Spirituality within the patient-surgeon relationship.

OBJECTIVE: To assess the attitudes of general and orthopaedic surgical outpatients regarding inquiry into their religious beliefs, spiritual practices, and personal faith. DESIGN: Prospective, voluntary, self-administered, and anonymously-completed questionnaire, regarding religious beliefs, spiritual practices, and personal faith, March-August, 2009. SETTING: General and orthopaedic surgical outpatient settings, Health Services Foundation, College of Medicine, University of South Alabama, a tertiary care academic medical center in Mobile, Alabama. PARTICIPANTS: All patients referred for evaluation and management of general and orthopaedic surgical conditions, pre- and postoperatively, were approached. METHODOLOGY: The questionnaire solicited data regarding patient: (1) demographics; (2) religious beliefs, spiritual practices, and personal faith; and (3) opinions regarding inquiry into those subjects by their surgeon. The latter opinions were stratified on a 5-point Likert scale ranging from "strongly disagree" to "strongly agree." Statistical analysis was conducted using software JMP(®) 8 Statistical Discovery Software (S.A.S. Institute Inc., Cary, North Carolina) and a 5% probability level was used to determine significance of results. RESULTS: Eighty-three percent (83%) of respondents agreed or strongly agreed that surgeons should be aware of their patients' religiosity and spirituality; 63% concurred that surgeons should take a spiritual history; and 64% indicated that their trust in their surgeon would increase if they did so. Nevertheless, 17%, 37%, and 36% disagreed or strongly disagreed with those perspectives, respectively. CONCLUSIONS: By inference to the best explanation of the results, we would argue that religiosity and spirituality are inherent perspectives of patient-surgeon relationships. Consequently, those perspectives are germane to the therapeutic milieu. Therefore, discerning each patient's perspective in those regards is warranted in the context of an integrative and holistic patient-surgeon relationship, the intent of which is to restore a patient to health and well-being.

The endoscopic radiofrequency approach to management of GERD.

PURPOSE OF REVIEW: Endoscopic treatment has been recently introduced as a new option for treating gastroesophageal reflux disease. In this article the authors review the radiofrequency approach known as the Stretta procedure, as more evidence has linked reflux to upper airway disease. RECENT FINDINGS: Since 1968, when laryngeal disorders were linked to gastroesophageal reflux disease, more upper airway diseases such as chronic laryngitis, subglottic stenosis, and even laryngeal carcinoma were found to be occasionally caused by extraesophageal reflux. Most otolaryngologists treat these patients with proton pump inhibitors, which improve symptoms in two thirds of patients. Antireflux surgery remains the treatment of choice, relieving symptoms in more than 90% of patients. Endoscopic treatment has recently emerged as an option for treatment of gastroesophageal reflux disease. The Stretta procedure delivers radiofrequency energy to the gastroesophageal junction. This has proved to be effective in controlling reflux by inhibiting transient, inappropriate lower esophageal sphincter relaxation, increasing postprandial lower esophageal spincter pressure, and decreasing lower esophageal sphincter compliance. Stretta is among the earliest endoscopic technologies to be approved by the Food and Drug Administration for the treatment of reflux. It has the longest term follow-up published to this date, and the most durable effect. It is performed under intravenous sedation on an outpatient basis and has a low incidence of complications. SUMMARY: The Stretta procedure is an endoscopic, noninvasive modality for the treatment of gastroesophageal reflux disease. It should be considered in the treatment of reflux-related upper airway diseases.

Paradigm shift in the management of gastroesophageal reflux disease.

OBJECTIVE: To compare the short-term results of the radiofrequency treatment of the gastroesophageal junction known as the Stretta procedure versus laparoscopic fundoplication (LF) in patients with gastroesophageal reflux disease (GERD). SUMMARY BACKGROUND DATA: The Stretta procedure has been shown to be safe, well tolerated, and highly effective in the treatment of GERD. METHODS: All patients presenting to Vanderbilt University Medical Center for surgical evaluation of GERD between August 2000 and March 2002 were prospectively evaluated under an IRB-approved protocol. All patients underwent esophageal motility testing and endoscopy that documented GERD preoperatively, either by a positive 24-hour pH study or biopsy-proven esophagitis. Patients were offered the Stretta procedure if they had documented GERD and did not have a hiatal hernia larger than 2 cm, LES pressure less than 8 mmHg, or Barrett's esophagus. Patients with larger hiatal hernias, LES pressure less than 8 mmHg, or Barrett's were offered LF. All patients were studied pre- and postoperatively with validated GERD-specific quality-of-life questionnaires (QOLRAD) and short-form health surveys (SF-12). Current medication use and satisfaction with the procedure was also obtained. RESULTS: Results are reported as mean +/- SEM. Seventy-five patients (age 49 +/- 14 years, 44% male, 56% female) underwent LF and 65 patients (age 46 +/- 12 years, 42%, 58% female) underwent the Stretta procedure. Preoperative esophageal acid exposure time was higher in the LF group. Preoperative LES pressure was higher in the Stretta group. In the LF group, 41% had large hiatal hernias (>2 cm), 8 patients required Collis gastroplasty, 6 had Barrett's esophagus, and 10 had undergone previous fundoplication. At 6 months, the QOLRAD and SF-12 scores were significantly improved within both groups. There was an equal magnitude of improvement between pre- and postoperative QOLRAD and SF-12 scores between Stretta and LF patients. Fifty-eight percent of Stretta patients were off proton pump inhibitors, and an additional 31% had reduced their dose significantly; 97% of LF patients were off PPIs. Twenty-two Stretta patients returned for 24-hour pH testing at a mean of 7.2 +/- 0.5 months, and there was a significant reduction in esophageal acid exposure time. Both groups were highly satisfied with their procedure. CONCLUSIONS: The addition of a less invasive, endoscopic treatment for GERD to the surgical algorithm has allowed the authors to stratify the management of GERD patients to treatment with either Stretta or LF according to size of hiatal hernia, LES pressure, Barrett's esophagus, and significant pulmonary symptoms. Patients undergoing Stretta are highly satisfied and have improved GERD symptoms and quality of life comparable to LF. The Stretta procedure is an effective alternative to LF in well-selected patients.