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Article
June 1996

The Role of a Defective Lower Esophageal Sphincter in the Clinical Outcome of Treatment for Gastroesophageal Reflux Disease

Author Affiliations

From the Department of Surgery, University of Padua (Italy) Medical School.

Arch Surg. 1996;131(6):655-659. doi:10.1001/archsurg.1996.01430180081017
Abstract

Objective:  To evaluate the clinical role of a defective lower esophageal sphincter in the long-term outcome of medical and surgical treatment for gastroesophageal reflux disease.

Design:  Nonrandomized control study (median followup, 33 months).

Setting:  Referred care.

Patients:  Fifty-five patients with gastroesophageal reflux disease were prospectively evaluated using a symptom questionnaire, upper endoscopy, esophageal manometry, and 24-hour pH monitoring. Patients were classified into three groups: (1) those with a manometrically defective lower esophageal sphincter, treated surgically; (2) those with a manometrically defective lower esophageal sphincter, treated medically; and (3) those with a manometrically normal lower esophageal sphincter, treated medically.

Intervention:  Nissen antireflux procedure and medical therapy with H2-blockers and/or omeprazole.

Main Outcome Measures:  Symptomatic improvement after treatment and need for continuous medication.

Results:  After therapy, symptoms improved significantly in all three groups (P<.05), but least in the patients who declined surgery. Among patients with a defective lower esophageal sphincter, medical therapy could be discontinued in 13 of 14 patients who had surgery compared with one of 14 who declined surgery. Of the 27 patients with a normal lower esophageal sphincter who were treated medically, medical therapy could be discontinued in 12.

Conclusions:  In patients with gastroesophageal reflux disease who have a defective lower esophageal sphincter, surgery can ensure durable symptom control. Patients with a defective sphincter who decline surgery are destined for lifelong therapy, whereas in approximately half of those with a normal sphincter, medical therapy can eventually be discontinued.(Arch Surg. 1996;131:655-659)

References
1.
Zaninotto G, DeMeester TR, Schwitzer W, Johansson K-E, Cheng S-C.  The lower esophageal sphincter in health and disease . Am J Surg . 1988;155:104-111.Article
2.
Zaninotto G, Costantini M, Bonavina L, et al.  Manometric characteristics of the distal oesophageal sphincter and patterns of gastro-esophageal reflux in healthy volunteers and patients . Eur Surg Res . 1987:19:217-224.Article
3.
Stein HJ, DeMeester TR, Naspetti R, et al.  Three-dimensional imaging of the lower esophageal sphincter in gastroesophageal reflux disease . Ann Surg . 1991; 214:364-384.Article
4.
Pope CE II, Meyer GW, Castell DO.  Is measurement of LES pressure clinically useful? Dig Dis Sci . 1981;26:1025-1031.Article
5.
Mugal MM, Bancewicz J, Marples M.  Oesophageal manometry and pH recording does not predict the bad results of Nissen fundoplication . Br J Surg . 1990; 77:43-45.Article
6.
DeMeester TR, Stein HJ.  Surgical treatment of gastroesophageal reflux . In: Castell DO, ed. The Esophagus . Boston, Mass: Little Brown & Co Inc; 1992: 579-625.
7.
DeMeesterTR, Johnson LF.  The evaluation of objective measurements of gastroesophageal reflux and their contribution to patient management . Surg Clin North Am . 1976;56:39-53.
8.
Miller LS.  Endoscopy of the esophagus . In: Castell DO, ed. The Esophagus . Boston, Mass: Little Brown & Co Inc; 1992:89-142.
9.
Zaninotto G, DiMario F, Costantini M, et al.  Oesophagitis and pH of refluxate: an experimental and clinical study . Br J Surg . 1992;79:161-164.Article
10.
Costantini M, Bremner RM, Hoeft SF, Cookes PF, DeMeester TR.  The slow motorized pull-through: an improved technique to evaluate the lower esophageal sphincter . Gastroenterology . 1992:103:1407.
11.
Bombeck CT, Vaz O, DeSalvo J, Donahue PE, Nyhus LM.  Computerized axial manometry of the esophagus: a new method for the assessment of antireflux operations . Ann Surg . 1987;206:465-472.Article
12.
DeMeester TR, Wang CI, Wernly JA, et al.  Technique, indications and clinical use of 24-hour oesophageal pH monitoring . J Thorac Cardiovasc Surg . 1980;79:656-667.
13.
Williams D, Thompson DG, Heggie L, O'Hanrahan T, Bancewicz J.  Esophageal clearance function following treatment of esophagitis . Gastroenterology . 1994; 106:108-116.
14.
Bremner RM, DeMeester TR, Crookes PF, et al.  The effect of symptoms and nonspecific motility abnormalities on outcomes of surgical therapy for gastroesophageal reflux disease . J Thorac Cardiovasc Surg . 1994;107:1244-1250.
15.
Grande L, Toledo-Pimentel V, Manterola C, et al.  Value of Nissen fundoplication in patients with gastro-oesophageal reflux judged by long-term symptom control . Br J Surg . 1994;81:548-550.Article
16.
Johansson J, Johnsson F, Joelsson B, Floren C-H, Walther B.  Outcome 5 years after 360° fundoplication for gastro-oesophageal reflux disease . Br J Surg . 1993; 80:46-49.Article
17.
Lundell L, Abrahamsson H, Ruth M, Sandberg N, Olbe LC.  Lower esophageal sphincter characteristics and esophageal acid exposure following partial or 360° fundoplication: results of a prospective, randomized, clinical study . World J Surg . 1991;15:115-121.Article
18.
Zaninotto G, Costantini M, Anselmino M, et al.  Excessive competence of the lower oesophageal sphincter after Nissen fundoplication: evaluation by three-dimensional computerized imaging . Eur J Surg . 1995;161:241-246.
19.
Spechler SJ, the Department of Veterans Affairs Gastroesophageal Reflux Disease Study Group.  Comparison of medical and surgical therapy for complicated gastroesophageal reflux disease in veterans . N Engl J Med . 1992;326:786-792.Article
20.
Robertson DAF, Aldersley MA, Shepherd H, Lloyd RS, Smith CL.  H2-antagonists in the treatment of reflux oesophagitis: can physiological studies predict the response? Gut . 1987;28:946-949.Article
21.
Lieberman DA.  Medical therapy for chronic reflux esophagitis: long-term follow-up . Arch Intern Med . 1987;147:1717-1720.Article
22.
Saco LS, Orlando RC, Levinson SL, Bozymski EM, Jones JD, Frakes JT.  Double-blind controlled trial of bethanechol and antacid versus placebo and antacid in the treatment of erosive esophagitis . Gastroenterology . 1982;82:1369-1373.
23.
Kuster E, Ros E, Toledo-Pimentel V, et al.  Predictive factors of the long-term outcome in gastro-oesophageal reflux disease: 6-year follow-up of 107 patients . Gut . 1994;35:8-14.Article
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