM + hypotensive LES in 10%, intra-thoracic LES (6%), hypertensive LES (4%), aperistalsis (2%) and achalasia (2%). Among the 43 symptomatic patients, 23 (53%) had abnormal EMN and 31/71 asymptomatic cases (44%) also presented this finding (P=0.30). PHM showed abnormal reflux in 60/114 patients (53%), with a predominance of bi-positional reflux (42%), followed by supine reflux (33%) and upright reflux (25%). Abnormal PHM was found in 26/43 symptomatic cases (60%) and also among 34/71 asymptomatic cases (48%) (P=0.19). Manometric abnormalities were common in obesity type III patients, the most frequent being hypotensive LES, followed by IEM. Most patients were asymptomatic. There was no correlation between the finding of motor abnormalities and the presence of symptoms. More than half the patients had abnormal reflux at PHM. We found no significant correlation between abnormal reflux and the presence of symptoms.

The correlation between gastric bubble size and laryngopharyngeal reflux pattern in patients with laryngopharyngeal reflux disease

Objective: To investigate the correlation between gastric bubble size and laryngopharyngeal reflux pattern in patients with laryngopharyngeal reflux disease(LPRD). Methods: A total of 52 LPRD patients who underwent Dx-pH monitoring and anteroposterior chest radiography at the same time from February 2016 to November 2018 were retrospectively studied. Patients were devided into three position-related groups according to the Ryan score of upright and supine: isolated upright reflux(IUR), isolated supine reflux(ISR) and bipositional reflux(BR) groups. In addition, 13 healthy volunteers with negative pH monitoring were selected as the control group. Gastric bubble size and pH monitoring data among the four groups were compared. SPSS 24.0 was used for statistical analysis. Results: In all the 52 patients, 35 cases (67.3%) were classified as IUR, 9 cases (17.3%) as ISR, and 8 cases (15.4%) as BR. The height of gastric bubbles in the four groups were: IUR (26±14) mm, ISR (9±8) mm, BR (20±13) mm, control (17±15) mm, and statistical difference was found among the four groups(P=0.004). Post Hoc Multiple Comparisons found that IUR group had statistical difference between ISR group and control group (P=0.001, P=0.034 respectively). There was no statistical difference of gastric bubble width and area among the four groups(P=0.340, P=0.186 respectively). The ROC curve of the gastric bubble height with isolated upright and supine reflux patterns was obtained, and the optimal cutoff value of the gastric bubble height was 11 mm. Accordingly, we divided the patiens into two groups with high and low gastric bubble. LPRD reflux pattern distribution was significantly different between the two groups(P<0.001). The comparison of reflux parameters in pH monitoring also showed that the supine reflux parameters in the lower group were significantly higher than those in the higher group, and the upright reflux parameters in the higher group were significantly higher than those in the lower group(P<0.001). Conclusions: The height of gastric bubble is significantly correlated with the reflux patterns in LPRD patients. The gastric bubble of patients with IUR is significantly higher than that of patients with ISR. Taking 11 mm as the cutoff value, patients with higher gastric bubble are more prone to upright laryngopharyngeal reflux, while those with lower gastric bubble are more prone to supine laryngopharyngeal reflux.

Toward an Improved Understanding of Isolated Upright Reflux: Positional Effects on the Lower Esophageal Sphincter in Patients with Symptoms of Gastroesophageal Reflux

The purpose of this study was to assess the effect of body position on lower esophageal sphincter (LES) structure and function. 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 was <upright fraction of time pH <4 and the supine fraction was >upright fraction of time pH <4, respectively. 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. 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.

The Pattern of Esophageal Acid Exposure and Esophageal Pressure Morphology in Patients With Hiatus Hernia

Introduction Gastro-oesophageal reflux disease (GORD) generally presents as pathological Upright, Supine or Bi-positional reflux. Hiatus hernia (HH) and dysmotility are common in chronic GORD. However, in the presence of HH, it is unclear how age, severity of oesophageal acid exposure and dysmotility are related to the different postural types of GORD. Methods From March 2006 to July 2010, 1242 patients with GORD symptoms had high resolution manometry (HRM; Manoscan 360, Sierra) and 24-h catheter-based pH-monitoring (Slimline™, Medtronic) performed. 124 consecutive patients with both pathologic reflux and HH were collected. Patients were classified as Upright (n = 24), Supine (n = 38) or Bi-positional (n = 62) predominant reflux. Total (TR > 4.2%), upright (UR > 8.15%) and supine (SR > 3.45%) reflux parameters were used to classify GORD into position subtypes. HH was defined as Type II (lower oesophageal sphincter (LOS)-crural diaphragm (CD), 1–2 cm) and Type III (LOS-CD > 2 cm) in accordance with the Chicago Classification. Student9s t test, χ 2 tests and Mann–Whitney-U test were used for statistical analysis. Results Mean ±SD age was 54 ± 14 years (range 16–85 years; 64 males). Patients with Bi-positional reflux (57 years) were older than those with Supine (49 years) (p = 0.013) or Upright reflux (53 years) (p = 0.04). Furthermore the severity of oesophageal acid exposure (TR, UR and SR) was greater in the Bi-positional (18.1%, 17.6%, 19.7%) than Supine (8.6%, 4.8%, 14.8%) (p Conclusion In patients with manometry-proven HH who present with symptoms suggestive of GORD, Bi-positional and Supine reflux predominance are associated with more severe disease and are more likely to be associated with failed peristalsis. Furthermore Bi-positional reflux disease is more common with increasing age as is Type III HH.

The pattern of oesophageal acid exposure and oesophageal pressure morphology in patients with hiatus hernia

<h3>Introduction</h3> Gastro-oesophageal reflux disease (GORD) generally presents as pathological Upright, Supine or Bi-positional reflux. Hiatus hernia (HH) and dysmotility are common in chronic GORD. However, in the presence of HH, it is unclear how age, severity of oesophageal acid exposure and dysmotility are related to the different postural types of GORD. <h3>Methods</h3> From March 2006 to July 2010, 1242 patients with GORD symptoms had high resolution manometry (HRM; Manoscan 360, Sierra) and 24-h catheter-based pH-monitoring (Slimline™, Medtronic) performed. 124 consecutive patients with both pathologic reflux and HH were collected. Patients were classified as Upright (n = 24), Supine (n = 38) or Bi-positional (n = 62) predominant reflux. Total (TR &gt; 4.2%), upright (UR &gt; 8.15%) and supine (SR &gt; 3.45%) reflux parameters were used to classify GORD into position subtypes. HH was defined as Type II (lower oesophageal sphincter (LOS)-crural diaphragm (CD), 1–2 cm) and Type III (LOS-CD &gt; 2 cm) in accordance with the Chicago Classification. Student9s t test, χ² tests and Mann–Whitney-U test were used for statistical analysis. <h3>Results</h3> Mean ±SD age was 54 ± 14 years (range 16–85 years; 64 males). Patients with Bi-positional reflux (57 years) were older than those with Supine (49 years) (p = 0.013) or Upright reflux (53 years) (p = 0.04). Furthermore the severity of oesophageal acid exposure (TR, UR and SR) was greater in the Bi-positional (18.1%, 17.6%, 19.7%) than Supine (8.6%, 4.8%, 14.8%) (p &lt; 0.001) or Upright (8.5%, 12.8%, 1.1%) (p &lt; 0.001) reflux group. Total supine reflux episodes in the Supine group were fewer in number (54) compared to the total upright reflux episodes in the Upright group (127) (p &lt; 0.001), although the total reflux time was similar in both positions (124 min supine vs 127 min upright; p = NS). Although there was no significant difference in the mean peristaltic wave contractility and velocity between the three groups, the % of successful peristalsis was higher in the Upright (65%) than Supine (54%) or Bi-positional (52%) GORD group (p = 0.008 and p = 0.001, respectively). Patients with Type III HH were older (mean age 57 years; n = 71) than Type II HH (mean age 50 years; n = 53) (p = 0.013). There was no difference in HH length between the GORD position subtypes (range 2.0–8.4 cm). Although there was no difference in TR, UR and SR, the LOS basal pressure was lower in Type III (8.9 mmHg) than Type II (12.0 mmHg) HH patients (p = 0.05). <h3>Conclusion</h3> In patients with manometry-proven HH who present with symptoms suggestive of GORD, Bi-positional and Supine reflux predominance are associated with more severe disease and are more likely to be associated with failed peristalsis. Furthermore Bi-positional reflux disease is more common with increasing age as is Type III HH.

The Preoperative Reflux Pattern as Prognostic Indicator for Long-Term Outcome After Nissen Fundoplication

We set out to investigate the impact of the preoperative reflux pattern on long-term outcome after Nissen fundoplication. Recent studies disagree on whether patients with pathological upright reflux should be discouraged from undergoing surgery. A total of 338 patients underwent Nissen fundoplication. Of these, 234 of 289 patients had pathological acid exposure on preoperative 24-h esophageal pH monitoring and their reflux was classified as pathological upright (n=81), supine (n=55), or bipositional (n=98). Clinical outcomes and results of endoscopy, manometry, and 24-h pH monitoring were compared before surgery, and at 3 months and 5 years after surgery. Patients with pathological upright and supine reflux had similar preoperative reflux parameters. In patients with pathological bipositional reflux, however, preoperative total acid exposure was higher than that in patients with upright or supine reflux (18.3% vs. 10.7 and 7.5%; P<0.001 and P<0.001). Prevalence of esophagitis was higher in patients with bipositional reflux than in those with upright reflux, both before (64.0 vs. 45.6%; P=0.035) and 3 months after surgery (16.0 vs. 3.5%; P=0.018). Before surgery, mean lower esophageal sphincter (LES) pressure was lower compared with the upright and supine reflux groups (1.0 vs. 1.5 and 1.6 kPa; P=0.007 and 0.005, respectively). The increase in quality of life, reduction of symptoms, use of acid-suppressing drugs, total acid exposure, and esophagitis were independent of reflux pattern at 3 months and 5 years after surgery (all P<0.05). Prevalence of recurrent pathological acid exposure was higher in the bipositional group than in the upright group (40.9 vs. 10.7%; P=0.013). Surgical reintervention was significantly more common in bipositional reflux patients (20.0 vs. 8.9% for upright and 4.1% for supine). All three pathological reflux patterns respond favorably to Nissen fundoplication in the long term. Patients with pathological bipositional reflux, however, suffer from more severe disease with higher chance of recurrence and reoperation.

Upright, supine, or bipositional reflux

This study was undertaken to determine if the body position in which gastroesophageal reflux occurs before fundoplication--i.e., pattern of reflux--affects symptoms before or after laparoscopic Nissen fundoplication. A total of 417 patients with gastroesophageal reflux disease (GERD) underwent pH studies, and the severity of reflux in the upright and supine positions was determined. The percent time with pH less than 4 was used to assign patients to one of four groups: upright reflux (pH < 4 more than 8.3% of time in upright position, n = 80), supine reflux (pH < 4 more than 3.5% of time in supine position, n = 73), bipositional reflux (both supine and upright reflux, n = 163), or neither (n = 101). Before and after laparoscopic Nissen fundoplication, the frequency and severity of symptoms of reflux (e.g., dysphagia, regurgitation, choking, heartburn, chest pain) were scored on a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). For each patient, symptom scores before versus after fundoplication were compared using the Wilcoxon matched pairs test; comparisons of symptom scores among patients grouped by reflux patterns were made using Kruskal-Wallis test. Before fundoplication, the patterns of reflux did not affect the frequency or severity of reflux symptoms. After laparoscopic fundoplication, all symptoms of bipositional reflux improved, and essentially all symptoms of isolated supine or upright reflux or neither improved. Preoperatively, regardless of the patterns of reflux, symptoms among patients were similar. After fundoplication, symptoms of GERD improved for all patterns of reflux. Laparoscopic fundoplication imparts dramatic and broad relief of symptoms of GERD, regardless of the patterns of reflux. Application of laparoscopic Nissen fundoplication is encouraged.

Preoperative gastric emptying and patterns of reflux as predictors of outcome after laparoscopic fundoplication

Some studies have suggested that patients with predominantly upright reflux have a poor outcome after laparoscopic antireflux surgery. It has been proposed that this might be related to gastric emptying. The aim of this study was to evaluate the relationship between preoperative upright reflux pattern, gastric emptying rate and outcome after laparoscopic fundoplication. Patients presenting for antireflux surgery underwent 24-h ambulatory pH testing and dual-isotope radionuclide gastric emptying studies. Reflux pattern was determined by the acid exposure in the distal oesophagus (percentage of time at pH < 4) during supine and upright posture. Outcome after fundoplication was assessed by a standardized postal questionnaire administered at 3 months, and 1, 2 and 5 years after surgery. Of 372 patients identified from a prospectively maintained database, 109 had upright reflux, 57 supine reflux and 206 bipositional reflux. Overall patient satisfaction was not influenced by reflux pattern at any time after surgery. Delayed gastric emptying was documented in 31.0 per cent of patients, but there was no relationship with reflux pattern. Patients with upright reflux did not have a less favourable outcome after fundoplication. Categorizing patients according to reflux pattern is of no value in predicting outcome or selecting patients for surgery.

Postoperative objective outcomes for upright, supine, and bipositional reflux disease following laparoscopic nissen fundoplication.

Traditionally, patients with gastroesophageal reflux disease fall into 3 categories based on 24-hour pH testing and the clinical occurrence of their acid exposure. Patients with upright reflux are believed to do worse following surgery compared with supine or bipositional reflux patients. We assessed objective postoperative outcomes for patients with upright, supine, and bipositional reflux following laparoscopic Nissen fundoplication to determine if there is a category of refluxing patient who should be counseled against antireflux surgery. Retrospective analysis of prospectively collected data. Esophageal physiology laboratory at a tertiary care teaching hospital. A total of 225 patients (supine, 45; upright, 92; bipositional, 88) with preoperative and postoperative 24-hour pH measurements, manometry results, and standardized symptom assessment forms were included in the study. A Nissen fundoplication was performed based on 24-hour pH and manometry result. Esophageal manometry was performed with a water-perfused system, and 24-hour pH was measured with a digital capture device. Preoperative and postoperative symptom correlation, 24-hour pH, and manometric variables. There was a significant difference in preoperative symptom correlation between groups. Patients with bipositional reflux disease have significantly worst reflux disease (percentage of time with a pH <4, total number of reflux episodes, longest reflux episode, and Johnson-DeMeester score) and the weakest preoperative lower esophageal sphincter pressure. Postoperative symptom correlation was low among all 3 groups. There was no significant difference in postoperative 24-hour pH or manometry among groups. Success following surgery was achieved in 73.3% with supine reflux, 80.4% with upright reflux, and 75.0% with bipositional reflux. Patients with bipositional reflux have the most severe disease. Supine, upright, and bipositional reflux patients perform equally well following laparoscopic fundoplication as defined by objective outcome criteria.

Patients With Upright Reflux Have Less Favorable Postoperative Outcomes After Laparoscopic Antireflux Surgery Than Those With Supine Reflux

The aim of this study was to compare symptomatic outcomes after laparoscopic antireflux surgery in patients with upright vs. supine reflux. A prospective database was used to assess postoperative clinical outcomes in relation to positional patterns of reflux in 117 patients. Supine reflux was present in 31%, upright in 24%, and the remaining 44% had bipositional reflux. Preoperatively there were no differences in the frequency of typical or atypical symptoms between groups. At a mean follow-up of 18 ± 11 months postoperatively, there were marked differences in symptoms between groups. Patients with upright reflux noted significantly more heartburn, chest pain, odynophagia, and bloating postoperatively when compared to patients with supine and bipositional reflux ( P < 0.05). According to visual analog scales, patients with upright reflux expressed less satisfaction with operative results, ascribing more symptoms to the esophagus and stomach, when compared to those with supine reflux ( P < 0.05). Although all patients reported improvement, the extent of the relief from preoperative symptoms was less in patients with upright reflux ( P < 0.05). When asked if, in retrospect, they favored operative therapy, the patients with upright reflux were less enthusiastic ( P < 0.05). Although antireflux surgery eliminates reflux in nearly all patients, postoperative symptomatic outcome is related to the preoperative pattern of reflux. Although all patients showed symptomatic improvement, the extent of that improvement was significantly less in patients with upright reflux. These patients should be carefully counseled preoperatively regarding expected symptomatic outcomes. ( J Gastrointest Surg 2002;6:819–830.)

Isolated upright gastroesophageal reflux is not a contraindication for antireflux surgery

Background . Patients with gastroesophageal reflux disease who reflux only in the upright position are thought to have a less severe abnormality. Controversy exists over whether these patients should be considered candidates for antireflux surgery. Methods . A total of 224 consecutive patients with increased esophageal acid exposure on 24-hour pH monitoring were classified as having upright (n = 54), supine (n = 72), or bipositional (n = 98) reflux and were evaluated by manometry and endoscopy. Of these, 116 patients had a laparoscopic Nissen fundoplication. Their clinical outcome at a median of 12 months (range 4 to 44 months) was compared. Results . Patients with upright reflux had a lower prevalence of a structurally defective lower esophageal sphincter, fewer hiatal hernias, and less esophageal injury when compared to those with bipositional reflux (p < 0.005). Excellent (asymptomatic) or good outcome (minor symptoms not requiring acid suppression therapy) was achieved in 86% of the patients with upright reflux, 90% of those with supine reflux, and 89% of those with bipositional reflux. Conclusions . Patients with upright reflux have less complicated, earlier disease and have results equivalent to those patients with supine and bipositional reflux after antireflux surgery.