Outcome of laparoscopic antireflux surgery in patients with nonerosive reflux disease.

As many as 50% of patients with gastroesophageal reflux disease (GERD) have no endoscopic evidence of esophagitis (EGD negative). Laparoscopic antireflux surgery (LARS) provides effective symptomatic and endoscopic healing in patients with erosive GERD (EGD positive). The surgical outcome of patients undergoing LARS for EGD-negative GERD has not received wide attention. The objective of this study was to compare surgical outcomes between EGD-negative and EGD-positive patients. During the period from June 1996 to September 1998, all patients undergoing LARS for persistent GERD symptoms despite medical therapy, who were EGD-negative, were invited to respond to a questionnaire regarding their clinical status before and after LARS. To perform a comparative analysis, the same questions were posed to a randomly selected equal number of EGD-positive patients who underwent surgery during the same study period. LARS was performed in 255 patients during the study period; 59 patients (23%) had EGD-negative GERD, and 148 (58%) were EGD-positive. Forty-eight patients (19%) did not meet the entry criteria and were excluded from analysis. LARS provided effective symptomatic relief in patients with EGD-negative and EGD-positive GERD. There were no significant differences in patient satisfaction or symptom improvement between the two groups (P = 0.82). The surgical outcome of EGD-negative patients is similar to the outcome for patients with erosive esophagitis. LARS is a valuable treatment option for patients with persistent GERD symptoms regardless of the endoscopic appearance of the esophageal mucosa.

Comparison of methods for determining cricopharyngeal intrabolus pressure in normal patients as possible indicator for cricopharyngeal myotomy.

OBJECTIVE: We sought to compare methods for determining intrabolus cricopharyngeal pressure as a possible indicator for cricopharyngeal myotomy. STUDY DESIGN: We determined multiple intrabolus pressures in the cricopharyngeal region of 20 normal volunteers, of whom 12 were 20 to 35 years old and 8 were older than 75 years. Data were collected using a commercially available manofluorography system and a 6-sensor unidirectional solid-state 2- x 4-mm catheter. Each subject underwent 5 5-mL and 5 10-mL liquid barium swallows. Data were analyzed, and young subjects were compared with old subjects. RESULTS: The mean mid-bolus pressures in young subjects were 5.2 +/- 4.9 mm Hg and 7.2 +/- 6.5 mm Hg for the 5-mL and 10-mL swallows, respectively, and in older subjects, 10.8 +/- 8.8 mm Hg and 12.3 +/- 7.4 mm Hg. The mean gradient pressures across the 3-cm cricopharyngeal region in young subjects were 2.02 +/- 5.0 mm Hg, and -0.91 +/- 4.8 mm Hg for the 5-mL and 10-mL swallows, respectively, and for older subjects, 4.38 +/- 3.1 mm Hg and 2.82 +/- 3.4 mm Hg. CONCLUSIONS: Cricopharyngeal intrabolus pressures were lower in young than in older subjects. The mid-bolus pressure and the gradient pressure across the cricopharyngeal region appeared to be the most consistent methods for evaluating intrabolus pressures. SIGNIFICANCE: Intrabolus pressure anomalies in the cricopharyngeal region have been proposed as an indicator for selecting patients who would benefit from cricopharyngeal myotomy. The methods of determining intrabolus pressures vary, with resulting variations in recommendations.

Failed antireflux surgery: surgical outcome of laparoscopic refundoplication in the elderly.

BACKGROUND/AIMS: Antireflux surgery has a failure rate between 5 and 20%. Laparoscopic redo-surgery is feasible, but little is known about the surgical outcome in elderly patients. The aim of this prospective study was to evaluate early surgical experience and outcome, including quality of life, after laparoscopic refundoplication in patients older than 65 years. METHODOLOGY: Eleven patients, mean age of 71 years (range: 65-78), underwent laparoscopic redo-surgery. Six patients had the former antireflux procedure performed by the open technique, one having had it twice, one had both laparoscopic and open antireflux procedures, and in 4 the primary intervention was performed laparoscopically. Quality of life was evaluated by using the Gastrointestinal Quality of Life Index. All patients were evaluated prior to surgery, and at 3 months and 12 months after laparoscopic refundoplication, as well as with esophageal manometry and 24-hour pH-monitoring. RESULTS: Redo-procedures were completed laparoscopically in 10 patients. In one patient conversion to an open laparotomy was necessary because of severe bleeding from the spleen. One patient had an injury to the gastric wall, successfully managed laparoscopically. Postoperatively, one patient had moderate dysphagia for a period of two months, another had epigastric pain for the same period. Esophageal manometry and 24-hour pH-monitoring showed normal values in all patients after redo-surgery. Prior to redo-surgery, the mean Gastrointestinal Quality of Life Index was 85.2 points. Three months (mean: 119.8 points) and one year (mean: 119.2 points) after laparoscopic reoperation the general score increased significantly (P < 0.01) and attained the equivalent level of comparable healthy individuals (118.7 points). CONCLUSIONS: Laparoscopic refundoplication in the elderly patient is feasible, safe and an effective treatment after failed antireflux surgery. Older patients with failed antireflux surgery have poor quality of life. Laparoscopic redo-surgery improves quality of life significantly to the level of healthy individuals and normalizes objective outcome criteria without any long-term restrictions in daily life.

Cost-effectiveness and budget impact of obesity surgery in patients with type 2 diabetes in three European countries(II).

BACKGROUND: This study aimed to establish a payer-perspective cost-effectiveness and budget impact model of adjustable gastric banding (AGB) and gastric bypass (GBP) vs. conventional treatment (CT) in patients with a body mass index (BMI) > or = 35 kg x m(-2) and type 2 diabetes mellitus (T2DM) in Austria, Italy, and Spain. METHODS: A health economics model described in a previous publication was applied to resource utilization and cost data in AGB, GBP, and CT from Austria, Italy, and Spain in 2009. RESULTS: The base case time scope is 5 years; the annual discount rate for utilities and costs is 3.5%. In Austria and Italy, both AGB and GBP are cost-saving and are thus dominant in terms of incremental cost-effectiveness ratio compared to CT. In Spain, AGB and GBP yield a moderate cost increase but are cost-effective, assuming a willingness-to-pay threshold of 30,000 euro per quality adjusted life-year. Under worst-case analysis, AGB and GBP remain cost-saving or around breakeven in Austria and Italy and remain cost-effective in Spain. CONCLUSION: In patients with T2DM and BMI > or = 35 kg x m(-2) at 5-year follow-up vs. CT, AGB and GBP are not only clinically effective and safe but represent satisfactory value for money from a payer perspective in Austria, Italy, and Spain.

Use of acid suppressive medications after laparoscopic antireflux surgery: prevalence and clinical indications.

Laparoscopic antireflux surgery (LARS) provides effective control of gastroesophageal reflux (GER) in more than 90% of patients. Despite this high success rate, some patients continue to consume acid suppressive medications after surgical intervention. In this study we evaluate the prevalence, clinical indications, and cause of use of acid reducing drugs in patients after LARS. Consecutive patients undergoing LARS for GERD were surveyed 2-3 years after surgery regarding use of acid suppressive medications, surgical outcome, and GERD specific symptoms. During the study period, 119 patients underwent LARS at our center. Ninety-eight (82%) were available for interview. Two patients died of unrelated causes and two declined to be interviewed. The remaining 94 individuals are the subject of this report. Ninety-four percent were satisfied with the outcome of surgery. Despite this high satisfaction rate, 37 of 94 (39%) were on antireflux medication (ARM; 62% proton pump inhibitors, 22% H2-receptor antagonists, and 16% others), with 70% using continuous medication. Of these patients, 54% took ARM after surgery for GERD-related symptoms, 95% of these patients responded to medical therapy, and yet again, 85% remained satisfied with the surgical outcome. Forty-six percent of patients on ARM after surgery had no GERD symptoms and took ARM for nonappropriate indications such as bloating. Only 47% of these responded to ARM; 82% of this group was satisfied with the surgical outcome. In conclusion, the use of ARM after LARS is a common occurrence despite a high satisfaction rate with this operation. Nearly half of patients consuming ARS after LARS are taking these medications for symptoms not necessarily related to GER. These findings underscore the importance of patient education in the use of these agents.

[Psycho-physiological aspects of gastroesophageal reflux disease]. / Psychophysiologische Aspekte der gastroösophagealen Refluxkrankheit.

It is well known that there is an interaction between physiological and psychological aspects of gastrointestinal diseases, also in esophageal symptoms. Based on this bio-psycho-social interaction, several multidisciplinary concepts of interventions in gastrointestinal disorders have been evaluated. The role of psychological factors in gastroesophageal reflux disease (GERD) is really unknown. The present article reviews the basic pathophysiological factors of GERD including psycho-physiological aspects and presents potential concepts of multidisciplinary GERD treatment.

Dilation after fundoplication: timing, frequency, indications, and outcome.

BACKGROUND: Dysphagia frequently develops shortly after fundoplication but is usually self-limited. This is an evaluation of the timing, frequency, indications, and outcome of dilation after fundoplication. METHODS: Two hundred thirty-three consecutive patients who underwent fundoplication were included. Preoperative motility, postoperative symptoms, endoscopic and radiographic data, timing and number of dilations, and caliber of the dilator used were evaluated in patients who required dilation. RESULTS: Twenty-nine of 233 (12.4%) patients underwent dilation(s). The mean time to dilation after surgery was 72 days (range 3 to 330 days). Ten of 29 (34.5%) required more than 1 dilation (mean 1.5, range 1 to 5). The mean diameter to which the fundoplication was dilated was 18.6 mm (range 15-20 mm). There were no complications. The indication for dilation was dysphagia in 20, chest pain 4, epigastric pain 1, globus 1, gas bloat 1, belching 1, and vomiting in 1 patient. Two patients were lost to follow-up. Dysphagia resolved with dilation in 12 of 18 (67%) patients. Of the 6 patients whose symptoms did not improve after dilation, 3 noted improvement after further surgery. Two patients with tight fundoplications still require periodic dilation. One patient had a stricture before surgery that persisted after surgery. Symptoms did not improve in any patient who underwent dilation for an indication other than dysphagia. CONCLUSIONS: Dilation after fundoplication was required in 12.4% of patients and was successful in most with dysphagia. Dilation shortly after surgery was safe and only a single dilation was required for most patients. Symptoms other than dysphagia did not respond to dilation.