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Is there a role for laparoscopic fundoplication in patients with non-erosive reflux disease (NERD)?
AGAA481
April 2000
(23.2 :t 23.0% versus 14.3 :t 18.9%, p<0.OO5). There was no difference in gastric bilirubin exposure comparing GERD patients with esophagitis with GERD patients without esophagitis (25.6 :t 24.9% versus 18.6 :t 21.6%, p=0.08). Conclusion: Gastric bilirubin exposure is not increased in GERD patients compared to other patients with foregut symptoms indicating that there is no additional functional gastric disorder in the majority of GERD patients.
2600 IS THERE A ROLE FOR LAPAROSCOPIC FUNDOPLICATION IN PATIENTS WITH NON-EROSIVE REFLUX DISEASE (NERD)? Peter Fenton, M. L. Terry, Kathy D. Galloway, C. Daniel Smith, John G. Hunter. J. Patrick Waring, Emory Univ Sch of Medicine, Atlanta, GA. Introduction: Non-erosive reflux disease (NERD) is defined as a burning retrosternal discomfort with a normal endoscopy, but with an abnormal esophageal pH study. Recent studies suggest that these patients have a similar clinical course as patients with erosive esophagitis (GERD). The role of laparoscopic fundoplication (LF) in patients with (NERD) is not established. Aim: To compare the results of LF in patients with NERD and patients with GERD. Methods: 364 patients underwent LF between 7/1/96 and 6130/98, and of these 39 met our criteria for NERD. A control group of 41 patients was derived by selecting every third patient from our surgical database from the same time frame with GERD. 34 patients in the NERD group and 33 patients in the GERD group were contacted by telephone interview I to 3 years postoperatively. The patients were asked for their pre and post operative assessment of heartburn, their most bothersome symptom (MBS), PPI use, dysphagia, bloating and satisfaction with surgery. The results were analyzed using X-squared tests. Results:There was no significant difference between the groups regarding postoperative PPI use, the need for dilation or gas-bloat symptoms. NERD patients whose most bothersome symptom resolved were more likely to have responded to PPI preoperatively (15/16 vs. 10/18, p<0.02) and have heartburn or regurgitation as the most bothersome symptom (13/16 vs. 2/18, p< .001) than NERD patients whose most bothersome symptom persisted after surgery. CONCLUSIONS: Patients with NERD have a modest benefit from LF. It should be considered selectively in these patients.
Heartburn improved Heartburn resolved Resolution MBS Dysphagia Would repeal surgery
NERD 34(patients)
GERD (33 patients)
29(85.3%)' 19(55.8%)" 16(48.5%)" 17(50%) • 27(79.4%) ...
33(100) 30(90.9%) 28(84.8%) 8 (24.2'10} 31 (939%)
·p<0.05 "p<0.01 ·"p=0.08
2601 DOES PREOPERATIVE ESOPHAGEAL DYSMOTILITY PREDICT OUTCOME AFTER LAPAROSCOPIC FUNDOPLICATION FOR GERD? A RANDOMIZED, PROSPECTIVE TRIAL, Christiane Fibbe, Ursula Strate, Alice Emmermann, Carsten Zomig, Peter Layer, Dept of Medicine, Israel Hosp, Hamburg, Germany; Dept of Surg, Israel Hosp, Hamburg, Germany. Background:Laparoscopic fundoplication has become a therapeutic alternative to long-term medical treatment for gastro-esophageal reflux disease(GERD). In order to avoid postoperative dysphagia it has been proposed to tailor antireflux surgery according to preexisting esophageal dysmotility: Thus, in patients with disordered preoperative peristalsis a partial fundoplication (270 0 Toupet;T)has been recommended, whereas the 360 0 Nissen(N)procedure, which is considered superior for reflux control, has been recommended in patients with normal motility. Aim:To determine whether preoperative esophageal dysmotility predicts clinical and/or manometric outcome following either T or N procedures. Methods:Between March and November 1999, 176 consecutive patients(106 men, 70 women) with a history of longstanding medical treatment of GERD(median age 55[range 20-77]years )in whom laparoscopic fundoplication was indicated, were included in a prospective study. All underwent esophageal function testing preoperatively(endoscopy, esophageal manometry, 24h pH-metrie, qualityof-life assessment according to Eypasch, clinical interview), and as postoperative follow-up 4 months later. Results:99 patients with normal peristalsis (n; 50N;49T)and 77 with abnormal (p; 37N;40T)peristalsis underwent fundoplication. 80 patients completed the follow up (38N, 25n/13p; 42T, 23n/19p). New onset dysphagia (25%) was significantly more frequent following N compared to T (15 vs. 4). Causes included incomplete LES relaxation (6N, IT), slipped or displaced fundoplication(6N, IT), or two-compartment stomach (2N). There was no association of new onset dysphagia with preoperative motility disorders. Recurrence of GERD was present in 16 patients(20%; 9N, 7T). However, > 90 % reported symptom relief and satisfactory quality-of-life assessment scores. Conclusions:Our data suggest, that(l)preexisting motility disturbances do not predict postoperative functional outcome following antireflux surgery independent of the procedure chosen;(2)hence, preoperative manometric studies do not provide reliable criteria to determine the surgical technique; (3)laparoscopic fundoplication is an effective treatment for refractory GERD, but clinical evaluation alone may underestimate its failures and complications.
2602 OESOPHAGEAL REFLUXATE ACIDITY IS NOT LOWERED BY MEAL RELATED INTRAGASTRIC PH BUFFERING. Jonathan Fletcher, Kenneth E. McColl, Univ of Glasgow, Glasgow, United Kingdom. BACKGROUND: GORD symptoms are aggravated after a meal. This is surprising as postprandial buffering will usually raise the gastric pH above the threshold necessary to induce oesophageal pain by oesophageal acid perfusion tests. AIMS: To examine the relationship between changes in gastric pH and oesophageal refluxate pH following meals. METHODS: Forty patients with dyspepsia and a normal endoscopy were studied. Dual channel 24 hour pH data was obtained from 5 em above the LOS and 15 em below this point, in the gastric body. Each upright reflux episode was analysed manually to determine the minimum oesophageal pH during that reflux episode and the corresponding minimum gastric pH over the 60 seconds leading up to this oesophageal pH nadir. Reflux episodes during meal related gastric buffering were compared to reflux episodes during the fasting period. RESULTS: Meals increased median intragastric pH from I.3 to 3.2. However, this buffering effect was much less apparent in the oesophageal refluxate which was pH 2.5 fasting and pH 3.0 postprandially. Oesophageal refluxate was less acidic than the gastric contents during fasting but more acidic postprandially. CONCLUSIONS: Our findings suggest regional variation in gastric pH postprandially. Gastric acid secreted into the proximal stomach appears to escape the buffering by food and may contribute to the pathogenesis of reflux disease. No. of reflux eplsodes/patienl
Oesophageal minimum pH
28 23
2.5 3.0 p<0.001
FASTING MEAL
Gastric minimum pH Difference oesophageal. gastric pH
1.3 32 p<0.001
+1.0 -0.4 p<0.001
2603 SHORT SEGMENT ACID REFLUX: MARKEDLY INCREASED ACID LOAD ON DISTAL OESOPHAGUS REVEALED BY NOVEL PHMETRY. Jonathan Fletcher, Elaine B. Henry. Angela Wirz, Kenneth E. McColl, Univ of Glasgow, Glasgow, United Kingdom. BACKGROUND: During oesophageal pH monitoring the electrode is conventionally positioned 5cm above the LOS. However it is possible that the squamous mucosa distal to this site is exposed to more acid due to undetected short segment reflux. AIMS: To measure acid exposure just above the squamo-columnar junction (Z-line) and compare it to the conventional electrode position. SUBJECTS: 9 H.Pylori negative patients with chronic dyspepsia, normal upper GI endoscopy and normal conventional oesophageal pH monitoring were examined. METHODS: Under endoscopic control a 4 channel pH catheter modified with prolene loops was secured to the oesophageal mucosa using haemostatic clips deployed with a clip fixing device. The two oesophageal electrode positions were at Scm proximal to the Z-line and 0.5cm proximal to the Z-line. Endoscopy was repeated after 24 hours to confirm the electrodes had maintained their position. The pH data from these electrodes were then compared. CONCLUSIONS: The degree of acid exposure of the squamous mucosa 0.5cm proximal to the Z line was 7 times greater than that observed 5cm above the LOS. This increased acid exposure may be important in the development of short segments of specialised intestinal metaplasia in the distal oesophagus. It may also explain symptoms which respond to acid suppression in patients with normal conventional oesophageal pH monitoring. RESULTS pH electrode position SCm above Zline O.SCm above Z line
No. of reflux episodes
%Tolal lime pH<4
Reflux episode (median pH nadir)
33 162 p<0.001
1.4 10 p<0.001
3.0 2.2 p<0.001
April 2000
(23.2 :t 23.0% versus 14.3 :t 18.9%, p<0.OO5). There was no difference in gastric bilirubin exposure comparing GERD patients with esophagitis with GERD patients without esophagitis (25.6 :t 24.9% versus 18.6 :t 21.6%, p=0.08). Conclusion: Gastric bilirubin exposure is not increased in GERD patients compared to other patients with foregut symptoms indicating that there is no additional functional gastric disorder in the majority of GERD patients.
2600 IS THERE A ROLE FOR LAPAROSCOPIC FUNDOPLICATION IN PATIENTS WITH NON-EROSIVE REFLUX DISEASE (NERD)? Peter Fenton, M. L. Terry, Kathy D. Galloway, C. Daniel Smith, John G. Hunter. J. Patrick Waring, Emory Univ Sch of Medicine, Atlanta, GA. Introduction: Non-erosive reflux disease (NERD) is defined as a burning retrosternal discomfort with a normal endoscopy, but with an abnormal esophageal pH study. Recent studies suggest that these patients have a similar clinical course as patients with erosive esophagitis (GERD). The role of laparoscopic fundoplication (LF) in patients with (NERD) is not established. Aim: To compare the results of LF in patients with NERD and patients with GERD. Methods: 364 patients underwent LF between 7/1/96 and 6130/98, and of these 39 met our criteria for NERD. A control group of 41 patients was derived by selecting every third patient from our surgical database from the same time frame with GERD. 34 patients in the NERD group and 33 patients in the GERD group were contacted by telephone interview I to 3 years postoperatively. The patients were asked for their pre and post operative assessment of heartburn, their most bothersome symptom (MBS), PPI use, dysphagia, bloating and satisfaction with surgery. The results were analyzed using X-squared tests. Results:There was no significant difference between the groups regarding postoperative PPI use, the need for dilation or gas-bloat symptoms. NERD patients whose most bothersome symptom resolved were more likely to have responded to PPI preoperatively (15/16 vs. 10/18, p<0.02) and have heartburn or regurgitation as the most bothersome symptom (13/16 vs. 2/18, p< .001) than NERD patients whose most bothersome symptom persisted after surgery. CONCLUSIONS: Patients with NERD have a modest benefit from LF. It should be considered selectively in these patients.
Heartburn improved Heartburn resolved Resolution MBS Dysphagia Would repeal surgery
NERD 34(patients)
GERD (33 patients)
29(85.3%)' 19(55.8%)" 16(48.5%)" 17(50%) • 27(79.4%) ...
33(100) 30(90.9%) 28(84.8%) 8 (24.2'10} 31 (939%)
·p<0.05 "p<0.01 ·"p=0.08
2601 DOES PREOPERATIVE ESOPHAGEAL DYSMOTILITY PREDICT OUTCOME AFTER LAPAROSCOPIC FUNDOPLICATION FOR GERD? A RANDOMIZED, PROSPECTIVE TRIAL, Christiane Fibbe, Ursula Strate, Alice Emmermann, Carsten Zomig, Peter Layer, Dept of Medicine, Israel Hosp, Hamburg, Germany; Dept of Surg, Israel Hosp, Hamburg, Germany. Background:Laparoscopic fundoplication has become a therapeutic alternative to long-term medical treatment for gastro-esophageal reflux disease(GERD). In order to avoid postoperative dysphagia it has been proposed to tailor antireflux surgery according to preexisting esophageal dysmotility: Thus, in patients with disordered preoperative peristalsis a partial fundoplication (270 0 Toupet;T)has been recommended, whereas the 360 0 Nissen(N)procedure, which is considered superior for reflux control, has been recommended in patients with normal motility. Aim:To determine whether preoperative esophageal dysmotility predicts clinical and/or manometric outcome following either T or N procedures. Methods:Between March and November 1999, 176 consecutive patients(106 men, 70 women) with a history of longstanding medical treatment of GERD(median age 55[range 20-77]years )in whom laparoscopic fundoplication was indicated, were included in a prospective study. All underwent esophageal function testing preoperatively(endoscopy, esophageal manometry, 24h pH-metrie, qualityof-life assessment according to Eypasch, clinical interview), and as postoperative follow-up 4 months later. Results:99 patients with normal peristalsis (n; 50N;49T)and 77 with abnormal (p; 37N;40T)peristalsis underwent fundoplication. 80 patients completed the follow up (38N, 25n/13p; 42T, 23n/19p). New onset dysphagia (25%) was significantly more frequent following N compared to T (15 vs. 4). Causes included incomplete LES relaxation (6N, IT), slipped or displaced fundoplication(6N, IT), or two-compartment stomach (2N). There was no association of new onset dysphagia with preoperative motility disorders. Recurrence of GERD was present in 16 patients(20%; 9N, 7T). However, > 90 % reported symptom relief and satisfactory quality-of-life assessment scores. Conclusions:Our data suggest, that(l)preexisting motility disturbances do not predict postoperative functional outcome following antireflux surgery independent of the procedure chosen;(2)hence, preoperative manometric studies do not provide reliable criteria to determine the surgical technique; (3)laparoscopic fundoplication is an effective treatment for refractory GERD, but clinical evaluation alone may underestimate its failures and complications.
2602 OESOPHAGEAL REFLUXATE ACIDITY IS NOT LOWERED BY MEAL RELATED INTRAGASTRIC PH BUFFERING. Jonathan Fletcher, Kenneth E. McColl, Univ of Glasgow, Glasgow, United Kingdom. BACKGROUND: GORD symptoms are aggravated after a meal. This is surprising as postprandial buffering will usually raise the gastric pH above the threshold necessary to induce oesophageal pain by oesophageal acid perfusion tests. AIMS: To examine the relationship between changes in gastric pH and oesophageal refluxate pH following meals. METHODS: Forty patients with dyspepsia and a normal endoscopy were studied. Dual channel 24 hour pH data was obtained from 5 em above the LOS and 15 em below this point, in the gastric body. Each upright reflux episode was analysed manually to determine the minimum oesophageal pH during that reflux episode and the corresponding minimum gastric pH over the 60 seconds leading up to this oesophageal pH nadir. Reflux episodes during meal related gastric buffering were compared to reflux episodes during the fasting period. RESULTS: Meals increased median intragastric pH from I.3 to 3.2. However, this buffering effect was much less apparent in the oesophageal refluxate which was pH 2.5 fasting and pH 3.0 postprandially. Oesophageal refluxate was less acidic than the gastric contents during fasting but more acidic postprandially. CONCLUSIONS: Our findings suggest regional variation in gastric pH postprandially. Gastric acid secreted into the proximal stomach appears to escape the buffering by food and may contribute to the pathogenesis of reflux disease. No. of reflux eplsodes/patienl
Oesophageal minimum pH
28 23
2.5 3.0 p<0.001
FASTING MEAL
Gastric minimum pH Difference oesophageal. gastric pH
1.3 32 p<0.001
+1.0 -0.4 p<0.001
2603 SHORT SEGMENT ACID REFLUX: MARKEDLY INCREASED ACID LOAD ON DISTAL OESOPHAGUS REVEALED BY NOVEL PHMETRY. Jonathan Fletcher, Elaine B. Henry. Angela Wirz, Kenneth E. McColl, Univ of Glasgow, Glasgow, United Kingdom. BACKGROUND: During oesophageal pH monitoring the electrode is conventionally positioned 5cm above the LOS. However it is possible that the squamous mucosa distal to this site is exposed to more acid due to undetected short segment reflux. AIMS: To measure acid exposure just above the squamo-columnar junction (Z-line) and compare it to the conventional electrode position. SUBJECTS: 9 H.Pylori negative patients with chronic dyspepsia, normal upper GI endoscopy and normal conventional oesophageal pH monitoring were examined. METHODS: Under endoscopic control a 4 channel pH catheter modified with prolene loops was secured to the oesophageal mucosa using haemostatic clips deployed with a clip fixing device. The two oesophageal electrode positions were at Scm proximal to the Z-line and 0.5cm proximal to the Z-line. Endoscopy was repeated after 24 hours to confirm the electrodes had maintained their position. The pH data from these electrodes were then compared. CONCLUSIONS: The degree of acid exposure of the squamous mucosa 0.5cm proximal to the Z line was 7 times greater than that observed 5cm above the LOS. This increased acid exposure may be important in the development of short segments of specialised intestinal metaplasia in the distal oesophagus. It may also explain symptoms which respond to acid suppression in patients with normal conventional oesophageal pH monitoring. RESULTS pH electrode position SCm above Zline O.SCm above Z line
No. of reflux episodes
%Tolal lime pH<4
Reflux episode (median pH nadir)
33 162 p<0.001
1.4 10 p<0.001
3.0 2.2 p<0.001