Skip to main content
SpringerLink
Log in

Reflux Parameters as Modified by Laparoscopic Fundoplication in 40 Patients with Heartburn/Regurgitation Persisting Despite PPI Therapy: A Study Using Impedance-pH Monitoring

  • Original Article
  • Published:
Digestive Diseases and Sciences Aims and scope Submit manuscript

Abstract

Background

Patients with typical reflux symptoms (heartburn/regurgitation) persisting despite proton pump inhibitor (PPI) therapy are not uncommon. Impedance-pH monitoring detects gastroesophageal reflux at all pH levels and may establish if ongoing symptoms on PPI therapy are associated with acid/nonacid reflux. Laparoscopic fundoplication is a therapeutic option in such patients but reflux parameters on PPI therapy and after intervention and their relationship with symptom persistence/remission have been scarcely studied.

Aims

The aim of this study was to assess reflux parameters and their relationship with symptoms before and after laparoscopic fundoplication, on and off PPI therapy, respectively, in patients with PPI-unresponsive heartburn/regurgitation and with a positive symptom-reflux association and/or abnormal reflux parameters detected on PPI therapy.

Methods

Impedance-pH monitoring was performed on high-dose PPI therapy and 3 months after laparoscopic fundoplication, off PPI therapy, in 40 patients with PPI-unresponsive heartburn/regurgitation. Symptoms were scored by a validated questionnaire.

Results

Esophageal acid exposure time as well as the number of total and proximal reflux events and of acid and weakly acidic refluxes decreased significantly after surgery: normal values were found in 100, 77, 95, 92 and 65% of cases, respectively. Weakly alkaline refluxes increased significantly postoperatively but neither before nor after intervention were associated with symptoms. All patients reported total/subtotal remission of heartburn/regurgitation 3 months after surgery.

Conclusions

Laparoscopic fundoplication improves acid and weakly acidic reflux parameters when compared with PPI therapy. This improvement justifies the very high post-surgical symptom remission rate that we observed. Prolonged follow-up is warranted but our findings strongly support the surgical option in PPI failures.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

GERD:

Gastroesophageal reflux disease

PPI:

Proton pump inhibitor

LES:

Lower esophageal sphincter

DEA:

Distal esophageal amplitude

GAET:

Gastric acid exposure time

EAET:

Esophageal acid exposure time

SAP:

Symptom association probability

SI:

Symptom index

References

  1. DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol. 2005;100:190–200.

    Article  PubMed  Google Scholar 

  2. Fass R, Shapiro M, Dekel R, Sewell J. Systematic review: Proton-pump inhibitor failure in gastro-oesophageal reflux disease—where next? Aliment Pharmacol Ther. 2005;22:79–94.

    Article  PubMed  CAS  Google Scholar 

  3. Fass R, Sifrim D. Management of heartburn not responding to proton pump inhibitors. Gut. 2009;58:295–309.

    Article  PubMed  CAS  Google Scholar 

  4. Sifrim D, Holloway R, Silny J, et al. Acid, nonacid, and gas reflux in patients with gastroesophageal reflux disease during ambulatory 24-hour pH-impedance recordings. Gastroenterology. 2001;120:1588–1598.

    Article  PubMed  CAS  Google Scholar 

  5. Vela M, Camacho-Lobato L, Srinivasan R, Tutuian R, Katz PO, Castell DO. Simultaneous intraesophageal impedance and pH measurement of acid and nonacid gastroesophageal reflux: Effect of omeprazole. Gastroenterology. 2001;120:1599–1606.

    Article  PubMed  CAS  Google Scholar 

  6. Hirano I, Richter JE, The Practice Parameters Committee of the American College of Gastroenterology. ACG practice guidelines: Esophageal reflux testing. Am J Gastroenterol. 2007;102:668–685.

    Article  PubMed  Google Scholar 

  7. Zerbib F, Bruley Des Varannes S, Roman S, et al. Normal values and day-to-day variability of 24-h ambulatory oesophageal impedance-pH monitoring in a Belgian–French cohort of healthy subjects. Aliment Pharmacol Ther. 2005;22:1011–1021.

    Article  PubMed  CAS  Google Scholar 

  8. Mainie I, Tutuian R, Shay S, et al. Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: A multicentre study using combined ambulatory impedance-pH monitoring. Gut. 2006;55:1398–1402.

    Article  PubMed  CAS  Google Scholar 

  9. Zerbib F, Roman S, Ropert A, et al. Esophageal pH-impedance monitoring and symptom analysis in GERD: A study in patients off and on therapy. Am J Gastroenterol. 2006;101:1956–1963.

    Article  PubMed  Google Scholar 

  10. Bredenoord AG, Tutuian R, Smout AJPM, Castell DO. Technology review: Esophageal impedance monitoring. Am J Gastroenterol. 2006;101:1–8.

    Article  Google Scholar 

  11. Castell DO. Reflux testing in the 21st century: Is there a role for pH only? Clin Gastroenterol Hepatol. 2008;6:840–841.

    Article  PubMed  Google Scholar 

  12. Pandolfino JE, Vela MF. Esophageal reflux monitoring. Gastrointest Endosc. 2009;69:917–930.

    Article  PubMed  Google Scholar 

  13. Frazzoni M, Grisendi A, Lanzani A, Melotti G, De Micheli E. Laparoscopic fundoplication versus lansoprazole for gastro-oesophageal reflux disease. A pH-metric comparison. Dig Liver Dis. 2002;34:99–104.

    Article  PubMed  CAS  Google Scholar 

  14. Frazzoni M, Lonardo A, Grisendi A, et al. Are routine duodenal and antral biopsies useful in the management of “functional” dyspepsia? A diagnostic and therapeutic study. J Clin Gastroenterol. 1993;17:101–108.

    Article  PubMed  CAS  Google Scholar 

  15. Sifrim D, Castell D, Dent J, Kahrilas PJ. Gastro-oesophageal reflux monitoring: Review and consensus report on detection and definitions of acid, non-acid, and gas reflux. Gut. 2004;53:1024–1031.

    Article  PubMed  CAS  Google Scholar 

  16. Kahrilas PJ, Shaheen NJ, Vaezi MF. American Gastroenterological Association Institute technical review on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135:1392–1413.

    Article  PubMed  Google Scholar 

  17. Mainie I, Tutuian R, Agrawal A, Adams D, Castell DO. Combined multichannel intraluminal impedance-pH monitoring to select patients with persistent gastro-oesophageal reflux for laparoscopic Nissen fundoplication. Br J Surg. 2006;93:1483–1487.

    Article  PubMed  CAS  Google Scholar 

  18. Broeders JA, Draaisma WA, Bredenoord AJ, et al. Oesophageal acid hypersensitivity is not a contraindication to Nissen fundoplication. Br J Surg. 2009;96:1023–1030.

    Article  PubMed  CAS  Google Scholar 

  19. Hemmink GJM, Bredenoord AJ, Weusten BLAM, Monkelbaan JF, Timmer R, Smout AJPM. Esophageal pH-impedance monitoring in patients with therapy-resistant reflux symptoms: “on” or “off” proton pump inhibitor? Am J Gastroenterol. 2008;103:2446–2453.

    Article  PubMed  Google Scholar 

  20. Frazzoni M, Savarino E, Manno M, et al. Reflux patterns in patients with short segment Barrett’s oesophagus: A study using impedance-pH monitoring off and on proton pump inhibitor therapy. Aliment Pharmacol Ther. 2009;30:508–515.

    Article  PubMed  CAS  Google Scholar 

  21. Bredenoord AJ, Draaisma WA, Weusten BLAM, Gooszen HG, Smout AJPM. Mechanisms of acid, weakly acidic and gas reflux after anti-reflux surgery. Gut. 2008;57:161–166.

    Article  PubMed  CAS  Google Scholar 

  22. Zerbib F, Duriez A, Roman S, Capedont M, Mion F. Determinants of gastro-oesophageal reflux perception in patients with persistent symptoms despite proton pump inhibitors. Gut. 2008;57:156–160.

    Article  PubMed  CAS  Google Scholar 

  23. Tutuian R, Vela MF, Hill EG, Mainie I, Agrawal A, Castell DO. Characteristic of symptomatic acid reflux episodes on acid suppressive therapy. Am J Gastroenterol. 2008;103:1090–1096.

    Article  PubMed  Google Scholar 

  24. Scheffer RCH, Samsom M, Hebbard GS, Gooszen HG. Effects of partial (Belsey Mark IV) and complete (Nissen) fundoplication on proximal gastric function and esophagogastric junction dynamics. Am J Gastroenterol. 2006;101:479–487.

    Article  PubMed  Google Scholar 

  25. Roberts NB. Review article: Human pepsins—their multiplicity, function and role in reflux disease. Aliment Pharmacol Ther. 2006;24(Suppl. 2):2–9.

    Article  PubMed  CAS  Google Scholar 

  26. Bredenoord AJ, Weusten BLAM, Curvers WL, Timmer R, Smout AJPM. Determinants of perception of heartburn and regurgitation. Gut. 2006;55:313–318.

    Article  PubMed  CAS  Google Scholar 

  27. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R, The Global Consensus Group. The Montreal definition and classification of gastroesophageal reflux disease: A global evidence-based consensus. Am J Gastroenterol. 2006;101:1900–1920.

    Article  PubMed  Google Scholar 

  28. Agrawal A, Roberts J, Sharma N, Tutuian R, Vela M, Castell DO. Symptoms with acid and nonacid reflux may be produced by different mechanisms. Dis Esophagus. 2009;22:467–470.

    Article  PubMed  CAS  Google Scholar 

  29. Aanen MC, Bredenoord AJ, Numans ME, Samson M, Smout AJPM. Reproducibility of symptom association analysis in ambulatory reflux monitoring. Am J Gastroenterol. 2008;103:2200–2208.

    Article  PubMed  Google Scholar 

  30. Pritchett JM, Aslam M, Slaughter JC, Ness RM, Garrett CG, Vaezi MF. Efficacy of esophageal impedance/pH monitoring in patients with refractory gastroesophageal reflux disease, on and off therapy. Clin Gastroenterol Hepatol. 2009;7:743–748.

    Article  PubMed  Google Scholar 

  31. Spechler JS. Surgery for gastroesophageal reflux disease: Esophageal impedance to progress? Clin Gastroenterol Hepatol. 2009;7:1264–1265.

    Article  PubMed  Google Scholar 

  32. Shay S, Tutuian R, Sifrim D, et al. Twenty-four hour ambulatory simultaneous impedance and pH-monitoring: A multicenter report of normal values from 60 healthy volunteers. Am J Gastroenterol. 2004;99:1037–1043.

    Article  PubMed  Google Scholar 

  33. Zentilin P, Iiritano E, Dulbecco P, et al. Normal values of 24-h ambulatory intraluminal impedance combined with pH-metry in subjects eating a Mediterranean diet. Dig Liver Dis. 2006;38:226–232.

    Article  PubMed  CAS  Google Scholar 

  34. Hila A, Agrawal A, Castell DO. Combined multichannel intraluminal impedance and pH esophageal testing compared to pH alone for diagnosing both acid and weakly acidic gastroesophageal reflux. Clin Gastroenterol Hepatol. 2007;5:172–177.

    Article  PubMed  CAS  Google Scholar 

  35. Campos GM, Peters JH, DeMeester TR, et al. Multivariate analysis of factors predicting outcome after laparoscopic Nissen fundoplication. J Gastrointest Surg. 1999;3:292–300.

    Article  PubMed  CAS  Google Scholar 

  36. Jackson PG, Gleiber MA, Askari R, Evans SR. Predictors of outcome in 100 consecutive laparoscopic antireflux procedures. Am J Surg. 2001;181:231–235.

    Article  PubMed  CAS  Google Scholar 

  37. Vakil N. Review article: The role of surgery in gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2007;25:1365–1372.

    Article  PubMed  CAS  Google Scholar 

  38. Roman S, Poncet G, Serray I, Zerbib F, Boulez J, Mion F. Characterization of reflux events after fundoplication using combined impedance-pH recording. Br J Surg. 2007;94:48–52.

    Article  PubMed  CAS  Google Scholar 

  39. Draaisma WA, Rijnhart-de Jong HG, Broeders IAMJ, Smout AJPM, Furnee EJB, Gooszen HG. Five-year subjective and objective results of laparoscopic and conventional Nissen fundoplication: A randomized trial. Ann Surg. 2006;244:34–41.

    Article  PubMed  Google Scholar 

Download references

Competing interests

The authors have no competing interests to declare.

Author information

Authors and Affiliations

  1. Fisiopatologia Digestiva, Nuovo Ospedale S. Agostino, Viale Giardini 1355, 41100, Modena, Italy

    Marzio Frazzoni

  2. Gastroenterologia, Nuovo Ospedale S. Agostino, Viale Giardini 1355, 41100, Modena, Italy

    Rita Conigliaro

  3. Chirurgia Generale, Nuovo Ospedale S. Agostino, Viale Giardini 1355, 41100, Modena, Italy

    Gianluigi Melotti

Authors
  1. Marzio Frazzoni
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rita Conigliaro
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Gianluigi Melotti
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Marzio Frazzoni.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Frazzoni, M., Conigliaro, R. & Melotti, G. Reflux Parameters as Modified by Laparoscopic Fundoplication in 40 Patients with Heartburn/Regurgitation Persisting Despite PPI Therapy: A Study Using Impedance-pH Monitoring. Dig Dis Sci 56, 1099–1106 (2011). https://doi.org/10.1007/s10620-010-1381-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10620-010-1381-4

Keywords

Search

Navigation