Complications Of Gastroesophageal Reflux Research Articles

An objective assessment of laparoscopic antireflux surgery

Complicated gastroesophageal reflux disease (GERD) requires long-term medical therapy, which in some instances is incompletely effective or poorly tolerated. Additionally, there is concern about the consequences of prolonged acid suppression therapy. Surgical correction of GERD has been a therapeutic option for decades. With the advent of video-assisted laparoscopic surgery, antireflux surgery has had a resurgence in popularity. Between October 1992 and June 1995, 20 patients who underwent laparoscopic antireflux surgery were completely studied preoperatively and 3 months postoperatively with 24-hour pH monitoring and esophageal manometry. Follow-up averaged 18 months. The indication for surgery was medically refractory disease in 75%, intolerance to medication in 10%, and concern regarding the consequences of long-term medical therapy in 15%. Two thirds of these patients had complicated GERD. Operative time averaged 4 hours. There was no conversion to an open procedure. There was no mortality. Two patients had recurrent reflux, for a failure rate of 10%. Overall, postoperative reflux episodes and percent of time pH was less than 4 dropped significantly. Lower esophageal sphincter function showed a statistically significant increase in mean postoperative resting pressure and residual sphincter pressure during swallowing. There was no change in motility postoperatively. Laparoscopic antireflux surgery is a safe, effective, therapeutic alternative in the management of gastroesophageal reflux disease.

The uncut Collis-Nissen fundoplication: Results for 79 consecutively treated high-risk children

Purpose: The Nissen fundoplication fails to control gastroesophageal reflux (GER) in up to 25% of children with neurological impairment or chronic lung disease. The uncut Collis modification lengthens the intraabdominal esophagus, improving the antireflux function without opening the stomach. This study reviews the results of the uncut Collis-Nissen fundoplication in a pediatric series. Methods: Seventy-nine children had an uncut Collis-Nissen fundoplication performed over a 5-year period. The median age was 1.4 years. Associated problems included neurological impairment (77%), chronic lung disease (38%), and esophageal atresia (3%). Surgery was undertaken only in children with objective documentation of pathological GER, who had GER complications unresponsive to medical treatment. The usual complications that led to surgery were pulmonary (73%), esophagitis (67%), or failure to thrive (35%). Liquid gastric emptying was assessed routinely preoperatively, and was delayed in 42% patients who then had concomitant pyloroplasty. Results: GER was controlled in 97% of patients after a median follow-up of 1.8 years. All children with recurrent symptoms were restudied, and only two children had documented recurrent GER. One of these required a repeat fundoplication. Thirty-three percent were on promotility medication for feeding difficulties, gagging, or retching. There were postoperative complications in 26% (minor 23%, major 3%) and one postoperative mortality. Eleven late deaths were unrelated to surgery or GER. Conclusion: The uncut Collis-Nissen fundoplication provides excellent control of GER in children and is associated with acceptable morbidity and low mortality. It should be particularly considered in children with neurological impairment or chronic lung disease.

Breakdown of gastric staple line as a complication of the uncut Collis-Nissen fundoplication in children.

Uncut Collis-Nissen fundoplication for complicated gastroesophageal reflux was performed in 102 children (46 girls; age 5.6 +/- 4.2 years). Five patients developed intractable emesis postoperatively (average 11 +/- 5 months after surgery) and were found to have two independent luminal openings at the gastroesophageal junction seen on upper endoscopy but not demonstrable on upper GI. The defect was presumed to occur from breakdown of the original staple line on the lesser gastric curve. The condition was successfully repaired in all patients by including a new staple line and rewrapping of the stomach. Practitioners should be aware of this previously unreported complication post uncut Collis-Nissen fundoplication and that this condition may not be excluded by a normal upper GI study.

Gastroesophageal reflux--how to mend it?

Gastroesophageal reflux (GER) is a common condition affecting children. The clinical presentation varies widely from innocuous spitting up to life threatening apnea. Various diagnostic tests are available to document the etiology, presence or complications of GER. In most cases, conservative approach is sufficient. In complicated cases, pharmacotherapy is indicated while surgical therapy is reserved for resistant cases with complications.

The surgery of complicated gastro-oesophageal reflux.

A properly performed anti-reflux operation is the most effective and durable method of control l ing gastrooesophageal reflux and its complications but is only required in a minority of affected patients TM. Because of recent advances in the medical management of reflux disease, maintenance medical therapy is a legitimate alternative to surgery and the frequency of anti-reflux operations has been reduced. In consequence, only those patients with the most severe form of disease or complex symptomatology are referred for surgical correction. Thus the surgical challenge is now greater and the avoidance of failure requires strict selection of the right patient with the right disease (reflux) for the right operation. Upper gastro-intestinal contrast studies, endoscopy, oesophageal manometry and 24 hour oesophageal pH monitoring are mandatory preoperative base-line investigations. Prior to selecting patients for surgery, the following cri teria should be satisfied: (a) pathological gastrooesophageal reflux should he demonstrated to he the cause of the symptoms. (b) complications of reflux should be sought these include oesophagitis, stricture, Barrett 's oesophagus, motor dysfunction, pulmonary aspiratio n and failure to thrive in children. (c) an oesophageal motility disorder such as achalasia, diffuse spasm or scleroderma should be excluded. (d) co-existing diseases with similar or overlapping symptoms such as angina pectoris, peptic ulceration and gallstones should be excluded. (e) the patient should have had an adequate trial of modern medical therapy. This should include a programme of weight reduction, withdrawal of alcohol or nicotine, and drug therapy with optimal doses of either an Histamine H2 receptor blocker or proton pump inhibitoi" together with antacids and/or prokinetic agent. Modern drugs are safe in the long term and economic reasons are a weak and rare justification for surgery. (f) The patient should be evaluated for a contraindicat ion to surgery such as intercurrent cardiac or pulmonary disease or a general medical problem. Patients undergoing definitive surgery for gastrooesophageal reflux fall into two general categories, the complex and the straight-forward case. The presence of an oesophageal stricture, oesophageal foreshortening, deep ulceration, irreducibility of an associated hiatal hernia, suspected carcinoma, scleroderma and previous surgery define the complex case and should b e approached

Traitement du reflux gastroœsophagien

Several therapeutic means are available for the treatment of pathological gastroesophageal reflux (GOR): positional therapy, thickening the feedings, dietetic modifications, antacids, mucosa-protecting agents, gastrokinetic drugs, antisecretory drugs, and surgery. In uncomplicated GOR, simple measures must be used first, associating positional therapy, thickening the feedings and a mucosa-protecting agent or an antacid; a gastrokinetic drug will be added if these measures are insufficient after 2 or 3 weeks. Peptic esophagitis requires a more drastic treatment, using antacid prekinetic and antisecretory drugs; in addition, its cure should be assessed by esophagoscopy. When GOR is associated with life-threatening events, treatment may be completed with an atropine derivative in case of vagal hypertonia, and its efficiency must be verified by monitoring of oesophageal pH under treatment. In infants, the medical treatment should be maintained until complete cure, wich usually occurs when walking is achieved. Surgery is indicated in complicated GOR (esophagitis, life-threatening event, pulmonary complication) with failure of the medical treatment, or as first-line treatment in the case of severe esophagitis in children with severe psychomotor impairment.

Diagnostic inconsistencies in Barrett's esophagus

Background/Aims: Few studies have compared the precision of various diagnostic tests used to determine the presence of Barrett's esophagus. The aim of this study was to compare the results of histological, endoscopic, and manometric tests for patients with Barrett's esophagus in two closely spaced examinations. Methods: In a Veterans Administration Cooperative Study, 192 patients with complicated gastroesophageal reflux disease had esophageal manometry and endoscopy performed at baseline and after 6 weeks. At each examination, the endoscopist localized the most proximal level of Barrett's epithelium and the lower esophageal sphincter and obtained esophageal biopsy specimens. Results: One hundred sixteen patients met the criteria for Barrett's esophagus on at least one of the two endoscopic examinations. Among patients with specialized columnar epithelium, 20% had specialized columnar epithelium found on only one of the two examinations. Although the mean lower esophageal sphincter level did not change, approximately 10% of patients had a change ≥4 cm on endoscopy and manometry between examinations. This led to an apparent change in the diagnosis in 18% of patients with Barrett's esophagus. Conclusions: From one endoscopic examination to another, inconsistencies in the ability to detect specialized columnar epithelium are common. This may lead to substantial problems in establishing an accurate diagnosis of Barrett's esophagus.

Successful management of severe gastroesophageal reflux disease with laparoscopic nissen fundoplication

Nissen fundoplication has been shown to be superior to medical treatment in the management of severe or complicated gastroesophageal reflux disease (GERD). Rapid advances in minimally invasive surgical technique and recognition of the advantages of reduced incision-related morbidity have fostered application of laparoscopic techniques to antireflux surgery. A prospective evaluation of 70 patients undergoing laparoscopic Nissen fundoplication for severe GERD was undertaken. Rigid selection criteria for laparoscopic Nissen fundoplication included severe or refractory disease with documentation of abnormal esophageal acid exposure by 24-hour pH probe monitoring, documentation of a mechanically defective lower esophageal sphincter by esophageal manometry, and absence of severe esophageal and/or gastric motility disorders. Sixty-eight of 70 patients were completed laparoscopically with an intraoperative morbidity rate of 9%. Major postoperative complications occurred in 3 patients (4%) and included deep venous thrombosis (n = 1), delayed gastric leak (n = 1), and trocar site hernia (n = 1). The average hospital stay was 3.0 days, and the average time to return to normal activity was 7.0 days. All patients experienced relief of symptoms of reflux with mean follow-up of 7.7 months. Transient, mild dysphagia was experienced by 37% of patients, and persistent, severe dysphagia by 7%. The mean increase in lower esophageal sphincter pressure was 16.2 mm Hg. The total and intra-abdominal sphincter lengths increased an average of 1.5 and 1.4 cm, respectively. These preliminary data suggest that laparoscopic Nissen fundoplication can be performed by experienced laparoscopic surgeons with excellent symptomatic and physiologic results and a morbidity rate comparable to conventional open antireflux procedures. Rigid patient selection criteria will help identify the patients most likely to benefit from reconstruction of a mechanically defective lower esophageal sphincter. Adherence to established operative principles for Nissen fundoplication will reduce the incidence of significant postfundoplication symptoms.

Gastroesophageal Reflux in Children

Operations for the control of complicated gastroesophageal reflux in children are commonly performed procedures in large pediatric centers. The comprehensive diagnostic scheme includes radiologic and endoscopic work-up coupled with extended pH probe analysis. Medical therapy remains the principle form of management, with surgery reserved for treatment failure.

Esophageal disorders in infants and children.

Although the esophagus functions simply as a conduit between the mouth and the more distal gastrointestinal tract, its physiology and pathophysiology display a complexity that contrasts with that simple function. Thus there are still mysteries about this "tube" and its disorders, and each year brings new revelations. Most attention continues to focus on gastroesophageal reflux, its emerging pathophysiology, multiple manifestations, various diagnostic techniques, and improving methods of treatment. Complications of gastroesophageal reflux, including optimal ways of preventing and treating them, have been explored further. Other aspects of esophageal motility and dysmotility and other causes of inflammation and injury of the esophagus have also been studied during the past year. The surgical literature, especially, continues to struggle with congenital esophageal lesions, particularly esophageal atresia and stenoses.

Long-term follow-up of infants with pathological gastroesophageal reflux

Between 1981 and 1984 330 infants with suspected gastroesophageal reflux (GER) were investigated by combined esophageal manometry and pH-monitoring. GER of 283 patients with a manometric reflux time more than 1% was classified as pathologic. After one year of conservative therapy a follow-up-study mainly by 24-hour-pH-monitoring could be performed in 108 patients. Two thirds (76 out of 108) still showed a pathological GER. In the age of about two years follow-up-investigation in 41 patients showed in one third of them (13 out of 41) a pathological GER. 5.4% of all investigated children (18 out of 330) hat to be operated because of complicated GER. Follow-up has been performed in 24 children over five years with manometry and/or pH-monitoring and/or barium swallow and/or endoscopy with biopsy. After one year of conservative therapy more than two thirds of them (19 out of 24), after two years one third (eight out of 24) showed a pathological GER. In a few cases (four out of 24) the pathological GER disappeared spontaneously in the age of four to five years. In the age of 1.5 to three years six children had to be operated because of complicated GER. We conclude from this study that a spontaneous healing of pathological GER occurs in about two thirds of the patients older than one year. In about 8% (two out of 24) a pathological GER persists over the fifth year of life representing a permanent risk of GER complications.

A novel endoscopic transgastric fundoplication procedure for gastroesophageal reflux: an initial animal evaluation.

Complications of gastroesophageal reflux are common in adults and children. A variety of surgical procedures have been successfully used to treat this condition. All current techniques require open surgery and are associated with significant morbidity and mortality, particularly in the high risk, neurologically damaged child. The authors have developed a novel method of creating a gastric fundoplication using an endoscopic transgastric approach in pigs. The procedure involves the creation of an esophageal intussusception into the stomach under direct vision with an endoscope. The gastric fundus is then plicated around the esophagus using a custom stapling device. The transgastric approach allows creation of a fundoplication, is easily performed, is potentially effective at preventing gastroesophageal reflux, and has the obvious advantages of minimally invasive surgery over open techniques of fundoplication.

Surgery preferable for complicated gastro-oesophageal reflux disease

Surgery preferable for complicated gastro-oesophageal reflux disease

Nursing responsibility in the diagnosis, care, and treatment of the child with gastroesophageal reflux.

Gastroesophageal reflux (GER) has been known to occur in infants but was thought to be normal. As a result of increased recognition of GER and a clear documentation of GER with extended (18 to 24 hour) esophageal pH monitoring, several severe complications of GER in children have become apparent. An immature cardiorespiratory system is susceptible to some complications of GER such as apnea, choking, recurrent cough or wheezing, and recurrent aspiration pneumonia. Noncardiorespiratory complications include weight loss, esophagitis, anemia, irritability, posturing, malnutrition, and developmental delays. Nursing assessment contributes to a complete clinical picture and the subsequent treatment choice of the physician. To form an accurate assessment of the child with suspected GER, the nurse must be aware of the symptoms and complications of this condition and must precisely execute diagnostic studies, particularly extended esophageal pH monitoring. Nursing responsibilities also include providing a safe yet stimulating environment for the child, teaching parents to participate in the child's care, supporting parents through hospitalization, and preparing both the parents and child for discharge and follow-up care at home.

New surgical approach to complicated gastroesophageal reflux disease: Transthoracic parietal cell vagotomy

Surgical treatment of peptic stricture of the esophagus associated with columnar (Barrett) metaplasia can be a difficult problem. Collis-Nissen fundoplication restores an intraabdominal antireflux barrier for most cases of peptic stricture; however, 20% of patients may have persistence of pathological acid reflux. By reducing acidity of postoperative reflux, parietal cell vagotomy may complement nonresectional surgical results for Barrett stricture.

Scleroderma esophagus

Scleroderma (systemic sclerosis) is a connective tissue disorder characterized by thickening and fibrosis of the skin and visceral involvement that may include the heart, lungs, kidneys, and gastrointestinal tract. At least 40-50% of patients with scleroderma experience esophageal symptoms such as heartburn and dysphagia, while up to 90% of patients have esophageal dysfunction on objective testing at some point in their disease. The disease results in smooth muscle dysfunction that causes esophageal aperistalsis and reduced lower esophageal sphincter pressures. Gastroesophageal reflux with poor acid clearance results with an increased incidence of complications such as peptic stricture and Barrett's esophagus. Aggressive medical therapy is necessary to prevent these and other complications of gastroesophageal reflux.

Technique of the transabdominal uncut Collis-Nissen fundoplication

Antireflux operations are commonly performed in infants and children with complicated gastroesophageal reflux. The Nissen fundoplication has emerged as the “gold standard” antireflux procedure, although troublesome problems with wrap slippage over the stomach, complete or partial wrap disruption, and herniation of the wrap into the posterior mediastinum are frequent complications, leading to recurrent symptoms of reflux and a difficult reoperative procedure. We presently perform the uncut Collis-Nissen fundoplication as a primary antireflux procedure. This operation is particularly useful in the treatment of children with failed Nissen fundoplication. In this report, we describe our technique of performing this operation through a transabdominal approach and outline the advantages of the procedure.

Randomized, prospective double-blind trial of metoclopramide and placebo for gastroesophageal reflux in infants

The effect of metoclopramide on gastroesophageal reflux was studied in 30 infants less than 1 year of age. Gastroesophageal reflux was documented in all infants by extended pH monitoring before enrollment in the study. Patients were randomly assigned to receive metoclopramide 0.1 mg/kg or placebo four times a day, 1/2 hour before feeding for 1 week, followed by the alternate regimen for 1 week. The infants were reevaluated with extended pH monitoring and scintigraphy after 4 to 7 days of each treatment. A symptom score was derived by determining the average number of occurrences of all symptoms recorded daily by parents on a symptom checklist during pretreatment, placebo, and metoclopramide treatment periods. There was a difference between pretreatment evaluation and placebo periods with respect to daily symptom scores (p less than 0.005), reflecting a significant placebo response. However, no difference in scintigraphic study was found between placebo and metoclopramide periods. A significant difference between placebo and metoclopramide periods was noted in the percentage of time esophageal pH was less than 4.0 (p less than 0.001). However, although metoclopramide decreased the proportion of time esophageal pH was less than 4.0, pH remained less than 4.0 for more than 5% of the time in most patients. Substratification of the total group into infants younger and older than 3 months revealed that older infants had greater average daily weight gain during the metoclopramide treatment period (34.3 gm/day) than in the placebo treatment period (6.6 gm/day, p = 0.05). We conclude that metoclopramide in the dosage 0.1 mg/kg four times daily reduces reflux in infants and may be useful for infants with poor weight gain and other serious complications of gastroesophageal reflux.

Barrett's Esophagus: Detection and Management

Barrett's esophagus is a disease that is common in patients with gastroesophageal reflux of acid but may also occur in association with bile reflux and rarely with other factors. It cannot be reliably distinguished from patients with reflux alone on the basis of demographic factors, clinical characteristics, or manometry. Radiology only serves to make Barrett's epithelium less likely in the presence of a completely normal study. The gold standard for diagnosing Barrett's esophagus is still multiple biopsies taken at the time of endoscopy. By performing multiple biopsies at various levels, the gastroenterologist will be effective not only in diagnosis but in selecting and screening that subset of patients with dysplasia that may predict coexisting or future adenocarcinoma. Treatment of high-grade dysplasia or carcinoma is resection, whereas medical treatment or fundoplication is still directed at the severity and complications of gastroesophageal reflux rather than at Barrett's characteristics alone. A decision tree given in Figure 5 summarizes these recommendations.

Pulmonary disease in progressive systemic sclerosis. A complication of gastroesophageal reflux and occult aspiration?

Pulmonary disease in progressive systemic sclerosis. A complication of gastroesophageal reflux and occult aspiration?