Surgical treatment of recalcitrant gastroesophageal reflux disease in patients with systemic sclerosis: a systematic review

Abstract

Introduction Gastroesophageal reflux disease (GERD) is frequently seen in patients with systemic sclerosis (SSc). Long-standing GERD may cause esophagitis, long-segment strictures, and Barrett’s esophagus and may worsen pre-existing pulmonary fibrosis with an increased risk of end-stage lung disease. Surgical treatment of recalcitrant GERD remains controversial. The purpose of this systematic review was to summarize the current data on surgical treatment of recalcitrant GERD in SSc patients. Materials and methods A systematic literature review according to PRISMA and MOOSE guidelines. PubMed, EMBASE, and Web of Science databases were consulted. Results A total of 101 patients were included from 7 studies. The age ranged from 34 to 61 years and the majority were females (73.5%). Commonly reported symptoms were heartburn (92%), regurgitation (77%), and dysphagia (74%). Concurrent pulmonary disease was diagnosed in 58% of patients. Overall, 63 patients (62.4%) underwent open fundoplication, 17 (16.8%) laparoscopic fundoplication, 15 (14.9%) Roux en-Y gastric bypass (RYGB), and 6 (5.9%) esophagectomy. The postoperative follow-up ranged from 12 to 65 months. Recurrent symptoms were described in up to 70% and 30% of patients undergoing fundoplication and RYGB, respectively. Various symptoms were reported postoperatively depending on the type of surgical procedures, anatomy of the valve, need for esophageal lengthening, and follow-up. Conclusions The treatment of recalcitrant GERD in SSc patients is challenging. Esophagectomy should be reserved to selected patients. Minimally invasive RYGB appears feasible and safe with promising preliminary short-term results. Current evidence is scarce while a definitive indication about the most appropriate surgical treatment is lacking.

Partial Fundoplication is Effective Treatment for Female Patients with Gastroesophageal Reflux and Scleroderma: A Multicenter Comparative Cohort Study

“…Second, there is a paucity of data examining the outcomes following partial fundoplication in patients with scleroderma. Most reports are based on 360‐degree fundoplication [13, 16, 19], which carries a higher rate of postoperative dysphagia than partial fundoplication [8]. In addition, the natural history of dysphagia following 360‐degree fundoplication in patients with scleroderma has not been elucidated.…”

“…These patients have undergone partial fundoplication alone, with longitudinal data describing their reflux control, swallowing function and overall satisfaction. Data are lacking to guide selection of the most appropriate surgical treatment for patients with scleroderma and medically refractory GERD [16]. Several studies have compared the outcomes of anti-reflux surgery to roux-en-Y gastric bypass, total gastrectomy and esophagectomy [13][14][15].…”

“…The literature reports mixed results regarding the use of anti‐reflux procedures for patients with scleroderma [16]. This may be explained by several reasons.…”

“…The fear of worsening dysphagia post-fundoplication has led some surgeons to consider, and even advocate for, other surgical approaches including roux-en-Y gastric bypass [13,14], total gastrectomy [15], and esophagectomy [13]. Recent reports have suggested that these aggressive strategies result in less postoperative dysphagia and may be superior to 360-degree fundoplication in controlling GERD for scleroderma patients [13][14][15][16]. However, these findings are based on single-center retrospective data with a small number of cases, non-comparative study design or inappropriately matched controls, short follow-up periods, heterogeneous patient cohorts, and they are often lacking in patient-centric outcome measures [16].…”

Gastrointestinal involvement in systemic sclerosis: pathogenesis, assessment and treatment

“…A total of seven studies, including 101 patients were included, and 63 patients (62.4%) underwent open fundoplication, 17 (16.8%) laparoscopic fundoplication, 15 (14.9%) Roux en-Y gastric bypass (RYGB) and six (5.9%) esophagectomy. Recurrent symptoms were identified in up to 70% undergoing fundoplication and 30% of patients undergoing RYGB, although minimally invasive RYGB was thought to be feasible and well tolerated based on short-term results [51].…”