Gastroesophageal Reflux Disease and Connective Tissue Disorders. Pathophysiology and Implications for Treatment
Warren J. Gasper*, Piero Fisichella, Francesco Palazzo, Marco G. Patti
Department of Surgery, University of California San Francisco, San Francisco, CA
Background: It has been postulated that in patients with connective tissue disorders (CTD) and gastroesophageal reflux disease (GERD), esophageal function is routinely deteriorated, often with absence of peristalsis. This belief has led to the common recommendation of avoiding antireflux surgery for fear of creating dysphagia.
Hypothesis: a) in most patients with CTD and GERD, esophageal function is preserved; b) only in patients with end-stage lung disease (ESLD) peristalsis is frequently absent; c) a tailored approach (total vs. partial fundoplication) allows control of reflux without a high incidence of postoperative dysphagia.Design: Retrospective review of a prospectively acquired database.
Setting: University tertiary care center.Patients: Forty-eight patients with CTD were evaluated by esophageal manometry and 24 hour pH monitoring (EFT). Twenty patients (Group A) had EFT because of foregut symptoms and 28 patients with ESLD (Group B) had EFT as part of the lung transplant evaluation. Two hundred eighty-eight consecutive patients with GERD (Group C) served as a control group. Eight patients in Group B underwent a laparoscopic fundoplication (3 patients, 360°; 5 patients, 240°).
Results: Fundoplication resulted in control of reflux for 8 patients in Group B. One patient developed post-operative dysphagia, which resolved with Savary dilatation.
Conclusions: These data show that: a) peristalsis was preserved in most patients with CTD, similar to patients who had GERD without CTD; b) peristalsis was absent in a third of patients with CTD and ESLD; and c) a surgical approach tailored to the esophageal peristalsis achieved control of reflux without a high incidence of dysphagia.
| Group A | Group B | Group C | |
| LES pressure (mean±SD) | 14±9 | 11±7 | 11±6 |
| % patients with abnormal peristalsis | 30%* | 79%*‡ | 36%‡ |
| % patients without peristalsis (median, mmHg) | 0 | 39% | 0 |
| Peristaltic amplitude (median, mmHg) | 76 (26-186)* | 19 (0-140)*‡ | 79 (11-292)‡ |
| Median reflux score (nl <14.7) | 83 (15-191)‡ | 49 (15-280)‡ |
*p<0.05, A vs. B; †p<0.05, A vs. C; ‡p<0.05, B vs. C
