Association Between OSAS And GERD And Systematic Review Of LNF And LTF In Treatment Of GERD

objective:1.To investigate the occurrence of esophageal hiatal hernia,pathologycal gastroesophageal reflux disease.To study the changes of esophageal function in obese or overweight OSAS patients.To investigate assotiation between lung volume,in sitting and supine position respiratory mechanical properties and pathological gastroesophageal reflux disease and esophageal functional properties in obesity and overweight patients.To evaluatethe Value and significance Lacoroscopic Nissen Fundiplication(LNF)and Lacoroscopic Toupet Fundiplication(LTF)in treatment of the gastroesophageal reflux disease.Methods:To 196 obese or overweight snoring patients Since March 2015 to April2016 in the people's Hospital of Xinjiang Uyghur Autonomous Region underwent routine pulmonary function,Mechanical properties of lung by impulse oscillation system,lung volume determination,sleep monitoring,esophageal manometry and 24 hour esophageal acid test,according to the sleep monitoring results divided into two groups as OSAS and non OSAS groups.we searched the cochrane library(Issue 2,2015);PubMed(1978-2016);Embase(1966.1~2016.5);CMB(1978.1~2016.5);VIP(1989.1~2016.5);CNKI(1989.1~2016.5);OVID(2006~2016.5).as well as hand searched several relateed journals and conference proceedings for the randomized controlled trials involving the comparison of the efficacy of the Lacoroscopic Nissen Fundiplication(LNF)versus Lacoroscopic Toupet Fundiplication(LTF)in patients with Gastroesophageal reflux disease(GERD).Results: While the sex,age,body weight,body mass index,lung function and lung volume were same between the case group and control group,the incidence of esophageal hiatal hernia in OSAS group was significantly higher than that in control group(P <0.001).insidence of pathological GERD in overweight and obese OSAS patients higher than non OSAS overweight and obese subjects(67.2%,P<0.001)Inoverweight or obese patients there are positive correlation with AHI and gastro-esophageal pressure gradient,absolute value of inspiratory-expiratory pressure garadient and insidence of hiatal hernia(P<0.001),negative correlation with the lower esophageal sphincter pressure(P<0.001).functional residual capacity has negativelycorrelated with absolute value of inspiratory-expiratory pressure garadient(P=0.01),expiratory reserve volume has positive correlation with the upper esophageal sphincter resting pressure(P=0.04).In sitting position,at Zat5 ZH,Rcentral and Rperipheral lung elastic resistance positively correlated with the absolute value of inspiratory-expiratory pressure garadient(P<0.05),Rperipheral lung elastic resistance negatively correlated with the upper esophageal sphincter pressure(P=0.04).In supine position,at Zat5 HZ and Rperipheral elastic resistance positively correlated with the absolute value of inspiratory-expiratory pressure gradient and insidnce of esophageal hiatal hernia and negatively correlated with absolutevalue of inspiratory-expiratory pressure garadient(P<0.001).In supine position,Rcentral lung elastic resistance positively correlated with absolute value of inspiratory-expiratory pressure gradient,gastro-esophageal pressure gradient and incidence of esophageal hiatal hernia(P<0.05),negatively correlated with lower esophageal sphincter pressure and distal systolic delay(P<0.05).In overweight or obese patients have positive correlation with AHI and gastro-esophageal pressure gradient,absolutevalue of inspiratory-expiratory pressure garadient(P<0.001),correlation coefficient:0.26,0.55.negative correlation with the LES pressure(P<0.001),correlation coefficient:-0.27.in OSAS group there are stastically significant correlation with gastro-esophageal pressure gradientand,LES pressure,distal contraction integral,percentage of proximal esophageal reflux(P<0.05)By Pulmonary volume testing of OSAS and non OSAS group overweight and obese patients,we found that FRC and ERV Significantly decreased in OSAS patients than non OSAS(P<0.05).And absolute value of Inspiratory-Expiratory pressure gradient is also Significantly higher in OSAS patients than controls(P<0.001).Between two groups except for Xat35HZ(P=0.09),Zat5 HZ elastic resistance,pulmonary Rcentral and Rperipheral elastic resistance,Rat5HZ~Rat35HZ and Xat5HZ~Xat25HZ elastic resistance have significant difference in sitting position(P <0.05).in supine position,Zat5 HZ elastic resistance,pulmonary Rcentral and Rperipheral elastic resistance,Rat5HZ~Rat35HZ and Xat5HZ~Xat35HZ elastic resistance have significant difference(P < 0.05)between case group and control groups.We also by Single factor analysis found that the AHI(P<0.001),FRC(P=0.03),ZAT5HZ(P=0.03)in sitting position,ZAT5Hz(P<0.001),Rcentral(P<0.001)and Rperipheral Pulmonary elastic resistance(P<0.001)in Supine position is associated with Demeeter score.Multiple linear stepwise regression analysis of the above indicators,the results show that Rcentral airwayresistance at the supine position(P<0.001)and AHI(P=0.002)correlated whith Demeester score.In ten studies involving 1468 patients were identified studies.When comparing LNF with LTF,for treatment of GERD,LNF Versus LTF showed have statistical difference postoperative Demeester score[OR=-1.56,95%CI(-2.69,-0.43),P=0.007],no statistical difference in operation time [OR=-6.90,95%CI(-14.95,1.15),P=0.09],no statistical difference 6months?1year postoperativedysphagea [OR=1.80,95%CI(0.72,4.50),P=0.21],no statistical difference 6months?1year postoperative heartburn [OR=0.94,95%CI(0.59,1.49),P=0.78],no statistical difference 6months1 year postoperative hyperflatualance[OR=1.61,95%CI(0.84,3.09),P=0.15],no statistical difference 6months?2years postoperative regurgitation [OR=1.39,95%CI(0.81,2.38),P=0.23].Conclusion:the obese or overweight patients with OSAS is one of the important factors leading to esophageal hiatal hernia and pathological GERD.In obese or overweight patients with snoring decrease in lung volume,increase of lung elastic resistance and apnea/hypopnea index effect the esophageal function may cause or exacerbate gastroesophageal reflux.there are high prevelence of GERD in OSAS overweight and obese patiens.About Pathophysiology prevelence of GERD in overweight and obese OSAS patiens,besides abnormal esophageal motility,a potential mechanisym may be negative intrathoracic pressure fluctuation that caused by increased lung elastic residtance and deceased lung volume(FRC,ERV)induce lower intraesophageal pressur gradiant sucking Gastric contents.When comparing LNF with LTF,for treatment of GERD,LNF Versus LTF showed no statistical difference in operation time?6months?1year postoperativedysphagea ?heartburn ? hyperflatualance;no statistical difference 6months ? 2years postoperative regurgitation;have statistical difference postoperative Demeester score[OR=-1.56,95%CI(-2.69,-0.43),p=0.007].Considering the differnt bias and insurancet evidence was obtained in this systematic review.therefore,It is necessary to carry out further high-quality multi-center prospective randomized trials or systimatic review to compare the efficacy ofLacoroscopic Nissen Fundiplication versus Lacoroscopic Toupet Fundiplicationfor the gastroesophageal reflux disease.Whether laparoscopic Niseen fundoplication or laparoscopic Toupet fundoplication have recurrence of heartburn,chest pain,gastroesophageal reflux.The objects of studies which incorporated in to systematic review have a certain degree of obesity may cause palindromia of reflux.