- Email: [email protected]
Laparoscopic anti-reflux surgery is an effective treatment for the acid-sensitive oesophagus
A478 AGA ABSTRACTS
GASTROENTEROLOGY Vol. 118, No.4
2586
2588
USE OF ACID SUPPRESSIVE MEDICATIONS AFTER LAPARO· SCOPIC ANTIREFLUX SURGERY: PREVALENCE, CLINICAL INDICIATIONS AND CAUSES. Tanja Bammer, Sami R. Achem, Kenneth R. DeVault, David A. Napoliello, Joaquin A. Rodriguez, Frank 1. Lukens, Ronald A. Hinder, Mayo Clin, Jacksonville, FL.
LAPAROSCOPIC ANTI·REFLUX SURGERY IS AN EFFECTIVE TREATMENT FOR THE ACID-SENSITIVE OESOPHAGUS. Michael I, Booth, Jane M. Stratford, Eunice Thompson, Thomas C. Dehn, Royal Berkshire Hosp, Reading, United Kingdom.
Laparoscopic antireflux surgery (LARS) provides effective control of gastroesophageal reflux (GER) in more than 90% of patients undergoing this procedure. Despite this high success rate, clinical observation suggests that patients continue to consume acid suppressive medications in the post-operative period. The prevalence and reasons for medication use by these patients have not been investigated. Aim: Evaluate the prevalence, clinical indications and cause of use of acid suppressive drugs and promotility agents in patients after LARS. Methods: Consecutive patients undergoing LARS for GER during 1997 were surveyed regarding their clinical status (surgical outcome and symptoms). They were also questioned about their use of acid suppressive and promotility medications. Results: During the study period, 119 patients were subjects to LARS at our center. Ninety-three (78%)were available for interview. Two patients died of unrelated causes and two declined to be interviewed. The remaining 89 individuals are the subject of this report. Thirty-five out of eighty-nine (39%) were on antireflux medication (66% PPI's, 20% H2-blocker and 14% others). Seventy-one percent were using continuous medication. Eighteen (20%) had symptoms of heartburn or regurgitation, but IS of these felt they had a good outcome of surgery. Seventeen (19%) had no symptoms of heartburn or regurgitation and IS of these felt they had a good surgical outcome. Their reasons for taking medication were abdominal pain (n=7), bloating (n=2), dysphagia (n=2), Barrett's (n=l), prevention of NSAID injury (n= I), burning tongue (n= 1), sore throat (n= 1), "help digestion" (n=l) and unknown reason to the patient (n=I). Conclusions: I) Thirtynine percent of patients 2 years after LARS were found to be on acid suppressive or promotility agents. 2) The majority of these subjects n= 30/35 (86%) reported a good surgical outcome despite continuing on medications. 3) Thirty-seven percent of the patients use these medications for unconventional indications. 4) These findings underscore the importance of patient education to prevent improper use of these drugs after LARS. 5) Our findings suggest that there is a group of patients who require both medication and surgery to obtain relief of GER symptoms.
2587 REFLUX RISING! A DISEASE IN EVOLUTION? Kama D. Bardhan, Christine Royston, Anil K. Nayyar, Rotherham Gen Hospitals NHS Trust, Rotherham, United Kingdom. INTRODUCTION AND AIM Gastroesophageal reflux disease (GERD) is thought to be seen more frequently now yet firm evidence is sparse. Our aim is to examine if there has been any increase in the incidence or changes in the demographic profile of GERO in our center (population 250,0(0). METHODS Detailed prospective records have been kept of all patients with upper gastrointestinal disease seen since 1977. DEFINITIONS Erosive esophagitis (EE) = presence of endoscopy verified erosive changes. Gastroesophageal reflux (GER) = heartburn +/- regurgitation but with normal endoscopy. GERD=EE+GER ie total. We examined: numbers of new patients seen each year; mean age at presentation; sex ratio; stricture; presentation with hemorrhage. RESULTS(Table)1. The number of patients with newly diagnosed GERO has increased markedly. 2.The mean age at presentation has risen, and an increasing proportion of women are now affected. 3.The percentage presenting with bleeding has risen. 4.Both stricture and hemorrhage remain uncommon. DISCUSSION The increase in GERD cannot be accounted for by greater awareness or misclassification for the demographic profile is changing, and the diagnosis of EE is based on objective evidence. CONCLUSION The dramatic 5-fold increase in the incidence of GERD is a new phenomenon, an example of a disease in evolution.
• Newly diagnosed pts(n)
GERO EE GER • Male:Female ratio GERO EE GER GERO • Mean age (y) EE GER • Mean age of general population (y) • Haemorrhage (%of EE) (%ofEE) • Stricture
1977·81
1982·86
1987·91
1992-96
714 480 259
1586 868 767
2381 1077 1379
3812 1645 2222
036 0.27 0.59 48.0 49.5 45.0 35.4 52 4.2
0.72 0.50 103 50.5 539 47.0 363 86 5.0
0.82 0.63 1.00 52.3 57.2 48.3 371 11.4 5.1
0.99 0.69 1.28 53.1 56.0 51.0 37.7 11.0 2.7
Aim: To assess the outcome of laparoscopic anti-reflux surgery (LARS) in patients with normal endoscopy and normal distal oesophageal acid exposure times ( % time with pH <4 of 0::::6 (day), 0::::2 (night) or 0::::4 (total» on two pre-operative 24-hour pH tests, but a positive (>50%) symptom index score - i.e patients with an "acid-sensitive oesophagus" (ASO). Methods: Prospective data collection in 11 ASO patients (6 male; age range 12-56, median 34 years) undergoing LARS. Results: DeMeester symptom score fell from 4.7::tO.7 pre-operatively to 0.5::tO.2 post-operatively (p<0.OOO3). Mean number of symptom events on 24-hour pH-metry fell from 28.1 ::t5.5 pre-operatively to 2.0::t2.0 post-operatively (p
6weeks
6 months
1year
I
4
"
5
7 3 1 0 11
6 3 0 0 9
III IV
Total
2 0 11
2589 PATIENT SELF-ASSESSMENT OF TEST DAY SYMPTOMS CAN HELP PREDICT THE RESULT OF REPEAT 24-HOUR PH TESTS IN SUSPECTED GASTRO-OESOPHAGEAL REFLUX DISEASE. Michael I. Booth, Jane M. Stratford, Eunice Thompson, Thomas C. Dehn, Royal Berkshire Hosp, Reading, United Kingdom. Aim: To observe how patients' self-assessment of the severity of their symptoms on the day of a 24-hour pH test for suspected GORD relates to the outcome of the test,and the potential value in repeating a normal test. Methods: 66 patients (36 male; age 11-72, median 37 years) with symptoms suggestive of gastro-oesophageal reflux underwent repeat 24-hour pH studies (median interval between tests 3 months). Patients assessed the severity of their symptoms on the test day as "better than typical", "typical" or "worse than typical". Results: Thirty-two patients had two normal pH tests. Twenty-six had a normal first and abnormal second pH test. A normal first test on a "better than typical" day was followed by an abnormal second test more often (55%) than a first test on a "typical" or "worse than typical" day (22%; p=0.025). Patient self-assessment of symptoms was more useful in predicting an abnormal second test than the symptom index score (p=0.25) or total acid exposure time (p=0.56) during the first test, or the presence of oesophagitis (p=O.28). Conclusion: Patients' self-assessment of the severity of their test day symptoms should be included in the interpretation of 24-hour pH tests for suspected GORD. Patients with a normal pH test on a "better than typical" day warrant a repeat test.
2590 MECHANICAL CONSEQUENCES OF TIGHTNESS AND LENGTH OF WRAP IN FUNDOPLICATION. Tamer A. Zaki, Peter J. Kahrilas, Sudip K. Ghosh, Rober P. Tatum, Raymond 1. Joehl, James G. Brasseur, Mechanical Engineering, Pennsylvania State Univ, University Park, PA; Northwestern Sch of Medicine, Chicago, IL; Northwestern Sch of Medicine, University Park, PA; Penn State Univ, University Park, PA. Fundoplication (FP) functions as a tradeoff between the enhancement of the barrier to reflux at the esophagogastric junction (EGJ), and increased resistance to antegrade flow. Our AIM was to evaluate potential supranormal tonic requirements of the distal esophagus induced by FP as a function of tightness and length of wrap using mathematical modeling based on the laws of physics with manofluoroscopic data. METHODS: A mathematical model of antegrade flow through the EGJ with and without FP was developed based on Newton's laws simplified for friction-dominated flows. In the model the time changes in hiatal diameter (HD) and ampullary geometry during emptying were parameterized and the corresponding required space-time changes in luminal pressure calculated relative to gastric pressure. Geometric parameters and pressure histories were obtained from recordings of combined videofluoroscopic and manometric swallowing sequences in 3 normal controls and a 6 patients post FP. RESULTS: Ampullary pressure increased with time during esophageal emptying, but with different time characteristics and greater magnitude with FP. Esophagogastric flow failed in nearly all FP swallows, requiring multiple contractions to complete esophageal emptying. Ampulla length decreased roughly linearly with time in both groups, but ampulla diameter changed nonlinearly. The mathematical model predicted: (1) at the same rate of emptying, average ampullary pressure increases rapidly with tight-
GASTROENTEROLOGY Vol. 118, No.4
2586
2588
USE OF ACID SUPPRESSIVE MEDICATIONS AFTER LAPARO· SCOPIC ANTIREFLUX SURGERY: PREVALENCE, CLINICAL INDICIATIONS AND CAUSES. Tanja Bammer, Sami R. Achem, Kenneth R. DeVault, David A. Napoliello, Joaquin A. Rodriguez, Frank 1. Lukens, Ronald A. Hinder, Mayo Clin, Jacksonville, FL.
LAPAROSCOPIC ANTI·REFLUX SURGERY IS AN EFFECTIVE TREATMENT FOR THE ACID-SENSITIVE OESOPHAGUS. Michael I, Booth, Jane M. Stratford, Eunice Thompson, Thomas C. Dehn, Royal Berkshire Hosp, Reading, United Kingdom.
Laparoscopic antireflux surgery (LARS) provides effective control of gastroesophageal reflux (GER) in more than 90% of patients undergoing this procedure. Despite this high success rate, clinical observation suggests that patients continue to consume acid suppressive medications in the post-operative period. The prevalence and reasons for medication use by these patients have not been investigated. Aim: Evaluate the prevalence, clinical indications and cause of use of acid suppressive drugs and promotility agents in patients after LARS. Methods: Consecutive patients undergoing LARS for GER during 1997 were surveyed regarding their clinical status (surgical outcome and symptoms). They were also questioned about their use of acid suppressive and promotility medications. Results: During the study period, 119 patients were subjects to LARS at our center. Ninety-three (78%)were available for interview. Two patients died of unrelated causes and two declined to be interviewed. The remaining 89 individuals are the subject of this report. Thirty-five out of eighty-nine (39%) were on antireflux medication (66% PPI's, 20% H2-blocker and 14% others). Seventy-one percent were using continuous medication. Eighteen (20%) had symptoms of heartburn or regurgitation, but IS of these felt they had a good outcome of surgery. Seventeen (19%) had no symptoms of heartburn or regurgitation and IS of these felt they had a good surgical outcome. Their reasons for taking medication were abdominal pain (n=7), bloating (n=2), dysphagia (n=2), Barrett's (n=l), prevention of NSAID injury (n= I), burning tongue (n= 1), sore throat (n= 1), "help digestion" (n=l) and unknown reason to the patient (n=I). Conclusions: I) Thirtynine percent of patients 2 years after LARS were found to be on acid suppressive or promotility agents. 2) The majority of these subjects n= 30/35 (86%) reported a good surgical outcome despite continuing on medications. 3) Thirty-seven percent of the patients use these medications for unconventional indications. 4) These findings underscore the importance of patient education to prevent improper use of these drugs after LARS. 5) Our findings suggest that there is a group of patients who require both medication and surgery to obtain relief of GER symptoms.
2587 REFLUX RISING! A DISEASE IN EVOLUTION? Kama D. Bardhan, Christine Royston, Anil K. Nayyar, Rotherham Gen Hospitals NHS Trust, Rotherham, United Kingdom. INTRODUCTION AND AIM Gastroesophageal reflux disease (GERD) is thought to be seen more frequently now yet firm evidence is sparse. Our aim is to examine if there has been any increase in the incidence or changes in the demographic profile of GERO in our center (population 250,0(0). METHODS Detailed prospective records have been kept of all patients with upper gastrointestinal disease seen since 1977. DEFINITIONS Erosive esophagitis (EE) = presence of endoscopy verified erosive changes. Gastroesophageal reflux (GER) = heartburn +/- regurgitation but with normal endoscopy. GERD=EE+GER ie total. We examined: numbers of new patients seen each year; mean age at presentation; sex ratio; stricture; presentation with hemorrhage. RESULTS(Table)1. The number of patients with newly diagnosed GERO has increased markedly. 2.The mean age at presentation has risen, and an increasing proportion of women are now affected. 3.The percentage presenting with bleeding has risen. 4.Both stricture and hemorrhage remain uncommon. DISCUSSION The increase in GERD cannot be accounted for by greater awareness or misclassification for the demographic profile is changing, and the diagnosis of EE is based on objective evidence. CONCLUSION The dramatic 5-fold increase in the incidence of GERD is a new phenomenon, an example of a disease in evolution.
• Newly diagnosed pts(n)
GERO EE GER • Male:Female ratio GERO EE GER GERO • Mean age (y) EE GER • Mean age of general population (y) • Haemorrhage (%of EE) (%ofEE) • Stricture
1977·81
1982·86
1987·91
1992-96
714 480 259
1586 868 767
2381 1077 1379
3812 1645 2222
036 0.27 0.59 48.0 49.5 45.0 35.4 52 4.2
0.72 0.50 103 50.5 539 47.0 363 86 5.0
0.82 0.63 1.00 52.3 57.2 48.3 371 11.4 5.1
0.99 0.69 1.28 53.1 56.0 51.0 37.7 11.0 2.7
Aim: To assess the outcome of laparoscopic anti-reflux surgery (LARS) in patients with normal endoscopy and normal distal oesophageal acid exposure times ( % time with pH <4 of 0::::6 (day), 0::::2 (night) or 0::::4 (total» on two pre-operative 24-hour pH tests, but a positive (>50%) symptom index score - i.e patients with an "acid-sensitive oesophagus" (ASO). Methods: Prospective data collection in 11 ASO patients (6 male; age range 12-56, median 34 years) undergoing LARS. Results: DeMeester symptom score fell from 4.7::tO.7 pre-operatively to 0.5::tO.2 post-operatively (p<0.OOO3). Mean number of symptom events on 24-hour pH-metry fell from 28.1 ::t5.5 pre-operatively to 2.0::t2.0 post-operatively (p
6weeks
6 months
1year
I
4
"
5
7 3 1 0 11
6 3 0 0 9
III IV
Total
2 0 11
2589 PATIENT SELF-ASSESSMENT OF TEST DAY SYMPTOMS CAN HELP PREDICT THE RESULT OF REPEAT 24-HOUR PH TESTS IN SUSPECTED GASTRO-OESOPHAGEAL REFLUX DISEASE. Michael I. Booth, Jane M. Stratford, Eunice Thompson, Thomas C. Dehn, Royal Berkshire Hosp, Reading, United Kingdom. Aim: To observe how patients' self-assessment of the severity of their symptoms on the day of a 24-hour pH test for suspected GORD relates to the outcome of the test,and the potential value in repeating a normal test. Methods: 66 patients (36 male; age 11-72, median 37 years) with symptoms suggestive of gastro-oesophageal reflux underwent repeat 24-hour pH studies (median interval between tests 3 months). Patients assessed the severity of their symptoms on the test day as "better than typical", "typical" or "worse than typical". Results: Thirty-two patients had two normal pH tests. Twenty-six had a normal first and abnormal second pH test. A normal first test on a "better than typical" day was followed by an abnormal second test more often (55%) than a first test on a "typical" or "worse than typical" day (22%; p=0.025). Patient self-assessment of symptoms was more useful in predicting an abnormal second test than the symptom index score (p=0.25) or total acid exposure time (p=0.56) during the first test, or the presence of oesophagitis (p=O.28). Conclusion: Patients' self-assessment of the severity of their test day symptoms should be included in the interpretation of 24-hour pH tests for suspected GORD. Patients with a normal pH test on a "better than typical" day warrant a repeat test.
2590 MECHANICAL CONSEQUENCES OF TIGHTNESS AND LENGTH OF WRAP IN FUNDOPLICATION. Tamer A. Zaki, Peter J. Kahrilas, Sudip K. Ghosh, Rober P. Tatum, Raymond 1. Joehl, James G. Brasseur, Mechanical Engineering, Pennsylvania State Univ, University Park, PA; Northwestern Sch of Medicine, Chicago, IL; Northwestern Sch of Medicine, University Park, PA; Penn State Univ, University Park, PA. Fundoplication (FP) functions as a tradeoff between the enhancement of the barrier to reflux at the esophagogastric junction (EGJ), and increased resistance to antegrade flow. Our AIM was to evaluate potential supranormal tonic requirements of the distal esophagus induced by FP as a function of tightness and length of wrap using mathematical modeling based on the laws of physics with manofluoroscopic data. METHODS: A mathematical model of antegrade flow through the EGJ with and without FP was developed based on Newton's laws simplified for friction-dominated flows. In the model the time changes in hiatal diameter (HD) and ampullary geometry during emptying were parameterized and the corresponding required space-time changes in luminal pressure calculated relative to gastric pressure. Geometric parameters and pressure histories were obtained from recordings of combined videofluoroscopic and manometric swallowing sequences in 3 normal controls and a 6 patients post FP. RESULTS: Ampullary pressure increased with time during esophageal emptying, but with different time characteristics and greater magnitude with FP. Esophagogastric flow failed in nearly all FP swallows, requiring multiple contractions to complete esophageal emptying. Ampulla length decreased roughly linearly with time in both groups, but ampulla diameter changed nonlinearly. The mathematical model predicted: (1) at the same rate of emptying, average ampullary pressure increases rapidly with tight-