Surgical Therapy For Gastroesophageal Reflux Disease Research Articles

Proton Pump Inhibitors, Associated Complications, and Alternative Therapies: A Shifting Risk Benefit Ratio.

Our goal was to compile the most recent and accurate data on the side effects of proton pump inhibitors (PPI). We also compared the efficacy of PPI to the efficacy of different surgical options for acid reflux control. Proton pump inhibitors are the primary therapy for chronic control of gastroesophageal reflux disease (GERD), but newer studies demonstrate deleterious side effects. Collating this information and contrasting it with surgical therapy for GERD provides evidence for possible practice changes in treatment. A literature search utilizing PubMed was performed evaluating for PPI and anti-reflux surgery (ARS), focusing on articles that reflected information regarding the usage and efficacy of symptom control of both PPI and ARS. Search terms included "ARS, fundoplication, MSA, acute interstitial nephritis, acute kidney injury, chronic kidney disease, meta-analysis, PPI, H2 blocker, cardiovascular risk, and gut dysbiosis." We evaluated 271 articles by title, abstract, and data for relevance and included 70. Long-term control of GERD with PPI may have a greater than expected side effect profile than initially thought. Surgical options may provide greater symptom control than PPI without the side effects of long-term medical therapy. Anti-reflux control can be safely achieved with either PPI or surgical options; however, the long-term side effects noted in the review such as increased risk of cardiovascular events, renal disease, and gut dysbiosis may suggest surgical anti-reflux control as a better long-term option.

356 Mucosal Ablation and Suturing at the Esophagogastric Junction (MASE): A Novel Procedure for the Management of Gastroesophageal Reflux Disease in Altered Anatomy Patients

INTRODUCTION: Gastroesophageal reflux disease (GERD) is caused by reflux of gastric contents into the esophagus. For patients with esophageal or gastric surgery there are limited options for endoscopic or surgical therapy for GERD. There has recently been introduced an endoscopic suturing platform that allows for full thickness suturing. We created a technique called Mucosal Ablation and Suturing at the Esophagogastric Junction (MASE) to anatomically correct the GEJ in patients where other surgical or endoscopic options may not be possible. METHODS: This is a single-center prospective observational study. The standardized procedure involved APC ablation below the GE junction to improve tissue apposition prior to suturing. Three sutures were placed along the lesser curvature of the cardia immediately below the EGJ. This creates a tightening and tissue bulge that acts as a barrier to reflux. The primary outcome evaluated was 30% improvement in reflux disease questionnaire (RDQ) and GERD Health Related Quality of Life Questionnaire. The secondary outcomes evaluated were reduction in PPI use, procedure tolerance and safety. RESULTS: 10 patients with a mean age of 63 years with altered anatomy: Fundoplication (N = 5), Billroth II (N = 1), Roux-en-Y (N = 3), and Sleeve gastrectomy (N = 1) underwent MASE procedure. The RDQ and HRQL questionnaires were recorded for each patient before and after MASE. Mean follow-up time was 113 days. Primary outcome of 30% improvement in RDQ and GERD HRQL were achieved for all patients (Figure 1). There was a 90 % reduction in PPI use in the study group; 6 patients (66%) were able to discontinue PPI use, and 2 patients (22%) reduced their dose. The most common side effect was self-limited post-procedure epigastric pain (9%). CONCLUSION: The MASE procedure represents a novel endoscopic treatment option for management of GERD in patients with altered anatomy. Altered anatomy patients have limited treatment options once they fail standard PPI therapy. The MASE procedure can reduce GERD symptoms in this difficult to treat patient population and reduce reliance of daily anti-secretory medication use. Further studies need to be performed to determine longevity of this procedure.

Gastroesophageal reflux disease: From pathophysiology to treatment

This review focuses on the pathophysiology of gastroesophageal reflux disease (GERD) and its implications for treatment. The role of the natural anti-reflux mechanism (lower esophageal sphincter, esophageal peristalsis, diaphragm, and trans-diaphragmatic pressure gradient), mucosal damage, type of refluxate, presence and size of hiatal hernia, Helicobacter pylori infection, and Barrett's esophagus are reviewed. The conclusions drawn from this review are: (1) the pathophysiology of GERD is multifactorial; (2) because of the pathophysiology of the disease, surgical therapy for GERD is the most appropriate treatment; and (3) the genesis of esophageal adenocarcinoma is associated with GERD.

Clinical Presentation and Management of Gastroesophageal Reflux Disease in a Referral Center in Turkey

The aim of this study was to analyze the characteristics of the pathway from the onset of clinical findings related to gastroesophageal reflux disease (GERD) until the surgical therapy to achieve a better organization of the multiple disciplines and create the best management scheme in a referral center in Turkey. All patients who underwent anti-reflux surgery for GERD in our unit between 2000 - 2006 were retrospectively reviewed. Information on their past medical follow-up, the clinical findings, diagnostic evaluation and the therapeutic approach was recorded. There were 24 girls and 40 boys with a median age of 36 months (3 - 192 months). Of the 64 cases, 36 (56.3 %) had a history of past medical follow-up. Of these 36 patients, 20 had received medical and/or surgical therapy for GERD without any standardization. The remaining 16 were treated supportively for neurological, respiratory and metabolic problems without having had a diagnosis of GERD. The median duration of symptoms in 28 patients without a past medical history was shorter than that in the remaining 36 patients (p = 0.03). Of the 64 patients at presentation, 35 had neurological, 4 had metabolic, and 3 had a respiratory pathology; the other 4 had a history of esophageal atresia and tracheoesophageal fistula operation; 5 had been operated in another center for GERD and only 13 cases had isolated GERD. The most commonly used diagnostic methods were contrast study (n = 52) and pH monitoring (n = 36). Forty-one of the 64 had anti-reflux surgery primarily after presentation, in addition to selection of medical therapies and/or other surgical interventions as a first step in the remaining 23. Reevaluation of those 23 patients after a median period of 7 months (1 - 36) finally led to anti-reflux surgery (ARS). Patients presenting with a stricture due to GERD (n = 13) underwent ARS, either as a primary procedure (n = 3) or after a course of dilatations (median period of time: 8.5 months) (n = 10). Extended nonresponsive medical therapy is as harmful as needless surgical therapy performed prior to appropriate medical management. Our experience emphasizes that guidelines on the use of a multidisciplinary approach is the first step for successful GERD treatment. ARS in early infancy should only be justified in the presence of severe neurological and/or respiratory pathologies. If there is any doubt about the diagnosis of GERD with preliminary methods, endoscopic and pathological confirmation of the disease is mandatory for a correct management.

Influence of Functional Bowel Disease on Outcome of Surgical Antireflux Procedures

Patients with gastroesophageal reflux disease (GERD) have a coexisting diagnosis of functional bowel disease (FBD) in approximately 30% of cases. Symptom improvement after surgical therapy for GERD may be less in patients with FBD when compared to patients without this coexisting problem. A retrospective review of patients undergoing Nissen fundoplication between 1996 and 2000 evaluated patients with documented FBD or FBD symptoms to determine operative outcome. Poor postoperative outcome included recurrent heartburn, gas bloat syndrome, dysphagia requiring reoperation or dilation, or delay in resumption of normal diet. Bivariate comparison and multivariate logistic regression evaluated the independent impact of a documented diagnosis of FBD or preoperative symptoms of FBD on outcome. This study examined 155 patients: 32% reported having symptoms of FBD and 10% had a confirmed diagnosis of FBD. Poor postoperative outcomes occurred in 27%. Patients with a documented diagnosis of FBD were significantly more likely to have a poor outcome when compared to patients without symptoms of FBD (53% vs. 23%, P = 0.01). Patients with preoperative symptoms of FBD (but without a documented diagnosis of FBD) also had a higher incidence of poor outcome (5% vs. 23%, P = 0.09). Patients with FBD are at increased risk of poor results after antireflux surgery. Patients with these conditions should be counseled preoperatively regarding the potential for recurrent postoperative symptoms. ( J Gastrointest Surg 2002;6:632–637.)