Cruroplasty as a standalone treatment for recurrent hiatal hernia repair.

PURPOSE: Following laparoscopic anti-reflux surgery (LARS), recurrence of hiatal hernia is common. Patients with symptomatic recurrence typically undergo revision of the fundoplication or conversion to magnetic sphincter augmentation (MSA) in addition to cruroplasty. However, patients with an intact fundoplication or MSA may only require repeat cruroplasty to repair their recurrent hiatal hernia. The purpose of this study is to compare outcomes following cruroplasty alone compared to full revision (i.e. redo fundoplication or MSA with cruroplasty) for the management of recurrent hiatal hernias. METHODS: A retrospective review of patients undergoing surgical revision of a symptomatic recurrent hiatal hernia between February 2009 and October 2022 was performed. Preoperative characteristics, intraoperative details, and postoperative outcomes were compared between patients undergoing cruroplasty alone versus full revision. RESULTS: A total of 141 patients were included in the analysis. 93 patients underwent full revision, and 48 patients underwent cruroplasty alone. The mean time between initial and revisional surgery was 8 ± 7.7 years. There was no significant difference in operative time or rates of intra-operative or post-operative complication between groups. Patients undergoing cruroplasty alone had a mean Gastroesophageal Reflux Disease Health Related Quality Life (GERD-HRQL) Questionnaire score of 9.6 ± 10.2 compared to a mean score of 8.9 ± 11.2 for full revision patients (p = 0.829). Recurrence rates following revision was 10.4% for cruroplasty alone patients and 11.8% in full revision patients (p > 0.999). CONCLUSION: In patients with intact fundoplication or MSA, cruroplasty alone results in similar post-operative outcomes compared to full revision for recurrent hiatal hernia.

The classification of hiatal shapes and their use as a marker for complexity, operative interventions, and recurrence.

BACKGROUND: Diaphragmatic reconstruction is a vital, but challenging component of hiatal hernia and antireflux surgery. Results are optimized by minimizing axial tension along the esophagus, assessed with intra-abdominal length, and radial tension across the hiatus, which has not been standardized. We categorized hiatal openings into 4 shapes, as a surrogate for radial tension, to correlate their association with operative interventions and recurrence. METHODS: We retrospectively reviewed all primary hiatal hernias (≥3 cm) repaired at a single center between 2010 and 2020. Patients with intraoperative hiatal photos with at least 1 year of follow-up were included. The hiatal openings were classified into 4 shapes: slit, inverted teardrop, "D," and oval, and ordered in this manner of hypothesized increased complexity and tension. RESULTS: A total of 239 patients were studied, with 113 (47%) having a recurrence. Age (P < .001), proportion of paraesophageal hernias (P < .001), hernia axial length (P < .001), and hiatal width (P < .001) all increased as shape progressed from slit to inverted teardrop to "D" to oval. Mesh (P = .003) and relaxing incisions (P < .001) were more commonly employed in more advanced shapes, "D" and ovals. However, recurrence (P = .88) did not correlate with hiatal shape. CONCLUSION: Four different hiatal shapes are commonly seen during hernia repair. These shapes represent a spectrum of hernia chronicity and complexity necessitating increased use of operative measures but not correlating with recurrence. Despite failing to be a direct marker for recurrence risk, hiatal shape may serve as an intraoperative tool to inform surgeons of the potential need for additional hiatal interventions.

Morbidity and mortality after antireflux and hiatal hernia surgery across a spectrum of ages.

BACKGROUND: Antireflux surgery (ARS) and hiatal hernia repair (HHR) are common surgical procedures with modest morbidity. Increasing age is a risk factor for complications; however, details regarding acute morbidity are lacking. This study aimed to describe the incidence rates and types of morbidities across the spectrum of ages. METHODS: A total of 2342 consecutive cases were retrospectively reviewed from 2003 to 2020 for 30-day complications. All complications were assessed using the Clavien-Dindo (CD) grading system. Patients were divided into 5 age groups: ≤59, 60 to 69, 70 to 79, 80 to 89, and ≥90 years. RESULTS: The numbers per age group were 1100 patients aged ≤59 years, 684 patients aged 60 to 69 years, 458 patients aged 70 to 79 years, 458 patients aged 80 to 89 years, and 6 patients aged ≥90 years. A total of 427 complications (18.2%) occurred, including 2 mortalities, each in the 60- to 69-year age group and the 70- to 79-year age group, for a mortality rate of 0.2%. The complication rate increased from 13.5% (149) in patients aged ≤59 years to 35.0% (35) in patients aged ≥80 years (P = .006), with CD grades I and II accounting for >70% of complications, except in patients aged ≥80 years (57.1%). CD grades IIIa and IIIb were higher in patients aged ≥80 years (26.5% [P = .001] and 11.8% [P = .021], respectively). CD grade IVa and IVb complications were rare overall. CONCLUSION: There is a modest rate of morbidity that increases as patients age, regardless of hernia type, elective or primary surgery, with most being minor complications (CD grade≤II). Our data should help patients, referring physicians, and surgeons counsel patients regarding the effect of increasing age in ARS and HHR.

Airway pepsinogen A4 identifies lung transplant recipients with microaspiration and predicts chronic lung allograft dysfunction.

BACKGROUND: Aspiration is a known risk factor for adverse outcomes post-lung transplantation. Airway bile acids are the gold-standard biomarker of aspiration; however, they are released into the duodenum and likely reflect concurrent gastrointestinal dysmotility. Previous studies investigating total airway pepsin have found conflicting results on its relationship with adverse outcomes post-lung transplantation. These studies measured total pepsin and pepsinogen in the airways. Certain pepsinogens are constitutively expressed in the lungs, while others, such as pepsinogen A4 (PGA4), are not. We sought to evaluate the utility of measuring airway PGA4 as a biomarker of aspiration and predictor of adverse outcomes in lung transplant recipients (LTRs) early post-transplant. METHODS: Expression of PGA4 was compared to other pepsinogens in lung tissue. Total pepsin and PGA4 were measured in large airway bronchial washings and compared to preexisting markers of aspiration. Two independent cohorts of LTRs were used to assess the relationship between airway PGA4 and chronic lung allograft dysfunction (CLAD). Changes to airway PGA4 after antireflux surgery were assessed in a third cohort of LTRs. RESULTS: PGA4 was expressed in healthy human stomach but not lung. Airway PGA4, but not total pepsin, was associated with aspiration. Airway PGA4 was associated with an increased risk of CLAD in two independent cohorts of LTRs. Antireflux surgery was associated with reduced airway PGA4. CONCLUSIONS: Airway PGA4 is a marker of aspiration that predicts CLAD in LTRs. Measuring PGA4 at surveillance bronchoscopies can help triage high-risk LTRs for anti-reflux surgery.

Reintervenciones por fallo de la cirugía antirreflujo / Reinterventions for Failed Antireflux Surgery

RESUMEN Introducción: En la actualidad, la fundoplicatura laparoscópica se considera el tratamiento de elección para la enfermedad por reflujo gastroesofágico con resultados excelentes en más del 90 por ciento de los pacientes. Sin embargo, a pesar de estos resultados, el 30 % de los pacientes presentan persistencia de los síntomas y del 3 por ciento al 10 por ciento requieren reintervención por fallo de la cirugía antirreflujo. Objetivo: Describir las causas del fracaso de la cirugía antirreflujo y las técnicas realizadas en la reintervención. Método: Se realizó un estudio descriptivo, retrospectivo y longitudinal, de una serie de pacientes a los cuales se les realizo cirugía antirreflujo en el Centro Nacional de Cirugía de Mínimo Acceso desde enero de 1994 hasta diciembre de 2016. Las variables analizadas fueron: reintervenciones y sus causas, tratamiento quirúrgico, morbilidad y el índice de conversión. Resultados: De un total de 1 550 pacientes operados, 37 (2,3 por ciento) fueron reintervenidos. Las causas más frecuentes de reintervención fueron la recidiva de los síntomas y la presencia de disfagia. La herniación de la fundoplicatura fue el hallazgo transoperatorio más frecuente. El índice de conversión fue bajo y no hubo fallecidos en las reintervenciones. La morbilidad triplicó la del total de la serie, así como la estadía hospitalaria. Conclusiones: Las reintervenciones por fallo de la cirugía antirreflujo resultan de gran complejidad pues aumentan considerablemente la morbilidad y la estadía hospitalaria. Debe realizarse en centros que acumulen una alta experiencia en estas técnicas(AU)

ABSTRACT Introduction: Nowadays, laparoscopic fundoplication is considered the treatment of choice for gastroesophageal reflux disease, showing excellent results in more than 90 percent of patients. However, despite these results, 30 percent of patients present with persistent symptoms, while 3 percent to 10 percent require reintervention for failed antireflux surgery. Objective: To describe the causes of failed antireflux surgery and the techniques performed in the reintervention. Method: A descriptive, retrospective and longitudinal study was conducted with a series of patients who underwent antireflux surgery at the National Center for Minimally Access Surgery, from January 1994 to December 2016. The variables analyzed were reinterventions and their causes, surgical treatment, morbidity and the conversion rate. Results: From among 1550 patients operated on, 37 (2.3 percent) were reintervened. The most frequent causes of reintervention were the recurrence of symptoms and the occurrence of dysphagia. The fundoplication herniation was the most frequent transoperative finding. The conversion rate was low and there were no deaths in the reinterventions. The morbidity tripled that of the total of the series, as well as hospital stay. Conclusions: Reinterventions for failed antireflux surgery are very complex, since they increase morbidity and hospital stay considerably. It must be performed in centers that accumulate a high experience in these techniques(AU)

Late evaluation of patients operated for gastroesophageal reflux disease by nissen fundoplication / Avaliação tardia de pacientes operados por doença do refluxo gastroesofágico pela técnica de nissen

ABSTRACT Background: Surgical treatment of GERD by Nissen fundoplication is effective and safe, providing good results in the control of the disease. However, some authors have questioned the efficacy of this procedure and few studies on the long-term outcomes are available in the literature, especially in Brazil. Aim: To evaluate patients operated for gastro-esophageal reflux disease, for at least 10 years, by Nissen fundoplication. Methods: Thirty-two patients were interviewed and underwent upper digestive endoscopy, esophageal manometry, 24 h pH monitoring and barium esophagogram, before and after Nissen fundoplication. Results: Most patients were asymptomatic, satisfied with the result of surgery (87.5%) 10 years after operation, due to better symptom control compared with preoperative and, would do it again (84.38%). However, 62.5% were in use of some type of anti-reflux drugs. The manometry revealed lower esophageal sphincter with a mean pressure of 11.7 cm H2O and an average length of 2.85 cm. The average DeMeester index in pH monitoring was 11.47. The endoscopy revealed that most patients had a normal result (58.06%) or mild esophagitis (35.48%). Barium swallow revealed mild esophageal dilatation in 25,80% and hiatal hernia in 12.9% of cases. Conclusion: After at least a decade, most patients were satisfied with the operation, asymptomatic or had milder symptoms of GERD, being better and with easier control, compared to the preoperative period. Nevertheless, a considerable percentage still employed anti-reflux medications.

RESUMO Racional: O tratamento cirúrgico para DRGE empregando a fundoplicatura à Nissen é eficaz e seguro, oferecendo bons resultados no controle da doença. Entretanto, alguns autores têm questionado quanto a sua eficácia, e poucos estudos com avaliação tardia destes doentes são encontrados na literatura, sobretudo no Brasil. Objetivo: Avaliar pacientes operados por doença do refluxo gastroesofágico há pelo menos 10 anos, pela técnica de Nissen. Métodos: Trinta e dois pacientes foram entrevistados e submetidos à endoscopia digestiva alta, manometria esofágica, pHmetria prolongada de 24h e esofagograma baritado, antes e após a fundoplicatura à Nissen. Resultados: A maioria estava assintomático 10 anos após a operação e satisfeitos com o resultado dela (87,5%) e a fariam novamente (84,38%), devido melhor controle sintomático com medicação, em comparação com o período pré-operatório. Entretanto, 62,5% empregavam algum tipo de medicação anti-refluxo. Quanto aos exames, a manometria revelou extensão média de 2,85 cm de esfíncter esofágico inferior, com pressão média de 11,7 cm de H2O. O índice médio de DeMeester na pHmetria foi de 11,47. Na endoscopia a maior parte dos pacientes apresentou exame normal (58,06%), ou esofagite leve (35,48%). O esofagograma revelou discreta dilatação esofágica em 25,80% e hérnia hiatal em 12,9% dos casos. Conclusão: Após no mínimo uma década, a maioria dos doentes estava satisfeita com a operação, assintomática ou apresentava sintomatologia mais branda da DRGE que era de melhor e mais fácil controle, comparado ao período pré-operatório. Porcentagem não desprezível ainda empregava medicações para refluxo.

Incidental splenic injury and splenectomy: an overview based on available evidence / Lesión esplénica incidental y esplenectomía: una visión general basada en la evidencia disponible

Splenectomy indications are hematologic disease, traumatic damage and iatrogenic injury. The aim of this study was to present an evidence-based overview of some clinical aspects of interest related with iatrogenic splenic injury and subsequent splenectomy. An overview of the available evidence was conducted. Articles that evaluated clinical aspects of interest related with iatrogenic splenic injury and subsequent splenectomy, without language limits, publication date and designs. BVS, PubMed, SciELO and TRIP databases were reviewed. Evaluated variables were: Frequency and etiology of surgical spleen injuries, treatment options, frequency of splenectomy, associated postoperative morbidity (POM) and mortality, recommendation for splenectomy. Classification of the available evidence was made using the classification proposed by Oxford Centre of Evidence-based Medicine. 1144 records were obtained. 1109 were discarded for not meeting eligibility criteria, or were not relevant for the purpose of this research. Finally, the study consisted of 35 articles, 3 of evidence level type 3a, 31 of evidence level type 4 and 1 of evidence level type 5. Splenectomy is a complication of common abdominal procedures, prevalence and incidence of iatrogenic splenic injury is underestimated because of lack of information, there is evidence of risk factors of surgical spleen injuries, the etiology of surgical spleen injuries are bariatric, esophago-gastric, antireflux, colorectal, abdominal vascular and urological procedures. POM in patients undergoing splenectomy is more frequent in emergency splenectomy secondary to trauma. There was no significant risk reduction of infectious complications after implementation of routine vaccination. Available evidence is based on few and heterogeneous articles, which make a meaningful conclusions difficult. Studies with better evidence levels, methodological quality and population size are needed for conclusions and recommendations.

Las indicaciones de esplenectomía son enfermedades hematológicas, daño por trauma y por lesiones iatrogénicas. El objetivo de este estudio es presentar una visión general basada en la evidencia actualmente disponible, respecto de algunos aspectos clínicos de interés relacionados con la lesión esplénica iatrogénica y posterior esplenectomía. Revisión global de la evidencia disponible. Se incluyeron artículos que evaluaron aspectos clínicos de interés relacionados con lesión esplénica iatrogénica y posterior esplenectomía; sin límites de lenguaje, fecha de publicación y diseño. Se revisaron las bases de datos BVS, PubMed, SciELO y Trip Database. Las variables evaluadas fueron: frecuencia y etiología de las lesiones, opciones de tratamiento, frecuencia de esplenectomía, morbimortalidad postoperatoria, recomendación de esplenectomía. La clasificación de la evidencia se realizó con la propuesta del Centro de Medicina Basada en la Evidencia de Oxford. Se obtuvieron 1144 registros. 1109 fueron descartados por no cumplir criterios de elegibilidad, o ser no relevantes para el objetivo de la investigación. La población en estudio quedó compuesta por 35 artículos, 3 de nivel de evidencia 3a, 31 de nivel de evidencia 4 y 1 de nivel de evidencia 5. La esplenectomía es una complicación propia de la cirugía abdominal. La prevalencia e incidencia de lesión esplénica iatrogénica es subestimada por falta de información. Hay evidencia de factores de riesgo de lesiones del bazo. La etiología de estas es: procedimientos bariátricos, esófago-gástricos, colorrectales, vasculares abdominales y urológicos. La morbilidad es más frecuente en esplenectomía de emergencia secundaria a trauma. No se ha registrado disminución significativa del riesgo de complicaciones infecciosas con la vacunación rutinaria. La evidencia disponible se basa en pocos artículos y heterogéneos, lo que impide sacar conclusiones. Se necesitan estudios de mejor nivel de evidencia, calidad metodológica y tamaño de muestra para obtener conclusiones válidas y recomendaciones adecuadas.

Evaluación intraoperatoria de la distensibilidad de la unión gastroesofágica en fundoplicatura antireflujo / Intraoperative assessment of the distensibility of the gastroesophageal junction in antireflux fundoplication

Introducción: La alteración de la distensibilidad de la unión gastro esofágica (UGE) es un factor etiológico para la enfermedad de reflujo gastroesofágico. El incremento de la distensibilidad permite el reflujo de contenido gástrico incrementa las relajaciones transitorias del esfínter, el número de reflujos y la exposición al ácido. Ha sido descrito que la UGE puede ser calibrada en el acto operatorio utilizando sonda balón, que permite una medida en tiempo real de la capacidad, diámetro y presión de la UGE. Objetivos: evaluar la utilidad de la medida de la distensibilidad de la UGE como predictor de éxito en fundoplicatura laparoscópica (FPL) mediante el uso de la sonda Endoflip ® (Crospon) utilizada intra operatoriamente en pacientes sometidos a FPL como tratamiento anti reflujo practicando mediciones antes y después de la plicatura. Materiales y métodos: La FP se realizó según técnica de Toupet. Se tomaron medidas de distensión del balón con llenado de 40 ml de solución salina 0,2% a) después de la inducción de la anestesia b) después de la reparación de la crura y c) al finalizar el arropado. Los datos fueron analizados por t students. P<0,05 fue considerado significativo. Resultados: Fueron evaluados 9 pacientes, el promedio de edad fue de 45,2; en todos los pacientes existía indicación de cirugía, todos presentaban hernia hiatal. La FPL redujo el promedio de distensibilidad de la UGE de 52,8 mm2/mmHg a 29,8 mm2/mmHg (p=0,0021, (43,5%). Conclusión: Este método permite tomar decisiones en cirugía de la UGE donde el valor objetivo de la distensibilidad puede definir el éxito de la cirugía y evitar eventos adversos post operatorios.

Introduction: The altered distensibility of the gastro esophageal junction (GEJ) is recognized as a primary pathophysiologic factor in the development of gastro esophageal reflux disease (GERD). The increase in GEJ distensibility allows reflux of large volumes of gastric contents into the esophagus, increases transient relaxations of the lower esophageal sphincter and increases the number of reflux and esophageal exposure to acid. Moreover, other pathologies with functional obstruction of the GEJ as achalasia have very little distensibility. Recently was reported that GEJ can be calibrated during surgery using balloon catheter, allowing real-time measurement of capacity, diameter and GEJ pressure during surgery. Objectives: To review the usefulness of the measurement of the distensibility of the GEJ as a predictor of success in laparoscopic fundoplication (LP) using Endoflip® commercial catheter, used intra-operatively in patients undergoing LP anti reflux surgery practicing measurements before and after plication. Material and Methods: The Toupet Fundoplication (TFP) was performed under standard technique, balloon distension measurements were taken, filling with 40 ml of 0.2% saline solution as specified by the manufacturer: a) after induction of anesthesia and once the pneumo peritoneum was stabilized b) After repairing the crura of the diaphragm and c) after the wrapping. Data was analyzed by students t P <0.05 and was considered significant. Results: A total of 9 patients (6 men), age average was 45.2 (32-72), all patients had previous functional and endoscopic studies and surgical indication existed, they all had a diagnosis of hiatal hernia, they all signed informed consent. No patient had postoperative complications. The Toupet Fundoplication (TFP) significantly reduced average GEJ distensibility to 40 ml of 52.8 to 29.8 mm2/mmHg mm2/mmHg (p = 0.0021, which represents a reduction of 43.5%). Conclusion: This method allows the gastro surgical team to make decisions on GEJ surgery in which the target value of distensibility can define the success of the surgery and avoid postoperative adverse events.

Identificação de fatores de risco pré-operatórios para disfagia pós-operatória persistente após cirurgia laparoscópica para doença do refluxo gastroesofágico / Identification of preoperative risk factors for persistent postoperative dysphagia after laparoscopic antireflux surgery

RACIONAL: Disfagia no pós-operatório é comum após a operação anti-refluxo. No entanto, uma parte dos pacientes relatam disfagia persistente, e técnica cirúrgica inadequada é uma causa bem documentada deste resultado. OBJETIVO: Este estudo retrospectivo avaliou os fatores de risco no pré-operatório para a disfagia persistente após operação anti-refluxo por via laparoscópica. MÉTODOS: Pacientes submetidos à operação anti-refluxo por via laparoscópica pela técnica de Nissen modificada foram avaliados no pré-operatório de forma retrospectiva. A severidade da disfagia pós-operatória foi avaliada prospectivamente usando uma escala estabelecida. A disfagia após seis semanas foi definida como persistente. Os testes estatísticos de associação e regressão logística foram utilizados para identificar os fatores de risco associados à disfagia persistente. RESULTADOS: Um total de 55 pacientes foram submetidos ao procedimento por via laparoscópica por uma única equipe de cirurgiões. Destes, 25 doentes referiam disfagia pré-operatório (45,45%). A disfagia pós-operatória persistente foi relatada por 20 (36,36%) pacientes. Dez (18,18%) necessitaram de dilatações por endoscopia digestiva. Houve associação estatística entre a satisfação com a operação e disfagia no pós-operatório e exigindo o uso de medicação anti-refluxo após o procedimento, e entre disfagia no pré-operatório e disfagia no pós-operatório. A regressão logística identificou a disfagia no pré-operatório, como fator de risco para a disfagia pós-operatória persistente. Não foram observadas correlações com manometria pré-operatória. CONCLUSÕES: Os pacientes com disfagia no pré-operatório foram mais propensos a relatar disfagia pós-operatória persistente. Os critérios manométricos atuais utilizados para definir dismotilidade esofágica não identificaram pacientes com risco de disfagia persistente pós-fundoplicatura. Análise minuciosa da história clínica sobre a presença e intensidade da disfagia no pré-operatório é muito importante na seleção de candidatos à operação anti-refluxo.

BACKGROUND: Postoperative dysphagia is common after antireflux surgery and generally runs a self-limiting course. Nevertheless, part of these patients report long-term dysphagia. Inadequate surgical technique is a well documented cause of this result. AIM: This retrospective study evaluated the preoperative risk factors not surgery-related for persistent dysphagia after primary laparoscopic antireflux surgery. METHODS: Patients who underwent laparoscopic antireflux surgery by the modified technique of Nissen were evaluated in the preoperative period retrospectively. Postoperative severity of dysphagia was evaluated prospectively using a stantardized scale. Dysphagia after six weeks were defined as persistent. Statistical tests of association and logistic regression were used to identify risk factors associated with persistent dysphagia. RESULTS: A total of 55 patients underwent primary antireflux surgery by a single surgeon team. Of these, 25 patients had preoperative dysphagia (45,45%). Persistent postoperaive dysphagia was reported by 20 (36,36%). Ten patients (18,18%) required postoperative endoscopic dilatation for dysphagia. There was statistical association between satisfaction with surgery and postoperative dysphagia and requiring the use of antireflux medication after the procedure; and between preoperative dysphagia and postoperative dysphagia. Logistic regression identified significant preopertive dysphagia as risk factor for persistent postoperative dysphagia. No correlations were found with preoperative manometry. CONCLUSIONS: Patients with significant preoperative dysphagia were more likely to report persistent postoperative dysphagia. This study confirms that the current manometric criteria used to define esophageal dysmotility are not reliable to identify patients at risk for post-fundoplication dysphagia. Minucious review of the clinical history about the presence and intensity of preoperative dysphagia is important in the selection of candidates for antireflux surgery.

Síntomas respiratorios asociados a la enfermedad por reflujo gastroesofágico: diagnóstico y tratamiento / GERD related respiratory symptoms: diagnosis and treatment

La enfermedad por reflujo gastroesofágico puede generarsíntomas respiratorios. Éstos se desencadenan cuandoel contenido esofágico refluye a la vía aérea, generandouna microaspiracion; o a través de un reflejo vago-vagal. Los síntomas respiratorios pueden ser vagos ycoexistir con la enfermedad por reflujo, sin una verdaderarelación causa-efecto. Para tratar estos pacientes,es fundamental realizar un diagnóstico preciso que asocielas dos entidades. El algoritmo debe incluir estudiosque detecten reflujo gastroesofágico, microaspiración y,de corresponder, lesión laríngea. A continuación, se debeaplicar la terapéutica más efectiva. El tratamientomédico posee menor tasa de éxito si lo comparamos conla obtenida en pacientes con síntomas típicos. Esto puededeberse a que episodios de reflujo no-ácido son losgeneradores de síntomas, a la existencia de un dañoirreversible en la vía aérea o a dosis insuficientes demedicación para neutralizar el ácido. La fundoplicaturaes un tratamiento efectivo que frena todo tipo dereflujo patológico (ácido y no-ácido). Este artículo describela utilidad de los tests diagnósticos y menciona losresultados obtenidos con las diversas formas de tratamiento.Adicionalmente, comenta acerca de la potencialaplicación de la impedancia esófago-faringea enesta población.

Gastroesophageal reflux disease can cause respiratory symptoms. These symptoms are triggered by reflux events that reach the pharynx, causing microaspiration or through vagal reflex. Respiratory symptoms can be vague and coexist with gastroesophageal reflux disease, without a real link between the two entities. To effectively treat these patients, it is important tofind an association between the two diseases. Work up should include the diagnosis of reflux disease, the diagnosis of pharyngeal reflux events -microaspiration - and, if possible, of laryngeal injury. Once the diagnosis has been established, an effective therapy must be offered to the patient. In these patients, medical treatment is less effective when compared to the results in the population with typical symptoms. This may be due to the fact that non-acid reflux episodes are causing the respiratory symptoms or as a result of an irreversible damage generated in the airway. Antireflux surgery is an effective therapy that reduces both acid and non-acid reflux events. This article describes the different diagnostic tests as well as the results obtained with surgical treatment in this population. Additionally, it describes potential applications of esophageal and pharyngeal impedance monitoring in these patients.