Ann Surg Treat Res.  2018 Aug;95(2):94-99. 10.4174/astr.2018.95.2.94.

Antireflux surgery is equally beneficial in nonerosive and erosive gastroesophageal reflux disease

• Park JM
• Chi KC

• KMID: 2417775
• DOI: http://doi.org/10.4174/astr.2018.95.2.94

Abstract

PURPOSE
Although nonerosive and erosive gastroesophageal reflux disease (GERD) have similar symptom severity, nonerosive reflux disease (NERD) is considered a milder type of GERD and gastroenterologists have hesitated to refer these patients for antireflux surgery. The aim of this study was to compare surgical outcomes of antireflux surgery between patients with NERD and erosive reflux disease (ERD).
METHODS
Seventy patients met the inclusion criteria of this study among a total of 117 patients who underwent antireflux surgery from November 2012 to October 2017. According to preoperative endoscopy, patients were classified into NERD group (minimal changes or no esophagitis) and ERD group. Clinical characteristics and surgical outcomes were compared between NERD and ERD.
RESULTS
There were 26 patients in NERD group and 44 patients in ERD group. The male:female ratio was higher in the ERD group than in the NERD group (P = 0.044). Preoperative symptoms, response to acid suppressive medication, acid exposure on pH monitoring study, and esophageal manometry results were similar in the 2 groups. Reflux on barium esophagography was more frequently observed in ERD (77.3%) than in NERD (50.0%, P = 0.019). At 6 months after surgery, complete resolution and partial improvement of GERD symptoms were similar in the 2 groups (80.8% and 15.4%, respectively, in NERD vs. 88.6% and 2.3%, respectively, in ERD; P = 0.363).
CONCLUSION
Laparoscopic Nissen fundoplication is equally beneficial to patients with NERD and ERD. Antireflux surgery should not be avoided for GERD patients without mucosal breaks on endoscopy as the evidence of erosive esophagitis.

Keyword

Gastroesophageal reflux; Nonerosive reflux disease; Fundoplication; Antireflux surgery

MeSH Terms

Barium
Endoscopy
Esophagitis
Fundoplication
Gastroesophageal Reflux*
Humans
Hydrogen-Ion Concentration
Manometry
Barium

Figure

• 

  Fig. 1 Study profile. NERD, nonerosive reflux disease; ERD, erosive reflux disease.

• 

  Fig. 2 Change in reflux symptoms 6 months after surgery compared with preoperative status in 26 patients with NERD and 44 patients with ERD. Complete resolution of GERD symptoms was observed in 80.8% of the NERD group versus 88.6% of the ERD group (P = 0.363). NERD, nonerosive reflux disease; ERD, erosive reflux disease; GERD, gastroesophageal reflux disease.

Reference

1. Jung HK. Epidemiology of gastroesophageal reflux disease in Asia: a systematic review. J Neurogastroenterol Motil. 2011; 17:14–27.

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

3. Hershcovici T, Fass R. Nonerosive reflux disease (NERD) - an update. J Neurogastroenterol Motil. 2010; 16:8–21.

4. Broeders JA, Draaisma WA, Bredenoord AJ, Smout AJ, Broeders IA, Gooszen HG. Long-term outcome of Nissen fundoplication in non-erosive and erosive gastrooesophageal reflux disease. Br J Surg. 2010; 97:845–852.

5. Park JM, Kim BJ, Kim JG, Chi KC. Factors predicting outcomes of laparoscopic Nissen fundoplication for gastroesophageal reflux disease: experience at a single institution in Korea. Ann Surg Treat Res. 2017; 92:184–190.

6. Lundell LR, Dent J, Bennett JR, Blum AL, Armstrong D, Galmiche JP, et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut. 1999; 45:172–180.

7. Ronkainen J, Aro P, Storskrubb T, Johansson SE, Lind T, Bolling-Sternevald E, et al. High prevalence of gastroesophageal reflux symptoms and esophagitis with or without symptoms in the general adult Swedish population: a Kalixanda study report. Scand J Gastroenterol. 2005; 40:275–285.

8. Goh KL. Gastroesophageal reflux disease in Asia: a historical perspective and present challenges. J Gastroenterol Hepatol. 2011; 26:Suppl 1. 2–10.

9. Pace F, Bollani S, Molteni P, Bianchi Porro G. Natural history of gastro-oesophageal reflux disease without oesophagitis (NERD)--a reappraisal 10 years on. Dig Liver Dis. 2004; 36:111–115.

10. Pace F, Bianchi Porro G. Gastroesophageal reflux disease: a typical spectrum disease (a new conceptual framework is not needed). Am J Gastroenterol. 2004; 99:946–949.

11. Fass R. Non-erosive reflux disease (NERD) and erosive esophagitis: a spectrum of disease or special entities? Z Gastroenterol. 2007; 45:1156–1163.

12. Fass R. Erosive esophagitis and nonerosive reflux disease (NERD): comparison of epidemiologic, physiologic, and therapeutic characteristics. J Clin Gastroenterol. 2007; 41:131–137.

13. Bardhan KD, Royston C, Nayyar AK. Reflux rising! An essay on witnessing a disease in evolution. Dig Liver Dis. 2006; 38:163–168.

14. Sontag SJ, Sonnenberg A, Schnell TG, Leya J, Metz A. The long-term natural history of gastroesophageal reflux disease. J Clin Gastroenterol. 2006; 40:398–404.

15. Isolauri J, Luostarinen M, Isolauri E, Reinikainen P, Viljakka M, Keyrilainen O. Natural course of gastroesophageal reflux disease: 17-22 year follow-up of 60 patients. Am J Gastroenterol. 1997; 92:37–41.

16. Martinez SD, Malagon IB, Garewal HS, Cui H, Fass R. Non-erosive reflux disease (NERD)--acid reflux and symptom patterns. Aliment Pharmacol Ther. 2003; 17:537–545.

17. Ho KY, Kang JY. Ref lux esophagitis patients in Singapore have motor and acid exposure abnormalities similar to patients in the Western hemisphere. Am J Gastroenterol. 1999; 94:1186–1191.

18. Bello B, Zoccali M, Gullo R, Allaix ME, Herbella FA, Gasparaitis A, et al. Gastroesophageal reflux disease and antireflux surgery-what is the proper preoperative work-up? J Gastrointest Surg. 2013; 17:14–20.

19. Dean BB, Gano AD Jr, Knight K, Ofman JJ, Fass R. Effectiveness of proton pump inhibitors in nonerosive reflux disease. Clin Gastroenterol Hepatol. 2004; 2:656–664.

20. Okamoto K, Iwakiri R, Mori M, Hara M, Oda K, Danjo A, et al. Clinical symptoms in endoscopic reflux esophagitis: evaluation in 8031 adult subjects. Dig Dis Sci. 2003; 48:2237–2241.

21. Desai KM, Frisella MM, Soper NJ. Clinical outcomes after laparoscopic antireflux surgery in patients with and without preoperative endoscopic esophagitis. J Gastrointest Surg. 2003; 7:44–52.

22. Kamolz T, Granderath FA, Schweiger UM, Pointner R. Laparoscopic Nissen fundoplication in patients with nonerosive reflux disease. Long-term quality-of-life assessment and surgical outcome. Surg Endosc. 2005; 19:494–500.

23. Thibault R, Coron E, Sébille V, Sacher-Huvelin S, Bruley des Varannes S, Gournay J, et al. Antireflux surgery for non-erosive and erosive reflux disease in community practice. Aliment Pharmacol Ther. 2006; 24:621–632.