Gastroesophageal reflux disease as a cause of death: analysis of fatal cases under conservative treatment.

BACKGROUND: Treatment of gastroesophageal reflux disease (GERD) with modern acid-suppressive agents is supposed to be effective and safe. However, there have been only a few studies on the mortality in GERD today. In the 1960s the mortality was 0.10-0.17/100,000 per year. METHODS: From 1990 to 1995, according to Statistics Finland, 78 official death certificates were issued in which GERD was stated to have been the immediate or a primary cause of death. RESULTS: On completion of analysis data on 52 patients were included in the study. The annual death rate was 0.20/100,000. The causes were hemorrhagic reflux esophagitis in 51.9%, aspiration pneumonia in 34.6%, perforation of esophageal ulcer in 9.6%, and spontaneous esophageal rupture with reflux esophagitis in 3.9%. Thirty-eight patients had been treated with omeprazole or an H2 antagonist, and 44 patients (85%) had severe concomitant disease. CONCLUSION: The mortality in conservatively treated GERD has not decreased. Patients with mental disorder, heart disease, or alcoholism constitute the group in which risk of death from conservatively treated GERD is likely to be greatest.

Outcome of erosive/ulcerative reflux oesophagitis in 181 consecutive patients 5 years after diagnosis.

BACKGROUND: Controversy exists as to whether oesophagitis worsens over the long-run and long-term follow-up studies of homogeneous series are scarce. AIMS: This study assessed the level of symptoms and the proportions of patients who underwent anti reflux surgery or were on antisecretory therapy. PATIENTS AND METHODS: Files from 286 patients with a first time diagnosis were retrieved. Outcome data was obtained over the phone from the general practitioners and from the patients. RESULTS: Seventy-five patients had died (26.2%), 2 of whom from anti reflux surgery, and 30 (14.2%) could not be contacted. Of the 181 patients contacted, 18 (9.9%) had undergone anti reflux surgery. Of the 163 remaining patients, 57.7% were no longer on medication (group 1), 31.9% were using antacids, alginate or cisapride (group 2) and 10.4% were on antisecretory therapy (group 3). High initial grades of oesophagitis and older age were linked to antisecretory drug consumption. There were no new cases of haemorrhage or stricture. CONCLUSIONS: Patients in this study showed a low rate of symptomatic relapse and of antisecretory drug requirements and no complications despite having had oesophageal breaks.

Peptic esophageal stricture: is surgery still necessary?

Gastroesophageal reflux disease is frequently complicated by peptic esophageal stricture formation. Treatment of choice over the past 25 years has changed from resection of the stenotic esophagus towards fundoplication, or conservative treatment combined with dilatation. Reports on the long-term results of the clinical course of such patients are still rare. Between 1965 and 1990 200 patients were treated for peptic esophageal stricture by surgery or bougienage with antisecretory medication. Retrospective analysis of the clinical outcome according to the primary therapeutic strategy was performed after a follow-up period of 1.5 to 267 months. 139 patients (group A) primarily received bougienage and medical treatment. After 71 months 36% of the patients were symptom-free, 52% had received further dilatation and 11% had undergone surgery. One fatal complication occurred. 61 patients (group B) underwent primary surgical treatment. Fundoplication was performed in 72% of the cases, resection in 18% and other procedures in 10%. After a median period of 84 months following standard fundoplication (n = 43) 44% were free of symptoms, 39% had received further dilatations and 12% had to be reoperated. Fatal complications occurred in 2 patients (5%). The risk of undergoing surgery after primary dilatation was 16% after 2 years, remaining on this level throughout follow-up time. We conclude that resection of peptic strictures of the esophagus is rarely indicated any more. Treatment of choice consists of primary bougienage combined with antisecretory medication. If conservative treatment fails or patient compliance is low we recommend fundoplication with intraoperative dilatation within the first 2 years after diagnosis of symptomatic stricture.

Surgical management of benign stricture from reflux oesophagitis.

From January 1976 to December 1994, out of 605 patients with reflux oesophagitis, 166 (27.4%) presented with an oesophageal stricture, and 68 of these (40.9%) underwent surgical therapy. Thirteen of the 68 patients (19.1%) had an associated Barrett's oesophagus. Oesophageal manometry revealed scleroderma in nine individuals (13.2%). The stricture was undilatable in 11 patients (16.1%) observed before 1985. An oesophageal-sparing operation was performed in the majority of patients: fundoplication (n = 39), Collis gastroplasty plus fundoplication (n = 10), and total duodenal diversion (n = 4). Oesophageal resection was performed in 15 patients (22%); 12 of these individuals were operated on before 1985. The mortality rate was 4.4%: two patients died of necrosis of the interposed colon and one of acute pancreatitis. The average follow-up time was 27 months (8-136). Oesophageal-sparing procedures significantly reduced the need for further endoscopic dilatation (P < 0.001). Standard fundoplication was successful in 30 out of 39 patients (77%). Reasons for a failed fundoplication were a long, hard stricture, an ineffective partial wrap in patients with unrecognized short oesophagus, or underlying scleroderma. Regression of Barrett's mucosa was not recorded with any of the conservative surgical procedures.

Tratamiento quirurgico de la esofagitis peptica / Peptical esophagitis surgical treatment

En 132 pacientes se empleo la tecnica de gastropexia posterior con calibracion del cardias, descrita originalmente por Hill en 1967. Los resultados fueron excelentes en 90 casos, de los 97 que puedieron ser controlados. Se considera que la existencia de epitelio columnar como revestimiento del extremo inferior del esofago, es una indicacion absoluta de cirugia, y que las estenosis severas que se presentan en estos otros pacientes, deben tratarse con dialataciones post-operatorias y que no tiene mayor objeto efectuarlas con anterioridad. Solamente el 50% de pacientes con estrecheces tratados en esta forma requirieron dilataciones post-operatorias. Hubo tres casos de mortalidad, pero solamente dos estuvieron relacionadas con la operacion

Fundoplication for reflux esophagitis: misadventures with the operation of choice.

Fundoplication, whether performed by thoracic or abdominal approach, is a sound method for control of reflux esophagitis. A series of 312 operations have been reviewed to assess the frequency of complications and the methods by which these can be prevented or treated effectively. Each source of an untoward outcome is examined in detail, and suggestions as to prevention or recognition are advanced. The current low death and complication rates have been lowered even more by a conscious effort to refine the procedure further; such efforts have been associated with a failure rate of less than 5% in a mean followup of 4 years.

Severe peptic oesophagitis.

The incidence, clinical and investigative features, treatment, and course of severe oesophagitis in 200 patients seen and followed up in the Thoracic Surgical Department for north east Scotland from 1951 to 1967 are reviewed. The male/female ratio was 1/1.9. The incidence of severe oesophagitis (grades III and IV) approximated to 4.5 per 100,000; there was a dramatic increase from the age of 50 years onwards.Reflux, with or without hiatal hernia, precedes oesophagitis and has an incidence in excess of 86 per 100,000. It is difficult to assess the extent to which reflux produces mild oesophagitis, but it is clear that it only infrequently leads to the severe grades. Severe oesophagitis does not always need operative treatment. A conservative regime, supplemented by bouginage as required, enables the poorer-risk older patient to live a near-normal life span, in very reasonable comfort. Fifty-three patients of the whole series were operated upon, half primarily and half after previous conservative treatment. The problems of operative treatment are discussed. Newer procedures designed to prevent reflux now allow operation to be more freely advised.Perhaps, rather surprisingly, severe oesophagitis had very little effect on the expectation of life, whether treatment was conservative or operative.