Persistent Gerd: Different Approach

Alaa Eldin Badawy, consultant of surgery, Ahmed Talha, Lecturer of surgery, Amani El-bana, Lecturer of Medicine, Ahmed Hemimi, Assistant professor of radiology. Alexandria university hospitals, Alexandria Medical research institute and faculty of medicine

Objective: To evaluate the intra-abdominal esophageal length (IAEL) in GERD by MRI or multi-slice CT after upper GIT endoscopy in relation to GERD Q-questionnaire, also to see if this has an impact on the clinical course of the patient and response to medical or surgical therapy.

Methods: Seventy patients presented by symptomatic reflux disease according to GERD Q-questionnaire. Investigations included upper gastrointestinal endoscopy (excluding hiatal hernia cases), esophageal manometry, Multi-slice CT and/or MRI for the lower esophagus.
Basically all patients were treated medically, only cases of failed or poor response to medical treatment were converted to (group B) for surgery, rendering patients with good medical response as (group A). The esophageal intra-abdominal length was compared in both groups. Again GERD Q-questionnaire was used to assess the response to surgery weather Toupet fundoplication or 180⁰ posterior fundoplication plus anterior truncal vagotomy after crural repair in both groups.

Results: Medical treatment in the form of proton pump inhibitor and gastric prokinetic was successful in 50 cases (group A) with IAEL of 2 cms or more (mean 2.9+1.8 cms.) whole esophageal length (mean 38.5+1.8 cms.). Surgical treatment was done for 20 cases (group B) not well responding to medical treatment, IAEL was less than 2 cms. (mean 1.4+1.5 cms), whole esophageal length (mean 37.3 + 1.5 cms.).
Upper gastro-intestinal endoscopy demonstrated negative endoscopy reflux disease –NERD- cases to be 31 (7 of them were in group B). There was a statistically significant difference between both groups for the whole esophageal length using the independent groups T-test ("T" value of 2.6347, P=0.0104), similarly the IAEL was very statistically significantly shorter in group B ("T" value of 3.2934, P=0.0016).
GERD Q-questionnaire score in Group A had a mean of 10.3 + 1.7, while Group B had a mean of 14.6 + 1.6 that dropped postoperatively to 12.4 + 1.1 for Toupet group-10 cases- (extremely statistically significant drop T= 3.8957, P=0.0006) and to 10.8 + 1.5 for the group where anterior truncal vagotomy was added (10 cases), with cessation of post-operative prokinetics and proton pump inhibitors in both surgical groups. There is still a statistically significant drop of the score between the two surgical techniques ( T= 2.72, P=0.014) with much improvement in symptoms and no significant side effects for adding anterior truncal vagotomy.

Conclusion: In view of evidence based medicine IAEL of approximately 1 cm. in symptomatic GERD responded better to anti-reflux surgery with cessation of postoperative medication, results were enhanced if anterior truncal vagotomy was added to the partial posterior anti-reflux procedure. Though non-invasive, multi-slice CT and MRI can plan GERD management.
 

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