Surgical Repair of Large Hiatal Hernias: Insight from a High-Volume Center

BACKGROUND

Laparoscopic-assisted hiatal hernia (HH) repair is safe and effective; however, it is unclear whether hernia size affects perioperative outcomes and whether a watch-and-wait strategy is appropriate for patients with asymptomatic large HHs. We aimed to investigate these issues.

METHODS

After IRB approval, we queried our prospectively maintained database for patients who underwent primary laparoscopic HH repair at our center between August 2016 and December 2019. All procedures were performed by a single surgeon (SKM). According to the intraoperative findings, HHs were divided into four groups: small (S-HH), medium (M-HH), large (L-HH), or giant (G-HH) when the percentage of herniated stomach was 0% (sliding), < 50%, 50-75%, or > 75%, respectively. Perioperative and mid-term outcomes were analyzed.

RESULTS

A total of 170 patients were grouped: S-HH (n = 46), M-HH (n = 69), L-HH (n = 20), and G-HH (n = 35) with mean age of 58.5.6 ± 11.0, 61.9 ± 11.3, 70.7 ± 10.3, and 72.6 ± 9.7 years (p < 0.001), respectively. Compared to M-HH patients, L-HH patients had significantly longer hospital stays (mean 2.8 ± 3.2 vs 1.4 ± 0.91 days; p = 0.001) and more postoperative complications (6/20 [30.0%] vs 3/69 [4.3%]; OR 6.9, 95% CI 5.4-8.4, p < 0.001). At a mean follow-up time of 43.1 ± 25.0 and 43.5 ± 21.6 months for the combined S/M-HH and L/G-HH groups, GERD-Health-Related Quality of Life scores were comparable (S/M-HH: 6.5 ± 10.9 vs L/G-HH: 7.1 ± 11.3; p = 0.63). There was no perioperative mortality.

CONCLUSIONS

HHs likely grow with age, reflecting their progressive nature. Laparoscopic L-HH repair was associated with higher morbidity than M-HH repair. Thus, patients with M-HH, even if less symptomatic, should be evaluated by a foregut surgeon. Regardless of HH size, good mid- and long-term quality of life outcomes can be achieved.

Safety and efficacy of Roux-en-Y gastric bypass as revisional bariatric surgery after failed anti-reflux surgery: a systematic review

This systematic review evaluates the safety and efficacy of Roux-en-Y gastric bypass (RYGB) on weight loss and anti-reflux outcomes when used as a revisional bariatric surgical procedure after failed anti-reflux surgery. A systematic literature search next to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed for articles published by 30 Mar 2022. After examining 416 papers, 23 studies were included (n = 874 patients). Primary anti-reflux surgery included mainly Nissen fundoplication (16 studies). Reasons for revisional surgery included predominantly gastroesophageal reflux disease (GERD) (reported by 18 studies), obesity (reported by 6 studies), and hiatal hernia (reported by 6 studies). Interval to surgical revision was 5.58 ± 2.46 years (range, 1.5-9.4 yr). Upper endoscopy at revision was performed for all patients; esophageal manometry and pH monitoring were reported in 6 and 4 studies, respectively. Mean body mass index (BMI) at revision was 37.56 ± 5.02 kg/m2 (range, 31.4-44 kg/m2). Mean excess weight loss was 69.74% reported by 12 studies. Delta BMI reported by 7 studies was 10.41 kg/m2. The rate of perioperative complications was 16.7%, including mostly stenosis, leakage, ventral hernia, and small bowel obstruction. Mean improvement rate of GERD was 92.62% with a mean follow-up of 25.64 ± 16.59 months reported in 20 studies. RYGB seems to be an efficient surgical treatment option in failed anti-reflux procedures, but should be performed in experienced centers for selected patients, since the rate of perioperative and long-term complications must be minimized. Cooperation between bariatric and reflux surgeons is essential to offer patients with obesity and GERD the best long-term outcome.

Peroral Endoscopic Myotomy (POEM) and Laparoscopic Heller Myotomy with Dor Fundoplication for Esophagogastric Junction Outflow Obstruction (EGJOO): a Comparison of Outcomes and Impact on Physiology

INTRODUCTION

Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by failure of lower esophageal sphincter (LES) relaxation with preserved peristalsis. Studies have shown that Heller myotomy with Dor fundoplication (HMD) and per oral endoscopic myotomy (POEM) are effective treatments for EGJOO. However, there is paucity of data comparing the efficacy and impact of these two procedures. Therefore, the aim of this study was to compare outcomes and impact on esophageal physiology in patients undergoing HMD or POEM for primary EGJOO.

METHODS

This was a retrospective review of patients who underwent either HMD or POEM for primary EGJOO at our institution between 2013 and 2021. Favorable outcome was defined as an Eckardt score ≤ 3 at 1 year after surgery. GERD-HRQL questionnaire, endoscopy, pH monitoring, and high-resolution manometry (HRM) results at baseline and 1 year after surgery were compared pre- and post-surgery and between groups. Objective GERD was defined as DeMeester score > 14.7 or LA grade C/D esophagitis.

RESULTS

The final study population consisted of 52 patients who underwent HMD (n = 35) or POEM (n = 17) for EGJOO. At a mean (SD) follow-up of 24.6 (15.3) months, favorable outcome was achieved by 30 (85.7%) patients after HMD and 14 (82.4%) after POEM (p = 0.753). After HMD, there was a decrease GERD-HRQL total score (31 (22-45) to 4 (0-19); p < 0.001), and objective reflux (54.2 to 25.9%; p = 0.033). On manometry, there was a decrease in LES resting pressure (48 (34-59) to 13 (8-17); p < 0.001) and IRP (22 (17-28) to 8 (3-11); p < 0.001), but esophageal body characteristics did not change (p > 0.05). Incomplete bolus clearance improved (70% (10-90) to 10% (0-40); p = 0.010). After POEM, there was no change in the GERD-HRQL total score (p = 0.854), but objective reflux significantly increased (0 to 62%; p < 0.001). On manometry, there was a decrease in LES resting pressure (43 (30-68) to 31 (5-34); p = 0.042) and IRP (23 (18-33) to 12 (10-32); p = 0.048), DCI (1920 (1600-5500) to 0 (0-814); p = 0.035), with increased failed swallows (0% (0-30) to 100% (10-100); p = 0.032). Bolus clearance did not improve (p = 0.539). Compared to HMD, POEM had a longer esophageal myotomy length (11 (7-15)-vs-5 (5-6); p = 0.001), more objective reflux (p = 0.041), lower DCI (0 (0-814)-vs-1695 (929-3101); p = 0.004), and intact swallows (90 (70-100)-vs-0 (0-40); p = 0.006), but more failed swallows (100 (10-100); p = 0.018) and incomplete bolus clearance (90 (90-100)-vs-10 (0-40); p = 0.004).

CONCLUSION

Peroral endoscopic myotomy and Heller myotomy with Dor fundoplication are equally effective at relieving EGJOO symptoms. However, POEM causes worse reflux and near complete loss of esophageal body function.

Barrett`s Esophagus in Bariatric Surgery: Regression or Progression?

INTRODUCTION

Morbid obesity is well known as a risk factor for gastroesophageal reflux disease (GERD) and its related disorders such as Barrett's esophagus (BE). This study aimed to evaluate the development of BE in patients who underwent bariatric surgery.

MATERIALS AND METHODS

Using a single-center prospectively established database of obese patients who underwent bariatric surgery from 01/2012 to 12/2019, we retrospectively compared the preoperative endoscopic findings of BE to those after 1-2 years and 3-5 years following bariatric surgery. The change of BE was detected endoscopically according to Prague classification and histologically according to the British guidelines of detecting columnar epithelium on the distal esophagus.

RESULTS

Among 914 obese patients who underwent bariatric surgery and received a preoperative esophagogastroduodenoscopy (EGD), we found 119 patients (13%) with BE. A follow-up EGD was performed in 74 of the BE patients (62.2%). A total of 37 (50%) patients underwent a follow-up EGD after 1-2 years and 45 (60.8%) patients underwent it after 3-5 years. Among many clinical parameters, the surgical procedure was the only significant factor for the change of BE after bariatric surgery (p < 0.05). A regression of BE was found in 19 patients (n = 54, 35%) after laparoscopic Roux-en-Y- gastric bypass (LRYGB). Furthermore, a progression of BE was detected in six patients (n = 20, 30%) after laparoscopic sleeve gastrectomy (LSG).

CONCLUSION

RYGB should be considered in obese patients with BE. Detecting BE prior to bariatric surgery may have an impact on decision-making regarding the suitable surgical bariatric procedure.

Laparoscopic Toupet fundoplication: a safe and effective anti-reflux option in lung transplant recipients

BACKGROUND

Fundoplication is known to improve allograft outcomes in lung transplant recipients by reducing retrograde aspiration secondary to gastroesophageal reflux disease, a modifiable risk factor for chronic allograft dysfunction. Laparoscopic Nissen fundoplication has historically been the anti-reflux procedure of choice, but the procedure is associated with discernable rates of postoperative dysphagia and gas-bloat syndrome. Laparoscopic Toupet fundoplication, an alternate anti-reflux surgery with lower rates of foregut complications in the general population, is the procedure of choice on our institution's lung transplant protocol. In this work, we evaluated the efficacy and safety of laparoscopic Toupet fundoplication in our lung transplant recipients.

METHODS

A prospective case series of 44 lung transplant recipients who underwent laparoscopic Toupet fundoplication by a single surgeon between September 2018 and November 2020 was performed. Preoperative and postoperative results from 24-h pH, esophageal manometry, gastric emptying, and pulmonary function studies were collected alongside severity of gastroesophageal reflux disease and other gastrointestinal symptoms.

RESULTS

Median DeMeester score decreased from 25.9 to 5.4 after fundoplication (p < 0.0001), while percentage of time pH < 4 decreased from 7 to 1.1% (p < 0.0001). The severity of heartburn and regurgitation were also reduced (p < 0.0001 and p = 0.0029 respectively). Overall, pulmonary function, esophageal motility, gastric emptying, severity of bloating, and dysphagia were not significantly different post-fundoplication than pre-fundoplication. Patients with decreasing rates of FEV1 pre-fundoplication saw improvement in their rate of change of FEV1 post-fundoplication (p = 0.011). Median follow-up was 32.2 months post-fundoplication.

CONCLUSIONS

Laparoscopic Toupet fundoplication provides objective pathologic acid reflux control and symptomatic gastroesophageal reflux improvement in lung transplant recipients while preserving lung function and foregut motility. Thus, laparoscopic Toupet fundoplication is a safe and effective antireflux surgery alternative in lung transplant recipients.

Pilot study of an endoluminal-suturing device as a treatment for patients with gastroesophageal reflux disease

Background and study aims Endoscopic therapy is a promising option for patients with gastroesophageal reflux disease (GERD). The aim of this study was to assess safety and feasibility of the Endomina suturing platform as a treatment for GERD. Patients and methods This was a two-center study of patients with chronic GERD symptoms that responded at least partially to proton pump inhibitors (PPIs). Primary endpoints were to assess the safety of the procedure and persistence of the sutures. Secondary endpoints were to assess esophageal pH-impedance and manometry parameters changes at 6 months, as well as GERD symptoms and PPI use up to 12 months of follow-up. Results Fourteen patients were treated (13 males, mean of 43±12 years), with a mean number of three plications per patient. Thirteen, 10, and nine patients were analyzed at 3, 6, and 12 months of follow-up, respectively. One device-related adverse event occurred (loss of needle tip requiring endoscopic retrieval 1 week later). A mean of two plications persisted at 3 and 12 months. A decrease in median acid exposure time and reflux episodes was observed after the procedure. Mean Reflux Symptom Index and GERD-Health-Related Quality of Life scores decreased during follow-up visits and 90% of the patients discontinued PPI use at 1 year. Conclusions Endoscopic full-thickness suturing of the esophagogastric junction with the Endomina suturing platform is feasible, allowing persistence of two-thirds of the plications, with promising results for decreasing reflux and improving GERD symptoms.

Indications and Findings of Upper Gastrointestinal Endoscopy at a Tertiary Hospital in Ethiopia: A Cross-Sectional Study

Background

Gastrointestinal disease is a significant global health problem. Symptoms related to digestive system diseases negatively affect quality of life and impose a significant economic impact. Upper gastrointestinal symptoms are common in the Ethiopian population, and the associated pathologies are diverse. Real-time endoscopic visualization of the upper gastrointestinal tract is crucial for diagnosis. However, local data on the indications for endoscopic evaluation and the common underlying pathologies are limited. This study aimed to assess the common indications and upper gastrointestinal endoscopic findings of patients presenting to Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.

Methods

A cross-sectional study was conducted by reviewing the complete records of patients who underwent upper gastrointestinal endoscopic evaluation between January 2012 and December 2019. A structured checklist was used to screen records for completeness. Data were analyzed using Statistical Package for the Social Sciences software version 25. Chi-square test was used to compare variables, with statistical significance set at P < 0.05.

Results

A total of 5753 patients underwent complete upper gastrointestinal tract endoscopic evaluation during the study period. The median age of the patients was 37 years. Males accounted for 63.4% of the patients. Dyspepsia (27.8%) was the most common indication for upper gastrointestinal endoscopic evaluation, followed by upper gastrointestinal bleeding (17.1%), and screening for varices (16.8%). Esophageal varices (35.8%), gastritis (18.1%), and duodenal ulcers (10.6%) were the most common pathologies found on esophagus, stomach, and duodenum, respectively. Common upper gastrointestinal pathologies are predominant among males and patients in their third decade of life.

Conclusion

Dyspepsia was the most common indication for endoscopic evaluation of the upper gastrointestinal tract. Esophageal varices were the most common pathological finding, followed by gastroesophageal reflux disease, gastritis, portal hypertensive gastropathy, duodenal ulcer, and hiatal hernia. Esophagogastroduodenoscopy remains a vital tool for the diagnosis of pathologies of the upper gastrointestinal tract.

[Diagnosis and Treatment of GastroEsophageal Reflux Disease at the Primary Health Care Clinics in Korea]

Background/Aims

The prevalence of GERD and treatment costs are continuously rising in Korea, and the importance of primary health care clinics where the most treatment of actual patients is conducted is increasing. In this study, the diagnosis of GERD, selection of therapeutic drugs, and treatment methods in primary health care clininics were investigated through a large-scale multi-dimensional surveys.

Methods

From January 2015 to December 2018, the study data of 18,010 patients with GERD were retrospectively investigated based on eletronic medical record at 542 primary health care clinics in Korea.

Results

Among all GERD patients, endoscopy was used for diagnosis in 16.11% of cases, and the most frequently performed in gastroenterology department (28.85%). The average BMI and the proportion of patients in stages 1 to 3 of obesity were highest in the ERD group, and the majority of the severity of ERD group was mild. Symptoms of the patients with GERD were mainly heartburn, gastric acid reflux, and chest pain. Drug treatment was performed in most of the patients with GERD, and PPI was the main drug, and Esomeprazol was prescribed the most among the main ingredients, and the ratio of PPI alone was high. The rate of symptom improvement after GERD treatment was slightly higher in the ERD group (75.91%) and the NERD group (74.36%) than in the GERD diagnosed without endoscopy group (63.89%).

Conclusions

In domestic primary health care clinics, the majority were diagnosed with GERD without endoscopy on the basis of symptoms. The most preferred treatment for GERD was PPI, which was prescribed alone in the majority.

Current complementary and alternative therapy forgastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a widely prevalent gastrointestinal disorder, affecting ∼13.3% of the global population. There are shortages and limitations of current GERD treatment modalities, and complementary and alternative therapy (CAT) is a promising option to fill in the gap. Dietary and lifestyle modifications might play an important and complementary role in alleviating GERD symptoms. Traditional Chinese medicine and brain-gut behavior therapy, particularly transcutaneous electrical acustimulation and diaphragmatic breathing therapy were shown to be useful adjuncts or alternatives in treating GERD. CAT may help to relieve GERD symptoms, minimize medication dosage, and slow the demand for surgery. The aim of this review was to summarize the existing evidence of some common CATs in treating symptomatic GERD, including dietary modification, lifestyle change, traditional Chinese medicine, and brain-gut behavior therapy.

Gastroesophageal reflux management after vertical sleeve gastrectomy

VSG is the most used surgical procedure in the world. Among the main complications linked to this procedure is GERD. It is apparent that endoscopic control protocols should be undertaken in all patients recovering from a VSG procedure. This is particularly key when taking into account the large number of patients suffering from GERD that show no symptoms, a situation that in many cases leads to severe esophagitis or even adenocarcinoma. Once the pertinent diagnostic tests have been carried out, the specialist should seek a conservative medical treatment including PPI. In the event that this treatment should fail, the next step to be considered should be a surgical procedure. In this case, the ideal procedure would be a reconversion to gastric bypass due to its low-risk and its results. There are other alternatives such as the Stretta, Linx or ARMS procedures; however, further research is necessary to prove their reliability.

Herbal Combination 'HAGE-101912' Ameliorates Gastroesophageal Reflux Disease in Rats

Background

Gastroesophageal reflux disease (GERD) is a chronic, relapsing disorder. In this era of modern and fast-track lifestyle and food habits, the incidence of GERD is rapidly increasing. Currently, proton pump inhibitors (PPIs) are the primary choice of treatment. However, the associated side effects and a high relapse rate give rise to the need to explore alternative therapies.

Objective

The study aimed to evaluate HAGE-101912, an herbal combination, in different experimental models of GERD.

Methods

Antacid activity was assessed based on H+/K+ATPase inhibitory activity of parietal cells using artificial gastric juice. Tonic contraction of the lower esophageal sphincter (LES) was evaluated using an AD Instrument. A GERD model of the pylorus and fundus ligation (preventive and curative models) in rats was selected to assess the efficacy of HAGE-101912 at a dose of 250 mg/kg body weight, and various parameters such as the gastric pH, gastric volume, total acidity, gross esophageal ulcer index, and histopathological changes were evaluated. The prokinetic activity was assessed using the phenol red method.

Results

HAGE-101912 increased the acid-neutralizing capacity (P < 0.001), decreased H+/K+ATPase activity (P < 0.01), and increased the contraction of the LES. In the preventive model, HAGE-101912 significantly reduced the gastric acid volume (P < 0.01), total acidity (P < 0.001), and gross esophageal ulcer index (P < 0.01); increased the gastric acid pH (P < 0.01); and protected the esophageal epithelium. In addition, HAGE-101912 increased gastric emptying and gastrointestinal transit through its prokinetic activity (P < 0.05).

Conclusion

HAGE-101912 has a beneficial effect in GERD as it effectively inhibits the H+/K+ATPase, increases the gastric pH, restores the LES function, protects the esophageal epithelium, and increases gastric emptying and transit.

The impact of primary peristalsis, contractile reserve, and secondary peristalsis on esophageal clearance measured by timed barium esophagogram

BACKGROUND

Primary and secondary peristalsis facilitate esophageal bolus transport; however, their relative impact for bolus clearance remains unclear. We aimed to compare primary peristalsis and contractile reserve on high-resolution manometry (HRM) and secondary peristalsis on functional lumen imaging probe (FLIP) Panometry with emptying on timed barium esophagogram (TBE) and incorporate findings into a comprehensive model of esophageal function.

METHODS

Adult patients who completed HRM with multiple rapid swallows (MRS), FLIP, and TBE for esophageal motility evaluation and without abnormal esophagogastric junction outflow/opening or spasm were included. An abnormal TBE was defined as a 1-min column height >5 cm. Primary peristalsis and contractile reserve after MRS were combined into an HRM-MRS model. Secondary peristalsis was combined with primary peristalsis assessment to describe a complementary neuromyogenic model.

KEY RESULTS

Of 89 included patients, differences in rates of abnormal TBEs were observed with primary peristalsis classification (normal: 14.3%; ineffective esophageal motility: 20.0%; absent peristalsis: 54.5%; p = 0.009), contractile reserve (present: 12.5%; absent: 29.3%; p = 0.05), and secondary peristalsis (normal: 9.7%; borderline: 17.6%; impaired/disordered: 28.6%; absent contractile response: 50%; p = 0.039). Logistic regression analysis (akaike information criteria, area under the receiver operating curve) demonstrated that the neuromyogenic model (80.8, 0.83) had a stronger relationship predicting abnormal TBE compared to primary peristalsis (81.5, 0.82), contractile reserve (86.8, 0.75), or secondary peristalsis (89.0, 0.78).

CONCLUSIONS AND INFERENCES

Primary peristalsis, contractile reserve, and secondary peristalsis were associated with abnormal esophageal retention as measured by TBE. Added benefit was observed when applying comprehensive models to incorporate primary and secondary peristalsis supporting their complementary application.

Gastroesophageal reflux after sleeve gastrectomy: The dimension of the problem

Sleeve gastrectomy is a safe and effective bariatric surgery in terms of weight loss and longterm improvement or resolution of comorbidities. However, its achilles heel is the possible association with the development with the novo and/or worsening of pre-existing gastroesophageal reflux disease. The anatomical and mechanical changes that this technique induces in the esophagogastric junction, support or contradict this hypothesis. Questions such as «what is the natural history of gastroesophageal reflux in the patient undergoing gastric sleeve surgery?», «how many patients after vertical gastrectomy will develop gastroesophageal reflux?» and «how many patients will worsen their previous reflux after this technique?» are intended to be addressed in the present article.

Study of gastroesophageal reflux. Interpretation of functional tests in the obese patient

Overweight and obesity are a public health problem and in 1997 obesity was recognized as a global epidemic by the World Health Organization (WHO). Overweight and obesity affect almost 60% of adults and one in three children in Europe according to the most recent WHO report. Objectively, gastroesophageal reflux disease (GERD) is defined as the presence of characteristic esophageal mucosal damage assessed by endoscopy and/or the demonstra-tion of pathological acid exposure by reflux monitoring studies. The prevalence of GERD is increased in obese patients In overweight and obese patients, the clinical symptoms of GERD are especially present in the supine position and this correlates with more frequent episodes of nocturnal reflux in the 24-h pH monitoring, there is also an increase in the number of refluxes with content acid. In the population with symptoms, digestive endoscopy detects data of erosive esophagitis in 50% of patients, while 24-h pH-impedanciometry diagnoses 92% of patients with non-erosive reflux disease (NERD) The presence of persistent GERD in the mucosa affects esophageal motility and patients may develop ineffective esophageal motility-type disorders, so we will review the interpre-tation of the functional tests that determine motility, which is esophageal manometry, and those that determine reflux gastroesophageal, acid and non-acid, which is the pH measure-ment with or without 24-h impedanciometry.

Neuromodulation for Gastroesophageal Reflux Disease: A Systematic Review

Background and objectives

In this systematic review, we evaluated the efficacy, mechanisms and safety of three neuromodulation therapies in patients with gastroesophageal reflux disease (GERD), including the effect of neuromodulation therapies on symptoms and key GERD pathophysiologies, lower esophageal sphincter (LES) pressure, esophageal motility, gastric motility, and parasympathetic activity. The first therapy is LES electrical stimulation using an implantable electrical stimulator, the second is transcutaneous electrical acustimulation, and the third is manual acupuncture.

Methods

A systematic review of literature according to the PRISMA guidelines was performed. Online databases searched include Medline (Ovid), Embase, and PubMed. Studies were assessed for inclusion and exclusion criteria with Covidence, a systematic review software.

Results

The analysis included thirteen clinical studies. Four papers included were registered under two open-label trials on ClinicalTrials.gov for LES electrical stimulation; Five randomized trials with sham-treated controls were analyzed for transcutaneous electrical acustimulation; Four studies, including three involving standard therapy controls and one involving shamtreated controls were included for manual acupuncture. All evaluated studies demonstrated significant beneficial effects on GERD symptoms, using patient-completed questionnaires, objective 24-h measurement of esophageal pH, and patient-reported use of proton pump inhibitors. In evaluating the effect on key GERD pathophysiologies, electrical stimulation significantly increased LES pressure, and transcutaneous electrical acustimulation significantly improved esophageal motility, gastric motility, and parasympathetic activity. None of the evaluated neuromodulation methods produced severe adverse effects.

Conclusions

Cumulative evidence from the evaluated studies indicates that neuromodulation therapies were effective in treating the GERD symptoms and key underlying GERD pathophysiologies. They are thus valuable options for individualized GERD treatment.

Zinc Deficiency and Therapeutic Value of Zinc Supplementation in Pediatric Gastrointestinal Diseases

The benefits of zinc in treating certain gastrointestinal (GI) diseases have been recognized for over two decades. This review aims to explore zinc deficiency (ZD) and the potential therapeutic value and safety of zinc supplementation in pediatric GI diseases. A systematic review of published articles on ZD and zinc as adjuvant treatments for GI diseases was conducted using various databases. Children with inflammatory bowel disease (IBD), celiac disease, and those receiving long-term proton pump inhibitor treatments are particularly susceptible to ZD. ZD in children with celiac disease and IBD is attributed to insufficient intake, reduced absorption, and increased intestinal loss as a result of the inflammatory process. Zinc plays a crucial role in maintaining the integrity of the gastric mucosa and exerts a gastroprotective action against gastric lesions. Although considerable evidence supports the use of zinc as adjuvant therapy for certain GI diseases in adults, its use is unspecified in children except for infectious diarrhea. Current evidence suggests that zinc supplementation with well-documented dosages helps reduce the duration of diarrhea in children with acute or persistent diarrhea, while there are no specific guidelines for zinc supplementation in children with IBD and celiac disease. Zinc supplementation appears to be beneficial in peptic ulcer disease or gastroesophageal reflux disease. The available evidence highlights the need for intervention programs to enhance zinc status and reduce the morbidity of certain GI diseases in children.

Optimizing the Management Algorithm for Heartburn in General Gastroenterology: Cost-Effectiveness and Cost-Minimization Analysis

BACKGROUND AND AIMS

Heartburn is the most common symptom seen in gastroenterology practice. We aimed to optimize cost-effective evaluation and management of heartburn.

METHODS

We developed a decision analytic model from insurer and patient perspectives comparing 4 strategies for patients failing empiric proton pump inhibitors (PPIs): (1) PPI optimization without testing, (2) endoscopy with PPI optimization for all patients, (3) endoscopy with PPI discontinuation when erosive findings are absent, and (4) endoscopy/ambulatory reflux monitoring with PPI discontinuation as appropriate for phenotypic management. Health outcomes were respectively defined on systematic reviews of clinical trials. Cost outcomes were defined on Centers for Medicare and Medicaid Services databases and commercial multipliers for direct healthcare costs, and national observational studies evaluating healthcare utilization. The time horizon was 1 year. All testing was performed off PPI.

RESULTS

PPI optimization without testing cost $3784/y to insurers and $3128 to patients due to lower work productivity and suboptimal symptom relief. Endoscopy with PPI optimization lowered insurer costs by $1020/y and added 11 healthy days/y by identifying erosive reflux disease. Endoscopy with PPI discontinuation added 11 additional healthy days/y by identifying patients without erosive reflux disease that did not need PPI. By optimizing phenotype-guided treatment, endoscopy/ambulatory reflux monitoring with a trial of PPI discontinuation was the most effective of all strategies (gaining 22 healthy days/y) and saved $2183 to insurers and $2396 to patients.

CONCLUSIONS

Among patients with heartburn, endoscopy with ambulatory reflux monitoring (off PPI) optimizes cost-effective management by matching treatment to phenotype. When erosive findings are absent, trialing PPI discontinuation is more cost-effective than optimizing PPI.

Esophageal Inlet Patch: Association with Barrett's Esophagus

BACKGROUND

Esophageal inlet patch (IP) with heterotopic gastric mucosa is an incidental finding on esophagogastroduodenoscopy (EGD). Although IP is thought to be embryologic in nature, IP has been associated with Barrett's esophagus (BE).

AIMS

The aim of this study was to compare prevalence, symptoms, demographic factors, and esophageal testing in patients with IP and BE.

METHODS

We retrospectively analyzed endoscopic findings of EGDs, high-resolution esophageal manometry and esophageal pH impedance studies from January 2010 to January 2021 at a single academic medical center. Patients were grouped by presence or absence of IP and BE.

RESULTS

Of 27,498 patients evaluated, 1.3% had endoscopic evidence of IP and 4.9% had BE. Of 362 patients with IP, 17.1% had BE; of 1356 patients with BE, 4.6% had IP. Both IP and BE patients presented primarily with heartburn and/or regurgitation. Patients with BE and/or IP were older and had higher BMI than those without (p < 0.001). Mean lower esophageal sphincter pressure was lower and mean acid exposure time (AET) was higher in patients with IP and/or BE than those without (p < 0.05).

CONCLUSIONS

Our study reports an IP prevalence of 1.3%, with 17.1% patients having concomitant BE; and a BE prevalence of 4.9%, with 4.6% also having IP. Patients with IP alone presented with similar symptoms to patients with concomitant BE. Esophageal function testing showed that patients with either IP or BE had decreased LES pressures and increased esophageal AET. During endoscopy, patients found to have one of these findings should be carefully examined for the other.

Impact of concomitant gastroesophageal reflux disease symptomology on prognosis and pulmonary function of chronic hypersensitivity pneumonitis

Background and Objectives

Comorbid risk factors in chronic hypersensitivity pneumonitis (CHP) are poorly characterised. Gastroesophageal reflux disease (GERD) is linked to interstitial lung diseases like idiopathic pulmonary fibrosis (IPF), but its association and treatment in CHP is less understood. This study aims to understand the role and prevalence of GERD in CHP, plus the effect of GERD treatment on lung function and mortality.

Methods

A tertiary referral centre panel was retrospectively reviewed for 214 patients diagnosed with CHP based on clinical history, bronchoalveolar lavage fluid analysis, imaging and histopathology. GERD diagnostic criteria included symptomology, acid suppressive therapy use and diagnostic testing. CHP patients with GERD (n = 89) and without GERD (n = 125) were compared via descriptive statistical analysis. Pulmonary function, GERD diagnosis plus treatment and other comorbidities were evaluated against CHP outcomes.

Results

Respective differences between diagnosis and study termination dates in the GERD population versus without GERD for functional vital capacity (FVC) were - 1 L vs - 2.5 L, diffusing capacity of the lungs for carbon monoxide (DLCO) were - 2 mL/min/mmHg versus - 1 mL/min/mmHg, per cent alive at the time of study 88% versus 81%, median date of survival 574.5 versus 850 and supplemental oxygen requirement 41% versus 37%. GERD prevalence was higher in CHP patients relative to the general population. No statistical significance was found between survival curves, oxygen requirement, smoking history, FVC, or DLCO.

Conclusions

GERD could be a harmful comorbidity in CHP though may not necessarily affect survival or functional outcomes. This aligns with previous IPF studies, though remains controversial. Further research is needed regarding this association and treatment benefit.

Postoperative outcomes for sleeve gastrectomy patients with positive pH-defined GERD

BACKGROUND

Gastroesophageal reflux disease (GERD) is a possible side effect of sleeve gastrectomy (SG). However, procedure selection for patients with GERD and risk factors for morbidity after bypass surgeries is complex. For patients with a preoperative GERD diagnosis, literature related to worsening postoperative symptoms is discordant.

OBJECTIVE

This study evaluated the effects of SG on patients with pre-operative GERD confirmed through pH testing.

SETTING

University Hospital, United States.

METHODS

This was a single-center case-series. SG patients with preoperative pH testing were compared based on DeMeester scoring. Preoperative demographics, endoscopy results, need for conversion surgery, and changes in gastrointestinal quality of life (GIQLI) scores were compared. Two-sample independent t-tests assuming unequal variances were used for statistical analysis.

RESULTS

Twenty SG patients had preoperative pH testing. Nine patients were GERD positive; median DeMeester score 26.7 (22.1-31.15). Eleven patients were GERD negative, with a median DeMeester score of 9.0 (4.5-13.1). The two groups had similar median BMI, preoperative endoscopic findings and use of GERD medications. Concurrent hiatal hernia repair was performed in 22% of GERD positive vs. 36% of GERD negative patients, (p = 0.512). Two patients in the GERD positive cohort required conversion to gastric bypass (22%), while none in the GERD negative cohort did. No significant postoperative differences were noted in GIQLI, heartburn, or regurgitation symptoms.

CONCLUSION

Objective pH testing may allow the differentiation of patients who would be higher risk for need for conversion to gastric bypass. For patients with mild symptoms, but negative pH testing, SG may represent a durable option.

The Utility of Symptom Association Probability (SAP) in Predicting Outcome After Laparoscopic Fundoplication in Patients with Abnormal Esophageal Acid Exposure

INTRODUCTION

Abnormal DeMeester score on pH monitoring is a well-established predictor of favorable outcome after antireflux surgery (ARS). Esophageal pH monitoring also facilitates analysis of the temporal association between symptoms and reflux episodes. This association can be expressed with several symptom-reflux association indices with symptom association probability (SAP) being the most reliable. SAP is often used as an adjunct to DeMeester score during preoperative assessment of patients seeking ARS. However, data on the utility of SAP in predicting ARS outcome is limited. The aim of this study was to determine the utility of SAP as an adjunct to DeMeester score in predicting outcomes after fundoplication.

METHODS

Records of patients who underwent primary fundoplication from 2015 to 2021 were reviewed. Patients with a preoperative DeMeester score >14.7 on Bravo pH monitoring were included. A SAP >95% was considered SAP-positive. Favorable outcome was defined as freedom from proton pump inhibitors (PPIs) and patient satisfaction at 1 year postoperatively. Outcomes were compared based on the presence and number of SAP-positive symptoms, individual typical and atypical SAP-positive symptoms, and within demographic, clinical, and reflux severity subgroups.

RESULTS

The final study population consisted of 597 patients (71.4% female) with a median (IQR) age of 59.0 (49-67). At a mean (SD) follow-up of 10.5 (8) months, 82.0% patients achieved favorable outcome (satisfaction and freedom from PPI), freedom from PPI was 91.7%, and satisfaction was 87.4%. SAP was positive in 430 (72.0%) patients, of which 221 (37.0%) had one SAP-positive symptom, 164 (27.5%) had two SAP-positive symptoms, and 45 (7.5%) had all three SAP-positive symptoms. There was no association between having at least one SAP-positive symptom and favorable outcome (p=0.767). There was no difference in favorable outcome between patients with one, two, or all SAP-positive symptoms (0.785). Outcomes were comparable for SAP-positive typical (p=0.873) and atypical symptoms (p=1.000) and all individual symptoms (p>0.05). Outcomes were also comparable within all subgroups (p>0.05).

CONCLUSION

Symptom association probability with an abnormal DeMeester score did not enhance the prediction of antireflux surgery outcome. These findings suggest that SAP should not be used in surgical decision-making in patients with objective evidence of reflux.

Ligamentum teres cardiopexy for post vertical sleeve gastrectomy gastroesophageal reflux

PURPOSE

Vertical sleeve gastrectomy (VSG) evolved in the early 2000s into the standalone weight loss procedure we see today. While numerous studies highlight VSG's durability for weight loss, and improvements co-morbidities such as type 2 diabetes mellitus and cardiovascular disease, patients with gastroesophageal reflux disease (GERD) have been counseled against VSG due to the concern for worsening reflux symptoms. When considering anti-reflux procedures, VSG patients are unable to undergo traditional fundoplication due to lack of gastric cardia redundancy. Magnetic sphincter augmentation lacks long-term safety data and endoscopic approaches have undetermined longitudinal benefits. Until recently, the only option for patients with a history of VSG with medically refractory GERD has been conversion to roux en Y gastric bypass (RNYGB), however, this poses other risks including marginal ulcers, internal hernias, hypoglycemia, dumping syndrome, and nutritional deficiencies. Given the risks associated with conversion to RNYGB, we have adopted the ligamentum teres cardiopexy as an option for patients with intractable GERD following VSG.

METHODS

A retrospective chart review was conducted of patients who had prior laparoscopic or robotic VSG and subsequently GERD symptoms refectory to pharmacological management who underwent ligamentum teres cardiopexy between 2017 and 2022. Pre-operative GERD disease burden, intraoperative cardiopexy characteristics, post-operative GERD symptomatology and changes in H2 blocker or PPI requirements were reviewed.

RESULTS

Of the study's 60 patients the median age was 50 years old, and 86% were female. All patients had a diagnosis of GERD through pre-operative assessments and were taking antisecretory medication. Of the 36 patients who have completed their one year follow up, 81% of patients had either a decrease in dosage or cessation of the antisecretory medication at one year following ligamentum teres cardiopexy.

CONCLUSION

Ligamentum teres cardiopexy is a viable alternative to RNYGB in patients with a prior vertical sleeve gastrectomy with medical refractory GERD.

Gastro‑oesophageal reflux disease in liver cirrhosis: Possible pathogenesis and clinical intervention (Review)

Oesophageal variceal bleeding is a common complication of decompensated liver cirrhosis (LC). Some studies have reported that reflux oesophagitis (RE) is a risk factor for upper gastrointestinal bleeding, and greatly impacts the quality of life. However, the frequency and mechanism of gastro-oesophageal reflux disease (GERD) in LC remain unclear. The present review explored the possible pathogenesis, and analysed the advantages and disadvantages of the interventional measures and the need for implementation of these measures. By combining the comprehensive terms associated with LC, GERD and RE, EMBASE, Medline/PubMed and the Cochrane Library were systematically searched. The underlying pathological mechanism of GERD in LC was summarized: Transient relaxation of the lower oesophageal sphincter, delayed gastric emptying, increased intra-abdominal pressure, increased intragastric pressure and excessive nitric oxide production destroyed the 'anti-reflux barrier', causing gastric content reflux. Proton pump inhibitors (PPIs) have been widely used empirically to lower the risk of oesophageal venous rupture and bleeding. However, long-term use of acid inhibitors in patients with LC may induce complications, such as spontaneous bacterial peritonitis. The metabolic half-life of PPIs is prolonged in patients with severe liver function impairment. Therefore, the indications for using acid inhibitors lack clarity. However, after endoscopic oesophageal variceal eradication, additional benefits may be gained from the long-term use of PPIs in small doses.

Preoperative patient factors and anatomy do not predict who will develop reflux after per oral endoscopic myotomy

BACKGROUND

Per oral endoscopic myotomy (POEM) has been shown to be an efficacious and safe therapy for the treatment of achalasia. Compared to laparoscopic Heller myotomy however, no antireflux procedure is routinely combined with POEM and therefore the development of symptomatic or silent reflux is of concern. This study was designed to determine if various patient factors and anatomy would predict the development of gastroesophageal reflux disease post-operatively.

METHODS

This was a retrospective cohort study of all patients who underwent a POEM at a single institution by a single surgeon over an eight-year period (2014-2022). It has been our practice to obtain a postoperative ambulatory pH test on all patients 6 months after POEM off all acid reducing medications. Patients without a postoperative ambulatory esophageal pH monitoring test were excluded. Age, sex, obesity (BMI > 30), achalasia type, presence of a hiatal hernia, history of prior endoscopic achalasia treatments or myotomy were analyzed using univariate analysis as predictive factors for the development of postoperative GERD (DeMeester score > 14.7 on ambulatory pH monitoring).

RESULTS

There were 179 total patients included in the study with 42 patients (23.5%) having undergone postoperative ambulatory pH testing. The majority of patients (137 or 76.5%) were lost to follow up and did not undergo ambulatory pH testing. Twenty-three out of those 42 patients (55%) had evidence of GERD on ambulatory pH testing. Multiple preoperative patient characteristics including demographics, manometric results, EGD findings, and history of prior achalasia interventions did not correlate with the development of post-operative GERD.

CONCLUSIONS

Despite the high rate of reflux after POEM, there does not appear to be any reliable preoperative indicators of which patients have a higher risk of developing post-operative GERD after POEM.