Gas-related symptoms after laparoscopic 360 degrees Nissen or 270 degrees Toupet fundoplication in gastrooesophageal reflux disease patients with aerophagia as comorbidity.

BACKGROUND: Aerophagia is a rare but well-known comorbidity in patients with gastrooesophageal reflux disease. Particularly after laparoscopic Nissen fundoplication, it has proven to result in worse symptomatic outcome and a lower postoperative quality of life in comparison to patients without preoperative gas-related symptoms. AIMS: Aim of the study was to compare the postoperative outcome in gastrooesophageal reflux disease patients with aerophagia as comorbidity after either laparoscopic 360 degrees 'floppy' Nissen fundoplication or 270 degrees Toupet fundoplication with main focus on the frequency and subjective impairment of gas-related symptoms. PATIENTS AND METHODS: In 56 gastrooesophageal reflux disease patients, the comorbidity of aerophagia was diagnosed prior to laparoscopic antireflux surgery. Irrespective of their preoperative manometric findings, the patients were either scheduled to a laparoscopic 360 degrees 'floppy' Nissen (n=28) or a laparoscopic 270 degrees Toupet fundoplication (n=28). All patients have been analysed concerning the presence of gas-related symptoms preoperatively as well as 3 months after surgery. Additionally, the subjective degree of impairment was evaluated using a numerous rating scale (0=no perception/impairment, 100=most severe perception/impairment). The following symptoms have been analysed: ability/inability to belch, 'gas bloat', flatulence, postprandial fullness and epigastric pain. RESULTS: Before surgery, there were no significant differences between both surgical groups. Three months after surgery, significant differences (p<0.05-0.01) were found: patients who underwent a laparoscopic 270 degrees Toupet fundoplication suffered from less impairing gas bloat, flatulence and postprandial fullness when compared with patients with a 360 degrees 'floppy' Nissen fundoplication. The majority of these patients were able to belch postoperatively but felt no impairment due to this symptom. In contrast, patients of the Nissen group felt a significant impairment due to the inability to belch. CONCLUSION: Gas-related symptoms are very common in gastrooesophageal reflux disease patients with aerophagia as a comorbidity. Patients who undergo a laparoscopic Toupet fundoplication show less impairment in relation to gas-related problems compared with patients treated with a Nissen fundoplication for a follow-up period of at least 3 months. In the Toupet group, the ability to belch postoperatively seems to be a positive aspect from the patients' view which also improves the percentage of gas-related problems. However, long-term results are necessary.

Qualitative analysis of the expectations of antireflux surgical outcomes of patients from different nationalities.

Patient-reported outcomes have grown in importance in assessing the value of a variety of treatments. One of the methods of assessing patient-reported outcomes is qualitative analysis. The purpose of this study was to assess if qualitative analysis can be used to assess patient expectations for antireflux surgery in different nationalities. Patients referred for antireflux surgery (ARS) in the US, Austria and Italy were prospectively studied. Preoperatively, they were asked: (i) 'How do you expect the surgery to affect your symptoms?'; (ii) 'What do you expect the possible complications or side effects to be?' These patients then underwent open or laparoscopic antireflux surgery. At 2-3 months postoperatively, they were asked: (i) 'Are you satisfied with your surgery? If so, why? If not, why not?'; (ii) 'Did your surgery meet your expectations? If not, why not?' Twenty patients in the US, 24 in Austria, and 18 in Italy completed the study. Preoperatively, there were significant differences between the patients in demographics and objective measurements of GERD. Symptomatic relief was the most common expectation. There was variation in question #2, with Austrian and Italian patients more likely to mention conversion and postoperative side effects. Postoperatively, 90% of American, 88% of Austrian, and 89% of Italian patients were satisfied. Causes for dissatisfaction were postoperative complications, symptomatic recurrences, or side effects. Ninety percent of American, 96% of Austrian, and 94% of Italian patients said that their expectations were met. Patients who did not mention the possibility of side effects or complications were more likely to be dissatisfied. Qualitative analysis is a useful tool in assessing patient expectations. Expectations were remarkably similar. Patients who did not mention postoperative adverse events as possibilities preoperatively were more likely to be dissatisfied.

Dysphagia after laparoscopic antireflux surgery: a problem of hiatal closure more than a problem of the wrap.

BACKGROUND: Postoperative dysphagia after laparoscopic antireflux surgery usually is transient and resolves within weeks after surgery. Persistent dysphagia develops in a small percentage of patients after surgery. There still is debate about whether postoperative dysphagia is caused by the type or placement of the fundic wrap or by mechanical obstruction of the hiatal crura. This study aimed to investigate patients who experienced recurrent or persistent dysphagia after laparoscopic antireflux surgery, and to identify the morphologic reason for this complication. METHODS: A sample of 50 patients consecutively referred to the authors' unit with recurrent, persistent, or new-onset of dysphagia after laparoscopic antireflux surgery were prospectively reviewed to identify the morphologic cause of postoperative dysphagia. According to their radiologic findings, these patients were divided into three groups: patients with signs of obstruction at or above the gastroesophageal junction suspicious of crural stenosis (group A; n = 18), patients with signs of total or partial migration of the wrap intrathoracically (group B; n = 27), and patients in whom the hiatal closure was radiologically assessed to be correct with a supposed stenosis of the wrap (group C; n = 5). The exact diagnosis of a too tight (group A) or too loose (group B) hiatus in contrast to a too tight wrap (group C) was established during laparoscopic redo surgery (groups B and C) or by x-ray during pneumatic dilation (group A). RESULTS: For all 18 group A patients, intraoperative x-ray during pneumatic dilation showed the typical signs of hiatal tightness. Of these, 15 were free of symptoms after dilation, and 3 had to undergo laparoscopic redo surgery because of persistent dysphagia. In all these patients, the hiatal closure was narrowing the esophagus. All the group B patients underwent laparoscopic redo surgery because of intrathoracic wrap migration. Intraoperatively, all the patients had an intact fundoplication, which slipped above the diaphragm. Definitely, only in 10% of all 50 patients (group C) presenting with the symptom of dysphagia, was the morphologic reason for the obstruction a problem of the fundic wrap. CONCLUSIONS: In most patients, postoperative dysphagia is more a problem of hiatal closure than a problem of the fundic wrap.

Austrian experiences with redo antireflux surgery.

BACKGROUND: From 1996, the entire number of fundoplications performed in Austria increased dramatically, favoring the laparoscopic technique. Despite good results, some patients experience failure of antireflux surgery and therefore require redo surgery if medical therapy fails to control symptoms. The aim of the study was to describe the refundoplication policy in Austria with evaluation of the postoperative results. METHODS: A questionnaire was sent to all Austrian surgical departments at the beginning of 2003 with questions about redo fundoplications (number, techniques, intraoperative complications, history, migration of patients, preoperative workup, mortality, and postoperative long-term complaints). It also included questions about primary fundoplications (number, technique, postoperative symptoms). RESULTS: Out of 4,504 primary fundoplications performed in Austria since 1990, 3,952 have been carried out laparoscopically. In a median of 31 months after the primary operation, 225 refundoplications have been performed, laparoscopically in the majority of patients. The Nissen and the partial posterior fundoplication were the preferred techniques. The conversion rate in these was 10.8%, mainly because of adhesions and lacerations of the spleen, the stomach, and the esophagus. The mortality rate after primary fundoplications was 0.04%, whereas the rate after refundoplications was 0.4%, all resulting from an open approach. CONCLUSION: Laparoscopic refundoplications are widely accepted as a treatment option after failed primary antireflux surgery in Austria. However, the conversion rate is 6 times higher and the mortality rate is 10 times higher than for primary antireflux surgery. Therefore, redo fundoplications should be performed only in departments with large experience.

Laparoscopic Nissen fundoplication in patients with nonerosive reflux disease. Long-term quality-of-life assessment and surgical outcome.

BACKGROUND: It is known that laparoscopic antireflux surgery (LARS) can achieve an excellent surgical outcome including quality of life improvement in patients with erosive gastroesophageal reflux disease (GERD; EGD-positive). Less is known about the long-term surgical outcome in GERD patients who have no evidence of esophagitis (EGD-negative) before surgery. The aim of this study was to evaluate the surgical outcome in a well-selected group of EGD-negative patients compared to that of EGD-positive patients. METHODS: From a large sample of more than 500 patients who underwent LARS, 89 EGD-negative patients (mean age, 51 +/- 6 years; 56 males) were treated surgically because of persistent reflux-related symptoms despite medical therapy. In all cases, preoperative 24-h pH monitoring showed pathological values. To perform a comparative analysis, a matched sample of EGD-positive patients (mean age, 54 +/- 10 years; 58 males) was selected from the database. Surgical outcome included for all patients objective data (e.g., manometry and pH data and endoscopy), quality of life evaluation [Gastrointestinal Quality of Life Index (GIQLI)] symptom evaluation, as well as patients' satisfaction with surgery. The data of a complete 5-year follow-up are available. RESULTS: There were no significant differences in symptomatic improvement, percentage of persistent surgical side-effects, or objective parameters. In general, patients' satisfaction with surgery was comparable in both groups: 95% rated long-term outcome as excellent or good and would undergo surgical treatment again if necessary, respectively. Quality of life improvement was significantly better (p < 0.05) in the EGD-negative group because of the fact that GIQLI was more impaired before surgery (preoperative GIQLI, 81.7 +/- 11.6 points/EGD-negative vs 93.8 +/- 10.3 points/EGD-positive). Five years after surgery, GIQLI in both groups (121.2 +/- 8.5 for EGD-negative vs 120.9 +/- 7.3 for EGD-positive) showed comparable values to healthy controls (122.6 +/- 8.5). CONCLUSION: We suggest that LARS is an excellent treatment option for well-selected patients with persistent GERD-related symptoms who have no endoscopic evidence of esophagitis.

Gastroesophageal reflux disease. Heart-burn from a psychological view.

Although gastroesophageal reflux disease (GERD) can be traced back to disorders of the gastroesophageal junction, stress and other relevant psychological factors can play an important role in the process of GERD. It would seem that, primarily, altered symptom perception based on threshold reduction exists in some patients. In an effort to describe the sensitisation for reflux symptoms, both central and peripheral factors can be discussed. The following is conceivable: that well defined personality factors moderate the effect of stress on the gastroesophageal junction, just as they can influence the perception and assessment of symptoms. Additionally, psychiatric disorders as comorbidities can also accompany GERD. For this reason, it is necessary to consider if an extension of hitherto psychological interventions could be helpful in patients with a subjective link between reflux and stress on an emotional personality related level, or in patients with attendant psychiatric disorders. This broadening relates both to the conservative use of antireflux medication and to surgical therapy, since a postoperative shift in symptoms can occur. The effectiveness of psychological interventions in several gastrointestinal patient groups could already be shown in the past, whereas evidence for their effectiveness in patients suffering with GERD is partly still outstanding and should be investigated in the future especially as several individual promising starts have been made.

What do heartburn sufferers expect from proton pump inhibitors when prescribed for the first time?

AIM: Based on several consensus reports, the official goals of gastroesophageal reflux disease (GERD) treatment are symptom relief, healing of esophagitis, prevention of complications and also prevention of relapses. The aim of the present study was to evaluate the expectations of heartburn sufferers referred to primary endoscopic examination in a prescribed proton-pump-inhibitor (PPI) therapy, also in relation to the official treatment goals. METHODS: A group of 91 patients has been sent to the Division of Gastroenterology of the Public Hospital of Zell am See for a first endoscopic examination because of recurrent GERD-related symptoms. All patients (59 men, 32 females), mean age 44.8 years (range 28 to 63 years), treated their symptoms themselves using over-the-counter medication and/or life-style modification and diet. Subsequent to endoscopic examination and medical prescription all patients were asked about their expectations in a prescribed PPI therapy (open technique). RESULTS: Of the complete sample, only 4 patients (4.4%) had no real expectations in the prescribed antireflux medication. The leading expectations were: 1) an improvement in (61%) or elimination of (33%) perceived symptoms; 2) healing of esophagitis (50%); 3) in 46% of the patients a return to normal daily life and in 44% an improvement in quality of life respectively. Thirty-six percent expected no further therapy following this initial treatment and 34% no side-effects of PPI treatment. CONCLUSIONS: The leading patient-related expectations in PPI therapy are related to their perceived symptomatology, an improvement in quality of life, healing of esophagitis, and also a long-term efficacy of treatment. Most of these factors expected by the patients are in relation to the official treatment goals, but especially aspects such as quality of life and normal daily activities should be included as endpoints of treatment.

The impact of gastroesophageal reflux disease on quality of life.

BACKGROUND: Quality of life as a medical endpoint has become an important measure in clinical research. METHODS: In this article, we review the recent literature that has examined the impact of gastroesophageal reflux disease (GERD) and its treatment of quality of life. RESULTS: The increasing interest in measuring patients' quality of life as an outcome reflects an increasing awareness that traditional physiological endpoints often do not correlate well with patients' functional status, general well-being, and satisfaction with therapy. It has been shown that GERD has a significant impact on patients' quality of life; therefore, improvement of quality of life is one of the major goals of GERD treatment. This can be achieved by medical as well as surgical treatment. CONCLUSION: In addition to the patients' perspective, quality of life is one of the major endpoints in medical research that will help provide more selective treatment regimens for our patients.

Laparoscopic antireflux surgery: disease-related quality of life assessment before and after surgery in GERD patients with and without Barrett's esophagus.

BACKGROUND: Several findings suggest that gastroesophageal reflux disease (GERD) has a significant impact on patients' quality of life. The aim of this prospective study was (a) to evaluate and compare quality-of-life data before and after laparoscopic antireflux surgery (LARS) in GERD patients with and without Barrett's esophagus (BE); and (b) to compare quality-of-life data of these patients to normative data for a comparable general population. METHODS: The Gastrointestinal Quality of Life Index (GIQLI) was administrated to 75 BE patients and to 174 patients with GERD without BE (Savary-Miller classification: grade 1: n = 49; grade 2: n = 69; grade 3: n = 56). The questionnaire was given to all patients preoperatively, 3months, 1 year, and 3 years after laparoscopic "floppy" Nissen fundoplication. RESULTS: Before surgery, BE patients (mean: 96.8 +/- 9.3 points) had a better but not significant (p<0.06) general score of the GIQLI when compared with patients without BE (mean: 86.4 +/- 10.1 points). This difference is solely based on the subdimension "gastrointestinal symptoms" which means that GERD symptoms are less intensively and frequently recognized in BE patients than in patients without BE. There are no other differences in the other four subdimensions of the GIQLI between both groups. Three months, 1 year, and 3 years after LARS, GIQLI was significantly (p<0.01) improved in both groups (BE patients mean after 3 years: 121.9 +/- 8.2 points; non-BE patients mean after 3 years: 122.8 +/- 9.3 points). This improvement was significantly better (p<0.05) in patients without BE than in BE patients. Before surgery, both groups scored significantly below average on all subscores of GIQLI compared to general population (mean: 122.6 +/- 8.5 points). After surgery, there are no differences detectable. CONCLUSION: As our data show, non-BE patients undergoing LARS achieve a better quality-of-life improvement than those patients with BE. However, after surgery GIQLI of both groups is comparable to the mean value of general population. This means that LARS is able to improve quality of life significantly in all GERD patients, with and without BE.

Does major depression in patients with gastroesophageal reflux disease affect the outcome of laparoscopic antireflux surgery?

BACKGROUND: It is known that psychological factors can affect end points of surgical treatment. The current study aimed to evaluate the outcome of laparoscopic antireflux surgery (LARS) in patients with gastroesophageal reflux disease (GERD) who experience concomitant major depression in comparison with GERD patients who have no known comorbidity. METHODS: Among a sample of more than 550 patients who underwent LARS, a group of 38 GERD patients with concomitant major depression (MD) were included in this study. The patients included 24 women and 14 men, with a mean age of 51 years. A group of 38 control patients (non-MD) matched in terms of age, gender, and esophageal manometry findings was selected from the database for comparison of surgical outcomes between patients with GERD accompanied by concomitant major depression and GERD patients with no known comorbidity. In each group, 23 patients received a Toupet fundoplication and 15 patients underwent a "floppy" Nissen fundoplication. The following factors were evaluated before surgery, 3 months afterward, and 1 year after LARS: symptoms (heartburn, regurgitation, chest pain, bloating, and dysphagia), quality of life (Gastrointestinal Quality of Life Index [GIQLI]), lower esophageal sphincter pressure (LESP), and 24-h pH monitoring (DeMeester score). RESULTS: Before and after surgery, there were no significant differences between the two groups in terms of LESP and DeMeester score. Preoperative GIQLI showed significant differences (p < 0.05) between the two groups (MD group, 71.8 +/- 8.6 vs non-MD group, 91.1 +/- 9.8), and significant differences (p < 0.01-0.001) between the mean data and that for healthy individuals (122.6 +/- 8.5). The GIQLI scores had improved significantly at 3 months and at 1 year after surgery (p < 0.05-0.001) in all the patients (1 year postoperatively: MD group, 99.3 +/- 8.6 vs non-MD group, 121.9 +/- 9.7). Before surgery, when symptoms were compared between the two groups, significant differences (p < 0.001) were found in the percentage of chest pain (81.6% vs 37.4%) and bloating (92.2% vs 37.4%), showing that these symptoms were more predominant and graded as much more severe among patients with MD. In both groups, all the symptoms but dysphagia showed a significant improvement in severity (p < 0.05-0.0001). A comparison of both groups postoperatively showed that significant differences were still present in chest pain (44.7% vs 2.6%), bloating (68.4% vs 18.4), and dysphagia (50.1% vs 2.6%). A significant difference (p < 0.001) was observed only in patients with major depression and depending on the kind of wrap procedure (Nissen vs Toupet), showing that dysphagia (78.9% vs 21.1%) and chest pain (82.4% vs 17.6%) were much more predominant in patients who underwent "floppy" Nissen fundoplication. CONCLUSIONS: Even if they are good surgical candidates from a physiologic point of view, GERD patients with concomitant major depression should be selected carefully. In these patients, LARS can normalize physiologic data, but some patients have demonstrated less symptomatic relief, suffered from postoperative dysphagia, and showed less quality-of-life improvement. Eventually, laparoscopic Toupet fundoplication used with these patients could result in a better subjective outcome.

Minimally invasive surgery for gastro-oesophageal reflux disease.

The last decade has been characterized by several changes in the therapeutic field for gastro-oesophageal reflux disease (GERD). Major improvements, in fact, have been made in the understanding of the pathophysiology underlying this disease and finally in the ability to diagnose it and in its potential medical as well as surgical treatment. From the surgeons' point of view, the advent of minimally invasive surgery has been the major development and has changed or influenced the treatment algorithm of GERD. The popularity of laparoscopic antireflux surgery is driven by several factors, including such aspects as the high cost of continuing prescription medications, patients' wish for a curative therapy, rapid advances in the laparoscopic techniques, but also a significant improvement of patients' quality of life. This review evaluated the efficacy and outcomes of laparoscopic antireflux surgery in routine clinical practice.

"Floppy" Nissen vs. Toupet laparoscopic fundoplication: quality of life assessment in a 5-year follow-up (part 2).

BACKGROUND AND STUDY AIMS: Quality of life as an outcome variable has become an important measure in clinical research. This study is the second part of a prospective assessment of the quality of life outcome, in a 5-year follow-up of patients who underwent laparoscopic Nissen fundoplication or Toupet fundoplication. Data from a 1-year follow-up have been previously published (part I). PATIENTS AND METHODS: Using the Gastrointestinal Quality of Life Index (GIQLI), the quality of life data of 169 consecutive patients who had undergone a laparoscopic Nissen fundoplication (LNF; n = 104) or a laparoscopic Toupet fundoplication (LTF; n = 65), were evaluated 3 years and 5 years postoperatively. Six patients out of the initial study group (n = 175), including three from each group, were excluded from the main analysis because they had undergone laparoscopic re-fundoplication during the 1-year follow-up. Data from patients with repeat surgery have been analysed separately. In addition to administering the GIQLI, we evaluated patient satisfaction with surgery, possible surgical side effects or recurrent disease-related symptoms, the use of antireflux medication, and also surgical interventions in relation to initial antireflux surgery. In those patients, who were willing (n = 111) we also performed esophageal manometry and 24-hour pH monitoring 5 years postoperatively. RESULTS: At 3 years and 5 years postoperatively, the analysis of quality of life data showed that the GIQLI score remained stable in comparison with the 1-year follow-up data, with mean scores of 121 +/- 8.7 points in the LNF-group and 119.8 +/- 9 points in the LTF-group, at 5 years after surgery. Laparoscopic re-fundoplication was necessary in four patients due to a "slipping" Nissen (LNF group n = 1) or recurrent symptoms (LTF group, n = 3). In two patients in the LTF group herniation of a trocar incision was found. No patient suffered from severe surgical side effects. Patient satisfaction with surgery was rated as "excellent" or "good" in 97.9 % of patients. There were no significant differences between the groups concerning these data. The results of esophageal manometry and 24-hour pH monitoring also remained stable and showed normal values in all but two patients (in the LTF group), who suffered from mild and infrequent symptoms of recurrent heartburn without endoscopic signs of esophagitis. The outcome in patients who underwent laparoscopic re-fundoplication is comparable to the outcomes for those with a successful primary intervention. CONCLUSIONS: Both Nissen and Toupet laparoscopic fundoplication can significantly improve patients' quality of life during the 5 years following surgical intervention. Quality of life scores for both surgical groups were almost equal and postoperative outcomes were comparable to values in healthy controls. Patient satisfaction with surgical treatment was very high, even though repeat laparoscopic surgery was necessary in some cases. Patients who had a repeat procedure experienced nearly identical outcomes.

Psychological and emotional aspects of gastroesophageal reflux disease.

A synergy exists between the psychological and physiological aspects of esophageal and other gastrointestinal symptoms. Based on a biopsychosocial model of disease, several multidisciplinary concepts of interventions in gastrointestinal disorders have been evaluated. The role of psychological factors in gastroesophageal reflux disease (GERD) has been under study. This article reviews psychological and emotional factors influencing GERD symptoms and treatment.

Mid- and long-term quality of life assessments after laparoscopic fundoplication and refundoplication: a single unit review of more than 500 antireflux procedures.

BACKGROUND: For the evaluation of surgical interventions, quality of life data are being increasingly used as an efficacy endpoint. AIMS: To evaluate impact of laparoscopic fundoplication and laparoscopic refundoplication on quality of life as well as on patient satisfaction with the procedure for at least 5 years after surgical intervention. PATIENTS: After more than 500 laparoscopic antireflux procedures, quality of life data have been prospectively reviewed and data compared with healthy individuals, untreated gastro-oesophageal reflux disease patients (n = 150) and successfully treated patients (n = B4) under adequate omeprazole therapy. METHODS: Gastrointestinal Quality of Life Index has been used in all patients and evaluated the day before surgery and 5 times after surgery. Moreover, the SF-36 questionnaire has been used up to 2 years after surgical intervention, but only in patients who underwent laparoscopic redo-surgery (n = 49). RESULTS: In both surgical groups, mean preoperative Gastrointestinal Quality of Life Index showed a significant (p < 0.01) impairment (before laparoscopic antireflux surgery: 90.4 +/- 10.3 points; before redo-surgery: 84.3 +/- 8.1 points) when compared with healthy individuals (mean: 122.6 +/- 8.5 points) and successfully treated patients with acid-suppressive therapy (mean: 121.4 +/- 9.2 points). After surgery, the mean Gastrointestinal Quality of Life Index increased significantly and remained stable for at least 5 years after laparoscopic antireflux surgery (120.8 +/- 8.6 points) or for at least 2 years after redo-proce-dure (120.9 +/- 7.2 points). Before laparoscopic refundoplication, 6 out of 8 SF-36 scores were significantly p < 0.05) decreased. Redo-surgery influenced these 6 scores significantly (p < 0.05-0.01), resulting in values comparable to those of general population. Patients' satisfaction with surgery was excellent or good in 95%. CONCLUSION: Both, laparoscopic fundoplication as well as laparoscopic refundoplication are able to improve patients' quality of life significantly for at least 5 years. Therefore, quality of life data provide useful information to discuss different treatment options with patients.