Surgical treatment for gastroesophageal reflux in asthmatic patient

Surgical treatment for gastroesophageal reflux in asthmatic patient

Omar Eissa,a MD; MohamedAbdelMonem,bMD; Nader Kotb,b MD;

Rafat AI Sokarry,c MD; Ahmed Gamal EL-Din,b MD

a) Departement of General Surgery, Menia University, Menia, Egypt.

b) Departement of General Surgery, Ain Shams University, Cairo, Egypt. c) Departement of Chest, Asuit University, Asuit, Egypt.

Abstract

Background and aim: Gastroesophageal  reflux disease (GERD) is one of the most common gastrointestinal diseases facing society today. Assosciation of bronchial asthma with GERD is a common problem, we tried to evaluate the surgical treatment (reflux surgery) and its results to choose the patients who will get benefit from reflux surgery.

Patients and methods: We report the  results of surgical repair of gastroesophageal reflux in

32 asthmatic patients who underwent surgery. The severe asthma was associated with clinically evident reflux, and repair was attempted by surgical techniqueNissentransabdominalgastropexy and laparoscopic fundoplication.

Results: Total cure, eight cases (25%); marked improvement, five (15.6%); moderate improvement, eight (25%); no improvement,  11 (34.4%).Cure  was attained in intrinsic asthma with  a  predominance  of  nocturnal  crises,  associated   with  nocturnal  tracheitis  and  with significant reflux, objective signs of which had appeared  before the beginning ofthe asthma. Other results concerned asthmas complicated secondarily by GER in which it was impossible to determine whether the reflux was only a complication, without effect on the respiratory illness, or exacerbating the asthma.

Conclusions: The question of surgery in these patients should be considered with care, being reserved for cases of severe asthma, poorly controlled by antiasthmatic drugs, and complicated by a severe reflux that encompasses  ulcerative esophagitis.  The majority  of patients in most studies seem to improve symptomatically after surgery. However, a small percentage remains unchanged  or worsens. The reported studies are so disparate in their methodology  that firm conclusions on the role of surgery are difficult. Further studies are needed.

Key words: Gastric, esophageal, reflux, surgery, bronchial asthma.

Introduction:

Gastroesophageal reflux  (GER)  is the commonest  upper   digestive   tract   disorder in    the     world,    occurnng    intermittently in approximately 30-40% of the adult population. 1    The   increased  incidence  of gastroesophageal reflux (GER) in asthmatic patients has been noted by several authors.l,3,4

The main problem  raised  is to determine whether the  reflux  aggravates the asthma  or is only  a  complication, with  no  respiratory

effects. Some authors5,6 have suggested clarifying the  connection through   study  of the   effect   of   medical   antireflux treatment on asthma. Similarly, several publications investigated  the   influence   of  surgical treatment of reflux  on the asthma  process.2,5

A proportion of these  patients  present  with atypical  reflux symptoms, which  are thought to be caused by the reflux of stomach contents into the larynx and pharynx. It is claimed that

10%  of  patients  presenting to  an  ear, nose,

and throat (ENT) specialist have a clinical condition that might be attributed to GERD7 and that reflux is present in up to 75% of patients   with   refractory   ENT   symptoms8

More than 80% ofunselected asthmatics have evidence of abnormal GER at pH monitoring.9

The esophagus is the most common site for noncardiac chest pain, which can be induced by GERD.10 Several reports have indicated that up to 50% of patients with asthma have either  endoscopic   evidence  of  esophagitis or  increased  esophageal  acid  exposure  on

24-hour    ambulatory    pH    monitoring.11,12

This suggests that the frequency of dual pathology  is higher than would be expected by serendipity alone. In addition, antireflux therapy may reduce the severity of respiratory symptoms in patients with both asthma and GERD.

Despite the ubiquitous nature of both diseases and the documented association between asthma and GERD, controversy remains regarding the value of antireflux therapy in asthma.

Current  guidelines,  based  on  data  from older studies with significant limitations, recommend considering treatment for reflux disease, even without the classic symptoms, in patients with uncontrolled asthma.13

The primary defect in classical GER is lower esophageal sphincter dysfunction, whereas in extraesophageal reflux (EER), it may be the upper esophageal sphincter, which also malfunctions.14 Patients with proximal reflux report significantly  worse asthma and health-related quality of life despite lack of physiologic impairment or increase in asthma symptoms.15

Anon cardiac chest pain is not well defined but is also considered as an extraesophageal symptom of gastroesophageal reflux disease, although it originates most likely from the esophagus. Antireflux  surgery restores the anatomy  of the  lower  esophageal  sphincter and inhibits the reflux of gastric and duodenal contents.  Therefore,  some  studies  suggest that antireflux surgery may be superior to medical therapy in controlling symptoms caused by EER.l6 In classical GER, Nissen fundoplication     1s   highly     successful     m

controlling reflux symptoms, with a reported

90% success rate at 10 years after surgery.17

There  are  many  reports  of  the  results  of treating EER with surgical fundoplication;18 however,  the  role  of surgery  in  alleviating EER symptoms  remains  controversial.  This is due to the fact that a cause-and-effect relationship between gastroesophageal  reflux and  extraesophageal  symptoms  is  often difficult to establish.

Patients and methods:

In  Menia  university   hospital  the  study group was limited to those patients operated on more  than four   years earlier. Of a total of  32  patients  in this  study,  13 were  men and  19  were  women  (mean  age  49.3±1.6 years).   Asthmatic   condition:   32   patients had severe chronic asthma with obstructive airways disease. 23 of these patients had chronic asthma with permanent obstructive airways, the other nine subjects had episodic, incapacitating asthma, but no permanent obstructive  airways  disease.  The  mean duration ofthe disease was 12.1±1 years.

All the  patients recorded  signs  of  reflux with  postural  pyrosis  and  retrostemal  pain or burning. This clinical data alone indicated the existence of GER. In all cases the classic examination was carried out; esophageal fibroscopy,  barium  esophagogram, manometry and PH metry. In all cases surgical intervention was preceded by a three months medical therapeutic trials, which involved taking daily metoclopramide, proton pump inhibitor and sodium alginate.

Surgery and post operative follow up:

Surgical  repair  was  carried  out  between

2004  and  2007  by  Nissen  fundoplication either open surgery (transabdominal) or laparoscopic. This process involves the positioning  of a double valve to form a cuff around the abdominal esophagus one valve posterior  and  one  anterior,   stitching   both to each other along the right border of the esophagus. The bulk of the assembly normally prevents it from  riding up to the  hiatus and ensures a long life  antireflux apparatus.

Results  were  evaluated by  individual check-ups   throughout    2009  to   2013,   on

average  4  years  after  surgical  intervention. For the digestive system, results were judged by the persistence or disappearance of clinical reflux.

Respiratory system  results were  evaluated by a scoring system  as follows:

* Clinical scores, based on crises frequency

and the possible importance ofintercritical dyspnea: 0 = no improvement; one = moderate reduction of symptoms; two = significant reduction of crises; three = total disappearance of respiratory symptoms.

* Treatment  scores:  related  to  the  average

consumption     of     bronchodilator     and corticosteroids   drugs:   0   =  unchanged consumption; one = less than 50 percent reduction; two = greater than 50 percent reduction     in    consumption;    three complete cessation oftreatment.

The  combined   respiratory  results  were defined as four patients groups:

Group1:   0  score  =   failure   of  surgical

treatment;  Group 2: 1 and 2 scores  = slight improvement, Group 3: 3-5 scores = marked improvement; Group 4: 6 score = cure of asthma Table(l).

Failure of surgical treatment, improvement,

and cure of the asthma defind the dependant variable. The possible prognostic factors were the sex, age , duration and severity of asthma, predominance of night attacks, nocturinal tracheitis,  etiology  of asthma,  clinical  signs and diagnostic criteria of GER, results of medical antireflux treatment Table(2).

Results:

Pulmonary results  Table(l):

Group1 - (failures) consisted of 11 cases (34.4%), including the surgical failure cases. In all cases asthma and drug consumption  were  in no  way  modified after  surgery;  nine    patients  from  this group had chronic obstructive airways disease that persisted after surgery.

Group 2- (moderate improvement) contained eight patients (25%); five of eight had chronic                 obstructive     airways     disease which  persisted   with   no  improvement after surgery.

Group 3 - (marked  improvement)  consisted of five cases (15.6); three of them had obstructive                       airway    diseases.    Despite clinical improvement, in all cases this disorder persisted but with a noticeable improvement .

Group  4-  (cure  of  asthma)  contained  eight cases (25%).  It is interesting  that  six of eight  patients  presented  before  surgery with  chronic obstructive airway disease which totally disappeared, two of these patients   were   corticosteroid   dependent and able to stop treatment completely.

Gastroenterolgy results:

In 30  out of 32 patients,  digestive  signs were completely and permanently abolished following surgical repair of reflux. In the two remaining cases, the signs reappeared during the month following surgery. How likely to benefit from surgical repair of GERD was by analyzing the clinical data  from each group. Tables(2,3)  summarize  the  main  data from each of the groups.

There was a negative correlation between the age ofthepatientatthetime of surgery and the percentage  of cure of asthma (p<0.005): the younger the patient, the better the result. This relation is not linked to the duration of the  disease,which  in tum  not related  to the age ofthe patient.

Predominantly nocturnal attacks and/or nocturnal tracheitis were a frequent feature in those cases improved or cured by surgery. The incidence of these symptoms  before surgery in groups was significantly different. The predominance of nocturinal attacks existed in only 15 cases of 24 in Groups1,2, and 3 and seven of eight in Group (4) (p<0.05).

Etiologically  Group  4 (cures) is set apart by the  constant absence  of the allergic element. In the total study group of patients, the improvement after surgical cure (Group 4) was more significant for intrinsic asthma than for extrinsic asthmas (p<0.05). Moreover, all the patients who were cured had had intrinsic asthma.  No extrinsic asthma was completely cured by surgery. We observed that the obstructive airways disease, its presence or absence had no indication of the possible results of surgery.

Table (1): Longterm effectiveness of surgical repair ofriflux in asthmatic patients.

*Results are taken from 32 cases operated on more than 4 years previously.

*Improvement was judged by a method of clinical and therapeutic scoring.

Table (2): Clinical profiles of asthma classified according to results of GERD surgery, No, (%).

Table (3): Data on gastroesophageal reflux in patients classified according to the results of

GERD surgery, No.(%).

Most of the asthma cured by antireflux surgery  was for  those  pertaining to  patients whose digestive problems began before their respiratory signs. This was true in seven cases of eight (Group  4). In the three  other groups, reflux  was secondary in patients  already subjectedto asthma(7/8) compared withothers (0/24)  (p<0.0001). Consequently, the  reflux was  a  possibly  aggravating complication of respiratory disorder,  and  cure  of  the  reflux will not result in the disappearance of the asthma.  Similarly Table(3), we observed  that in Group  4 the results  of the four  diagnostic reflux    tests   (barium    esophagogram, esophageal fiberoscopy, manometry, and determinations) confirmed the  clinical  data and were all positive  in 6 cases of 8 (75  %), while in the other three groups this positive concordance of  the  four  tests  was  noted  in only 10 out of24 cases (41.7 %, p<0.01).

Discussion:

Whereas in most published studies, the majority of patients  with GER associated bronchial asthma had some degree of symptomatic   improvement   after    surgical

fundoplication; further  conclusions are difficult   because  there   are  major  problems with  the published literature. They thus confirm  the  possible  interest  in this  surgery and  make  it possible  to  establish  that  there is  not  a  simple,   one-way   relation   between asthma  and GER since,  while  surgical  repair of reflux  can abolish  reflux and asthma  at the same time, such surgery can also heal reflux without having any effect on asthma. This indicates that the reflux can be a complication of the asthma without necessarily aggravating it (Group  1) or, on the contrary,  it may have a seriously harmful  effect  on the disease (Groups  3 and 4). The problem thus revolves around the  possibility of predicting which  is the case in each individual patient. Analytical study  of our results  can supply  only a partial answer to the problem, not a solution. Laparoscopic Nissen  fundoplication has proven safe and effective in long-term  studies when performed  by experienced esophageal surgeons.l 9

Asthma can be secondary to reflux indeed, caused   by  it  and  therefore  remediable  by reflux  surgery  (Group  4).  But  this  is a rare

situation,   associated  with  intrinsic   asthma, which  is in general  severe,  and with marked GER. It appears that these cases of asthma  do not present highly individual clinical features, except   that   they   are   mostly   accompanied by   serious    nocturnal  tracheitis   and   that the   attacks   are  often   nocturnal.  However, these   characteristics  are   not   exclusive to such  cases   of  asthma   Table(2).   The  most important clinical  feature  is  that  the  reflux symptoms  appear   prior  to   the  pulmonary disease:  a knowledge of  the  order  in which the symptoms occur  is therefore essential  to define the situation. However,  in one case of eight, it was not possible  to apply this theory Table(3).   In  these  patients   GER  is  always an apparent, major  clinical  feature,  and  the diagnostic reflux tests all correlated positively in  the  majority  of  cases.   The   etiology   of reflux   is  for  the   most   part  indeterminate. In the  majority of  cases  (Groups   1,  2,  and

3),  reflux   appeared   secondarily  during  the asthmatic   disease.    In   tum,    asthma    may worsen   GER.   Airway   restriction  can  lead to   hyperinflation   and   increased  negative inspiratory   pleural  pressure,  both  of  which may  reduce  the  effectiveness  of  the  lower esophageal sphincter.   In  addition,  the  beta­ agonists  and  methylxanthines used  to  treat asthma   may  impair   function  of  the  lower esophageal sphincter   and  exacerbate  reflux (20-22).  Whatever the case, in this  situation, it is obvious  that  treatment of reflux  cannot hope to cure the respiratory disease.  The crux of  the  problem,   therefore, is  to  determine whether the  reflux  is a simple  complication of the asthma  and is not a causal factor  of the latter, orwhetheritplays an exacerbating role. Clinical  analysis  cannot  completely answer this question.  At best, in our experience, one may  suspect  this  exacerbating role  in  cases of  long  standing   asthmas, with  or  without allergic    components,  or   in   asthmas    that become   worse,  especially  at  night,  for  no apparent  reason, and also when antiasthmatic medicaments  lose  their   efficacy.   However, when  signs  of GER  disappear after surgery, there seems  to be no explanation of why the asthma is sometimes improved and sometimes unaffected. Study of pulmonary clinical  data

or  gastroenterologic data  sheds  no  light  on the  problem.  Several  authors5  have  stressed the significance of the predictive value  of a medical  treatment trial.  We have  seen  that the  trial   result   was   always   positive   when surgery   was  effective   and  always   negative when surgery failed. On the other hand, the medical  trial   may be negative  when surgery improves the asthma without it being possible to  differentiate  patients   who   will   respond well from  those  who  will not. Thus, it is not possible  to  base  the  indications for  surgery on  medical   drug  trial  results.  Nevertheless, when  this  trial  fails,  reflux  surgery   should only  rarely  be proposed and in particular be reserved for cases where the reflux is badly tolerated and complicated by ulcerative esophagitis.

Regarding the extrinsic or intrinsic  nature of asthma,  only one clear fact may be drawn from  our  study:  surgery   of  the  reflux  in  a patient suffering from extrinsic asthma cannot cure  the  asthma.  This  is normal,  since  such a cure cannot act in any way on the allergic element.   It may,  however,   improve  the respiratory condition of the same patient.  On the  other  hand,  in  intrinsic  asthma,  surgical cure can abolish  the asthma. It is nonetheless more   common   for  surgical   intervention to result in partial improvement.

In both  cases, failure  is always  possible. The mechanism by which  the reflux  acts on the tracheobronchial tree is still not fully understood. Several authors23 have suggested that aspiration of gastric contents may take place. As this occurs when in a recumbent position, it would  explain the nocturnal incidence of crises in asthmatic patients with reflux.    Esophageal   scintiscanning   makes it possible to study this mechanism, rarely present    in  adults.24   A  more   likely   cause would   seem   to  be  the   esophagobronchial vagal reflex,  demonstrated by Mansfield  and colleagues;25   however,  this  reflex  can only lead  to  bronchoconstriction in  cases  where a state  of  bronchial hyperreactivity  exists.26

If  the  vagal  reflex   is  the  cause  of  reflux­ induced bronchoconstriction, practice of the acid  perfusion test   perfected  by  Bernstein and Baker27 should  prove  highly  interesting,

since the occurrence of bronchoconstriction following perfusion bears witness to the noxious nature of acid reflux. 23

However, even when resting values of ventilatory function remained unchanged following acid instillation, the bronchial responsiveness to stimuli such as methacoline and cold air increased.28 Nevertheless, we do not yet know if the asthmatic patients likely to be improved  by reflux surgery are those for which the acid perfusion test is positive. Further studies are necessary to clarify this problem, all the more critical since at present we have no objective criterion by which to classify indications for surgery.

Conclusion:

Studying   our   surgical  results   and   the relation between asthma and gastroesophageal reflux enables us to identify those asthmas provoked  by reflux  and likely  to  be  cured by surgery. Most frequently, GER develops secondarily, and it is not possible to distinguish those  refluxes which  exacerbate  the asthma and are therefore  possibly  amenable to surgery. It is for this reason that recourse to such surgery should be made with great care.

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