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Back To Vidyya Reflux Disease - Abstracts

Therapeutic Interventions

Listed below are a set of recent MEDLINE abstracts on the surgical interventions currently used in the treatment of gastroesophageal reflux disease. With the FDA's approval of two new non-drug treatments for the disease, current non-pharmaceutical interventions are worth a quick review.

Br J Surg 2000 Mar;87(3):338-43

Prospective study of the effect of laparoscopic hemifundoplication on motor and sensory function of the proximal stomach.

Vu MK, Ringers J, Arndt JW, Lamers CB, Masclee AA

Departments of Gastroenterology-Hepatology, Surgery and Nuclear Medicine, Leiden University Medical Centre, Leiden, The Netherlands.

BACKGROUND: Some 30 per cent of patients develop dyspeptic symptoms following antireflux surgery. These symptoms may result from alterations in the motor and sensory function of the proximal stomach. METHODS: Proximal gastric motor and sensory function was studied with an electronic barostat in 12 patients with reflux who underwent laparoscopic hemifundoplication. In addition, 24-h pHmetry, gastric emptying (scintigraphy) and vagus nerve integrity (pancreatic polypeptide response to hypo-glycaemia) were assessed. Fifteen healthy volunteers served as controls. RESULTS: Laparoscopic hemifundoplication significantly decreased total acid exposure time (P < 0.05). Vagus nerve function remained intact in all but one patient. The mean(s.e.m.) lag phase for emptying of solids was significantly shorter after operation than before (15(3) versus 21(3) min; P < 0.05). Proximal gastric compliance was not significantly different before and after fundoplication. However, mean(s.e.m.) postprandial relaxation was significantly reduced (P < 0.05) after hemifundoplication compared with the value before operation (3341(1105) versus 12 763(3616) ml over 90 min) and in controls (14 567(2358) ml over 90 min). Postprandial fullness was significantly increased after hemi-fundoplication (P < 0.05). Postprandial gastric relaxation correlated with the lag phase for emptying of solids (r = 0.55, P < 0.02). CONCLUSION: After hemifundoplication, proximal gastric compliance is not altered but postprandial relaxation is impaired and associated with sensations of fullness and shorter duration of the lag phase for emptying of solids.

PMID: 10718804, UI: 20183401

Br J Surg 2000 Mar;87(3):289-97

Late results of a randomized clinical trial comparing total fundoplication versus calibration of the cardia with posterior gastropexy.

Csendes A, Burdiles P, Korn O, Braghetto I, Huertas C, Rojas J

Department of Surgery, University of Chile Hospital, Santiago, Chile.

BACKGROUND: The aim was to perform a prospective randomized study in patients with chronic gastro-oesophageal reflux treated either by total fundoplication or calibration of the cardia with posterior gastropexy. Late follow-up considered subjective and objective parameters, and related outcome to the presence of Barrett's oesophagus. METHODS: A total of 164 patients were randomized to fundoplication (n = 76) or calibration of the cardia (n = 88). They were evaluated by clinical questionnaire, upper gastrointestinal endoscopy with biopsies, oesophageal manometry and gastro-oesophageal reflux studies, including scintigraphy and 24-h oesophageal pH monitoring. RESULTS: There were no operative deaths. There was 95 per cent follow-up at a mean of 85 months. The mean recurrence rate for both operations was near 40 per cent at 10 years, but patients without Barrett's oesophagus had a recurrence rate after both operations of around 23 per cent compared with 83 per cent after 10 years for those with Barrett's oesophagus (P < 0.0001). Low-grade dysplasia developed in 13 per cent of the patients with Barrett's oesophagus. There were significant differences in all objective parameters in a comparison of patients with Visick I or II and those with Visick III or IV disease at the late assessment. CONCLUSION: Both total fundoplication and calibration of the cardia with posterior gastropexy had similar subjective and objective late results. However, results were significantly worse in patients with Barrett's oesophagus.

Publication Types:
  • Clinical trial
  • Randomized controlled trial

PMID: 10718796, UI: 20183393

Am J Med 2000 Mar 6;108 Suppl 4a:181S-191S

Life after antireflux surgery.

Hogan WJ, Shaker R

Department of Medicine, Medical College of Wisconsin, Milwaukee 53226, USA.

Laparoscopic fundoplication technique has become the operative modality of choice for antireflux surgery. An increasing number of patients and physicians have enthusiastically embraced this "minimally-invasive" technologic development for treatment of gastroesophageal reflux disease (GERD). However, laparoscopic fundoplication has been frequently advertised as the therapeutic solution for all GERD patients. Subsequently, the number and severity of complications resulting from laparoscopic surgery--often performed indiscriminately--has increased dramatically. This article reviews the efficacy of the laparoscopic fundoplication operation for GERD based on current, relatively short-term reports from centers specializing in this treatment modality. The majority of these reports are very positive. Unfortunately, the results of fundoplication operations performed by community surgeons are unknown. There are a number of disturbing factors relating to laparoscopic treatment for GERD that should raise a red flag of caution to the medical community, particularly primary-care physicians and their patients. The central portion of this report devotes itself to discussing the problems associated with this new minimally-invasive technique for fundoplication operations. These problems include the selectivity of current reports on outcomes of the laparascopic fundoplication operation and the lack of uniform data acquisition associated with these postoperative studies. The technical difficulties of the laparascopic fundoplication surgery are discussed, and the need for operator expertise and appreciation of esophageal physiology and anatomy are stressed. Finally, the long-term durability of the fundoplication wrap is questioned and the morbidity associated with the operation--particularly dysphagia--is addressed. In the final segment, the complications encountered after laparoscopic fundoplication operations are detailed and the techniques for evaluating the symptomatic postfundoplication patient are discussed. Laparoscopic fundoplication operation is good therapy in an appropriate clinical setting when performed by a well-trained and experienced surgeon. However, the operation should not be first-line therapy for the majority of GERD patients. An esophagus disabled by an inappropriate or dysfunctional fundoplication wrap is a terrible price to pay for control of acid reflux.

Publication Types:
  • Review
  • Review, tutorial

PMID: 10718474, UI: 20181402

Am J Med 2000 Mar 6;108 Suppl 4a:178S-180S

Surgical therapy for supraesophageal reflux complications of gastroesophageal reflux disease.

Hinder RA, Branton SA, Floch NR

Department of Surgery, Mayo Clinic Jacksonville, Florida 32224, USA.

Supraesophageal complications of gastroesophageal reflux can be successfully treated by antireflux surgery. Careful preoperative testing, including 24-hour esophageal pH, manometry, and endoscopy, will help to identify appropriate patients who will benefit from surgery. The best results are achieved in patients with nocturnal asthma, the onset of reflux before pulmonary symptoms, laryngeal inflammation, and a good response to medical therapy. Cough is more responsive to surgical therapy than is asthma. The benefits of minimally-invasive surgery are evident in patients with pulmonary disease, who have a faster recovery with fewer complications than after open surgery.

Publication Types:
  • Review
  • Review, tutorial

PMID: 10718473, UI: 20181401

Am J Med 2000 Mar 6;108 Suppl 4a:170S-177S

Medical therapy of supraesophageal gastroesophageal reflux disease.

Katz PO, Castell DO

Department of Medicine, Graduate Hospital, Philadelphia, Pennsylvania 19146, USA.

Medical therapy of supraesophageal gastroesophageal reflux disease (GERD) is based on the principals for treating patients with heartburn and erosive esophagitis, observations from the few available clinical trials, and clinical experience. In general, patients with supraesophageal GERD require higher doses of antireflux therapy, principally with proton pump inhibitors, for longer periods of time to effectively relieve symptoms compared with patients with heartburn and/or erosive esophagitis. This article reviews the current literature and discusses a suggested approach to medical management of these often complex patients.

Publication Types:
  • Review
  • Review, tutorial

PMID: 10718472, UI: 20181400

Surgery 2000 Mar;127(3):258-63

Measuring improved quality of life after laparoscopic Nissen fundoplication.

Rattner DW

Department of Surgery, Harvard Medical School and Massachusetts General Hospital, Boston 02114, USA.

BACKGROUND: While the correction of pathologic gastroesophageal reflux by means of laparoscopic Nissen fundoplication (LNF) has been well documented, the psychological profiles of patients with this disease and the impact on their quality of life are less well understood. We obtained a baseline psychological profile and measured the impact of LNF on patients' quality of life with 2 standardized instruments: the psychological general well-being index (PGWB) and the gastrointestinal symptoms rating scale (GSRS). The study included 34 consecutive patients with typical symptoms of gastroesophageal reflux who underwent LNF in 1995 at a tertiary care university medical center. METHODS: Patients filled out PGWB and GSRS surveys preoperatively and at 2 weeks, 2 months, and 12 months postoperatively. Data were collected in a blinded fashion by a study nurse and analyzed after completion of the study. Data are expressed as mean +/- standard deviation. RESULTS: The mean preoperative PGWB score (69.6 +/- 17.3) of study patients with gastroesophageal reflux disease was lower than that expected for a healthy population. This was primarily attributable to low scores in the general health domain of the questionnaire, although LNF patients also had low scores in the vitality and positive well-being domains of the PGWB scale. LNF improved the PGWB score to a normal level (78.7 +/- 19.3) (P = .05 vs the preoperative PGWB score) at 12 months post surgery. The GSRS also showed improvement from 34.7 +/- 7.8 to 28.1 +/- 10 (P = .008). The improvement in GSRS was attributed to improvement in the heartburn (7.12 +/- 2.4 to 2.72 +/- 1.2, P < .001) and abdominal pain (6.58 +/- 2.5 to 4.92 +/- 1.6, P = .006) domains of the scale. LNF had no impact on the diarrhea, indigestion, and obstipation domains of the GSRS. CONCLUSIONS: Patients with gastroesophageal reflux disease who are candidates for LNF have low psychological and general well-being scores that are restored to normal levels by successful LNF. When compared with baseline measurements, LNF effectively relieved heartburn and did not cause significant new gastrointestinal complaints.

PMID: 10715979, UI: 20180928

Can J Surg 2000 Feb;43(1):48-52

National trends in gastroesophageal reflux surgery.

McMahon RL, Mercer CD

Department of Surgery, Queen's University, Kingston, Ont.

OBJECTIVES: To assess the surgical technique and the frequency of different types of antireflux surgery used in Canada after the introduction of laparoscopic antireflux surgery. DESIGN: Gastroesophageal reflux (GER) surgery and population data in fiscal years 1992 through 1996. were accessed through the Canadian Institute of Health Information, provincial health ministries, MED ECHO and Statistics Canada databases. Data were also analysed by province and nationally for type of surgery (e.g., open abdominal, thoracic, thoracoscopic and laparoscopic). RESULTS: National data showed a slight increase in GER surgery in the last 5 years. Laparoscopic surgery increased 2.8 fold in 1993 and 1.6 fold in 1995 over the previous years. Open abdominal cases decreased 1.1 fold from 1992 to 1996. Thoracic cases remained essentially unchanged. Provincial and regional disparities in procedures per 100,000 population exist (Ontario 7.1 versus Nova Scotia 20.7). Areas in which little or no laparoscopic surgery was done had an average increase of 3%, whereas areas in which laparoscopic surgery was done had an average increase of 16% in GER surgery during the course of the study. In provinces west of Quebec (with the exception of Manitoba) more than 50% of GER surgery is laparoscopic; in areas east of Ontario less than 25% of GER surgery is performed laparoscopically. Five provinces (Manitoba, Quebec, Nova Scotia, Prince Edward Island and Newfoundland) performed significantly fewer laparoscopic procedures than the national average. CONCLUSIONS: The frequency of GER surgery is increasing modestly in Canada and is performed most often by the open abdominal route. Regional disparities in open and laparoscopic techniques are apparent. Laparoscopic surgery for GER is increasing rapidly and accounts for the decrease in open GER surgery.

  • Comment in: Can J Surg 2000 Feb;43(1):7-8

PMID: 10714258, UI: 20178636

J Laparoendosc Adv Surg Tech A 2000 Feb;10(1):35-40

Fundoplication: a model for immunologic aspects of laparoscopic and conventional surgery.

Zieren J, Jacobi CA, Wenger FA, Volk HD, Muller JM

Department of Surgery, Charite, Humboldt University of Berlin, Germany.

BACKGROUND AND PURPOSE: Immunologic investigations of laparoscopic and conventional procedures have recently been performed during cholecystectomy or colon resection, but the results might have been influenced by the amount of dissection or the presence of malignant tumor. Because fundoplication is characterized by moderate dissection and no resection, we supposed it to be an appropriate procedure for comparing immunologic changes during laparoscopic and conventional surgery. PATIENTS AND METHODS: Immunologic analysis (interleukin [IL]-6, IL-10, leukocytes, HLA-DR monocytes) was carried out on the peripheral blood of 34 patients who underwent elective Nissen fundoplication by the laparoscopic (LAP; N = 26) or conventional (OPEN; N = 8) technique for gastroesophageal reflux disease. Blood samples were obtained before and 1 and 4 hours after the beginning of the operation and on days 1, 2, 4, 7 after the procedure. RESULTS: A very fast and significant (P < 0.01) increase of the proinflammatory cytokines (IL-6, IL-10) and leukocytes and a decrease of cell-mediated functions (HLR-DR monocytes) were detected. Most of the analyzed measures had returned to preoperative values by 2 days after the procedure. All of the changes were similar in the two groups with the exception of IL-6. Throughout the post-operative study period, IL-6 concentrations were higher in the OPEN group, being significant 4 hours, 1 day, 2 days, and 4 days after the operation. CONCLUSION: The investigation measures do not give evidence that laparoscopic fundoplication is superior to conventional fundoplication in its immunologic effects.

PMID: 10706301, UI: 20168818

Aust N Z J Surg 2000 Jan;70(1):22-5

Open Nissen fundoplication and highly selective vagotomy as a treatment for gastro-oesophageal reflux disease.

Bohmer RD, Roberts RH, Utley RJ

Department of Surgery, Christchurch Hospital, New Zealand.

BACKGROUND: Open Nissen fundoplication has been the most common surgical treatment of gastro-oesophageal reflux disease (GORD). The present paper describes the symptomatic result, and quantifies the acid reduction achieved by open Nissen fundoplication combined with highly selective vagotomy (HSV) in a consecutive case series. METHODS: A study of 106 patients undergoing open Nissen fundoplication and HSV for GORD was performed between 1988 and 1996. A history consistent with reflux was obtained and the diagnosis confirmed with ambulatory oesophageal pH studies and endoscopy. Postoperative pH studies were performed, and peri-operative and late complications were recorded. A standard questionnaire was sent out to patients postoperatively to assess the efficacy of surgery. RESULTS: Pre-operative pH studies were performed on 104 (98%) patients, and on 97 (91.5%) following surgery. There was a highly significant improvement in all parameters of the pH study postoperatively. All symptoms, including bloating and dysphagia, improved significantly postoperatively, except flatulence, which was exacerbated. The majority of patients were very satisfied with their outcome, 82% rating the operation from 80 to 100% successful. Complications were rare and there was no mortality. CONCLUSIONS: Open Nissen fundoplication and HSV is an effective method of treating GORD, producing an improvement in symptoms and in ambulatory pH studies.

PMID: 10696938, UI: 20160011

Gastroenterol Clin North Am 1999 Dec;28(4):1007-19, viii-ix

Postfundoplication complications. Prevention and management.

Waring JP

Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA.

Management of post-fundoplication problems begins by preventing complications from occurring. The prevention of complications after antireflux surgery can be divided into three important areas: (1) patient selection, (2) selection of the surgery, and (3) selection of the surgeon. After addressing prevention techniques, the author discusses the management of new postoperative symptoms such as Dysphagia, gas-bloat syndrome, and nausea and vomiting.

Publication Types:
  • Review
  • Review, tutorial

PMID: 10695014, UI: 20159337

Gastroenterol Clin North Am 1999 Dec;28(4):987-1005, viii

Antireflux surgery. Indications, preoperative evaluation, and outcome.

Hinder RA, Libbey JS, Gorecki P, Bammer T

Department of Surgery, Mayo Clinic Jacksonville, Florida, USA.

Gastroesophageal reflux disease (GERD) is an extremely common disorder. Many patients require lifelong medical therapy for symptom control. In patients being considered for antireflux surgery, thorough evaluation is required. Laparoscopic antireflux surgery is a safe and effective method of treating patients who have severe, refractory, or complicated GERD. Excellent long-term results are obtained with minimal morbidity, freeing the patient from the burden of chronic medical therapy.

Publication Types:
  • Review
  • Review, tutorial

PMID: 10695013, UI: 20159336

Gastroenterol Clin North Am 1999 Dec;28(4):971-85, viii

Helicobacter pylori and gastroesophageal reflux disease.

Metz DC, Kroser JA

Division of Gastroenterology, University of Pennsylvania Health System, Philadelphia, USA.

The nature of the relationship between Helicobacter pylori (Hp) infection and gastroesophageal reflux disease (GERD) remains unclear. This article reviews the current body of knowledge regarding the association between these two common entities. The authors examine the potential interactions of Hp and GERD from epidemiologic and pathophysiologic viewpoints and summarize and critique the prevalence and eradication studies that have been performed to date. Special consideration is given to the possible effects that long-term use of proton pump inhibitors may have on Hp gastritis.

Publication Types:
  • Review
  • Review, tutorial

PMID: 10695012, UI: 20159335

Gastroenterol Clin North Am 1999 Dec;28(4):847-60

Medical therapy. Management of the refractory patient.

Hatlebakk JG, Katz PO, Castell DO

Department of Medicine, Haukeland Sykehus, University of Bergen, Norway.

Although relatively rare, GERD patients refractory to medical therapy remain a challenge for the clinician. Refractoriness can be diagnosed only if the patient is properly studied on medication and if what should be adequate medical therapy has been given a sufficient therapeutic trial. Use of 24-hour intragastric and intraesophageal pH-metry has improved the ability to manage patients who appear to be nonresponders. Simple advice and minor adjustments to medical therapy are usually all that is needed for most patients, but in some, management requires knowledge of the principles outlined in this article. If followed, only a small group of patients should be medically refractory.

Publication Types:
  • Review
  • Review, tutorial

PMID: 10695005, UI: 20159328

Gastroenterol Clin North Am 1999 Dec;28(4):831-45

Overview of medical therapy for gastroesophageal reflux disease.

DeVault KR

Division of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, Florida, USA.

There appears to be a hierarchy in the efficacy of therapies that are directed against GERD. A summary of this hierarchy, including therapies [table: see text] not approved by the U.S. Food and Drug Administration, is presented in Table 4. The individual practitioner must evaluate the appropriate point at which to place each patient on this hierarchy. Whether it is best to begin with the drug with the highest efficacy and step-down as possible for maintenance, never to step down, or to start with a less efficacious therapy and step up must also be individualized because there are no clear data to support a universal approach to all or even most GERD patients.

Publication Types:
  • Review
  • Review, tutorial

PMID: 10695004, UI: 20159327

Am J Gastroenterol 2000 Feb;95(2):395-407

A cost-effectiveness analysis of prescribing strategies in the management of gastroesophageal reflux disease.

Gerson LB, Robbins AS, Garber A, Hornberger J, Triadafilopoulos G

Department of Medicine, Stanford University School of Medicine, California, USA.

OBJECTIVE: Patients who have uncomplicated gastroesophageal-reflux disease (GERD) typically present with heartburn and acid regurgitation. We sought to determine the cost-effectiveness of H2-receptor antagonists (H2RAs) and proton-pump inhibitors (PPIs) as first-line empiric therapy for patients with typical symptoms of GERD. METHODS: Decision analysis comparing costs and benefits of empirical treatment with H2RAs and PPIs for patients presenting with typical GERD was employed. The six treatment arms in the model were: 1) Lifestyle therapy, including antacids; 2) H2RA therapy, with endoscopy performed if no response to H2RAs; 3) Step up (H2RA-PPI) Arm: H2RA followed by PPI therapy in the case of symptomatic failure; 4) Step down arm: PPI therapy followed by H2RA if symptomatic response to PPI, and antacid therapy if response to H2RA therapy; 5) PPI-on-demand therapy: 8 wk of treatment for symptomatic recurrence, with no more than three courses per year; and 6) PPI-continuous therapy. Measurements were lifetime costs, quality-adjusted life years (QALYs) gained, and incremental cost effectiveness. RESULTS: Initial therapy with PPIs followed by on-demand therapy was the most cost-effective approach, with a cost-effectiveness ratio of $20,934 per QALY gained for patients with moderate to severe GERD symptoms, and $37,923 for patients with mild GERD symptoms. This therapy was also associated with the greatest gain in discounted QALYs. The PPI-on-demand strategy was more effective and less costly than the H2RA followed by PPI strategy or the other treatment arms. The results were not highly sensitive to cost of therapy, QALY adjustment from GERD symptoms, or the success rate of the lifestyle arm. However, when the success rate of the PPI-on-demand arm was < or =59%, the H2RA-PPI arm was the preferred strategy. CONCLUSION: For patients with moderate to severe symptoms of GERD, initial treatment with PPIs followed by on-demand therapy is a cost-effective approach.

PMID: 10685741, UI: 20148177

Semin Laparosc Surg 1999 Dec;6(4):194-212

Current state, techniques, and results of laparoscopic antireflux surgery.

Bowrey DJ, Peters JH

Department of Surgery, University of Southern California, Los Angeles, CA 90033-4612, USA.

The introduction of laparoscopic fundoplication has dramatically changed the face of antireflux surgery. Central to the success of laparoscopic fundoplication is careful preoperative patient evaluation and attention to surgical technique. Emerging evidence has questioned the long-term durability of laparoscopic partial fundoplications underscoring the place of laparoscopic Nissen fundoplication as the procedure of choice for most patients. The technique of laparoscopic Nissen fundoplication should incorporate crural closure, complete fundic mobilization by short gastric vessel division, and the creation of a short, loose fundoplication by enveloping the anterior and posterior fundic walls around the esophagus. Relief of typical reflux symptoms can be anticipated in over 90% of patients. The outcome of atypical reflux symptoms is less predictable, on average two thirds of patients benefiting. The cost of laparoscopic fundoplication compares favorably to long-term medical therapy and open fundoplication. Current trends indicate that laparoscopic fundoplication is being used increasingly as an alternative to long-term medical therapy.

PMID: 10684552, UI: 20149357

Clin Cornerstone 1999;1(5):1-17

Gastroesophageal reflux: practical management of a common, challenging disorder.

Soll AH, Fass R

CURE-UCLA Digestive Disease Center, USA.

Gastroesophageal reflux (GER) occurs in 2 distinct forms that differ in pathophysiology, clinical presentation, natural history, and therapy: mild GER (with no or minimal esophagitis) and classic, severe reflux (at risk for erosive esophagitis). A minority of subjects (< 20%) have the classic, potentially severe pattern of GER caused by reduced lower esophageal sphincter (LES) pressure and prolonged acid reflux, particularly at night, but also during the day. Evaluation and management must be catered to patients with this pattern of reflux. In contrast, symptoms in mild reflux (the majority) often occur during the day after meals in an upright posture (upright reflux); resting LES pressure is usually normal (reflux episodes are related to transient relaxation of the LES) and little reflux occurs at night. Acid reflux, which occurs mostly during the day, overlaps with the normal range and esophagitis is rare; however, symptoms can be distressing. Optimal management is controversial because no outcome trials have been conducted to address management in primary care settings. However, clinical clues can help differentiate mild and severe reflux and guide management decisions. This article provides a detailed approach to current management of GER syndromes.

Publication Types:
  • Review
  • Review, tutorial

PMID: 10682178, UI: 20146759

Br J Surg 2000 Feb;87(2):243-249X

Surgical treatment for recurrent gastro-oesophageal reflux disease after failed antireflux surgery.

Bais JE, Horbach TL, Masclee AA, Smout AJ, Terpstra JL, Gooszen HG

Department of Surgery, University Medical Centre Leiden, Leiden, The Netherlands.

BACKGROUND: Recurrent or persistent symptoms occur in 10-15 per cent of patients after antireflux surgery. Failure of surgery is not uniform in its presentation. The cause of failure is not easily detected and even harder to treat. Different approaches have been proposed and few reports are available on the objective and subjective outcome of reoperation. METHODS: This study focuses on 30 patients (16 men and 14 women; age range 20-69 years) with recurrent symptomatic gastro-oesophageal reflux disease (GORD) resistant to medical treatment. In all patients reoperation was by the Belsey Mark IV antireflux operation. A clinical history, endoscopy and oesophageal manometry were obtained in all patients, and 24-h pH monitoring was performed in 27 of 30 before and in most patients after the Belsey procedure. RESULTS: Symptomatic improvement was reported in 24 of 30 patients. Oesophagitis (present before operation in 19 patients) was cured or remained absent in 24 of 30 patients, stabilized in one, improved in four and deteriorated in one. Relief of symptoms combined with absence of oesophagitis was obtained in 21 of 30 patients, with concomitant normalization of the 24-h pH profile in 11 of 22 patients. The median basal lower oesophageal sphincter (LOS) pressure increased significantly from 6. 9 to 9.0 mmHg (P < 0.01). Redo surgery had no effect on oesophageal body motility. CONCLUSION: Reoperation performed for documented recurrent GORD had a good and lasting effect on symptoms, on oesophagitis (both in 24 of 30 patients) and on the combination of both (21 of 30). In these patients reoperation increased basal LOS pressure and decreased reflux time. Overall, the results approximate to those of primary operation.

PMID: 10671935, UI: 20137854

Langenbecks Arch Surg 2000 Jan;385(1):57-63

Laparoscopic fundoplication for gastro-oesophageal reflux disease - a consensus development conference and the evidence-based benefit.

Eypasch E, Thiel B, Sauerland S

Chirurgische Klinik, St.Hildegardis-Krankenhaus Koln-Lindenthal, Bachemer Strasse 29-31, D-50931 Koln, Germany.

The aim of this paper is to demonstrate an example of evidence-based medicine for a clinically relevant and frequent disease - gastro-oesophageal reflux disease - for which an increasing number of laparoscopic operations is performed. A consensus development conference was performed on this topic in 1996. During the following 3-year period, increase of knowledge shown by the number of publications was monitored and the consecutive changes of the consensus as well as its consequences and impact were analysed. The six published randomised clinical trials revealed important information about the technique of the laparoscopic operation focussing on the gastric fundic mobilisation and the modification of the anti-reflux wrap. Five consecutive consensus conferences were performed and published. Citations of the 1996 consensus conference could not be found in the major surgical journals - not even by participants of the conference. The responsibility of societies to run such conferences continues.

PMID: 10664122, UI: 20131079

Pharmacoeconomics 1999 Nov;16(5 Pt 1):483-97

Cost effectiveness of omeprazole and ranitidine in intermittent treatment of symptomatic gastro-oesophageal reflux disease.

Stalhammar NO, Carlsson J, Peacock R, Muller-Lissner S, Bigard MA, Porro GB, Ponce J, Hosie J, Scott M, Weir DG, Fulton C, Gillon K, Bardhan KD

Astra Hassle AB, Molndal, Sweden.

OBJECTIVE: This 1-year study compared the cost effectiveness of omeprazole and ranitidine when used as initial therapy in an intermittent treatment strategy for the management of patients with symptomatic gastro-oesophageal reflux disease with or without erosive oesophagitis. DESIGN AND SETTING: A prospective health economic analysis was conducted alongside an international multicentre randomised, double-blind clinical study. The economic analysis was performed from a societal perspective. PATIENTS: A total of 704 patients in the UK, the Republic of Ireland, Germany, France, Italy and Spain were randomised to 1 of the 3 treatment groups. INTERVENTIONS: Patients were randomised to receive either omeprazole 20 mg once daily, omeprazole 10 mg once daily or ranitidine 150 mg twice daily. Initial treatment failure resulted in dose titration and drug switching from ranitidine to omeprazole, and subsequently open maintenance treatment. MAIN OUTCOME MEASURES AND RESULTS: The estimated mean direct medical costs (medication and number of visits and endoscopies) were found to be lower for both dosages of omeprazole than for ranitidine in all countries except Germany. However, none of the differences were statistically significant. The differences between omeprazole 10 mg and omeprazole 20 mg were small and nonsignificant. With regard to numbers of symptom-free days, both omeprazole 20 mg and omeprazole 10 mg were found to be more effective than ranitidine. However, none of the differences were statistically significant. CONCLUSIONS: Following a pragmatic interpretation, incorporating intermediate short term results, the results in this study give no support to the notion that a step-up approach, either as dose titration from omeprazole 10 mg to omeprazole 20 mg or as drug switching from ranitidine to omeprazole, will result in cost savings and thereby be cost effective.

Publication Types:
  • Clinical trial
  • Multicenter study
  • Randomized controlled trial

PMID: 10662395, UI: 20073329

Otolaryngol Clin North Am 2000 Feb;33(1):151-61

Pediatric gastroesophageal reflux and laryngopharyngeal reflux.

Zalzal GH, Tran LP

Department of Otolaryngology, Children's National Medical Center, Washington, DC 20010-2970, USA.

Pediatric gastroesophageal reflux (GER) and laryngopharyngeal reflux (LPR) have gained better recognition over the past few years. GER and LPR usually present as regurgitation, emesis, epigastric pain, failure to thrive, esophagitis, or stricture. Many patients suffer respiratory disorders associated with reflux. Classification of reflux, pathophysiology, manifestations of reflux, diagnosis, and management of the disease are discussed in this article.

Publication Types:
  • Review
  • Review literature

PMID: 10637349, UI: 20105474

J Paediatr Child Health 1999 Dec;35(6):568-71

Gastro-oesophageal reflux: clinical profiles and outcome.

Lee WS, Beattie RM, Meadows N, Walker-Smith JA

Department of Paediatrics, University of Malaya Medical Centre, Kuala Lumpur, Malaysia.

OBJECTIVES: To assess the clinical features, investigations and outcome of 69 children (40 males, 29 females) with gastro-oesophageal reflux (GOER) referred to a tertiary referral centre in paediatric gastroenterology. METHODS: A study of all patients with significant GOER seen at the Paediatric Gastroenterology Unit, Queen Elizabeth Hospital for Children, Hackney Road, London, between December 1994 and August 1995. RESULTS: The median age at referral was 16 months. Presenting symptoms were recurrent vomiting (72%), epigastric and abdominal pain (36%), feeding difficulties (29%), failure to thrive (28%) and irritability (19%). Continuous 24-h lower oesophageal pH studies performed in 57 children showed 20 (35%) had a reflux index of between 10% to 20%, 14 (25%) had a index > 20%, and six (11%) had a postprandial reflux index > 10%. Reflux was shown in 38 (62%) of 62 children who underwent barium studies. None had significant anatomical abnormalities, but in the 22 children who had a negative barium studies, six had severe reflux (reflux index > 20%). Upper gastrointestinal endoscopy performed in 47 children showed reflux oesophagitis in 29 (62%), oesophageal ulceration in three, and Barrett's oesophagus in one. All of the children were treated with standard medical therapy. Sixty-six per cent were able to discontinue medication within 12 months and remained well. Four children (6%) required Nissen's fundoplication for failure to respond to medical therapy. CONCLUSIONS: Most infants with GOER have an uncomplicated course. False negative results were noted in both pH monitoring and barium meal. Up to 80% of children, with therapy, will improve within 12 months.

PMID: 10634985, UI: 20099120

Can J Gastroenterol 1999 Nov;13(9):761-4

Role of laparoscopic antireflux surgery in the management of chronic GERD symptoms.

Anvari M

Department of Surgery, St Joseph's Hospital, McMaster University, Hamilton, Ontario.

Since the application of minimally invasive techniques to antireflux surgery eight years ago, there has been a rapid increase in the use of laparoscopic antireflux surgery. It is increasingly used as an alternative to long term medical therapy with proton pump inhibitors. The factors responsible for the rapid popularity of this procedure are reviewed, and the choice of techniques, current indications and available literature on the outcomes of these procedures are discussed.

PMID: 10633829, UI: 20099646

Hosp Pract (Off Ed) 1999 Nov 15;34(12):89-94, 97-8

A practical approach to heartburn.

Castell DO

School of Medicine, Allegheny University of the Health Sciences, Philadelphia, USA.

Heartburn and other symptoms of gastroesophageal reflux disease can be a lifelong problem, affecting millions of Americans each year. Fortunately, treatment has improved dramatically over the past decade. Medications currently available are remarkably safe and, with proper selection, almost universally effective. When indicated, surgical treatment is also highly effective.

Publication Types:
  • Review

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