New Developments in the Diagnosis and Management of Gastroesophageal Reflux

PURPOSE OF REVIEW

To examine recent key developments in the pathophysiology, diagnosis, and treatment of gastroesophageal reflux disease (GERD).

RECENT FINDINGS

Newer research has suggested cytokine-mediated inflammation may play a role in the physiology of GERD, implying that the underlying mechanism may not be entirely related to chemical damage due to acid. Aided by novel technologies, diagnostic testing is also moving toward elucidating individual mechanisms and better defining specific GERD phenotypes with the goal of providing directed therapy. This is especially important in current times given the increase in coverage of adverse events reportedly linked to long-term proton pump inhibitor use.

SUMMARY

As patients are looking for potential alternatives, we highlight the key recent updates in pathophysiology and understanding of GERD and current medical and endoscopic/surgical options and explore the exciting treatments in the pipeline.

GER characteristics after fundoplication in children with aerodigestive disorders

PURPOSE

The purpose of this study was to determine GER characteristics after Nissen fundoplication in children with aerodigestive disorders using pH-impedance technology.

METHODS

In this cross-sectional study, the institutional database of Cincinnati Children's Hospital Medical Center was reviewed to identify patients ages below 21 years who had a Nissen fundoplication and underwent esophageal pH-impedance (pH-MII) monitoring over a nine-year period. All reflux-related metrics were modeled as a Poisson random variable as a function of time since fundoplication.

RESULTS

A total of 242 patients were included in the study. The range for time since surgery was 1-192 months. Median total reflux events were 8.5 episodes per 24 h, median acidic reflux events were 0, and median proximal reflux event was 2. There was no significant trend towards increasing reflux episodes over time.

CONCLUSIONS

Children had a low number of reflux events after a fundoplication, as measured by pH-impedance, and there was no statistically significant increase observed in the number of reflux events over time. Despite most patients having a functional fundoplication with minimal reflux events throughout the entire age range, up to 58% of our cohort was still on a proton pump inhibitor.

Mean Nocturnal Baseline Impedance Correlates With Symptom Outcome When Acid Exposure Time Is Inconclusive on Esophageal Reflux Monitoring

BACKGROUND & AIMS

Abnormal acid exposure time (AET) is associated with good outcomes of symptoms from antireflux therapy. Low esophageal mean nocturnal baseline impedance (MNBI) is an additional marker of reflux disease. We aimed to evaluate the value of MNBI when analysis of AET produces borderline or inconclusive results.

METHODS

We studied a retrospective cohort of 371 patients (mean age, 54.5 ± 0.7 y; 60.0% female) who had persistent reflux symptoms after treatment and underwent ambulatory pH-impedance monitoring off antisecretory therapy at 1 tertiary center in Europe or 1 in the United States. Total AET was determined from pH impedance studies (pathologic, >6%; physiologic, <4%; borderline or inconclusive, 4%-6%). Baseline impedance values were calculated at the 5-cm impedance channel at 3 nocturnal 10-minute periods and averaged to yield MNBI (abnormal, <2292 ohms). The primary outcome was response to antireflux therapy, defined as global symptom improvement of 50% or greater on patients' answers on standardized visual analog scales.

RESULTS

Among the 371 patients, 107 (28.8%) had pathologic AET and 234 (63.1%) had abnormal MNBI. Low MNBI was concordant in 99.1% of patients with pathologic AET, in 91.2% with borderline AET, and in 33.7% with physiologic AET. During 38.7 ± 0.8 months of follow-up evaluation, 43.0% of patients had improved symptoms with medical therapy and 76.2% had improved symptoms with surgical antireflux therapy (P < .0001). When MNBI was low, response to medical therapy did not differ significantly between patients with borderline AET and patients with pathologic AET (P = .44), but did differ significantly when each group was compared with patients with physiologic AET, regardless of whether MNBI was normal or low (P < .0001 for each comparison).

CONCLUSIONS

When low, MNBI identifies patients with pathologic and borderline AET who respond to antireflux therapy. MNBI analysis complements AET in defining esophageal reflux burden. MNBI correlates with response of symptoms to antireflux therapy.

Research landscape of a global environmental challenge: Microplastics

Microplastics can be found all over the world, in the remotest regions and even in the Arctic snow. Primary microplastic is either produced as microparticles or enters the natural environment already as microparticles. Whereas secondary microplastic is generated by fragmentation or abrasion of other products in the natural environment. Both pollute the global ecospheres and even enter the human food chain. This study aims at the evaluation of the global publication output on both types of microplastic referring to absolute and contextual numbers. Only since 2006, the focus on the environmental burden led to an enormous increase of publications on MP. While China, USA and Germany are leading players regarding the absolute numbers, Portugal, Chile and Ireland are among the top countries when including socio-economic features and research expenditures. The responsibility for the big plastic waste producers can be shown by significantly correlating numbers of articles and the plastic waste generation, albeit here China and USA fall behind. However, the biggest producers are not the most affected countries. Despite the strong international interest, our study shows that many countries play no role at all in the publication landscape of MP. For future planning, it is necessary to extend the international collaborations to reach sustainable solutions for the whole planet earth.

Correlation between reflux burden, peristaltic function, and mucosal integrity in GERD patients

BACKGROUND

Mean nocturnal baseline impedance (MNBI) augments the diagnostic yield of multichannel intraluminal impedance-pH (MII-pH) monitoring. While acid exposure time (AET) correlates with MNBI, it remains unclear whether esophageal motility affects MNBI values. The present study was aimed at evaluating the respective roles of esophageal motor function and AET on MNBI.

METHODS

High-resolution manometry (HRM) studies and ambulatory 24-hour MII-pH monitoring tracings were retrospectively analyzed from consecutive endoscopy-negative GERD patients with typical symptoms responsive to previous acid-suppressive therapy from three tertiary care centers. Univariate and multivariate analyses were performed to determine predictors of pathologic MNBI values at 3 cm and 5 cm above the lower esophageal sphincter (LES).

KEY RESULTS

Patients with pathological AET displayed lower MNBI values at 3 cm and 5 cm (P < .01) compared to patients with non-pathological AET. Similarly, significantly lower MNBI values were also noted at both sites with type 3 EGJ compared to type 1 EGJ (P ≤ .02 for each comparison), and with absent contractility compared to normal peristalsis (P ≤ .02 for each comparison). On multivariate analysis, the presence of type 2 or 3 EGJ and absent contractility were associated with a significantly higher probability of pathological MNBI values at 3 cm and 5 cm above the LES.

CONCLUSIONS AND INFERENCES

Disruption of the EGJ and absent contractility on HRM are both associated with lower MNBI values. HRM findings complement reflux testing using MII-pH monitoring.

Real-time MRI for dynamic assessment of gastroesophageal reflux disease: Comparison to pH-metry and impedance

PURPOSE

To evaluate the diagnostic potential of real-time MRI for dynamic assessment of gastroesophageal reflux in patients with GERD (gastroesophageal reflux disease)-like symptoms compared to pH-metry and impedance.

METHODS

Patients who underwent real-time MRI and pH-metry between 2015-2018 were included in this retrospective study. Real-time MRI at 3 T was achieved by undersampled radial FLASH acquisitions with iterative image reconstruction by NLINV. Real-time MRI visualized transit of pineapple juice through the gastroesophageal junction and during Valsalva maneuver. MRI results were compared to 24 h pH-metry to assess acidic reflux (following Lyon Consensus guidelines) and to impedance to assess non-acidic reflux. A standard 2 × 2 table was chosen to calculate diagnostic performance.

RESULTS

91/93 eligible patients fulfilled inclusion criteria (male n = 49; female n = 42; median age 55 y). All MRI studies were successfully completed without adverse events at a mean examination time of 15 min. On real-time MRI, reflux was evident in 60 patients (66 %). pH-metry revealed reflux in 41 patients (45 %), and impedance in 54 patients (59 %). Compared to pH-metry and impedance, real-time MRI sensitivity was 0.78 (95 % CI: 0.66-0.87), specificity 0.67 (95 % CI: 0.45-0.84) and PPV 0.87 (95 % CI: 0.75-0.94).

CONCLUSION

Real-time MRI is an imaging method for assessment of gastroesophageal reflux in patients with GERD-like symptoms. Considering its high positive predictive value, real-time MRI can accurately identify patients in which further invasive testing with pH-metry and impedance might be considered.

Validation of the Brazilian Portuguese Version of the Reflux Finding Score

INTRODUCTION

Laryngopharyngeal reflux (LPR) poses a diagnostic challenge. Clinical diagnosis, based on suggestive symptoms and laryngoscopic signs of inflammation, should be acceptable, as long as diligent differential diagnosis is sought. In order to minimize subjectivity, a number of diagnostic instruments have been proposed, being the most common the Reflux Symptom Index and the Reflux Finding Score (RFS). The latter has been translated into several languages including Portuguese, but it still has not been properly validated in this language.

OBJECTIVE

To validate the Brazilian Portuguese version of the RFS.

MATERIAL AND METHOD

For validity and internal consistency, 172 adults were studied (106 with LPR and 66 healthy controls). Flexible transnasal laryngoscopy images were randomly examined twice by each of the two experienced otolaryngologists with a 72-hour interval. Strict exclusion criteria were applied to avoid other possible known causes of chronic laryngitis. For assessment of reproducibility and temporal stability, a random sample of 108 subjects (53 patients and 55 controls) were tested and retested.

RESULTS

A statistically significant difference was observed in the mean RFS between patients with LPR (10.26 ± 3.58) and controls (5.52 ± 1.34) (P < 0.001). The interclass correlation coefficient comparing test and retest for both raters was high (R1 = 0.956; R2 =  0.948).

CONCLUSION

The Brazilian Portuguese version of the RFS proved to be a reliable and reproducible instrument for the diagnosis of LPR with a sensitivity of 82.08%, a specificity of 93.94%, a positive predictive value of 95.60%, and a negative predictive value was 76.54%.

Characteristics of Chronic Cough in adults in Pakistani population: A cross sectional study

Background and Objective:

Data about causes of chronic cough are lacking in our part of world. The aim of our study was to look for spectrum of causes in our setup and to determine a correlation between causes of cough and baseline factors of age, gender, and BMI and compare it to other populations.

Methods:

Total 236 chronic cough patients who attended chest clinic at KRL Hospital Islamabad from January 2018 to June 2019 were included in this cross-sectional study. Chronic cough was defined as cough greater than eight weeks. Main causes of chronic cough taken were cough variant asthma, allergic rhinitis, interstitial lung disease, Gastro-esophageal reflux disease, bronchial hyper-reactivity, ACE-I induced cough and others’. Other demographic and clinical data were also recorded.

Results:

The mean age was 45.16± 16.50 years and BMI was 26.23 ± 4.68kg/m². Major cause of chronic cough was cough variant asthma in 111(47%). Age had significant positive correlations with ILD, ACE-I induced cough and CCF, while significant negative correlations with CVA and AR. On gender correlation, ILD and ACE-I cough were significantly found more in females. BMI had significant correlation with ACE-I cough only.

Conclusion:

Variability of epidemiology of cough variant asthma, allergic rhinitis and ACE-I induced cough is comparable to worldwide data while differences exist with epidemiology of interstitial lung disease. Further research is needed in the field to delineate the local trends in this regard and compare to other population groups.

Assessing the efficacy and safety of laparoscopic antireflux procedures for the management of gastroesophageal reflux disease: a systematic review with network meta-analysis

BACKGROUND

Despite the extensive literature on laparoscopic antireflux surgery, comparative evidence across different procedures is scarce. The aim of this study was to assess and rank the most efficacious and safe laparoscopic procedures for the management of gastroesophageal reflux disease.

METHODS

Medline, Embase, AMED, CINAHL, CENTRAL, and OpenGrey databases were queried for randomized trials comparing two or more laparoscopic antireflux procedures with each other or with medical treatment for the management of gastroesophageal reflux disease. Pairwise meta-analyses were conducted for each pair of interventions using a random-effects model. Network meta-analysis was employed to assess the relative efficacy and safety of laparoscopic antireflux procedures for the management of gastroesophageal reflux disease.

RESULTS

Forty-four publications reporting 29 randomized trials which included 1892 patients were identified. The network of treatments was sparse with only a closed loop between different types of wraps; 270°, 360°, anterior 180° and anterior 90°; and star network between 360° and other treatments; and between anterior 180° and other treatments. Laparoscopic 270° (odds ratio, OR 1.19, 95% confidence interval, CI 0.64-2.22), anterior 180°, and anterior 90° were equally effective as 360° for control of heartburn, although this finding was supported by low quality of evidence according to GRADE modification for NMA. The odds for dysphagia were lower after 270° (OR 0.38, 95%, CI 0.24-0.60), anterior 90° (moderate quality evidence), and anterior 180° (low-quality evidence) compared to 360°. The odds for gas-bloat were lower after 270° (OR 0.51, 95% CI 0.27, 0.95) and after anterior 90° compared to 360° (low-quality evidence). Regurgitation, morbidity, and reoperation were similar across treatments, albeit these were associated with very low-quality evidence.

CONCLUSION

Laparoscopic 270° fundoplication achieves a better outcome than 360° total fundoplication, especially in terms of postoperative dysphagia, although other types of partial fundoplication might be equally effective.

REGISTRATION NO

CRD42017074783.

Post-reflux swallow-induced peristaltic wave index and mean nocturnal baseline impedance predict PPI response in GERD patients with extra esophageal symptoms

BACKGROUND

Mean nocturnal baseline impedance (MNBI) and post-reflux swallow-induced peristaltic wave (PSPW) index are able to increase the diagnostic yield of impedance-pH and are associated to proton pump inhibitor (PPI) response. Few data concerning these variables in patients with extra-esophageal symptoms (EES) are available.

AIMS

To evaluate, in EES patients, the role of the conventional and new impedance-pH variables in diagnosing GERD and the predictive value of impedance-pH variables for PPI response.

METHODS

Consecutive patients presenting suspected GERD-related EES underwent impedance-pH. Patients treated in the last six months with double dose PPI therapy were enrolled. The presence of concomitant typical symptoms was assessed.

RESULTS

239 EES patients were studied; 102 responders and 137 non-responders. Eighty-one (34%) were affected by non-erosive reflux disease (NERD), 61 (26%) presented reflux hypersensitivity (RH) and 97 (40%) were non-GERD. In NERD and RH groups, a significantly higher proportion of patients with pathological PSPW index or MNBI values compared to non-GERD group was observed. 24 (25%) non-GERD patients presented a pathological PSPW index and/or MNBI. Pathological PSPW index, MNBI and presence of typical symptoms were associated to PPI response.

CONCLUSIONS

MNBI and PSPW index measurement increases the diagnostic yield of impedance-pH; abnormal values are associated with a satisfactory response to acid-suppressive therapy in EES patients.

Hiatal Hernia is More Frequent than Expected in Bariatric Patients. Intraoperative Findings during Laparoscopic Sleeve Gastrectomy

Background: obesity is a risk factor for gastro-esophageal disease (GERD) and hiatal hernia (HH) occurrence. A substantial number of obese patients have HH. Esophago-gastro-duodenoscopy (EGD) and Barium X-ray oral study are used for preoperative gastrointestinal evaluation. Not all HH can be diagnosed before surgery, some are discovered during laparoscopic sleeve gastrectomy (LSG).

AIM

to assess the possible correlations between intraoperative presence of hiatal hernia (known or new discovered) and preoperative clinical, radiological and endoscopic data specific for GERD and HH.

SETTING

single institution Ponderas Academic Hospital, Center of Excellence in Bariatric and Metabolic Surgery. Material and Methods: The prospectively maintained database of the institution was retrospectively quired to identify all the patients who underwent primary Laparoscopic Sleeve Gastrectomy (LSG) without/with concomitant hiatal hernia (HH) repair between January 2015 to May 2016. Patient characteristics, co-morbidities, GERD symptoms, radiologic oral contrast study, endoscopy and operative details were analyzed. Results: six hundred ninety-five patients (260 male and 435 female) were identified meeting inclusion criteria (LSG +- HH repair). Mean age of patients was 41 +- 11.71years and average body mass index (BMI) was 41.96 +- 7.28 kg/m2. Preoperative upper gastrointestinal contrast series and endoscopy were performed for entire group study and demonstrated a hiatal hernia in 339 patients (48.78%). In all these cases, HH was repaired concomitantly with LSG. One hundred ninety-two patients (56.63%) were diagnosed with HH before operation and confirmed intraoperatively (Group A). The diagnosis of hiatal hernia was established intraoperatively for 147 patients (43.37%) - group B, using the surgical protocol for active identification of preoperative undiagnosed hiatal hernia - SPAIH.

CONCLUSION

preoperative investigations such as EGD and barium X-ray oral study are suboptimal in diagnosing HH, therefore, in a significant number of patients, the presence of HH has been established using our surgical protocol - SPAIH. Crura approximation (HHR) concomitantly with laparoscopic sleeve gastrectomy is reproducible, may prevent the HH progression and possible GERD complications in the postoperative period of time.

Localization of Helicobacter pylori gastritis and the relation of existing histopathological features with reflux esophagitis

Background/aims: Interactions between Helicobacter pylori (Hp) and gastroesophageal reflux disease (GERD), which are common diseases worldwide, are confusing. In this study, the aim was to compare and evaluate the relationship between reflux esophagitis (RE) and Hp infection in adult patients with both the gastric localization of Hp and its histopathologic features.Materials and methods: 248 patients with RE were compared with 249 age and sex matched control groups. Biopsy specimens obtained from the gastric antrum and corpus were histologically evaluated.Findings: The incidence of Hp infection was significantly lower in patients with RE than in the control group (Ratio 1.53, 95% CI 1.07-2.20; p = .02, p < .05). Corpus Hp colonization and corpus gastritis scores were notably lower in the study group (p = .01, p < .05), whereas there was no significant difference in Hp colonization and antrum gastritis scores in the antrum. Corpus Hp colonization and gastritis scores were found to be negatively correlated with esophagitis development (r = -0.11; p = .01; (r = -0.14; p = .00 respectively, p < .05). There was no difference between the groups in terms of atrophy development (p > .05).Conclusion: This study showed that the presence of Hp infection in the corpus and corpus gastritis score was significantly lower in patients with erosive reflux esophagitis than in the control group. It also showed that Hp colonization and corpus gastritis scores were negatively correlated with esophagitis development. This inverse relationship was independent of atrophy.

Proton Pump Inhibitors and Radiofrequency Ablation for Treatment of Barrett's Esophagus

Gastroesophageal Reflux Disease (GERD) is characterized by acid and bile reflux in the distal oesophagus, and this may cause the development of reflux esophagitis and Barrett's oesophagus (BE). The natural histological course of untreated BE is non-dysplastic or benign BE (ND), then lowgrade (LGD) and High-Grade Dysplastic (HGD) BE, with the expected increase in malignancy transfer to oesophagal adenocarcinoma (EAC). The gold standard for BE diagnostics involves high-resolution white-light endoscopy, followed by uniform endoscopy findings description (Prague classification) with biopsy performance according to Seattle protocol. The medical treatment of GERD and BE includes the use of proton pump inhibitors (PPIs) regarding symptoms control. It is noteworthy that long-term use of PPIs increases gastrin level, which can contribute to transfer from BE to EAC, as a result of its effects on the proliferation of BE epithelium. Endoscopy treatment includes a wide range of resection and ablative techniques, such as radio-frequency ablation (RFA), often concomitantly used in everyday endoscopy practice (multimodal therapy). RFA promotes mucosal necrosis of treated oesophagal region via high-frequency energy. Laparoscopic surgery, partial or total fundoplication, is reserved for PPIs and endoscopy indolent patients or in those with progressive disease. This review aims to explain distinct effects of PPIs and RFA modalities, illuminate certain aspects of molecular mechanisms involved, as well as the effects of their concomitant use regarding the treatment of BE and prevention of its transfer to EAC.

Cost-Effectiveness Analysis of the Surgical Management of Infants Less than One Year of Age with Feeding Difficulties

BACKGROUND

We compared the cost-effectiveness of the common surgical strategies for the management of infants with feeding difficulty.

METHODS

Infants with feeding difficulty undergoing gastrostomy alone (GT), GT and fundoplication, or gastrojejunostomy (GJ) tube were enrolled between 2/2017 and 2/2018. A validated GERD symptom severity questionnaire (GSQ) and visual analog scale (VAS) to assess quality of life (QOL) were administered at baseline, 1 month, and every 6 months. Data collected included demographics, resource utilization, diagnostic studies, and costs. VAS scores were converted to quality adjusted life months (QALMs), and costs per QALM were compared using a decision tree model.

RESULTS

Fifty patients initially had a GT alone (71% laparoscopically), and one had a primary GJ. Median age was 4 months (IQR 3-8 months). Median follow-up was 11 months (IQR 5-13 months). Forty-three did well with GT alone. Six (12%) required conversion from GT to GJ tube, and one required a fundoplication. Of those with GT alone, six (14%) improved significantly so that their GT was removed after a mean of 7 ± 3 months. Overall, the median GSQ score improved from 173 at baseline to 18 after 1 year (p < 0.001). VAS scores also improved from 70/100 at baseline to 85/100 at 1 year (p < 0.001). ED visits (59%), readmissions (47%), and clinic visits (88%) cost $58,091, $1,442,139, and $216,739, respectively. GJ tube had significantly higher costs for diagnostic testing compared to GT (median $8768 vs. $1007, p < 0.001). Conversion to GJ tube resulted in costs of $68,241 per QALM gained compared to GT only.

CONCLUSIONS

Most patients improved with GT alone without needing GJ tube or fundoplication. GT and GJ tube were associated with improvement in symptoms and QOL. GJ tube patients reported greater gains in QALMS but incurred higher costs. Further analysis of willingness to pay for each additional QALM will help determine the value of care.

STUDY AND LEVEL OF EVIDENCE

Cost-effectiveness study, Level II.

Statement for gastroesophageal reflux disease after peroral endoscopic myotomy from an international multicenter experience

It has been 10 years since peroral endoscopic myotomy (POEM) was reported for the first time, and POEM has currently become the standard treatment for achalasia and related disorders globally because it is less invasive and has a higher curative effect than conventional therapeutic methods. However, there are limited studies comparing the long-term outcomes of POEM with those of conventional therapeutic methods, particularly in the occurrence of gastroesophageal reflux disease (GERD) after therapy. With this background, we held a consensus meeting to discuss the pathophysiology and management of GERD after POEM based on published papers and experiences of each expert and to discuss the prevention of GERD and dealing with anti-acid drug refractory GERD. This meeting was held on April 27, 2018 in Tokyo to establish statements and finalize the recommendations using the modified Delphi method. This manuscript presents eight statements regarding GERD after POEM.

Esophageal High-Resolution Manometry Can Unravel the Mechanisms by Which Different Bariatric Techniques Produce Different Reflux Exposures

INTRODUCTION

Bariatric surgery is increasingly performed. Since there are numerous surgical techniques, the effects of these on the esophageal function are still poorly understood. We aimed at assessing the effect of different techniques on esophagogastric junction (EGJ), esophageal peristalsis and reflux exposure using high-resolution manometry (HRM), and impedance-pH monitoring (MII-pH).

METHODS

All obese patients underwent symptomatic questionnaires, endoscopy, HRM, and MII-pH before and 1 year after surgery. Esophageal function and EGJ were classified according to Chicago Classification V. 3.0. Intragastric pressure (IGP) and gastroesophageal pressure gradient (GEPG) were assessed. Total acid exposure time (AET %), total number of refluxes, and symptom association probability (SAP) were assessed. A group of healthy volunteers (HVs) served as control.

RESULTS

One hundred and twelve obese subjects and 15 HVs (normal weight) were studied. Thirteen underwent endoscopic balloon placement (BIB), 12 gastric banding (GB), 26 sleeve gastrectomy (SG), 18 Roux-en-Y gastric bypass (RYGB), 15 mini-gastric bypass (MGB), 16 biliointestinal bypass (BIBP), and 12 biliopancreatic diversion (BPD). IGP and GEPG significantly decreased after RYGP, BPD, and BPBP, whereas they significantly increased after GB and SG. Post-operative greater AET (p < 0.05) and increased total number of reflux (p < 0.001) were present after GB and SG. RYGB and MGB showed a significant decrease in AET (p < 0.05) and total number of reflux (p < 0.001).

CONCLUSIONS

HRM verified that different bariatric techniques produced different modification of IGP and GEPG, leading to different reflux exposure. Only GB and SG can negatively impact on esophageal function and reflux exposure.

Laparoscopic Adjustable Gastric Banding: an Underestimated Risk Factor for the Development of Esophageal Cancer?-a Nationwide Survey

BACKGROUND

Approximately 14% of Austria's 8.5 million inhabitants have a body mass index (BMI) > 30 kg/m². The laparoscopic adjustable gastric banding (LAGB) was introduced in Austria in 1994, where about 10.300 patients have received it so far. One of our LAGB patients developed an adenocarcinoma of the distal esophagus 13 years after implantation.

OBJECTIVES

In order to calculate whether after LAGB patients are at higher risk for carcinoma of the esophagus, we performed a nationwide survey.

METHODS

A questionnaire was sent to all surgical departments in Austria, primarily in order to detect cases with esophageal carcinoma after LAGB, but also to evaluate the policy in Austria concerning preoperative work-up, operation, and follow-up in LAGB patients.

RESULTS

Since 1994, 37 of the 119 surgical departments in Austria have performed a total of about 10.300 LAGB implantations. Six patients have been identified with esophageal cancer following LAGB. The WHO statistical report on esophageal cancer shows an incidence of 2.8/100.000 per year in Austria, about 1/3 of which cases are adenocarcinoma of the distal esophagus.

CONCLUSION

Following LAGB, the incidence of esophageal cancer might be up to fivefold higher than the aged standardized overall population of Austria.

Combined therapy of gabapentin with pantoprazole exhibited better protective action against forestomach and pylorus ligation-induced gastric esophageal reflux disease in albino Wistar rats

The current study was undertaken to evaluate the effect of combined therapy of gabapentin and pantoprazole against forestomach and pylorus ligation-induced gastric esophageal reflux disease (GERD) in albino Wistar rats. Rats were randomly divided into five groups, each group consisting of six rats, fasted for 24 h, underwent forestomach and pylorus ligation, received normal saline (3 ml/kg, p.o.), normal control, toxic control, pantoprazole (30 mg/kg, p.o.), gabapentin (50 mg/kg, p.o.), or their combination. After 10 h, animals were killed by cervical dislocation and evaluated for pH of gastric content, volume of gastric juice, total acidity, and esophagitis index. Esophageal tissues were further analyzed for biochemical parameters such as superoxide dismutase, glutathione, catalase, thiobarbituric acid reactive substances, and protein carbonyl, and scanning electron microscopy (SEM) and histopathology were used for morphological evaluation. The results show the combination therapy of gabapentin and pantoprazole significantly inhibited the volume of gastric juice and total acidity esophagitis index and significantly increased the pH of gastric juice. Treatment with gabapentin and pantoprazole exhibited maximum antioxidant effect in comparison with monotherapy. Marked protection and restoration of normal morphology was observed through SEM and histopathology in the combination therapy as compared to monotherapy. Finally, it was concluded that combination therapy of pantoprazole and gabapentin has beneficial effect against GERD.

The Use of Inhaled N-Acetylcysteine for Laryngopharyngeal Reflux Disease: A Randomized Controlled Trial

OBJECTIVES

Proton pump inhibitors (PPIs) are the mainstay of the medical treatment for laryngopharyngeal reflux disease (LPRD). However, extraesophageal symptoms of LPRD, such as globus, are often refractory to PPI treatment. Many kinds of adjunctive medications have been attempted to address those refractory cases. We aimed to study whether inhaled N-acetylcysteine (NAC), a mucolytic agent, has additive effects for the treatment of LPRD when used in conjunction with PPIs.

METHODS

Patients with reflux symptom index (RSI) greater than 13 and reflux finding scores (RFS) greater than 7 were prospectively enrolled and were randomly assigned to control or study group. Patients were treated with oral rabeprazole in the control group and with oral rabeprazole and inhaled NAC in the study group. Patients were followed once a month for 2 months with questionnaires and stroboscopic examination. At every follow-up, RSI and RFS were checked. The extent of improvements of RSI and RFS were evaluated and compared between two groups.

RESULTS

With treatment, the mean RSI changed from 21.0 to 7.6 (P < 0.001) in control group and from 19.7 to 4.5 (P < 0.001) in study group. The mean RFS also changed from 12.9 to 7.1 (P < 0.001) in control group and from 13.5 to 6.9 (P < 0.001) in study group. For both RSI and RFS, the extents of improvement were not significantly different between two groups. In patients whose RSI improved less than nine at the first follow-up (poor early responders), RSI became significantly lower in the study group (4.6 ± 2.0) than in the control group (9.5 ± 4.6) at second follow-up (P = 0.019). In good early responders, however, RSI was not significantly different between the two groups in the second follow-up.

CONCLUSIONS

In this study, there were no significant differences in the overall outcome between patients treated with inhaled NAC and PPI and those with PPI alone. Interestingly, some additional therapeutic effect of NAC appeared late for the patients with poor early response. Further studies are required to investigate the underlying mechanism for this.

Safety of concurrent sleeve gastrectomy and hiatal hernia repair: a propensity score-matched analysis of the MBSAQIP registry

BACKGROUND

Hiatal hernia repair is an essential step to reduce the incidence of gastroesophageal acid reflux disease in patients undergoing sleeve gastrectomy. The safety of addition, a hiatal hernia repair to sleeve gastrectomy, is a critical question.

OBJECTIVES

Our study aimed to assess the safety of concurrent hiatal hernia repair and sleeve gastrectomy based on Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data.

SETTING

University health network, United States.

METHODS

This study was a registry-based analysis. Preoperative characteristics and 30-day outcomes from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Files 2015 to 2017 were selected for all patients who underwent sleeve gastrectomy with hiatal hernia repair. Propensity score matching (1:1) was used to control for potential confounding.

RESULTS

A total of 101,902 patients (50,951 patients matched pairs) were included in the study. The groups were closely matched as intended. Sleeve gastrectomy with hiatal hernia repair, compared with sleeve gastrectomy alone, was associated with similar risks of death (.02% versus .02%; relative risk [RR], 1.50; 95% confidence interval [CI], .61-3.67, P = .503), and higher risk of 30-day readmission (4.01% versus 2.96%; RR, 1.35; 95%CI, 1.27-1.45, P < .001), 30-day reoperation (1.10% versus .77%; RR, 1.42; 95% CI, 1.25-1.61, P < .001), 30-day intervention (1.24% versus .95%; RR, 1.31; 95%CI, 1.16-1.47, P < .001), and 30-day morbidity (1.85% versus 1.47%; RR, 1.25; 95%CI, 1.14-1.38, P < .001).

CONCLUSIONS

Sleeve gastrectomy with hiatal hernia repair is relatively safe in the short term with no increase in the risk of mortality. However, this additional procedure slightly increases the risk of readmission, reoperation, and postoperative intervention, as well as morbidity.

Caregiver Burden in Gastroparesis and GERD: Correlation with Disease Severity, Healthcare Utilization and Work Productivity

BACKGROUND

Caregiver burden can be significant in chronic gastrointestinal diseases. No studies have been performed to evaluate caregiver burden in gastroparesis or gastroesophageal reflux disease (GERD).

AIMS

(1) Assess the caregiver burden in gastroparesis and GERD patients and healthy volunteers (HVs); (2) correlate the caregiver burden of these patients to the severity of patients' symptoms, healthcare utilization, and work productivity of the patients and the caregivers.

METHODS

Patients with gastroparesis and GERD, seen between June 2018 and November 2018, completed Patient Assessment of Gastrointestinal Symptoms, Work Productivity and Activity Impairment (WPAI) and healthcare utilization questionnaires. The caregivers of these patients completed Zarit Burden Interview (ZBI) and WPAI questionnaire. HVs and their potential caregivers also completed these questionnaires.

RESULTS

Forty-seven patients (gastroparesis = 31, GERD = 17), 12 HVs, and their caregivers completed questionnaires. Caregivers of gastroparesis patients reported high burden on ZBI (27.7 ± 2.9), greater than the caregivers of GERD (14.9 ± 2.5) and HVs (5.5 ± 1.6, p < 0.01). Among all patients, the caregiver burden had a strong correlation with patients' Gastroparesis Cardinal Symptom Index (GCSI) total score (r_s = 0.63, p < 0.01) and moderate correlations with the number of patients' physician office visits (r_s = 0.46, p < 0.01) and the number of work hours missed by caregivers due to patients' symptoms (r_s = 0.36, p = 0.04). Using multivariable regression, both presence of gastroparesis and other comorbidities significantly predicted caregiver burden, F(2, 33) = 15.94, p < 0.0001, R² = 0.491.

CONCLUSIONS

Caregivers of gastroparesis patients have high caregiver burden that strongly correlates with patients' GCSI total score. Interventions to reduce symptom severity of Gp patients may reduce the caregiver burden.

Surgical management of gastroesophageal reflux disease in the obese patient

BACKGROUND

Gastroesophageal reflux disease (GERD) affects two thirds of the American population. Obesity is also a disease that affects two thirds of the population. The pathophysiology of reflux disease is reasonably understood, however, the degree to which obesity affects this disease remains poorly defined. Therefore the approach to GERD in the obese patient requires special attention and its own algorithm.

METHODS

A literature search was conducted to consolidate the current available literature on GERD and its management in the obese. In addition, the authors reviewed the literature and present expert opinion on controversial topics.

RESULTS

It is well established that GERD is increased in obesity and the pathophysiology is reviewed. Management options for GERD are discussed, with a focus on the obese population. Management strategies including fundoplication and gastric bypass are discussed. In addition, bariatric surgery in the setting of GERD is also reviewed.

CONCLUSIONS

Currently this is an extremely controversial topic and this white paper presents a strong review of the literature to help guide the management of this challenging disease in this population. Expert recommendations are given throughout the paper based upon the current available data.

Cardiovascular Risk of Proton Pump Inhibitors

Proton pump inhibitors (PPIs) are effective agents for the treatment of gastroesophageal reflux (GERD). However, these drugs have not been approved for long-term use. Now sold over the counter, these agents are being used chronically for GERD without medical supervision. The long-term use of PPIs may have significant adverse effects, in part mediated by their effect of accelerating vascular aging. Physicians should assist patients in tapering off their use of PPIs and replacing them with lifestyle modifications and/or other agents that have better long-term safety profiles.