Nissen fundoplication vs proton pump inhibitors for laryngopharyngeal reflux based on p H-monitoring and symptom-scale

AIM To compare the outcomes between laparoscopic Nissen fundoplication(LNF)and proton pump inhibitors(PPIs)therapy in patients with laryngopharyngeal reflux(LPR)and typeⅠhiatal hernia diagnosed by oropharyngeal p H-monitoring and symptom-scale assessment.METHODS From February 2014 to January 2015,70 patients who were diagnosed with LPR and type I hiatal hernia and referred for symptomatic assessment,oropharyngeal p H-monitoring,manometry,and gastrointestinal endoscopy were enrolled in this study.All of the patients met the inclusion criteria.All of the patients underwent LNF or PPIs administration,and completed a2-year follow-up.Patients’baseline characteristics and primary outcome measures,including comprehensive and single symptoms of LPR,PPIs independence,and satisfaction,and postoperative complications were assessed.The outcomes of LNF and PPIs therapy were analyzed and compared. RESULTS There were 31 patients in the LNF group and 39patients in the PPI group.Fifty-three patients(25 in the LNF group and 28 in the PPI group)completed reviews and follow-up.Oropharyngeal p H-monitoring parameters were all abnormal with high acid exposure,a large amount of reflux,and a high Ryan score,associated reflux symptom index(RSI)score.There was a significant improvement in the RSI and LPR symptom scores after the 2-year follow-up in both groups(P<0.05),as well as typical symptoms of gastroesophageal reflux disease.Improvement in the RSI(P<0.005)and symptom scores of cough(P=0.032),mucus(P=0.011),and throat clearing(P=0.022)was significantly superior in the LNF group to that in the PPI group.After LNF and PPIs therapy,13 and 53 patients achieved independence from PPIs therapy(LNF:44.0%vs PPI:7.14%,P<0.001)during follow-up,respectively.Patients in the LNF group were more satisfied with their quality of life than those in the PPI group(LNF:62.49±28.68 vs PPI:44.36±32.77,P=0.004).Body mass index was significantly lower in the LNF group than in the PPI group(LNF:22.2±3.1kg/m^2 vs PPI:25.1±2.9 kg/m^2,P=0.001).CONCLUSION Diagnosis of LPR should be assessed with oropharyngeal p H-monitoring,manometry,and the symptom-scale.LNF achieves better improvement than PPIs for LPR with type I hiatal hernia.

Is patient satisfaction sufficient to validate endoscopic anti-reflux treatments?

Endoscopic anti-reflux treatment is emerging as a new option for gastroesophageal reflux disease(GERD)treatment in patients with the same indications as for laparoscopic fundoplication.There are many techniques,the first of which are transoral incisionless fundoplication(TIF)and nonablative radio-frequency(STRETTA)that have been tested with comparative studies and randomized controlled trials,whereas the other more recent ones still require a deeper evaluation.The purpose of the latter is to verify whether reflux is abolished or significantly reduced after intervention,whether there is a valid high pressure zone at the gastroesophageal junction,and whether esophagitis,when present,has disappeared.Unfortunately in a certain number of cases,and especially in the more recently introduced ones,the evaluation has been based almost exclusively on subjective criteria,such as improvement in the quality of life,remission of heartburn and regurgitation,and reduction or suspension of antacid and antisecretory drug consumption.However,with the most studied techniques such as TIF and STRETTA,an improvement in symptoms better than that of laparoscopic fundoplication can often be observed,whereas the number of acid episodes and acid exposure time are similar or higher,as if the acid refluxes are better tolerated by these patients.The suspicion of a local hyposensitivity taking place after antireflux endoscopic intervention seems confirmed by a Bernstein test at least for STRETTA.This examination should be done for all the other techniques,both old and new,to identify the ones that reassure rather than cure.In conclusion,the evaluation of the effectiveness of the endoscopic anti-reflux techniques should not be based exclusively on subjective criteria,but should also be confirmed by objective examinations,because there might be a gap between the improvement in symptoms declared by the patient and the underlying pathophysiologic alterations of GERD.

Outcome of Stretta radiofrequency and fundoplication for GERD- related severe asthmatic symptoms

This study aimed to investigate the outcome of treatment with Stretta radiofrequency （SRF） or laparoscopic Nissen fundoplication （LNF）. A total of 137 gastroesophageal reflux disease （GERD） patients with severe asthmatic symptoms who responded inadequately to medical treatment for asthma were investigated. The patients were followed up 1 year and 5 years after SRF （n = 82） or LNF （n = 55） treatment. A questionnaire covering 29 related symptoms and medication use was employed. Digestive, respiratory, and ear-nose-throat （ENT） symptom scores significantly decreased after antireflux treatment. Symptom scores respectively changed from 17.2 ± 10.1, 31.9 ± 6.6, and 21.1± 11.8 to 5.0 ±6.2, 11.5 ±10.2, and 6.3± 6.8 at 1 year and to 5.6 ± 6.5, 13.1± 10.1, and 7.8 ± 7.2 at 5 years （P 〈 0.001）. The outcome of LNF was significantly better than that of SRF in terms of digestive （P 〈 0.001, P = 0.001）, respiratory （P = 0.006, P = 0.001）, and ENT symptoms （P = 0.006, P = 0.003） at both 1 year and 5 years. SRF and LNF were both effective against the digestive symptoms of GERD as well as GERD-related severe asthmatic and ENT symptoms, with better outcomes exhibited by the LNF group. Severe asthmatic symptoms and GERD were closely associated, and this finding warrants further study.