الفهرس 
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Abstract
A total of 48 patients with moderate or severe GERD entered this study. These patients were selected from those referred to the Gastroenterology Center of Mansoura University Hospital. The study spanned the period from August 1998 to September 2001. They were 26 males and 22 females with a mean age of 40.13 years. The patients were randomized by use of sealed envelops to either medical treatment (No, 23) or surgical treatment (No, 25). The aim of this study was to compare the effect of medical and surgical treatment on GERD patients. At the pre-entery every patient was subjected to a thorough clinical and diagnostic (barium meal, endoscopy, esophageal motility and 24-hour pH study) work-up. The patients were followed for a mean period of 10.4 months in the medical group and 18 months in the surgical group. The medical treatment consisted of a variety of dietary, postural and drug therapy. The latter consisted essentially of a proton pump inhibitor (omeprazole 20 mg once daily). One patient required the addition of a prokitetic drug (Motipred) to control his symptoms. The surgical treatment consisted of Nissen fundoplication or one of its modification (7 patients had the operation by the open method (5 patients had complete wrap and 2 patients had Toupet operation) and 18 patients had the laparoscopic method). In the medical group (no, 23) the clinical results were: excellent (60.9%) good (17.4%) fair (17.4%) and poor (4.3%). In the surgical group (no, 25), the clinical results were: excellent (88%), and good (12%). In the medical group, heartburn was completely resolved in (18 patients), 85.7%; it was present in (21 patients) 91.3% at the preentery. Epigastric pain was completely resolved in (13 patients), 72.2%; it was present in (18 patients), 78% at the pre-entery. Regurgitation was comletely resolved in (7 patients), 41.2%; it was present in (13 patients), 56.5% at the pre-entery. Dysphagia (5 patients) 21.7%, nausea (2 patients) 8.9%, vomiting (6 patients), 26.1% and bleeding (2 patients ) 8.9%, were completely resolved. Respiratory symptoms in the form of frequent aspiration and a sense of chocking was present in 2 patients were resolved in one patient only. The patient who was complaining of eructation showed no improvement. In the surgical group, heartburn was completely relieved in all patients (21 patients, 84% at the pre-entery); epigastric pain was resolved (p < 0.01 vs. medical group) in 20 patients, 95.2% (21 patients, 84% at the pre-entery); regurgitation was completely resolved (p < 0.01 vs. medical group in all patients (10 patients, 40% at the pre-entery); dysphagia was completely resolved in all patients except one patient from the laparoscopic group (3 patients, 12% at the pre-entery) and vomiting was completely resolved in all patients (one patients at the pre-entery) and mild flatulance was present in one patient (no patient at the pre-entery). The mean operating time for laparoscopic cases was 109 minutes compared with 66 minutes for the open cases. The conversion rate was 5.6% due to trocar injury of the aorta. There was no mortality in either the open or laparoscopic group. The overall morbidity was 11.1% in the laparoscopic. Esophageal dilatation was done in one case of the laparoscopic group to relieve dysphagia. The hospital stay was longer (4.35 days) in the laparoscopic cases than in the open cases (3.55 days). The comparable results of the open and laparoscopic groups, in our study, means that laparoscopic antireflux surgery is a promising tool for treating GERD instead of long-term medical therapy. Esophagitis was healed in 14 patients, 87.5% in the medical group (16 patients, 69.5% at the pre-entery) and in 15 patients 93.8% of the surgical group (16 patients, 64% at the pre-entery). The LESP increased from 13.06 7.15 mm Hg to 21.4 8.59 mm Hg in the surgical group, while in the medical group it increased from 12.64 5.56 mm Hg to 13.9 6.65 mm Hg (p < 0.05). The incomplete relief of regurgitation, incomplete healing of esophagitis and persistent abnormal acid score in the medical group, may be explained by the failure of the LESP to show significant rise. On the other hand, the rise of LESP in the surgical group appears to be an important factor an the prevention of reflux and thus a deciding factor an the success of the surgical treatment. The medical group showed a significant rise (p < 0.05) the amplitude of the esophageal wave in the distal esophagus (it increased from 74.9 36.4 mm Hg to 83 35-3 mm Hg). Both the medical and surgical groups showed significant reduction in the esophageal acid exposure. The total acid score decreased from 36.66 24.32 to 17.74 13.89 in the medical group and decreased from 40.34 23.35 to 3.94 8.06 in the surgical group. 8 patients (34.8%) from the medical group had abnormal acid score and were found to have a LESP less than 10 mm Hg. Only one patient from the surgical group had abnormal acid score. The rapid symptom relief in the medical group and the realization of continued reflux in 8 patients is a proof that symptom relief is unreliable in the follow-up of patients and pH monitoring is strongly recommended in the diagnosis and follow-up of patients. Only patients with non erosive GERD and patients with mild esophagitis are likely to respond to medical treatment. An advantage of omeprazole therapy is that, during the study, no patient had worsening endoscopic grading of esophagitis and no patient remained at his pre-entery grade but improved to a less grade. It was found that, although omeprazole is a potent acid inhibitor, this was not complete as reflected by the failure to achieve normal acid score in 8 patients (34.8%) of the medical group. In approaching a patient with GERD, we should identify risk factors for persistent and progressive disease early in the course of disease and encourage surgical treatment when these factors are present. from the results of the medical group, the presence of the following features in any patient with GERD are predictive of poor response: grade of esophagitis more than II at initial presentation, large hiatus hernia, LESP less than 10 mm Hg and abnormal supine reflux. The surgical group, in our study, showed better results as compared with the medical group both subjectively (88% excellent clinical results, surgical, 60.9%, medical) and objectively (LESP = 21.4 8.59, surgical; LESP = 13.9 6.65 mm Hg, medical: acid score = 3.94 8.06 surgical; acid score = 17.74 13.39, medial). Surgical therapy should not be a method of last resort for patients who failed every other attempt of medical treatment, but should be considered as a reasonable alternative for patients with moderate or severe GERD. Surgery is definitive therapy, and its results are long term, eliminating both medication compliance problems and the high cost of lifelong drug therapy.