Ronnie Fass

Preoperative diagnostic workup before antireflux surgery: An evidence and experience-based consensus of the esophageal diagnostic advisory panel

BACKGROUND Gastroesophageal reflux disease (GERD) is a very prevalent disorder. Medical therapy improves symptoms in some but not all patients. Antireflux surgery is an excellent option for patients with persistent symptoms such as regurgitation, as well as for those with complete symptomatic resolution on acid-suppressive therapy. However, proper patient selection is critical to achieve excellent outcomes. STUDY DESIGN A panel of experts was assembled to review data and personal experience with regard to appropriate preoperative evaluation for antireflux surgery and to construct an evidence and experience-based consensus that has practical application. RESULTS The presence of reflux symptoms alone is not sufficient to support a diagnosis of GERD before antireflux surgery. Esophageal objective testing is required to physiologically and anatomically evaluate the presence and severity of GERD in all patients being considered for surgical intervention. It is critical to document the presence of abnormal distal esophageal acid exposure, especially when antireflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach. CONCLUSIONS Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. Additional studies with long-term follow-up are required to evaluate the diagnostic and therapeutic benefit of new technologies, such as oropharyngeal pH testing, multichannel intraluminal impedance, and hypopharyngeal multichannel intraluminal impedance, in the context of patient selection for antireflux surgery.

Systematic review: the treatment of noncardiac chest pain

Aliment Pharmacol Ther 2012; 35: 5–14

Systematic review: the relationship between interstitial lung diseases and gastro-oesophageal reflux disease.

Aliment Pharmacol Ther 2011; 34: 1295–1305

Distribution of Esophageal Motor Disorders in Diabetic Patients With Dysphagia

Background: Diabetes mellitus can cause various gastrointestinal symptoms. Assessment of esophageal dysmotility in diabetic patients has been scarcely studied. The aim of this study was to determine the esophageal motor characteristics of diabetic versus nondiabetic patients who present with dysphagia. Methods: High-resolution esophageal manometries (HREMs) of 83 diabetic patients and 83 age and gender-matched nondiabetic patients with dysphagia from 2 medical centers were included in this study. Demographic information, medical comorbidities, and medication usage were recorded for each patient in a single registry. HREM of each patient was evaluated and the different functional parameters were recorded. Key Results: Overall, 46% of diabetic patients were found to have an esophageal motor disorder. Diabetic patients with dysphagia were more likely to have failed swallows on HREM (50.6% vs. 33.7%; P=0.03) as compared with nondiabetic patients. Among diabetic patients, those being treated with insulin were more likely to have failed (69.0% vs. 40.7%; P=0.01) and weak (65.5% vs. 33.3%; P=0.005) swallows as compared with diabetic patients not on insulin. Among diabetic patients, those with abnormal manometry were more likely to demonstrate diabetic retinopathy (27.0% vs. 8.7%; P=0.04). There was a trend toward increased incidence of esophagogastric junction outflow obstruction in diabetic patients (10.8% vs. 2.4%; P=0.057) as compared with nondiabetic patients. Conclusions: Nearly half of diabetic patients with dysphagia have some type of an esophageal motility disorder. Diabetic retinopathy and the use of insulin are predictive of esophageal motor abnormalities among diabetic patients.

Dysphagia, GER, and Aspiration in the Elderly

Within the United States, where it is estimated that >20 % of the population will be over the age of 65 by 2050 [1], a greater understanding of the impact of disorders affecting older adults is paramount. Due to physiologic changes of aging, an increased prevalence of comorbid conditions, and abundance of medication usage, the elderly comprise a distinct segment of the population at increased risk for upper gastrointestinal (GI) disorders. Furthermore, the risk for lung disease, either directly or indirectly related to impaired swallowing or GI function, is high among older adults. The elderly manifest distinct presentations of certain GI disorders when compared to younger adults. Additionally, as people age, alterations in normal lung physiology place them at risk for pulmonary complications of GI disorders.