Sleeping on the Right Side After Esophagectomy

We read with great interest the article by Schuitenmaker et al.1Schuitenmaker J.M. et al.Clin Gastroenterol Hepatol. 2022; PubMed Google Scholar Over the past 50 years, the association between supine reflux, gastroesophageal reflux disease (GERD), and quality of life (QOL) has unquestionably been proven. Early esophageal pH monitoring studies showed that patients with supine/nocturnal reflux pattern are unable to clear acid reflux and are at risk of developing esophagitis and respiratory complications.2DeMeester T.R. et al.Ann Surg. 1976; 184: 459-469Crossref PubMed Scopus (629) Google Scholar On the basis of these observations, it has been recommended to elevate the head of the bed up to 20 cm using blocks or, more recently, motorized bed frames. Prolonged pH-monitoring studies have demonstrated an acceleration of acid clearance compared with sleeping flat,3Johnson L.F. et al.Dig Dis Sci. 1981; 26: 673-680Crossref PubMed Scopus (141) Google Scholar,4Ness-Jensen E. et al.Clin Gastroenterol Hepatol. 2016; 14: 175-182Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar but proof that this may relieve symptoms and GERD complications is lacking. Sleeping position, rather than head of the bed elevation, has more recently emerged as a key factor in controlling nocturnal reflux; therefore, pillows or wedges to elevate the shoulders and adjust the body angle have been proposed. Esophageal acid exposure was shown to decrease in the left-side position compared with right-side, prone, and supine.5Katz L.C. et al.J Clin Gastroenterol. 1994; 18: 280-283Crossref PubMed Scopus (56) Google Scholar Also, acid reflux was shown to increase during the postprandial period in the right-side position compared with left-side.6Van Herwaarden M. et al.Am J Gastroenterol. 2000; 95: 2731-2736Crossref PubMed Scopus (63) Google Scholar The study by Schuitenmaker et al1Schuitenmaker J.M. et al.Clin Gastroenterol Hepatol. 2022; PubMed Google Scholar is the first randomized, double-blind, and sham-controlled clinical trial confirming that sleep position plays a significant role in determining the burden of overnight gastroesophageal reflux. Even more importantly, this study shows that the active vibration pattern from a simple wearable electronic technology may condition the patient to avoid the right lateral decubitus position, thus significantly alleviating nocturnal reflux symptoms and improving quality of sleep. Of note, on subgroup analysis, treatment success was achieved in patients on proton pump inhibitor therapy and without hiatal hernia. The authors should be commended not only for confirming the link between sleep position and GERD but also for presenting a simple and effective technology that may benefit a large patient population. We would like to highlight the relationship between sleep position and reflux in patients undergoing esophagectomy and gastric conduit reconstruction for cancer. The pathophysiology of intrathoracic stomach includes disruption of the abdominothoracic pressure gradient, vagal denervation, delayed gastric emptying, and mixed acid and biliary reflux. Up to 60%–80% of patients complain of reflux symptoms after esophagectomy, and progression to severe reflux esophagitis and even Barrett’s esophagus is frequently reported.7Aly A. et al.Br J Surg. 2004; 91: 137-141Crossref PubMed Scopus (81) Google Scholar In a large proportion of patients who are cancer-free after curative esophagectomy, troublesome nocturnal regurgitation and choking can severely impair tolerance to daily activity and reduce the likelihood of returning to work. It has been shown that severe reflux occurs in 27% of esophagectomy patients, and these individuals are more likely to suffer from poor sleep quality (odds ratio, 4.9; 95% confidence interval, 1.9–12.4).8Lagergreen P. et al.J Cancer Surviv. 2021; 15: 818-824Crossref PubMed Scopus (2) Google Scholar Proton pump inhibitors are recommended to control heartburn, but volume regurgitation and recurrent aspiration pneumonia remain a major issue. Elevation of the head of the bed using multiple pillows, a wedge pillow, or an ergonomic adjustable bed is generally advised, but it is often uncomfortable because patients tend to slide down, and the overall sleep quality is compromised by refractory regurgitation, morning tiredness, and reduced daytime energy. In a recent survey of 177 patients followed between 1 and 6 years after hybrid Ivor Lewis esophagectomy at our Institution (unpublished data), 88 (48.58%) reported to sleep preferably in the right-lateral position, 57 (32.20%) in the semirecumbent supine position, and 32 (18.07%) either in the right-lateral or semirecumbent position. Interestingly, only 9 individuals (5.08%) were able to sleep in the left-lateral position because this decubitus was commonly associated with volume regurgitation, especially in the postprandial phase. Most patients were using multiple pillows or a wedge, and only a few used an ergonomic adjustable bed. Despite continuous proton pump inhibitor therapy, the median GERD–health-related QOL score was 11 (interquartile range, 6), and about 50% of these patients complained of insomnia and nocturnal regurgitation. At last follow-up endoscopy, the overall prevalence of erosive esophagitis, intestinal metaplasia, and Helicobacter pylori infection was 20%, 6.2%, and 7.9%, respectively. Interestingly, sleeping on the right side reduced the prevalence of insomnia and regurgitation (P < .05), although the prevalence of endoscopic findings was similar in both groups. A physiological mechanism accounting for the observed reflux relief in the right lateral decubitus after esophagectomy remains elusive. Besides recommending proton pump inhibitor and a light meal at least 3 hours before going to bed, we suggest testing these patients to sleep on the right side and wear the electronic device described by Schuitenmaker et al.1Schuitenmaker J.M. et al.Clin Gastroenterol Hepatol. 2022; PubMed Google Scholar This simple adjunctive treatment may contribute to prevent the “nightmare” of restless sleeping and to improve overall QOL. Sleep Positional Therapy for Nocturnal Gastroesophageal Reflux: A Double-Blind, Randomized, Sham-Controlled TrialClinical Gastroenterology and HepatologyPreviewExperimental studies have suggested that sleep position plays a role in the occurrence of nocturnal gastroesophageal reflux and the left lateral decubitus position is most favorable. The aim of this study was to evaluate the effect of a novel electronic sleep positional therapy wearable device on sleep position and nocturnal reflux symptoms. Full-Text PDF Open Access