Esophageal symptoms following antireflux surgery: Issues and management
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Corresponding author Gregory S. Sayuk, MD, MPH Division of Gastroenterology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8124, St. Louis, MO 63110, USA. E-mail: [email protected] Current GERD Reports 2007, 1:41– 49 Current Medicine Group LLC ISSN 1934-967X Copyright © 2007 by Current Medicine Group LLC
Laparoscopic antireflux surgery is a widely used and effective option in the properly selected patient with gastroesophageal reflux disease. Poor symptomatic outcomes occur even in the best of hands, the most common being recurrent or persistent heartburn (or atypical symptoms) and dysphagia. When heartburn predominates, anatomic and physiologic evaluation is needed to determine whether acid reflux is controlled and if the postoperative neoanatomy is appropriate. Dysphagia in the immediate postoperative setting mandates reassurance, as conservative measures alone often suffice. With persistent dysphagia, anatomic and physiologic evaluation again is indicated in search of a mechanical, motility, or reflux-related symptom basis. Reoperation carries substantial morbidity and reduced success rates when compared with the initial procedure, mandating careful patient selection and referral to a center with thorough surgical experience in these procedures.
Introduction Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal (GI) complaints for which patients seek medical attention, with the estimated prevalence reaching 18.6 million individuals in the United States alone [1]. Surgical enhancement of the antireflux barrier by correcting anatomic defects at the esophagogastric junction (EGJ) offers a viable therapeutic option to patients otherwise facing lifelong dependency on medications for symptom control. Over the past four decades, numerous surgical techniques have evolved [2], although the Toupet (180- to 270-degree posterior wrap)
and Nissen (complete 360-degree posterior wrap) fundoplication procedures have emerged as the most popular operations [3–5]. Considerable experience performing these procedures laparoscopically has yielded similar outcome successes and shorter hospitalizations than their open counterparts, fueling an increased interest in operative GERD management [6–8]. Earlier in the antireflux surgery experience, these procedures were reserved for patients with GERD who were refractory to medical therapy. However, it has become evident that optimal surgical candidates are actually those who demonstrate not only objective evidence of excessive acid reflux but also significant improvement in symptoms with proton pump inhibitor (PPI) therapy [9••,10], increasing the number of eligible patients and operations performed. This review addresses the assessment and management of the more commonly encountered post-fundoplication adverse symptomatic outcomes: recurrent (or persistent) heartburn and dysphagia. Where appropriate, mention of the available data regarding other post-fundoplication symptoms (eg, gas-bloat syndrome) is made. Pharmacologic, endoscopi
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