Management Of Refractory Gastroesophageal Reflux Disease Research Articles

597. THE ROLE OF SURGERY IN THE ESOPHAGEAL INVOLVEMENT IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITTERATURE REVIEW

Abstract In Systemic Sclerosis (SSc), gastroesophageal reflux disease (GERD) occurs in 75% of patients. Chronic doses of proton pump inhibitors may elicit in the general population long-term risk. When medical therapy fails, surgery can be employed but consensus on surgical procedures for refractory GERD is still lacking in SSc. Our aim was to evaluate the surgical approaches employed in the management of refractory GERD with a systematic literature research (SLR). Four research questions, based on the PICO framework, guided the SLR which was conducted up to December 22nd, 2021. The search was performed across different databases including PubMed, MEDLINE (OVID), EMBASE, Cochrane Library, Web of Science, Google Scholar, Emcare and Academic Search Premier. References were independently screened by two reviewers (PMC and AA) who also independently assessed the full text of eligible articles, and extracted data. Due to heterogeneity of retrieved studies, narrative summaries are used to present the data. In 30/916 papers, eligible for review, 348 patients were identified: 257 underwent an anti-reflux surgical procedure and included in the analysis. Refractory GERD was the most frequent indication for surgery, and post-operative dysphagia was a frequent complication. In 18 studies, fundoplication (FP) was effective, whereas 4 studies had equivocal findings and 5 didn’t report efficacy. Surgical procedures have changed in time: overall, the Collis-Nissen FP was the most popular in old studies, followed by Nissen FP, while Dor FP has been used more recently. The data extracted show also an acceptable rate of mortality and morbidity related to surgery. In SSc, FP seems a safe and effective procedure for GERD management. In many studies, transient post-operative dysphagia was related with the posterior FP. Our SLR shows that the surgical management of GERD is still highly challenging and minimal requirements should be provided to perform surgical studies in SSc, designing studies to define clinical criteria for surgical referral. In SSc, the right timing for surgery and the best surgical procedure still remain an unmet need.

Impedance-detected Symptom Association and Number of Reflux Episodes as Pre-treatment Parameters That Predict Outcomes of Gastroesophageal Reflux Disease Patients.

TO THE EDITOR: We read with interest the study by Khan et al,1 who investigated patients with non-erosive reflux disease (NERD) refractory to anti-secretory therapy by means of impedance-pH monitoring on-therapy and concluded that nearly 60% of these patients had primarily a non-acid reflux disease. Moreover, they found that approximately half of NERD patients with normal multichannel intraluminal impedance (MII)-pH monitoring could be sub-divided into functional heartburn and hypersensitive esophagus equally. Differently from previous study,2–4 they used the bolus exposure time (BET) together with symptoms association analysis (symptom index [SI] and symptom association probability) to define NERD as true NERD, hypersensitive esophagus, or functional heartburn. We congratulate the authors with their study, however, we believe that the strength of their experimental findings would have improved if a more in depth analysis symptom-reflux association was also reported. Indeed, one of the major advantage of impedance-pH is to correlate symptoms to both kind of reflux episodes (acid and non-acid).5,6 Therefore, it is possible to observe a positive symptom correlation with non-acid reflux and, furthermore, to find a positive correlation by summing up the 2 measurements in order to obtain the so-called impedance-detected symptoms-reflux association (for example, 1 out of 3 [33%] episodes of heartburn related to acid and 1 [33%] related non-acid result in a negative SI to acid or non-acid, but a positive impedance-detected SI since 2 out of 3 [66%] episodes are related to symptoms).7–9 The strength of this analysis was recently highlighted by Patel et al,7 who underlined as the correlation between symptoms and reflux events detected by impedance consistently predicted symptomatic outcome in patients with reflux disease treated with either medical or surgical therapy. Thus, given the increased advantage provided by impedance to symptom association analysis, we believe that this issue should be investigated and, then, considered in studies aimed to investigate patients with suspect gastroesophageal reflux disease (GERD). Finally, we would like to emphasize the presence of data in medical literature supporting the importance of the number of distal reflux episodes, instead of BET, in refractory GERD outcome after surgical therapy. Indeed, recently Frazzoni et al10 reported as 29% of their refractory patients surgically-treated with persistent symptom remission at 3-year follow-up had an abnormal number of total refluxes as the only preoperative abnormal impedance-pH finding. However, further outcome studies assessing the role of BET or number of reflux events on GERD outcome are mandatory to define their relevance in the management of refractory GERD.

Diagnostic testing in patients with refractory GERD

Refractory gastroesophageal reflux disease (GERD) usually refers to patients with persisting symptoms despite proton pump inhibitor therapy. The diagnostic yield of esophageal pH monitoring is low in patients with symptoms on proton pump inhibitors, especially for those presenting with atypical symptoms and no response to adequate acid suppressive therapy. In these patients, pH monitoring should be performed off therapy to rule out pathologic GER. In contrast, in patients presenting with typical symptoms or partial response to proton pump inhibitors, pH-monitoring studies on therapy can demonstrate pathologic GER in approximately 10% of the patients. However, 30% to 40% of these patients clearly have symptoms that can be associated with nonacid reflux, detected by pH-impedance monitoring. Outcome studies will help to determine the actual impact of pH-impedance monitoring on the management of refractory GERD.