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Ma S, Tong Z, He Y, Zhang Y, Guo X, Qi X. Association between hiatal hernia and Barrett's esophagus: an updated meta-analysis with trial sequential analysis. Therap Adv Gastroenterol 2024; 17:17562848231219234. [PMID: 38187927 PMCID: PMC10771746 DOI: 10.1177/17562848231219234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
Background Barrett's esophagus (BE) is a precursor of esophageal adenocarcinoma. It is critical to recognize the risk factors associated with BE. Objectives The present meta-analysis aims to systematically estimate the association of hiatal hernia with the risk of BE. Design A meta-analysis with trial sequential analysis. Data sources and methods The PubMed, EMBASE, and Cochrane Library databases were searched. The pooled odds ratios (ORs) and adjusted ORs (aORs) with their 95% confidence intervals (CIs) were calculated for the combined estimation of unadjusted data and data adjusted for confounders, respectively. Heterogeneity was quantified using the Cochrane Q test and I² statistics. Subgroup, meta-regression, and leave-one-out sensitivity analyses were employed to explore the sources of heterogeneity. Results Forty-seven studies with 131,517 participants were included. Based on the unadjusted data from 47 studies, hiatal hernia was significantly associated with an increased risk of any length BE (OR = 3.91, 95% CI = 3.31-4.62, p < 0.001). The heterogeneity was significant (I² = 77%; p < 0.001) and the definition of controls (p = 0.014) might be a potential contributor to heterogeneity. Based on the adjusted data from 14 studies, this positive association remained (aOR = 3.26, 95% CI = 2.44-4.35, p < 0.001). The heterogeneity was also significant (I² = 65%; p < 0.001). Meta-analysis of seven studies demonstrated that hiatal hernia was significantly associated with an increased risk of long-segment BE (LSBE) (OR = 10.01, 95% CI = 4.16-24.06, p < 0.001). The heterogeneity was significant (I² = 78%; p < 0.001). Meta-analysis of seven studies also demonstrated that hiatal hernia was significantly associated with an increased risk of short-segment BE (OR = 2.76, 95% CI = 2.05-3.71, p < 0.001). The heterogeneity was not significant (I² = 30%; p = 0.201). Conclusion Hiatal hernia should be a significant risk factor for BE, especially LSBE. Registration PROSPERO registration number CRD42022367376.
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Affiliation(s)
- Shaoze Ma
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Graduate School, Dalian Medical University, Dalian, China
| | - Zhenhua Tong
- Section of Medical Service, General Hospital of Northern Theater Command, Shenyang, China
| | - Yong He
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Graduate School, Shenyang Pharmaceutical University, Shenyang, China
| | - Yiyan Zhang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Graduate School, China Medical University, Shenyang, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenyang, Liaoning 110840, China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenyang, Liaoning 110840, China
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Sillcox R, Carrera R, Wright AS, Oelschlager BK, Yates RB, Tatum RP. Esophageal Motility Patterns in Paraesophageal Hernia Patients Compared to Sliding Hiatal Hernia: Bigger Is Not Better. J Gastrointest Surg 2023; 27:2039-2044. [PMID: 37340102 DOI: 10.1007/s11605-023-05754-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/11/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND In patients with paraesophageal hernias (PEH), the course of the esophagus is often altered, which may affect esophageal motility. High-resolution manometry (HRM) is frequently used to evaluate esophageal motor function prior to PEH repair. This study was performed to characterize esophageal motility disorders in patients with PEH as compared to sliding hiatal hernia and to determine how these findings affect operative decision-making. METHODS Patients referred for HRM to a single institution from 2015 to 2019 were included in a prospectively maintained database. HRM studies were analyzed for the appearance of any esophageal motility disorder using the Chicago classification. PEH patients had confirmation of their diagnosis at the time of surgery, and the type of fundoplication performed was recorded. They were case-matched based on sex, age, and BMI to patients with sliding hiatal hernia who were referred for HRM in the same period. RESULTS There were 306 patients diagnosed with a PEH who underwent repair. When compared to case-matched sliding hiatal hernia patients, PEH patients had higher rates of ineffective esophageal motility (IEM) (p<.001) and lower rates of absent peristalsis (p=.048). Of those with ineffective motility (n=70), 41 (59%) had a partial or no fundoplication performed during PEH repair. CONCLUSION PEH patients had higher rates of IEM compared to controls, possibly due to a chronically distorted esophageal lumen. Offering the appropriate operation hinges on understanding the involved anatomy and esophageal function of each individual. HRM is important to obtain preoperatively for optimizing patient and procedure selection in PEH repair.
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Affiliation(s)
- Rachel Sillcox
- Department of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.
| | - Rocio Carrera
- Department of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Andrew S Wright
- Department of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Brant K Oelschlager
- Department of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Robert B Yates
- Department of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Roger P Tatum
- Department of Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
- Department of Surgery, VA Puget Sound HCS, University of Washington, Seattle, WA, USA
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S2k-Leitlinie Gastroösophageale Refluxkrankheit und eosinophile Ösophagitis der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – März 2023 – AWMF-Registernummer: 021–013. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:862-933. [PMID: 37494073 DOI: 10.1055/a-2060-1069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
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Hao Y, Wang M, Jiang X, Zheng Y, Ran Q, Xu X, Zou B, Wang J, Liu N, Qin B. Non-acid reflux and esophageal dysmotility is associated with early esophageal squamous cell carcinoma. J Cancer Res Clin Oncol 2023:10.1007/s00432-023-04772-5. [PMID: 37074455 DOI: 10.1007/s00432-023-04772-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 04/08/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Studies have demonstrated that non-acid reflux (NAR) is associated with esophageal squamous cell carcinoma (ESCC). Esophageal dysmotility is associated with NAR but few studies have focused on the esophageal motility of ESCC patients. We explored the relationship between ESCC, NAR and esophageal dysmotility with the aid of multichannel intraluminal impedance and pH (MII-pH) and high-resolution manometry (HRM). METHODS From Jan 2021 to Oct 2022, 20 patients with superficial ESCC were enrolled as the ESCC group, while 20 age and gender matched individuals without gastroesophageal reflux disease (GERD) symptoms and 20 age and gender matched patients with GERD symptoms were recruited as the control groups. Patients received 24 h MII-pH and HRM procedure before endoscopic submucosal dissection (ESD), and the data were then collected to identify the type of reflux and esophageal dysmotility. RESULTS Prevalence of esophageal dysmotility was significantly different among the three groups, 75.0% in the ESCC group, 35.0% in the non-GERD group and 70.0% in the GERD group (P = 0.029). NAR episodes at 15 cm above the lower esophageal sphincter (LES) in the ESCC group were significantly higher than that in the non-GERD group (6.5 (3.5-9.3) vs 1.0 (0.8-4.0), P = 0.001) and were similar with that in the GERD group (6.5 (3.5-9.3) vs 5.5 (3.0-10.5), P > 0.05). NAR episodes at 5 cm above LES was significantly higher in the ESCC group than that in the non-GERD group (38.0 (27.0-60.0) vs 18.0 (11.8-25.8), P = 0.001) and was significantly higher than that in the GERD group (38.0 (27.0-60.0) vs 20.0 (9.8-30.5)), P = 0.010). Prevalence of pathologic non-acid reflux was significantly different among the three groups, 30.0% in the ESCC group, 0.0% in the non-GERD group and 10.0% in the GERD group (P < 0.001). CONCLUSION Our study found NAR and esophageal dysfunction frequently occur in ESCC patients. NAR and esophageal dysmotility may be associated with ESCC. CLINICAL TRIAL REGISTRATION NUMBER ChiCTR2200061456.
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Affiliation(s)
- Yujie Hao
- Department of Gastroenterology, Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710004, China
| | - Mo Wang
- Department of Gastroenterology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, 210008, China
| | - Xiaosa Jiang
- Department of Gastroenterology, Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710004, China
| | - Yueqin Zheng
- Department of Gastroenterology, Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710004, China
| | - Qiuju Ran
- Department of Gastroenterology, Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710004, China
| | - Xiaoyu Xu
- Department of Gastroenterology, Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710004, China
| | - Baicang Zou
- Department of Gastroenterology, Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710004, China
| | - Jinhai Wang
- Department of Gastroenterology, Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710004, China.
| | - Na Liu
- Department of Gastroenterology, Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710004, China.
| | - Bin Qin
- Department of Gastroenterology, Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710004, China.
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Shibli F, Fass OZ, Teramoto OM, Remes-Troche JM, Rangan V, Kurin M, Fass R. Esophageal Hypocontractile Disorders and Hiatal Hernia Size Are Predictors for Long Segment Barrett's Esophagus. J Neurogastroenterol Motil 2023; 29:31-37. [PMID: 36606434 PMCID: PMC9837537 DOI: 10.5056/jnm21255] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 07/22/2022] [Accepted: 08/06/2022] [Indexed: 01/07/2023] Open
Abstract
Background/Aims Presently, there is paucity of information about clinical predictors, especially esophageal motor abnormalities, for long segment Barrett's esophagus (LSBE) as compared with short segment Barrett's esophagus (SSBE). The aims of this study are to compare the frequency of esophageal function abnormalities between patients with LSBE and those with SSBE and to determine their clinical predictors. Methods This was a multicenter cohort study that included all patients with a diagnosis of BE who underwent high-resolution esophageal manometry. Motility disorders were categorized as hypercontractile disorders or hypocontractile disorders and their frequency was compared between patients with LSBE and those with SSBE. Multivariable logistic regression modeling was used to calculate the odds of being diagnosed with LSBE relative to SSBE for demographics, comorbidities, medication use, endoscopic findings, and the type of motility disorders. Results A total of 148 patients with BE were identified, of which 89 (60.1%) had SSBE and 59 (39.9%) LSBE. Patients with LSBE had a significantly larger hiatal hernia and higher likelihood of erosive esophagitis than patients with SSBE (P = 0.002). Patients with LSBE had a significantly lower mean LES resting pressure, distal contractile integral, distal latency, and significantly higher failed swallows and hypocontractile motility disorders than those with SSBE (P < 0.05). Hiatal hernia and hypocontractile motility disorder increased the odds of LSBE by 38.0% and 242.0%, as opposed to SSBE. Conclusions The presence of a hypocontractile motility disorder increased the risk for LSBE. Furthermore, the risk for LSBE was directly associated with the length of the hiatal hernia.
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Affiliation(s)
- Fahmi Shibli
- Department of Medicine, Division of Gastroenterology and Hepatology, Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Ofer Z Fass
- Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA, USA
| | - Oscar Matsubara Teramoto
- Department of Gastroenterology, ABC Medical Center PMG, Santa Fe, Contadero, Cuajimalpa de Morelos, Mexico
| | - José M Remes-Troche
- Deapartment of Digestive Physiology and Motility Laboratory, Medical Biological Research Institute, University of Veracruz, Veracruz, Mexico
| | - Vikram Rangan
- Department of Medicine, Division of Gastroenterology and Hepatology, Digestive Disease Center, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA
| | - Michael Kurin
- Department of Medicine, Division of Gastroenterology and Hepatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Ronnie Fass
- Department of Medicine, Division of Gastroenterology and Hepatology, Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Froiio C, Tareq A, Riggio V, Siboni S, Bonavina L. Real-world evidence with magnetic sphincter augmentation for gastroesophageal reflux disease: a scoping review. Eur Surg 2023. [DOI: 10.1007/s10353-022-00789-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Summary
Background
The burden of gastroesophageal reflux disease (GERD) is high, with up to 30% of the Western population reporting reflux-related symptoms with or without hiatal hernia. Magnetic sphincter augmentation (MSA) is a standardized laparoscopic procedure for patients who are dissatisfied with medical therapy and for those with early-stage disease who would not usually be considered ideal candidates for fundoplication. The MSA device is manufactured in different sizes and is designed to augment the physiologic barrier to reflux by magnetic force.
Methods
An extensive scoping review was performed to provide a map of current evidence with respect to MSA, to identify gaps in knowledge, and to make recommendations for future research. All the authors contributed to the literature search in PubMed and Web of Science and contributed to summarizing the evidence.
Results
Magnetic sphincter augmentation, especially in combination with crural repair, is effective in reducing GERD symptoms, proton pump inhibitor use, and esophageal acid exposure, and in improving patients’ quality of life. Safety issues such as device erosion or migration have been rare and not associated with mortality. The MSA device can be removed laparoscopically if necessary, thereby preserving the option of fundoplication or other therapies in the future. Contraindication to scanning in high-power Tesla magnetic resonance systems remains a potential limitation of the MSA procedure. High-resolution manometry and functional lumen imaging probes appear to be promising tools to predict procedural outcomes by improving reflux control and reducing the incidence of dysphagia.
Conclusion
A consensus on acquisition and interpretation of high-resolution manometry and impedance planimetry data is needed to gain better understanding of physiology, to improve patient selection, and to pave the way for a personalized surgical approach in antireflux surgery.
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Gastroesophageal Reflux Disease in Idiopathic Pulmonary Fibrosis: Viewer or Actor? To Treat or Not to Treat? Pharmaceuticals (Basel) 2022; 15:ph15081033. [PMID: 36015181 PMCID: PMC9412643 DOI: 10.3390/ph15081033] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/14/2022] [Accepted: 08/19/2022] [Indexed: 02/07/2023] Open
Abstract
Background: Idiopathic pulmonary fibrosis (IPF) is a rare and severe disease with a median survival of ∼3 years. Several risk factors have been identified, such as age, genetic predisposition, tobacco exposure, and gastro-oesophageal reflux disease (GERD). Prevalence of GERD in IPF is high and may affect 87% of patients, of whom only half (47%) report symptoms. Objective: The aim of this study is to review current evidence regarding the correlation between GERD and IPF and to evaluate the current studies regarding treatments for GERD-IPF. Methods: A review to identify research papers documenting an association between GERD and IPF was performed. Results: We identified several studies that have confirmed the association between GERD and IPF, with an increased acid exposure, risk of gastric aspiration and bile acids levels in these patients. Few studies focused their attention on GERD treatment, showing how antiacid therapy was not able to change IPF evolution. Conclusions: This review investigating the correlation between GERD and IPF has confirmed the hypothesized association. However, further large prospective studies are needed to corroborate and elucidate these findings with a focus on preventative and treatment strategies.
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Pyloric Incompetence Associated with Helicobactor pylori Infection and Correlated to the Severity of Atrophic Gastritis. Diagnostics (Basel) 2022; 12:diagnostics12030572. [PMID: 35328125 PMCID: PMC8947545 DOI: 10.3390/diagnostics12030572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 11/16/2022] Open
Abstract
Duodenogastric reflux (DGR) causes bile reflux gastritis (BRG) and may develop into gastric cancer. DGR is classified as primary in non-operated stomachs or secondary to surgical intervention. Primary DGR and Helicobacter pylori (H. pylori) infection are reportedly related. However, the mechanism is not fully understood. This study aimed to elucidate the relationship between H. pylori infection and pyloric incompetence in a non-operated stomach. A total of 502 non-operated participants who underwent an upper intestinal endoscopy were prospectively enrolled. Endoscopic findings (EAC, endoscopic atrophy classification; nodular gastritis; xanthoma; fundic gland polyp; and incompetence of pylorus), sex, age, gastrin, pepsinogen (PG) I and PG II levels were evaluated. PG I/PG II ratio, anti-H. pylori-Ab positivity, and atrophic gastritis status were significantly different between the normal and incompetent pylori (p = 0.043, <0.001, and 0.001, respectively). Open-type atrophic gastritis was significantly higher in the incompetent pylori. Incompetence of the pylorus and EAC were moderately correlated (Cramer’s V = 0.25). Multivariate analysis revealed that the presence of anti-H. pylori-Ab was the only independent factor associated with the incompetence of the pylorus, with an adjusted odds ratio of 2.70 (95% CI: 1.47−4.94, p = 0.001). In conclusion, pyloric incompetence was associated with H. pylori infection and moderately correlated to the severity of atrophic gastritis in non-operated stomachs.
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Fuchs KH, Breithaupt W, Varga G, Babic B, Schulz T, Meining A. Primary laparoscopic fundoplication in selected patients with gastroesophageal reflux disease. Dis Esophagus 2022; 35:6277415. [PMID: 34002235 DOI: 10.1093/dote/doab032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/30/2021] [Accepted: 04/20/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite proton pump inhibitors being a powerful therapeutic tool, laparoscopic fundoplication (LF) has proven successful in the treatment of gastroesophageal reflux disease (GERD), through mechanical augmentation of a weak antireflux barrier and the advantages of minimally invasive access. A critical patient selection for LF, based on thorough preoperative assessment, is important for the management of GERD-patients. The purpose of this study is to provide an overview on the management of GERD-patients treated by primary LF in a specialized center and to illustrate the possible outcome after several years. METHODS Patients were selected after going through diagnostic workup consisting of patient's history and physical examination, upper gastrointestinal endoscopy, assessment of gastrointestinal Quality of Life Index, screening for somatoform disorders, functional assessment by esophageal manometry, (impedance)-24-hour-pH-monitoring, and selective radiographic studies. The indication for LF was based on EAES-guidelines. Either a floppy and short Nissen fundoplication was performed or a posterior Toupet-hemifundoplication was chosen. A long-term follow-up assessment was attempted after surgery. RESULTS In total, n = 1131 patients were evaluated (603 males; 528 females; mean age; 48.3 years; and mean body mass index: 27). The mean duration between onset of symptoms and surgery was 8 years. Nissen: n = 873, Toupet: n = 258; conversion rateerativ: 0.5%; morbidity 4%, mortality: 1 (1131). Mean follow-up (n = 898; 79%): 5.6 years; pre/post-op results: esophagitis: 66%/12.1%; Gastrointestinal Quality of Life Index: median: 92/119; daily proton pump inhibitors-intake after surgery: 8%; and operative revisions 4.3%. CONCLUSIONS In conclusion, our data show that careful patient selection for laparoscopic fundoplication and well-established technical concepts of mechanical sphincter augmentation can provide satisfying results in the majority of patients with severe GERD.
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Affiliation(s)
- K H Fuchs
- Laboratory for Interventional and Experimental Endoscopy, University of Würzburg, Würzburg, Germany
| | - W Breithaupt
- Department of General and Visceral Surgery, St. Elisabethen Krankenhaus, Frankfurt, Germany
| | - G Varga
- AGAPLESION Markus Krankenhaus, Department of General and Visceral Surgery, Frankfurt, Germany
| | - B Babic
- University of Cologne, Department of General-, Visceral-and Cancer Surgery, Cologne, Germany
| | - T Schulz
- Department of General and Visceral Surgery, St. Elisabethen Krankenhaus, Frankfurt, Germany
| | - A Meining
- Laboratory for Interventional and Experimental Endoscopy, University of Würzburg, Würzburg, Germany.,University of Würzburg, Zentrum Innere Medizin, Head of Gastroenterology, Würzburg, Germany
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Fuchs KH, Lee AM, Breithaupt W, Varga G, Babic B, Horgan S. Pathophysiology of gastroesophageal reflux disease-which factors are important? Transl Gastroenterol Hepatol 2021; 6:53. [PMID: 34805575 DOI: 10.21037/tgh.2020.02.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 02/10/2020] [Indexed: 12/16/2022] Open
Abstract
Background Pathophysiology of gastroesophageal reflux disease (GERD) shows a multifactorial background. Different anatomical and functional alterations can be determined such as weakness of the lower esophageal sphincter (LES), changes in anatomy by a hiatal hernia (HH), an impaired esophageal motility (IEM), and/or an associated gastric motility problem with either duodeno-gastro-esophageal reflux (DGER) or delayed gastric emptying (DGE). The purpose of this study is to assess a large GERD-patient population to quantitatively determine different pathophysiologic factors contributing to the disease. Methods For this analysis only patients with documented GERD (pathologic esophageal acid exposure) were selected from a prospectively maintained databank. Investigations: history and physical, body mass index, endoscopy, esophageal manometry, 24 h-pH-monitoring, 24 h-bilirbine-monitoring, radiographic-gastric-emptying or scintigraphy, gastrointestinal quality of life index (GIQLI). Results In total, 728 patients (420 males; 308 females) were selected for this analysis. Mean age: 49.9 years; mean BMI: 27.2 kg/m2 (range, 20-45 kg/m2); mean GIQLI of 91 (range: 43-138; normal level: 121); no esophagitis: 30.6%; minor esophagitis (Savary-Miller type 1 or Los Angeles Grade A): 22.4%; esophagitis [2-4]/B-D: 36.2%; Barrett's esophagus 10%. Presence of pathophysiologic factors: HH 95.4%; LES-incompetence 88%, DGER 55%, obesity 25.6%, IEM 8.8%, DGE 6.8%. Conclusions In our evaluation of GERD patients, the most important pathophysiologic components are anatomical alterations (HH), LES-incompetence and DGER.
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Affiliation(s)
- Karl-Hermann Fuchs
- Department of Surgery, Center for the Future of Surgery, University of California San Diego, La Jolla, CA, USA
| | - Arielle M Lee
- Department of Surgery, Center for the Future of Surgery, University of California San Diego, La Jolla, CA, USA
| | - Wolfram Breithaupt
- AGAPLESION Markus Krankenhaus, Klinik für Allgemeine und Viszeralchirurgie, Frankfurt am Main, Germany
| | - Gabor Varga
- AGAPLESION Markus Krankenhaus, Klinik für Allgemeine und Viszeralchirurgie, Frankfurt am Main, Germany
| | - Benjamin Babic
- Klinik und Poliklinik für Allgemeine-, Viszeral- und Tumorchirurgie, Universitätskliniken Köln, Cologne, Germany
| | - Santiago Horgan
- Department of Surgery, Center for the Future of Surgery, University of California San Diego, La Jolla, CA, USA
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Clinical usefulness of esophageal high resolution manometry and adjunctive tests: An update. Dig Liver Dis 2021; 53:1373-1380. [PMID: 33994122 DOI: 10.1016/j.dld.2021.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 12/11/2022]
Abstract
High resolution manometry (HRM), developed from conventional manometry, is the gold standard for assessment of esophageal motor function worldwide. The Chicago Classification, now in its fourth iteration, is the modern standard for HRM categorization of esophageal motility disorders. The HRM protocol has expanded from the original 10 supine swallow standard, to include upright swallows, and provocative maneuvers such as multiple rapid swallows, rapid drink challenge and standardized test meal. Impedance has been incorporated into HRM for visualization of bolus clearance. Futhermore, barium radiography and functional lumen imaging probe complement HRM when evidence of esophagogastric junction obstruction is inconclusive. The biggest impact of HRM is in the improved diagnosis and subtyping of achalasia spectrum disorders, with implications on management. Spastic disorders and absent contractility are better characterized. Within the reflux spectrum, HRM provides definition of morphology and tone of the esophagogastric junction, and assesses integrity of esophageal body peristalsis, which have pathophysiologic implications for reflux and its clearance. HRM provides characterization of behavioral disorders such as supragastric belching and rumination syndrome, which can mimic reflux disease. Thus, HRM has revolutionized the evaluation of esophageal motor function, and has expanded the utility of esophageal manometry in clinical practice.
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Mahmoud T, Jaruvongvanich V, Ghazi R, Abusaleh R, Abu Dayyeh BK. Complete endoscopic removal of an eroded magnetic sphincter augmentation device. VideoGIE 2021; 6:450-453. [PMID: 34660945 PMCID: PMC8503934 DOI: 10.1016/j.vgie.2021.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Tala Mahmoud
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Rabih Ghazi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Rami Abusaleh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Fuchs KH, DeMeester TR, Otte F, Broderick RC, Breithaupt W, Varga G, Musial F. Severity of GERD and disease progression. Dis Esophagus 2021; 34:6133416. [PMID: 33575739 DOI: 10.1093/dote/doab006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 12/01/2020] [Accepted: 01/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Many factors may play a role in the severity and progression of gastroesophageal reflux disease (GERD) since pathophysiology is multifactorial. Data regarding the progression of GERD are controversial: some reports of increased esophageal acid exposure (EAE) and mucosal damage were considered as evidence for a stable disease course, while others interprete these findings as disease progression. The aim of this study is to analyze a large patient-population with persisting symptoms indicative of GERD under protonpumpinhibitor-therapy and identify components characterizing disease severity and progression. METHODS Patients with symptoms indicative of GERD were included in the study in a tertiary referral center (Frankfurt, Germany). All selected patients were under long-term protonpumpinhibitor-therapy with persistant symptoms. All patients underwent investigations to collect data on their physical status, EAE, severity of esophagitis, anatomical changes, and esophageal functional defects as well as their relation to the duration of the disease. Incidence over time was plotted as survival curves and tested with Log-rank tests for the four main disease markers. Multivariate modeling with COX-regression model was used to estimate the general impact of the four main disease markers on the time course of the disease. In order to elucidate possible causal relationships over time, a path analysis (structural equation model) was calculated. RESULTS From the database with 1480 data sets, 972 patients were evaluated (542 males, 430 females). The mean age was 50.5 years (range18-89). The mean body mass index was 27.2(19-48). The mean time between the onset of symptoms and the diagnostic investigations was 8.2 years (1-50). A longer disease history for GERD was significantly associated with a higher risk for LES-incompetence. The mean duration from symptom onset to the time of clinical investigation was 9 years for patients with LES-incompetence (n = 563), compared to a mean of 6 years for those with mechanically intact LES (n = 95). A longer period from symptom onset to diagnostics was significantly associated with higher acid exposure. The pathway analysis was significant for the following model: 'history' (P < 0.001➔LES-incompetence & Hiatal Hernia➔(p < 0,001)➔pH-score (P < 0.001).Conclusion: LES-incompetence, the functional deterioration of the LES, and the anatomical alteration at the esophagogastric junction (Hiatal Hernia) as well as an increased EAE were associated with a long history of suffering from GERD. Path modeling suggests a causal sequence overtime of the main disease-parameters, tentatively allowing for a prediction of the course of the disease.
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Affiliation(s)
- K H Fuchs
- University of California San Diego, Department of Surgery, Center for the Future of Surgery, La Jolla, CA, USA
| | - T R DeMeester
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - F Otte
- University of Cologne, Department of General-, Visceral- and Cancer Surgery Cologne, Germany
| | - R C Broderick
- University of California San Diego, Department of Surgery, Center for the Future of Surgery, La Jolla, CA, USA
| | - W Breithaupt
- St. Elisabethen Krankenhaus, Department of General and Visceral Surgery, Frankfurt am Main, Germany
| | - G Varga
- AGAPLESION Markus Krankenhaus, Department of General and Visceral Surgery, Frankfurt am Main, Germany
| | - F Musial
- The National Research Center in Complementary and Alternative Medicine NAFKAM, Department of Community Medicine, UiT, The Artic University of Noeway, Tromsø, Norway
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Fass R, Boeckxstaens GE, El-Serag H, Rosen R, Sifrim D, Vaezi MF. Gastro-oesophageal reflux disease. Nat Rev Dis Primers 2021; 7:55. [PMID: 34326345 DOI: 10.1038/s41572-021-00287-w] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2021] [Indexed: 02/07/2023]
Abstract
Gastro-oesophageal reflux disease (GERD) is a common disorder in adults and children. The global prevalence of GERD is high and increasing. Non-erosive reflux disease is the most common phenotype of GERD. Heartburn and regurgitation are considered classic symptoms but GERD may present with various atypical and extra-oesophageal manifestations. The pathophysiology of GERD is multifactorial and different mechanisms may result in GERD symptoms, including gastric composition and motility, anti-reflux barrier, refluxate characteristics, clearance mechanisms, mucosal integrity and symptom perception. In clinical practice, the diagnosis of GERD is commonly established on the basis of response to anti-reflux treatment; however, a more accurate diagnosis requires testing that includes upper gastrointestinal tract endoscopy and reflux monitoring. New techniques and new reflux testing parameters help to better phenotype the condition. In children, the diagnosis of GERD is primarily based on history and physical examination and treatment vary with age. Treatment in adults includes a combination of lifestyle modifications with pharmacological, endoscopic or surgical intervention. In refractory GERD, optimization of proton-pump inhibitor treatment should be attempted before a series of diagnostic tests to assess the patient's phenotype.
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Affiliation(s)
- Ronnie Fass
- The Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, MetroHealth Medical System, Case Western Reserve University, Cleveland, OH, USA.
| | - Guy E Boeckxstaens
- Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - Hashem El-Serag
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Sifrim
- Wingate Institute of Neurogastroenterology, Royal London Hospital, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
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15
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Zerbib F, Bredenoord AJ, Fass R, Kahrilas PJ, Roman S, Savarino E, Sifrim D, Vaezi M, Yadlapati R, Gyawali CP. ESNM/ANMS consensus paper: Diagnosis and management of refractory gastro-esophageal reflux disease. Neurogastroenterol Motil 2021; 33:e14075. [PMID: 33368919 DOI: 10.1111/nmo.14075] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/11/2020] [Accepted: 12/13/2020] [Indexed: 02/08/2023]
Abstract
Up to 40% of patients with symptoms suspicious of gastroesophageal reflux disease (GERD) do not respond completely to proton pump inhibitor (PPI) therapy. The term "refractory GERD" has been used loosely in the literature. A distinction should be made between refractory symptoms (ie, symptoms may or may not be GERD-related), refractory GERD symptoms (ie, persisting symptoms in patients with proven GERD, regardless of relationship to ongoing reflux), and refractory GERD (ie, objective evidence of GERD despite adequate medical management). The present ESNM/ANMS consensus paper proposes use the term "refractory GERD symptoms" only in patients with persisting symptoms and previously proven GERD by either endoscopy or esophageal pH monitoring. Even in this context, symptoms may or may not be reflux related. Objective evaluation, including endoscopy and esophageal physiologic testing, is requisite to provide insights into mechanisms of symptom generation and evidence of true refractory GERD. Some patients may have true ongoing refractory acid or weakly acidic reflux despite PPIs, while others have no evidence of ongoing reflux, and yet others have functional esophageal disorders (overlapping with proven GERD confirmed off therapy). In this context, attention should also be paid to supragastric belching and rumination syndrome, which may be important contributors to refractory symptoms.
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Affiliation(s)
- Frank Zerbib
- CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, Gastroenterology Department, Université de Bordeaux, INSERM CIC 1401, Bordeaux, France
| | | | - Ronnie Fass
- Digestive Health Center, MetroHealth System, Cleveland, OH, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Sabine Roman
- Hospices Civils de Lyon, Hôpital E Herriot, Digestive Physiology, Université de Lyon, Inserm U1032, LabTAU, Lyon, France
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padua, Padua, Italy
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michael Vaezi
- Division of Gastroenterology, Vanderbilt University, Nashville, TN, USA
| | - Rena Yadlapati
- Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla, CA, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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16
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Thota PN, Malik S, Shakya S, AnilKumar M, Gabbard S, Sanaka MR, Rice T, Raja S, Murthy S, Lopez R. Changes in esophageal physiology after paraesophageal hernia repair and Collis gastroplasty. Esophagus 2021; 18:339-345. [PMID: 32734586 DOI: 10.1007/s10388-020-00766-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/24/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND The surgical approach and technique for paraesophageal hernia (PEH) repair is much debated. The changes in the esophageal physiology after PEH repair with a concomitant Collis gastroplasty (PEH-CG) are not clearly known. The aim of this study was to determine the changes in high resolution esophageal manometry (HREM) and esophageal pH testing after PEH-CG. METHODS Retrospective analysis of all patients who underwent PEH-CG at our institution between 2006 and 2013 was performed. Patients had esophageal pH testing, HREM, barium swallow and an upper endoscopy before and after PEH-CG. RESULTS A total of 182 patients underwent PEH-CG during the study period. Majority of patients had Nissen fundoplication (176, 96.7%) with Toupet in 6 (3.3%). Basal lower esophageal sphincter pressure (LESP) was lower after fundoplication (20.3 mmHg ± 11.3 vs. 25.8 mmHg ± 15.6, p < 0.001), whereas residual LESP was noted to be higher after fundoplication (7.7 mmHg ± 4.9 vs. 6.1 mmHg ± 6.7, p < 0.009). There were no significant changes in the esophageal motility patterns. There was an improvement in total pH and upright pH but not supine pH post PEH-CG. Normalization of total acid exposure after fundoplication was noted in 31 (59.6%) of the 52 patients who had abnormal total acid exposure prior to fundoplication. CONCLUSIONS Objective clinical assessment in patients undergoing PEH-CG demonstrates an effective operation for this complex problem. There was an increase in residual LESP but interestingly, decrease in basal LESP. Additionally, there was an improvement in esophageal acid exposure afterwards. These findings will facilitate future management of PEH.
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Affiliation(s)
- Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
| | - Sonika Malik
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Sampurna Shakya
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Mythri AnilKumar
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Scott Gabbard
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Madhusudhan R Sanaka
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Thomas Rice
- Department of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Siva Raja
- Department of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Sudish Murthy
- Department of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Rocio Lopez
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
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17
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Papadia FS, Marabotto E, Mascherini M, Rubartelli A, Camerini G, Giannini EG. Sleeve gastrectomy may double the risk of esophageal adenocarcinoma in morbidly obese patients. Surg Obes Relat Dis 2021; 17:1029-1030. [PMID: 33712394 DOI: 10.1016/j.soard.2021.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 01/24/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Francesco S Papadia
- Department of Surgical Sciences and Integrated Diagnostics, School of Medical and Pharmaceutical Sciences, Ospedale Policlinico San Martino- IRCCS per l'Oncologia Genoa, Italy
| | - Elisa Marabotto
- Department of Internal Medicine, University of Genoa School of Medical and Pharmaceutical Sciences, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | | | | | | | - Edoardo G Giannini
- Department of Internal Medicine, University of Genoa School of Medical and Pharmaceutical Sciences, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
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18
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Mukundu Nagesh N, Osilli D, Khoo D. Giant hiatus hernia presenting as a chronic cough masking a sinister diagnosis. BMJ Case Rep 2020; 13:13/12/e235802. [PMID: 33303497 DOI: 10.1136/bcr-2020-235802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a case of an 82-year-old gentleman with an 18-month history of productive cough. Urgent CT scan of the thorax revealed type 1 hiatus hernia (HH). The patient was managed conservatively with lifestyle modifications to help his reflux symptomology. The patient subsequently presented with acute shortness of breath and vomiting. Repeat CT scan reported a giant incarcerated HH (15 cm). Endoscopy revealed an incidental finding of a 3 cm polypoid lesion in the oesophagus at the level of the carina and histology of biopsies reported an invasive adenocarcinoma. During admission, the patient unfortunately had a hospital acquired infection and cardiac complications which prevented surgical intervention. Patients with suspected HH should be investigated thoroughly with imaging studies including chest X-ray, CT or MRI alongside oesophageal manometry and gastroscopy. Endoscopic evaluation is particularly important as these patients are at higher risk of Barrett's oesophagus and invasive malignancy.
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Affiliation(s)
| | - Dixon Osilli
- General Surgery, Queen's Hospital, Romford, London, UK
| | - David Khoo
- General Surgery, Queen's Hospital, Romford, London, UK
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19
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Kim MS, Oh Y, Lee JH, Park JM, Kim JJ, Song KY, Ryu SW, Seo KW, Kim HI, Kim DJ, Park S, Han SU. Trends in laparoscopic anti-reflux surgery: a Korea nationwide study. Surg Endosc 2020; 35:4241-4250. [PMID: 32875418 DOI: 10.1007/s00464-020-07909-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 08/17/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND In 2014, the results derived from the nationwide data of the Korean Anti-reflux Surgery Study (KARS) demonstrated short-term feasibility and safety of anti-reflux surgery. This study aimed to update the longer-term safety and feasibility of laparoscopic anti-reflux surgery up to 1-year follow-up with the KARS nationwide cohort. METHODS The data of 310 patients with GERD who received anti-reflux surgery up to 2018 were analyzed. Baseline patient characteristics, postoperative symptom resolution, and postoperative complications were evaluated at postoperative 3 months and 1 year using the questionnaire designed by KARS. We divided the patients into two groups according to the operation period (up to and after 2014) to identify changes in the trends of the characteristics of surgical patients and operative qualities. RESULTS The typical preoperative symptoms were present in 275 patients (91.7%), and atypical symptoms were present in 208 patients (71.0%). Ninety-seven (35.5%) and 124 patients (46.1%) had inadequate PPI responses and hiatal hernia, respectively. At postoperative 1 year, typical and atypical symptoms were either completely or partially controlled in 90.3% and 73.5.0% of patients, respectively. Moderate-to-severe dysphagia, inability to belch, gas bloating, and flatulence at postoperative 1 year were identified in 23.5%, 29.4%, 23.2%, and 22.0% of patients, respectively. The number of surgical patients continuously increased from 2011 to 2018 in Korea. The proportion of patients with hiatal hernia and comorbidities increased (p < 0.01, p = 0.053), and the operation time decreased significantly (p < 0.01) in the late period (2015-2018) as compared with the early period (2011-2014). Symptom control and complication rate were equivalent between the two periods. CONCLUSIONS Anti-reflux surgery was effective with > 90% of typical symptom resolution and posed a comparable postoperative complication rate with those in Western studies with mid-term to long-term follow-up. This result supports the feasibility and safety of anti-reflux surgery as a treatment for GERD in the Korean population.
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Affiliation(s)
- Min Seo Kim
- Korea University College of Medicine, Seoul, Republic of Korea
| | - Youjin Oh
- Korea University College of Medicine, Seoul, Republic of Korea
| | - Jun-Hyun Lee
- Department of Surgery, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Joong-Min Park
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Jin-Jo Kim
- Department of Surgery, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Kyo Young Song
- Department of Surgery, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Seung Wan Ryu
- Department of Surgery, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Kyung Won Seo
- Department of Surgery, Kosin University College of Medicine, Busan, Republic of Korea
| | - Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Jin Kim
- Department of Surgery, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Sungsoo Park
- Division of Upper Gastrointestinal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Inchon-ro 73, Seongbuk-gu, Seoul, 136-705, Republic of Korea.
| | - Sang-Uk Han
- Department of Surgery, Ajou University School of Medicine, 206 WorldCup-ro, Yeongtong-gu, Suwon, 443-749, Republic of Korea.
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20
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The Development and Natural History of Hiatal Hernias: A Study Using Sequential Barium Upper Gastrointestinal Series. Ann Surg 2020; 275:534-538. [PMID: 32773629 DOI: 10.1097/sla.0000000000004140] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to use barium upper gastrointestinal series (UGI) to evaluate the development and natural history of a hiatal hernia. SUMMARY OF BACKGROUND DATA Hiatal hernias are common but the natural history of sliding and paraesophageal type hernias is poorly understood. METHODS We reviewed UGI reports from 1987 to 2017 using a word scanning software program to identify individuals that had a hiatal hernia. Only those with at least 2 UGI studies 5 or more years apart were selected. The studies were then reviewed. RESULTS There were 89 individuals that met inclusion criteria. Twenty-one people had no hiatal hernia on initial UGI and over a median of 99 months a sliding hiatal hernia (SHH) developed in 16 and a PEH developed in 5 people. A SHH was present on initial UGI in 55 people and at a median of 84 months subsequent UGI showed the SHH was stable in 11 (20%), increased in size in 30 (55%), and changed to a PEH in 14 people (25%). In 13 people a PEH was present on initial UGI and over a median of 97 months it was stable in 5 and increased in size in 8 people (62%). CONCLUSIONS We showed that both SHH and PEH can develop over time and that the majority of both increased in size on follow-up UGI study. Further, 25% of SHH became a PEH over time. Recognizing an increase in size or change in type of a hiatal hernia may be clinically relevant to help understand changing or worsening symptoms in an individual.
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21
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Abstract
Various esophageal functional abnormalities have been described in patients with Barrett's esophagus (BE). A significantly higher esophageal acid exposure especially in the supine position has been documented in BE, as compared with the other gastroesophageal reflux disease phenotypes. In addition, weakly acidic reflux and duodenogastroesophageal reflux are more common in BE patients. The presence of Barrett's mucosa reduces esophageal mucosal impedance, occasionally to a level that prevents detection of reflux episodes. Reduced amplitude contractions and lower esophageal sphincter basal pressure are more common in BE patients as compared with the other gastroesophageal reflux disease groups. Ineffective esophageal motility is the most commonly defined motor disorder in BE. Reduced chemoreceptor and mechanoreceptor sensitivity to acid and balloon distention, respectively, have been suggested to explain lack or significantly less reports of reflux-related symptoms by BE patients.
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22
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Bonavina L, Fisichella PM, Gavini S, Lee YY, Tatum RP. Clinical course of gastroesophageal reflux disease and impact of treatment in symptomatic young patients. Ann N Y Acad Sci 2020; 1481:117-126. [PMID: 32266986 DOI: 10.1111/nyas.14350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 12/14/2022]
Abstract
In symptomatic young patients with gastroesophageal reflux symptoms, early identification of progressive gastroesophageal reflux disease (GERD) is critical to prevent long-term complications associated with hiatal hernia, increased esophageal acid and nonacid exposure, release of proinflammatory cytokines, and development of intestinal metaplasia, endoscopically visible Barrett's esophagus, and dysplasia leading to esophageal adenocarcinoma. Progression of GERD may occur in asymptomatic patients and in those under continuous acid-suppressive medication. The long-term side effects of proton-pump inhibitors, chemopreventive agents, and radiofrequency ablation are contentious. In patients with early-stage disease, when the lower esophageal sphincter function is still preserved and before endoscopically visible Barrett's esophagus develops, novel laparoscopic procedures, such as magnetic and electric sphincter augmentation, may have a greater role than conventional surgical therapy. A multidisciplinary approach to GERD by a dedicated team of gastroenterologists and surgeons might impact the patients' lifestyle, the therapeutic choices, and the course of the disease. Biological markers are needed to precisely assess the risk of disease progression and to tailor surveillance, ablation, and management.
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Affiliation(s)
- Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, Milano, Italy
| | - P Marco Fisichella
- Department of Surgery, Northwestern University, Feinberge School of Medicine, Chicago, Illinois
| | - Sravanya Gavini
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Malaysia.,Gut Research Group, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.,St George & Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Roger P Tatum
- Department of Surgery, University of Washington School of Medicine and VA Puget Sound Health Care System, Seattle, Washington
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23
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Abstract
GERD is a spectrum disorder, and treatment should be individualized to the patient's anatomic alterations. Trans-oral incisionless fundoplication (TIF 2.0) is an endoscopic procedure which reduces EGJ distensibility, thereby decreasing tLESRs, and also creates a 3-cm high pressure zone at the distal esophagus in the configuration of a flap valve. As it produces a partial fundoplication with a controlled valve diameter, gas can still escape from the stomach, minimizing the side-effect of gas-bloat. Herein we discuss the rationale, mechanism of action, patient selection, step-by-step procedure, safety and efficacy data, it's use with concomitant laparoscopic hernia repair, and future emerging indications.
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24
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DeMeester SR. Laparoscopic Hernia Repair and Fundoplication for Gastroesophageal Reflux Disease. Gastrointest Endosc Clin N Am 2020; 30:309-324. [PMID: 32146948 DOI: 10.1016/j.giec.2019.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Antireflux surgery is challenging, and has become even more challenging with the introduction of alternative endoscopic and laparoscopic options for patients with gastroesophageal reflux disease (GERD). The Nissen fundoplication remains the gold standard for the durable relief of GERD symptoms and esophagitis. All antireflux procedures have a failure rate, and it is important to minimize factors that are associated with failure. The selection of patients for antireflux surgery as well as the choice of the procedure requires a thorough understanding of esophageal physiology and the pros and cons of various options.
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Affiliation(s)
- Steven R DeMeester
- Thoracic and Foregut Surgery, General and Minimally Invasive Surgery, The Oregon Clinic, 4805 Northeast Glisan Street, Suite 6N60, Portland, OR 97213, USA.
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25
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Does Treatment of the Hiatus Influence the Outcomes of Magnetic Sphincter Augmentation for Chronic GERD? J Gastrointest Surg 2019; 23:1104-1112. [PMID: 30877608 DOI: 10.1007/s11605-019-04180-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 02/22/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hiatal dissection, restoration of esophageal intra-abdominal length, and crural closure are key components of successful antireflux surgery. The necessity of addressing these components prior to magnetic sphincter augmentation (MSA) has been questioned. We aimed to compare outcomes of MSA between groups with differing hiatal dissection and closure. METHODS We retrospectively reviewed 259 patients who underwent MSA from 2009 to 2017. Patients were categorized based on hiatal treatment: minimal dissection (MD), crural closure (CC), formal crural repair (FC), and extensive dissection without closure (ED). The primary outcome was normalization of postoperative DeMeester score (≤ 14.72). Univariable and multivariable logistic regression was used to assess which preoperative predictors achieved normalization. RESULTS Of the 197 patients, MD was used in 81 (41%); FC in 42 (22%); CC in 40 (20%); and ED in 34 (17%). Normalization occurred in 104 (53%) patients, with MD achieving normalization in 45/81 (56%); FC in 25/42 (60%); CC in 21/40 (53%); and ED 13/34 (38%). After regression, FC was most likely to normalize acid exposure. The presence of a hiatal hernia, defective LES, and higher preoperative DeMeester score were less likely to achieve normalization. CONCLUSIONS Hiatal dissection with restoration of esophageal length and crural closure during MSA increases the likelihood of normalizing acid exposure.
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26
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Chang KJ. Endoscopic foregut surgery and interventions: The future is now. The state-of-the-art and my personal journey. World J Gastroenterol 2019; 25:1-41. [PMID: 30643356 PMCID: PMC6328959 DOI: 10.3748/wjg.v25.i1.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 02/06/2023] Open
Abstract
In this paper, I reviewed the emerging field of endoscopic surgery and present data supporting the contention that endoscopy can now be used to treat many foregut diseases that have been traditionally treated surgically. Within each topic, the content will progress as follows: "lessons learned", "technical considerations" and "future opportunities". Lessons learned will provide a brief background and update on the most current literature. Technical considerations will include my personal experience, including tips and tricks that I have learned over the years. Finally, future opportunities will address current unmet needs and potential new areas of development. The foregut is defined as "the upper part of the embryonic alimentary canal from which the pharynx, esophagus, lung, stomach, liver, pancreas, and part of the duodenum develop". Foregut surgery is well established in treating conditions such as gastroesophageal reflux disease (GERD), achalasia, esophageal diverticula, Barrett's esophagus (BE) and esophageal cancer, stomach cancer, gastric-outlet obstruction, and obesity. Over the past decade, remarkable progress in interventional endoscopy has culminated in the conceptualization and practice of endoscopic foregut surgery for various clinical conditions summarized in this paper. Regarding GERD, there are now several technologies available to effectively treat it and potentially eliminate symptoms, and the need for long-term treatment with proton pump inhibitors. For the first time, fundoplication can be performed without the need for open or laparoscopic surgery. Long-term data going out 5-10 years are now emerging showing extended durability. In respect to achalasia, per-oral endoscopic myotomy (POEM) which was developed in Japan, has become an alternative to the traditional Heller's myotomy. Recent meta-analysis show that POEM may have better results than Heller, but the issue of post-POEM GERD still needs to be addressed. There is now a resurgence of endoscopic treatment of Zenker's diverticula with improved technique (Z-POEM) and equipment; thus, patients are choosing flexible endoscopic treatment as opposed to open or rigid endoscopy options. In regard to BE, endoscopic submucosal dissection (ESD) which is well established in Asia, is now becoming more mainstream in the West for the treatment of BE with high grade dysplasia, as well as early esophageal cancer. In combination with all the ablation technologies (radiofrequency ablation, cryotherapy, hybrid argon plasma coagulation), the entire spectrum of Barrett's and related dysplasia and early cancer can be managed predominantly by endoscopy. Importantly, in regard to early gastric cancer and submucosal tumors (SMTs) of the stomach, ESD and full thickness resection (FTR) can excise these lesions en-bloc and endoscopic suturing is now used to close large defects and perforations. For treatment of patients with malignant gastric outlet obstruction (GOO), endoscopic gastro-jejunostomy is now showing better results than enteral stenting. G-POEM is also emerging as a treatment option for patients with gastroparesis. Obesity has become an epidemic in many western countries and is becoming also prevalent in Asia. Endoscopic sleeve gastroplasty (ESG) is now becoming an established treatment option, especially for obese patients with body mass index between 30 and 35. Data show an average weight loss of 16 kg after ESG with long-term data confirming sustainability. Finally, in respect to endo-hepatology, there are many new endoscopic interventions that have been developed for patients with liver disease. Endoscopic ultrasound (EUS)-guided liver biopsy and EUS-guided portal pressure measurement are exciting new frontiers for the endo-hepatologists.
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Affiliation(s)
- Kenneth J Chang
- H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, CA 92868, United States
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Seo HS, Choi M, Son SY, Kim MG, Han DS, Lee HH. Evidence-Based Practice Guideline for Surgical Treatment of Gastroesophageal Reflux Disease 2018. J Gastric Cancer 2018; 18:313-327. [PMID: 30607295 PMCID: PMC6310769 DOI: 10.5230/jgc.2018.18.e41] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 12/21/2018] [Accepted: 12/21/2018] [Indexed: 12/13/2022] Open
Abstract
The prevalence of gastroesophageal reflux disease (GERD) is increasing in Korea, and physicians, including surgeons, have been focusing on its treatment. Indeed, in Korea, medical treatment using a proton pump inhibitor is the mainstream treatment for GERD, while awareness of surgical treatment is limited. Accordingly, to promote the understanding of surgical treatment for GERD, the Korean Anti-Reflux Surgery Study Group published the Evidence-Based Practice Guideline for the Surgical Treatment of GERD. The guideline consists of 2 sections: fundamental information such as the definition, symptoms, and diagnostic tools of GERD and a recommendation statement about its surgical treatment. The recommendations presented 5 debates regarding fundoplication: 1) comparison of the effectiveness of medical and surgical treatments, 2) effectiveness of surgical treatment in cases of refractory GERD, 3) effectiveness of surgical treatment of extraesophageal symptoms, 4) comparison of effectiveness between total and partial fundoplication, and 5) effectiveness of fundoplication in cases of hiatal hernia. The present guideline is the first to demonstrate the efficacy of the surgical treatment GERD in Korea.
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Affiliation(s)
- Ho Seok Seo
- Guideline Committee of Korean Anti-Reflux Surgery (KARS) Study Group.,Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Miyoung Choi
- Division of Health Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Sang-Yong Son
- Guideline Committee of Korean Anti-Reflux Surgery (KARS) Study Group.,Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Min Gyu Kim
- Guideline Committee of Korean Anti-Reflux Surgery (KARS) Study Group.,Department of Surgery, Hanyang University Guri Hospital, Hanyang University School of Medicine, Seoul, Korea
| | - Dong-Seok Han
- Guideline Committee of Korean Anti-Reflux Surgery (KARS) Study Group.,Department of Surgery, Seoul National University Boramae Hospital, Seoul, Korea
| | - Han Hong Lee
- Guideline Committee of Korean Anti-Reflux Surgery (KARS) Study Group.,Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Impact of reflux esophagitis on the esophageal function before and after laparoscopic fundoplication. Esophagus 2018; 15:224-230. [PMID: 30225739 DOI: 10.1007/s10388-018-0618-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 04/17/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND High-resolution manometry (HRM), which is breakthrough testing equipment to evaluate esophageal motor function, was developed in Europe and United State and has garnered attention. Moreover, multichannel intraluminal impedance pH (MII-pH) testing has allowed us to grasp all liquid/gas reflux including not only acid but also non-acid reflux. We examined the impact of the presence of reflux esophagitis (RE) on esophageal motor function before and after laparoscopic fundoplication. MATERIALS AND METHODS The subjects included 100 patients (male: 63 patients, mean age: 54.1 ± 15.8) among 145 patients who underwent laparoscopic fundoplication for GERD associated diseases during a 4-year period from October 2012 to September 2016, excluding 6 patients who underwent further surgery, 32 patients on whom HRM was not performed, 3 patients who had technical errors during testing, and 4 patients for whom the status of RE was unknown. Regarding HRM, Mano Scan from Given Imaging Ltd. was used, and for the analysis, Mano View version 3.0 from the same company was used, after which data was calculated based on the Chicago Classification advocated by Pandolfino et al. Moreover, for the MII-pH testing, Sleuth manufactured by Sandhill Scientific. Inc. was used and automatic analysis was conducted by a computer. Postoperative assessments were conducted 3 months following surgery for all. Data was described in the median value and inter-quartile range, with a statistically significant difference defined as p < 0.05 by Chi square, Mann-Whitney, and Wilcoxon tests. RESULTS RE+ group (Los Angeles classification A:B:C:D = 7:9:16:12 patients) included 44 patients (44%), of older age compared to the RE- group (62 vs. 50 years, p = 0.012) and a higher Body Mass Index value (24.0 vs. 22.5, p = 0.045); however, no differences were observed in terms of gender and duration of symptoms. In the preoperative findings on MII-pH, the RE+ group demonstrated significantly longer acid reflux time (4.7 vs. 1.3%, p = 0.005), while in the HRM findings, the RE- group demonstrated a significantly longer abdominal esophagus (0 vs. 0.4 cm, p = 0.049) and maintained esophageal body motor function (DCI: 1054 vs. 1407 mmHg s cm, p = 0.021, Intact peristalsis ratio: 90 vs. 100%, p = 0.037). As to the comparison of the treatment effect before and after laparoscopic fundoplication (Toupet fundoplication for all), significant improvements were observed in both groups in various parameters regarding reflux including acid reflux time, total number of liquid reflux episodes and total number of reflux episodes. Moreover, for both groups, the total length of the lower esophageal sphincter (LES) (RE+ group: 2.7 vs. 3.2 cm, p = 0.001, RE- group: 3.0 vs. 3.4 cm, p = 0.003) and the total length of the abdominal esophagus (RE+ group: 0 vs. 1.6 cm, p < 0.001, RE- group: 0 vs. 1.8 cm, p = 0.001) were significantly extended following surgery; however, no change was observed in DCI before and after surgery. CONCLUSIONS Regardless of the presence of RE, cardiac function and LES function were improved following laparoscopic Toupet fundoplication, but no changes were observed in esophageal body motor function.
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Labenz J, Chandrasoma PT, Knapp LJ, DeMeester TR. Proposed approach to the challenging management of progressive gastroesophageal reflux disease. World J Gastrointest Endosc 2018; 10:175-183. [PMID: 30283600 PMCID: PMC6162253 DOI: 10.4253/wjge.v10.i9.175] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/22/2018] [Accepted: 06/13/2018] [Indexed: 02/06/2023] Open
Abstract
The progression of gastroesophageal reflux disease (GERD) in patients who are taking proton pump inhibitors (PPIs) has been reported by several investigators, leading to concerns that PPI therapy does not address all aspects of the disease. Patients who are at risk of progression need to be identified early in the course of their disease in order to receive preventive treatment. A review of the literature on GERD progression to Barrett’s esophagus and the associated physiological and pathological changes was performed and risk factors for progression were identified. In addition, a potential approach to the prevention of progression is discussed. Current evidence shows that GERD can progress; however, patients at risk of progression may not be identified early enough for it to be prevented. Biopsies of the squamocolumnar junction that show microscopic intestinalization of metaplastic cardiac mucosa in endoscopically normal patients are predictive of future visible Barrett’s esophagus, and an indicator of GERD progression. Such changes can be identified only through biopsy, which is not currently recommended for endoscopically normal patients. GERD treatment should aim to prevent progression. We propose that endoscopically normal patients who partially respond or do not respond to PPI therapy undergo routine biopsies at the squamocolumnar junction to identify histological changes that may predict future progression. This will allow earlier intervention, aimed at preventing Barrett’s esophagus.
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Affiliation(s)
- Joachim Labenz
- Internal Medicine, Diakonie Klinikum, Jung-Stilling Hospital, Siegen 57074, Germany
| | - Parakrama T Chandrasoma
- Keck School of Medicine, University of Southern California, Los Angeles, CA 91108, United States
| | - Laura J Knapp
- PharmaGenesis London, London SW1A 2DD, United Kingdom
| | - Tom R DeMeester
- Keck School of Medicine, University of Southern California, Los Angeles, CA 91108, United States
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Schlottmann F, Andolfi C, Herbella FA, Rebecchi F, Allaix ME, Patti MG. GERD: Presence and Size of Hiatal Hernia Influence Clinical Presentation, Esophageal Function, Reflux Profile, and Degree of Mucosal Injury. Am Surg 2018. [DOI: 10.1177/000313481808400651] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A hiatal hernia (HH) is a frequent finding in patients with gastroesophageal reflux disease (GERD). We examined a consecutive series of patients with GERD diagnosed by a 24-hour pH monitoring. Based on the presence and size of HH on barium swallow, patients were divided into the following groups: no HH, HH <3 cm, HH 3–5 cm and HH >5 cm. A total of 175 patients were included: 43 with no HH, 86 with HH <3 cm, 34 with HH 3–5 cm, and 12 with HH >5 cm. Patients with larger HH had more frequent episodes of coughing and wheezing associated with episodes of reflux. High-resolution manometry showed that the increasing size of the HH was associated with decreasing pressure of the lower esophageal sphincter and weaker peristalsis. Ambulatory pH monitoring revealed that patients with larger HH had more acid reflux, in both the distal and proximal esophagus. Endoscopy showed that patients with larger HH had more severe esophagitis. Fifty per cent of patients with HH >5.0 cm had Barrett's esophagus. These findings should guide gastroenterologists and surgeons in choosing the appropriate therapy in patients with GERD and large HH.
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Affiliation(s)
- Francisco Schlottmann
- Department of Surgery and Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, North Carolina
| | - Ciro Andolfi
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Fernando A. Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Fabrizio Rebecchi
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Marco E. Allaix
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Marco G. Patti
- Department of Surgery and Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, North Carolina
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Tolone S, Savarino E, Zaninotto G, Gyawali CP, Frazzoni M, de Bortoli N, Frazzoni L, Del Genio G, Bodini G, Furnari M, Savarino V, Docimo L. High-resolution manometry is superior to endoscopy and radiology in assessing and grading sliding hiatal hernia: A comparison with surgical in vivo evaluation. United European Gastroenterol J 2018; 6:981-989. [PMID: 30228885 DOI: 10.1177/2050640618769160] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 03/15/2018] [Indexed: 12/12/2022] Open
Abstract
Background Hiatal hernia is diagnosed by barium-swallow esophagogram or esophagogastroduodenoscopy, with possible suboptimal results. High-resolution manometry clearly identifies crural diaphragm and lower esophageal sphincter. Objectives To assess the diagnostic accuracy of high-resolution manometry in detecting hiatal hernia compared to esophagogram and esophagogastroduodenoscopy, using as reference the surgical in vivo measurement. Methods Patients were studied with esophagogram, esophagogastroduodenoscopy, high-resolution manometry and in vivo evaluation of the esophago-gastric junction. Esophago-gastric junction was classified as type I (no separation between crural diaphragm and lower esophageal sphincter); type II (≥1, ≤ 2 cm separation); type III (>2 cm). During in vivo measurement, distance between the esophago-gastric junction and crural diaphragm proximal border was recorded. Results Surgery identified 53 hiatal hernias in 100 patients. Forty-seven percent were classified as type I esophago-gastric junction, 35% type II and 18% type III. Referenced to in vivo evaluation, high-resolution manometry showed superior diagnostic sensitivity and specificity (94.3% and 91.5%, respectively) to esophagogram and esophagogastroduodenoscopy, with 92.6% predictive value of a positive test and 93.5% predictive value of a negative test. The kappa value for high-resolution manometry and in vivo evaluation was 0.85. High-resolution manometry showed optimal sensitivity and specificity in detecting types I, II and III esophago-gastric junction. Conclusions High-resolution manometry enables an accurate diagnosis of hiatal hernia and a better classification than endoscopy and radiology, reaching optimal agreement with in vivo assessment.
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Affiliation(s)
- Salvatore Tolone
- Department of Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Edoardo Savarino
- Department of Gastroenterology, University of Padua, Padua, Italy
| | | | - C Prakash Gyawali
- Department of Gastroenterology, Washington University School of Medicine, St Louis, USA
| | - Marzio Frazzoni
- Department of Gastroenterology, Baggiovara Hospital, Modena, Italy
| | | | - Leonardo Frazzoni
- Department of Gastroenterology, University of Bologna, Bologna, Italy
| | | | - Giorgia Bodini
- Department of Gastroenterology, University of Genoa, Genoa, Italy
| | - Manuele Furnari
- Department of Gastroenterology, University of Genoa, Genoa, Italy
| | | | - Ludovico Docimo
- Department of Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
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Tatum JM, Samakar K, Bowdish ME, Mack WJ, Bildzukewicz N, Lipham JC. Videoesophagography versus Endoscopy for Prediction of Intraoperative Hiatal Hernia Size. Am Surg 2018. [DOI: 10.1177/000313481808400322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Magnetic sphincter augmentation is a novel surgical procedure for gastroesophageal reflux disease. Limited dissection at the hiatus is one of the benefits of the procedure, but makes precise and accurate preoperative assessment of even small hiatal hernia critical. Retrospective cohort study of 136 patients having undergone both endoscopy (EGD) and videoesophagography followed by operative assessment for hiatal hernia during magnetic sphincter augmentation. The objective of the study is to determine which preoperative modality more accurately predicts operative hiatal hernia size. Videoesophagography underestimated operative measurement by 0.37 ± 1.41 cm ( P = 0.003) and was less accurate in predicting intraoperative hiatal hernia size than EGD on linear regression analysis (β -0.729, SE 0.057, P < 0.001). EGD was less accurate at predicting hiatal hernia size as patient age increased (β -0.018, SE 0.007, P = 0.014) and with larger hernias (β -0.615, standard error (SE) 0.067, P < 0.001); however, endoscopic measurements did not differ significantly from intraoperative measurements (0.93 ± 1.23 cm vs 1.12 ± 1.43 cm, P = 0.12). EGD better predicts the size of small hiatal hernia measured during subsequent laparoscopic surgery.
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Affiliation(s)
- James M. Tatum
- Departments of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Kamran Samakar
- Departments of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Michael E. Bowdish
- Departments of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Wendy J. Mack
- Departments of Preventive Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Nikolai Bildzukewicz
- Departments of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - John C. Lipham
- Departments of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
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Manometric Changes to the Lower Esophageal Sphincter After Magnetic Sphincter Augmentation in Patients With Chronic Gastroesophageal Reflux Disease. Ann Surg 2017; 266:99-104. [PMID: 27464617 DOI: 10.1097/sla.0000000000001935] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To evaluate the manometric changes, function, and impact of magnetic sphincter augmentation (MSA) on the lower esophageal sphincter (LES). BACKGROUND Implantation of a MSA around the gastroesophageal junction has been shown to be a safe and effective therapy for gastroesophageal reflux disease, but its effect on the LES has not been elucidated. METHODS Retrospective case control study (n = 121) evaluating manometric changes after MSA. Inclusion criteria consisted of a confirmed diagnosis of gastroesophageal reflux disease by an abnormal esophageal pH study (body mass index <35 kg/m, hiatal hernia <3 cm, and absence of endoscopic Barrett disease). Manometric changes, pH testing, and proton pump inhibitor use were assessed preoperatively and 6 and 12 months after MSA. RESULTS MSA was associated with an overall increase in the median LES resting pressure (18 pre-MSA vs 23 mm Hg post-MSA; P = 0.0003), residual pressure (4 vs 9 mm Hg; P < 0.0001), and distal esophageal contraction amplitude (80 vs 90 mm Hg; P = 0.02). The percent peristalsis remained unaltered (94% vs 87%; P = 0.71).Overall, patients with a manometrically defective LES were restored 67% of the time to a normal sphincter with MSA. Those with a structurally defective or severely defective LES improved to a normal LES in 77% and 56% of patients, respectively. Only 18% of patients with a normal preoperative manometric LES deteriorated to a lower category. CONCLUSION MSA results in significant manometric improvement of the LES without apparent deleterious effects on the esophageal body. A manometrically defective LES can be restored to normal sphincter, whereas a normal LES remains stable.
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Fuchs KH, Musial F, Ulbricht F, Breithaupt W, Reinisch A, Babic B, Fuchs H, Varga G. Foregut symptoms, somatoform tendencies, and the selection of patients for antireflux surgery. Dis Esophagus 2017; 30:1-10. [PMID: 28475727 DOI: 10.1093/dote/dox022] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Indexed: 12/11/2022]
Abstract
A large variety of foregut symptoms can occur in patients with gastroesophageal reflux disease (GERD), which can overlap with other disorders such as somatoform disorders and dyspepsia. Due to unclear diagnostic situations, these patients are often not adequately treated. The aim of this study was the evaluation of patients with foregut symptoms, referred for possible antireflux surgery, regarding their relationship with GERD and somatization tendencies based on control data from an unselected population. Symptom evaluation and somatization screening were initiated both in volunteers and in patients with foregut symptoms and GERD. Unselected volunteers from a village population were also evaluated by symptom analysis and for somatisation tendency. In addition, patients with foregut symptoms were diagnosed for GERD, and symptom analysis and psychodiagnostic evaluation were performed. There is no major significant difference in the symptom-spectrum in patients with foregut symptoms, whether they have a proven pathologic acid exposure from GERD or not. The probability for the risk of somatization was 5.6% in the unselected population of nonpatient volunteers (n = 267). In patients with foregut symptoms (n = 750), the probability for the presence of somatoform tendencies was approximately 20%, independent whether these patients had a documented GERD or a normal esophageal acid exposure, implicating further diagnostic work-up for the selection of patients for antireflux surgery. There is a remarkable symptom load and variety in patients with GERD, in patients with foregut symptoms, and in an unselected population of volunteers. There is no difference in the risk for somatization between patients with foregut symptoms and those with documented GERD. Therapeutic decision making especially prior to antireflux surgery requires an awareness of mental and emotional challenges.
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Affiliation(s)
- K-H Fuchs
- AGAPLESION-Markus-Krankenhaus, Department of Surgery, Academic Teaching Hospital
| | - F Musial
- The National Research Center in Complementary and Alternative Medicine, UIT University Tromso, Norway
| | - F Ulbricht
- AGAPLESION-Markus-Krankenhaus, Department of Surgery, Academic Teaching Hospital
| | - W Breithaupt
- AGAPLESION-Markus-Krankenhaus, Department of Surgery, Academic Teaching Hospital
| | - A Reinisch
- AGAPLESION-Markus-Krankenhaus, Department of Surgery, Academic Teaching Hospital.,Department of General Surgery, Goethe University Frankfurt, Frankfurt
| | - B Babic
- AGAPLESION-Markus-Krankenhaus, Department of Surgery, Academic Teaching Hospital
| | - H Fuchs
- Department of General Surgery, University of Cologne, Cologne, Germany
| | - G Varga
- AGAPLESION-Markus-Krankenhaus, Department of Surgery, Academic Teaching Hospital
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Comparison of the multichannel intraluminal impedance pH and conventional pH for measuring esophageal acid exposure: a propensity score-matched analysis. Surg Endosc 2017; 31:5241-5247. [DOI: 10.1007/s00464-017-5595-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 05/08/2017] [Indexed: 12/14/2022]
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Efficacy of Magnetic Sphincter Augmentation versus Nissen Fundoplication for Gastroesophageal Reflux Disease in Short Term: A Meta-Analysis. Can J Gastroenterol Hepatol 2017; 2017:9596342. [PMID: 28466002 PMCID: PMC5390656 DOI: 10.1155/2017/9596342] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 03/20/2017] [Indexed: 12/12/2022] Open
Abstract
Background. The efficacy of Magnetic Sphincter Augmentation (MSA) and its outcomes for Gastroesophageal Reflux Disease (GERD) are uncertain. Therefore, we aimed to summarize and analyze the efficacy of two treatments for GERD. Methods. The meta-analysis search was performed, using four databases. All studies from 2005 to 2016 were included. Pooled effect was calculated using either the fixed or random effects model. Results. A total of 4 trials included 624 patients and aimed to evaluate the differences in proton-pump inhibitor use, complications, and adverse events. MSA had a shorter operative time (MSA and NF: RR = -18.80, 95% CI: -24.57 to -13.04, and P = 0.001) and length of stay (RR = -14.21, 95% CI: -24.18 to -4.23, and P = 0.005). Similar proton-pump inhibitor use, complication (P = 0.19), and severe dysphagia for dilation were shown in both groups. Although there is no difference between the MSA and NF in the number of adverse events, the incidence of postoperative gas or bloating (RR = 0.71, 95% CI: 0.54-0.94, and P = 0.02) showed significantly different results. However, there is no significant difference in ability to belch and ability to vomit. Conclusions. MSA can be recommended as an alternative treatment for GERD according to their short-term studies, especially in main-features of gas-bloating, due to shorter operative time and less complication of gas or bloating.
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Tolone S, Gualtieri G, Savarino E, Frazzoni M, de Bortoli N, Furnari M, Casalino G, Parisi S, Savarino V, Docimo L. Pre-operative clinical and instrumental factors as antireflux surgery outcome predictors. World J Gastrointest Surg 2016; 8:719-728. [PMID: 27933133 PMCID: PMC5124700 DOI: 10.4240/wjgs.v8.i11.719] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/17/2016] [Accepted: 09/22/2016] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is nowadays a highly prevalent, chronic condition, with 10% to 30% of Western populations affected by weekly symptoms. Many patients with mild reflux symptoms are treated adequately with lifestyle modifications, dietary changes, and low-dose proton pump inhibitors (PPIs). For those with refractory GERD poorly controlled with daily PPIs, numerous treatment options exist. Fundoplication is currently the most commonly performed antireflux operation for management of GERD. Outcomes described in current literature following laparoscopic fundoplication indicate that it is highly effective for treatment of GERD; early clinical studies demonstrate relief of symptoms in approximately 85%-90% of patients. However it is still unclear which factors, clinical or instrumental, are able to predict a good outcome after surgery. Virtually all demographic, esophagogastric junction anatomic conditions, as well as instrumental (such as presence of esophagitis at endoscopy, or motility patterns determined by esophageal high resolution manometry or reflux patterns determined by means of pH/impedance-pH monitoring) and clinical features (such as typical or atypical symptoms presence) of patients undergoing laparoscopic fundoplication for GERD can be factors associated with symptomatic relief. With this in mind, we sought to review studies that identified the factors that predict outcome after laparoscopic total fundoplication.
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Crespin OM, Tatum RP, Yates RB, Sahin M, Coskun K, Martin AV, Wright A, Oelschlager BK, Pellegrini CA. Esophageal hypermotility: cause or effect? Dis Esophagus 2016; 29:497-502. [PMID: 25893778 DOI: 10.1111/dote.12367] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Nutcracker esophagus (NE), Jackhammer esophagus (JHE), distal esophageal spasm (DES), and hypertensive lower esophageal sphincter (HTLES) are defined by esophageal manometric findings. Some patients with these esophageal motility disorders also have abnormal gastroesophageal reflux. It is unclear to what extent these patients' symptoms are caused by the motility disorder, the acid reflux, or both. The aim of this study was to determine the effectiveness of laparoscopic Nissen fundoplication (LNF) on esophageal motility disorders, gastroesophageal reflux, and patient symptoms. Between 2007 and 2013, we performed high-resolution esophageal manometry on 3400 patients, and 221 patients were found to have a spastic esophageal motility disorder. The medical records of these patients were reviewed to determine the manometric abnormality, presence of gastroesophageal symptoms, and amount of esophageal acid exposure. In those patients that underwent LNF, we compared pre- and postoperative esophageal motility, gastroesophageal symptom severity, and esophageal acid exposure. Of the 221 patients with spastic motility disorders, 77 had NE, 2 had JHE, 30 had DES, and 112 had HTLES. The most frequently reported primary and secondary symptoms among all patients were: heartburn and/or regurgitation, 69.2%; respiratory, 39.8%; dysphagia, 35.7%; and chest pain, 22.6%. Of the 221 patients, 192 underwent 24-hour pH monitoring, and 103 demonstrated abnormal distal esophageal acid exposure. Abnormal 24-hour pH monitoring was detected in 62% of patients with heartburn and regurgitation, 49% of patients with respiratory symptoms, 36.8 % of patients with dysphagia, and 32.6% of patients with chest pain. Sixty-six of the 103 patients with abnormal 24-hour pH monitoring underwent LNF. Thirty-eight (13NE, 2JHE, 6 DES, and 17 HTLES) of these 66 patients had a minimum of 6-month postoperative follow-up that included clinical evaluation, esophageal manometry, and 24-hour pH monitoring. Postoperatively, all 38 patients had normal distal esophageal acid exposure. Of these 38 patients, symptoms resolved in 28 and improved in 10. Of six patients (one with NE, two JHE, and three with HTLES) that underwent postoperative esophageal manometry, five exhibited normal motility. Typical reflux symptoms are common among patients with esophageal hypermotility disorders. Abnormal 24-hour pH monitoring is present in the majority of patients with who report typical reflux symptoms and almost half of patients who report respiratory symptoms. Conversely, the majority of patients who report dysphagia or chest pain have normal distal esophageal acid exposure. Based on a small number of patients in this study, it also appears that motility disorders often improve after LNF. LNF is associated with resolution or improvement in reflux related symptoms and esophageal motility parameters in patients exhibiting abnormal esophageal acid exposure. This suggests that patient symptoms are due to abnormal acid exposure and not the motility disorder.
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Affiliation(s)
- O M Crespin
- University of Washington, Surgery, Seattle, WA, USA
| | - R P Tatum
- University of Washington, Surgery, Seattle, WA, USA
| | - R B Yates
- University of Washington, Surgery, Seattle, WA, USA
| | - M Sahin
- University of Washington, Surgery, Seattle, WA, USA
| | - K Coskun
- University of Washington, Surgery, Seattle, WA, USA
| | - A V Martin
- University of Washington, Surgery, Seattle, WA, USA
| | - A Wright
- University of Washington, Surgery, Seattle, WA, USA
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Ma X, Peng LH, Wang XX, Ai J, Guo ZY, Yang YS. Characteristics of esophageal motility measured by high resolution esophageal manometry in hiatal hernia patients. Shijie Huaren Xiaohua Zazhi 2016; 24:1718-1724. [DOI: 10.11569/wcjd.v24.i11.1718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the functional change of esophageal motility in hiatal hernia (HH) patients using high resolution esophageal manometry (HRM), in order to determine the possible pathogenesis of HH and provide more evidence for detection and treatment of HH.
METHODS: We performed a retrospective study of 66 patients with hiatal hernia who underwent HRM from June 2014 to April 2015 as well as upper endoscopy and/or barium esophagogram within 3 mo at our hospital. Among them, 31 patients were diagnosed with reflux esophagitis (RE) by endoscopy. Besides, we selected 28 healthy volunteers as controls to compare clinical characteristics and HRM data between the three groups.
RESULTS: In total there were 35 patients with HH alone (Group A), of whom 16 had typical symptoms including acid reflux and heartburn, 12 suffered main symptoms resembling retrosternal pain, and the remainder had typical symptoms including dysphagia and belching. After HRM, 4 of them were diagnosed with esophagogastric junction (EGJ) outflow obstruction, 1 with severe esophageal motility disorder, and 9 with mild esophageal motility disorder. In total there were 31 patients with RE (Group B), of whom 20 had typical symptoms including acid reflux and heartburn, 6 suffered main symptoms resembling retrosternal pain, and the remainder had typical symptoms including dysphagia and belching. After HRM, 2 of them were diagnosed with esophagogastric junction (EGJ) outflow obstruction, 3 with severe esophageal motility disorder, and 10 with mild esophageal motility disorder. There was no significant difference in the above findings between groups A and B (P > 0.05). Lower esophageal sphincter (LES) pressure in groups A and B was significantly lower than that in the control group (P = 0.016), especially group A (13.43 mmHg ± 8.75 mmHg vs 21.66 mmHg ± 7.19 mmHg, P = 0.004). Upper esophageal sphincter (UES) pressure had no significant difference among the three groups (P = 0.854). However, the morbidity of UES hypotensive pressure was significantly higher in group A than the control group (25.7% vs 3.6%, P = 0.041).
CONCLUSION: About 40% of HH patients have esophageal motility disorders. HH patients have significantly lower LES and UES pressure than the health group. The reduced LES and UES pressure and esophageal motility disorder may play a crucial role in reflux events and even result in esophageal mucosal injury. HRM can provide accurate and exhaustive data to guide diagnosis and evaluate prognosis.
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Wróblewski T, Kobryn K, Nowosad M, Krawczyk M. Surgical treatment of GERD. Comperative study of WTP vs. Toupet fundoplication - results of 151 consecutive cases. Wideochir Inne Tech Maloinwazyjne 2016; 11:60-6. [PMID: 27458484 PMCID: PMC4945603 DOI: 10.5114/wiitm.2016.58947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/25/2016] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is recognized as one of the most common disorders of the upper gastrointestinal tract (GIT). The best choice of management for advanced GERD is laparoscopic surgery. AIM To compare and evaluate the results of surgical treatment of GERD patients operated on using two different techniques. MATERIAL AND METHODS Between 2001 and 2012, 353 patients (211 female and 142 male), aged 17-76 years (mean 44), underwent laparoscopic antireflux surgery. The study included patients who underwent a Toupet fundoplication or Wroblewski Tadeusz procedure (WTP). RESULTS The mean age of the group was 47.77 years (17-80 years). Forty-nine (32.45%) patients had severe symptoms, 93 (61.58%) had mild symptoms and 9 (5.96%) had a single mild but intolerable sign of GERD. Eighty-six (56.95%) patients had a Toupet fundoplication and 65 (43.04%) had a WTP. The follow-up period was 18-144 months. The average operating time for Toupet fundoplication and the WTP procedure was 164 min (90-300 min) and 147 min (90-210 min), respectively. The perioperative mortality rate was 0.66%. The average post-operative hospitalization period was 5.4 days (2-16 post-operative days (POD) = Toupet) vs. 4.7 days (2-9 POD = WTP). No reoperations were performed. No major surgical complications were identified. CONCLUSIONS Wroblewski Tadeusz procedure due to a low percentage of post-operative complications, good quality of life of patients and a zero recurrence rate of hiatal hernia should be a method of choice.
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Affiliation(s)
- Tadeusz Wróblewski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Konrad Kobryn
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Małgorzata Nowosad
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Marek Krawczyk
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
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Warren HF, Reynolds JL, Lipham JC, Zehetner J, Bildzukewicz NA, Taiganides PA, Mickley J, Aye RW, Farivar AS, Louie BE. Multi-institutional outcomes using magnetic sphincter augmentation versus Nissen fundoplication for chronic gastroesophageal reflux disease. Surg Endosc 2015; 30:3289-96. [PMID: 26541740 DOI: 10.1007/s00464-015-4659-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 10/28/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) has emerged as an alternative surgical treatment of gastroesophageal reflux disease (GERD). The safety and efficacy of MSA has been previously demonstrated, although adequate comparison to Nissen fundoplication (NF) is lacking, and required to validate the role of MSA in GERD management. METHODS A multi-institutional retrospective cohort study of patients with GERD undergoing either MSA or NF. Comparisons were made at 1 year for the overall group and for a propensity-matched group. RESULTS A total of 415 patients (201 MSA and 214 NF) underwent surgery. The groups were similar in age, gender, and GERD-HRQL scores but significantly different in preoperative obesity (32 vs. 40 %), dysphagia (27 vs. 39 %), DeMeester scores (34 vs. 39), presence of microscopic Barrett's (18 vs. 31 %) and hiatal hernia (55 vs. 69 %). At a minimum of 1-year follow-up, 354 patients (169 MSA and 185 NF) had significant improvement in GERD-HRQL scores (pre to post: 21-3 and 19-4). MSA patients had greater ability to belch (96 vs. 69 %) and vomit (95 vs. 43 %) with less gas bloat (47 vs. 59 %). Propensity-matched cases showed similar GERD-HRQL scores and the differences in ability to belch or vomit, and gas bloat persisted in favor of MSA. Mild dysphagia was higher for MSA (44 vs. 32 %). Resumption of daily PPIs was higher for MSA (24 vs. 12, p = 0.02) with similar patient-reported satisfaction rates. CONCLUSIONS MSA for uncomplicated GERD achieves similar improvements in quality of life and symptomatic relief, with fewer side effects, but lower PPI elimination rates when compared to propensity-matched NF cases. In appropriate candidates, MSA is a valid alternative surgical treatment for GERD management.
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Affiliation(s)
- Heather F Warren
- Division of Thoracic Surgery, Swedish Medical Center and Cancer Institute, 1101 Madison Street Suite 900, Seattle, WA, 98104, USA
| | - Jessica L Reynolds
- Division of Upper GI and General Surgery, Keck Medical Center at University of Southern California, Los Angeles, CA, USA
| | - John C Lipham
- Division of Upper GI and General Surgery, Keck Medical Center at University of Southern California, Los Angeles, CA, USA
| | - Joerg Zehetner
- Division of Upper GI and General Surgery, Keck Medical Center at University of Southern California, Los Angeles, CA, USA
| | - Nikolai A Bildzukewicz
- Division of Upper GI and General Surgery, Keck Medical Center at University of Southern California, Los Angeles, CA, USA
| | | | | | - Ralph W Aye
- Division of Thoracic Surgery, Swedish Medical Center and Cancer Institute, 1101 Madison Street Suite 900, Seattle, WA, 98104, USA
| | - Alexander S Farivar
- Division of Thoracic Surgery, Swedish Medical Center and Cancer Institute, 1101 Madison Street Suite 900, Seattle, WA, 98104, USA
| | - Brian E Louie
- Division of Thoracic Surgery, Swedish Medical Center and Cancer Institute, 1101 Madison Street Suite 900, Seattle, WA, 98104, USA.
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Tolone S, De Bortoli N, Marabotto E, de Cassan C, Bodini G, Roman S, Furnari M, Savarino V, Docimo L, Savarino E. Esophagogastric junction contractility for clinical assessment in patients with GERD: a real added value? Neurogastroenterol Motil 2015; 27:1423-31. [PMID: 26227513 DOI: 10.1111/nmo.12638] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 06/23/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The role of esophagogastric junction contractile integral (EGJ-CI) as assessed by high-resolution manometry (HRM) is unclear. We aimed to correlate the EGJ-CI with impedance-pH findings in gastro-esophageal reflux disease (GERD) patients. METHODS Consecutive patients with GERD symptoms were enrolled. All patients underwent upper endoscopy, HRM, and impedance-pH testing. The EGJ-CI was calculated using the distal contractile integral tool box during three consecutive respiratory cycles. The value was then divided by the duration of these cycles. A value below 13 was considered as a defective EGJ-CI. We also assessed EGJ morphology, esophageal acid exposure time (AET), number of reflux episodes (NRE), and symptom association analysis (SAA). A positive impedance-pH monitoring was considered in case of abnormal AET and/or NRE and/or positive SAA. KEY RESULTS Among 130 patients we enrolled, 91 had GERD (abnormal AET and/or elevated NRE and/or positive SAA) and 39 had functional heartburn (FH) (negative endoscopy, normal AET, normal NRE, and negative SAA). The GERD patients had a lower median value of EGJ-CI (11 [3.1-20.7] vs 22 [9.9-41], p < 0.02) compared to FH patients. Patients with a defective EGJ-CI had, more frequently, a positive impedance-pH monitoring or esophageal mucosal lesions at endoscopy (p < 0.05 and p < 0.05, respectively) than patients with a normal EGJ-CI. An EGJ-CI cut-off value of 5 mmHg cm yielded the optimal performance in identifying GERD at impedance-pH (sensitivity 89%-specificity 63%). CONCLUSIONS & INFERENCES A defective EGJ-CI at HRM is clearly associated with evidence of GERD at impedance-pH monitoring. Evaluating EGJ-CI may be useful to predict an abnormal impedance-pH testing.
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Affiliation(s)
- S Tolone
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy
| | - N De Bortoli
- Division of Gastroenterology, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - E Marabotto
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - C de Cassan
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - G Bodini
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - S Roman
- Digestive Physiology, Hospices Civils de Lyon, Lyon I University and Labtau, INSERM 1032, Lyon, France
| | - M Furnari
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - V Savarino
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - L Docimo
- Division of Surgery, Department of Surgery, Second University of Naples, Naples, Italy
| | - E Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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Gambino JM, Sivacolundhu R, DeLucia M, Hiebert E. Repair of a sliding (type I) hiatal hernia in a cat via herniorrhaphy, esophagoplasty and floppy Nissen fundoplication. JFMS Open Rep 2015; 1:2055116915602498. [PMID: 28491383 PMCID: PMC5361999 DOI: 10.1177/2055116915602498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2015] [Indexed: 11/24/2022] Open
Abstract
Case summary A 10-month-old domestic shorthair cat was evaluated for severe esophagitis and protracted vomiting and regurgitation secondary to a sliding (type I) hiatal hernia. The hernia and concurrent upper airway obstruction (nasopharyngeal polyp) were diagnosed with a multi-modality approach, including thoracic and abdominal radiographs, abdominal ultrasound, computed tomography and endoscopy. Following unsuccessful attempts at medical management, lower esophageal incompetence was successfully treated by employing a combination of surgical techniques, including herniorrhaphy, esophagopexy and modified (floppy) Nissen fundoplication. Relevance and novel information A multi-modality imaging approach was valuable in completely assessing the extent of this cat’s disease. Although an untraditional approach, the authors report herein the first clinical description of the use of combined surgical techniques with the floppy Nissen fundoplication technique (an antireflux procedure) in a cat. This procedure was used as a first-line surgical technique in this cat with severe lower esophageal incompetence, and may be a viable option for cases non-responsive to other therapeutic interventions. Further investigation of this surgical technique is warranted.
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Affiliation(s)
- Jennifer M Gambino
- Department of Diagnostic Imaging, Mississippi State University, College of Veterinary Medicine, Mississippi State, MS, USA
| | - Ramesh Sivacolundhu
- Balcatta Veterinary Hospital, Perth, Western Australia, University of Western Australia, Honorary Research Associate, Murdoch University
| | - Meghan DeLucia
- Department of Internal Medicine, VCA Katonah Bedford Veterinary Center, Bedford Hills, NY, USA
| | - Elizabeth Hiebert
- Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Blacksburg, VA, USA
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Roman S, Kahrilas PJ. Mechanisms of Barrett's oesophagus (clinical): LOS dysfunction, hiatal hernia, peristaltic defects. Best Pract Res Clin Gastroenterol 2015; 29:17-28. [PMID: 25743453 PMCID: PMC4354716 DOI: 10.1016/j.bpg.2014.11.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 11/02/2014] [Indexed: 01/31/2023]
Abstract
Barrett's oesophagus, with the potential to develop into oesophageal adenocarcinoma (OAC), is a major complication of gastrooesophageal reflux disease (GORD). However, about 50% of patients developing OAC had no known GORD beforehand. Hence, while GORD symptoms, oesophagitis, and Barrett's have a number of common determinants (oesophagogastric junction (OGJ) incompetence, impaired oesophageal clearance mechanisms, hiatus hernia) they also have some independent determinants. Further, although excess oesophageal acid exposure plays a major role in the genesis of long-segment Barrett's oesophagus there is minimal evidence supporting this for short-segment Barrett's. Hence, these may have unique pathophysiological features as well. Long-segment Barrett's seems to share most, if not all, of the risk factors for oesophagitis, particularly high-grade oesophagitis. However, it is uncertain if OGJ function and acid clearance are more severely impaired in patients with long-segment Barrett's compared to patients with high-grade oesophagitis. With respect to short-segment Barrett's, the acid pocket may play an important pathogenic role. Conceptually, extension of the acid pocket into the distal oesophagus, also known as intra-sphincteric reflux, provides a mechanism or acid exposure of the distal osophageal mucosa without the occurrence of discrete reflux events, which are more likely to prompt reflux symptoms and lead to the development of oesophagitis. Hence, intra-sphincteric reflux related to extension of the acid/no acid interface at the proximal margin of the acid pocket may be key in the development of short segment Barrett's. However, currently this is still somewhat speculative and further studies are required to confirm this.
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Affiliation(s)
- Sabine Roman
- Claude Bernard Lyon I University and Hospices Civils de Lyon, Digestive Physiology, Lyon, France
| | - Peter J Kahrilas
- Northwestern University, Feinberg School of Medicine, Department of Medicine, Chicago, USA
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MORAIS DJ, LOPES LR, ANDREOLLO NA. Dysphagia after antireflux fundoplication: endoscopic, radiological and manometric evaluation. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2014; 27:251-5. [PMID: 25626933 PMCID: PMC4743216 DOI: 10.1590/s0102-67202014000400006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 08/21/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND The transient dysphagia after fundoplication is common and most often disappears until six weeks postoperatively. AIM Analyze a group of patients who presented late and persistent dysphagia postoperatively. METHODS Forty-one patients after Nissen fundoplication, 14 male and 27 female, mean age 48 year, were evaluated based on medical history, esophagogastroduodenoscopy, contrast radiographic examination and esophageal manometry. The results were compared with another 19 asymptomatic individuals. RESULTS Contrast radiographic examination of the esophagus revealed in six cases delayed emptying, characterizing that four patients had achalasia and two diffuse spasm of the esophagus. Esophageal manometry showed that maximal expiratory pressure of the lower sphincter ranged from 10 to 38 mmHg and mean respiratory pressure from 14 to 47 mmHg, values similar to controls. Residual pressure ranged from 5 to 31 mmHg, and 17 patients had the same values as the control group. CONCLUSION The residual pressure of the lower sphincter was higher and statistically significant in patients with dysphagia compared with those operated without dysphagia. Future studies individualizing and categorizing each motility disorder, employing other techniques of manometry, and the analysis of the residual pressure may contribute to understand of persistent dysphagia in the postoperative fundoplication.
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Affiliation(s)
- Drausio Jeferson MORAIS
- From the Disciplina de Moléstias do Aparelho Digestivo e Gastrocentro,
Departamento de Cirurgia, Faculdade de Ciências Médicas da Unicamp
(Digestive Diseases and Surgical Unit and Gastrocenter, Department of Surgery, School
of Medical Sciences, State University of Campinas, Unicamp), Campinas, SP,
Brazil
| | - Luiz Roberto LOPES
- From the Disciplina de Moléstias do Aparelho Digestivo e Gastrocentro,
Departamento de Cirurgia, Faculdade de Ciências Médicas da Unicamp
(Digestive Diseases and Surgical Unit and Gastrocenter, Department of Surgery, School
of Medical Sciences, State University of Campinas, Unicamp), Campinas, SP,
Brazil
| | - Nelson Adami ANDREOLLO
- From the Disciplina de Moléstias do Aparelho Digestivo e Gastrocentro,
Departamento de Cirurgia, Faculdade de Ciências Médicas da Unicamp
(Digestive Diseases and Surgical Unit and Gastrocenter, Department of Surgery, School
of Medical Sciences, State University of Campinas, Unicamp), Campinas, SP,
Brazil
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Mwandri MB, Mwita JC, Magafu MGMD, Mgwaya M, Kilonzo KG, Urasa SJ, Urasa S. Risks, precipitants and clinical presentation of gastro-oesophageal reflux disease at the Kilimanjaro Christian medical centre in Tanzania [corrected]. Pan Afr Med J 2014; 19:119. [PMID: 25745527 PMCID: PMC4341257 DOI: 10.11604/pamj.2014.19.119.3575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 09/06/2014] [Indexed: 12/14/2022] Open
Abstract
Introduction Risk factors and precipitants of gastro-oesophageal disease (GERD) differ widely in communities. We conducted an observational study to describe these risks, precipitants and clinical presentation of GERD patients at Kilimanjaro Christian Medical Centre (KCMC) in Tanzania. Methods We consecutively recruited 92 GERD patients who were referred for endoscopy at KCMC from March to November 2008. By using structured questionnaire we enquired: risk factors, precipitants and symptoms of GERD and upper gastrointestinal endoscopic findings. Their upper gastrointestinal endoscopic findings were as well documented. Results The mean (± SD) age of the study population was 47.32 (±17) years. Reported symptoms included water brash (37%), dyspepsia (6%), chronic cough (11%) and hemoptysis (5%). More than half (56%) of the patients surveyed identified food precipitants for their GERD symptoms. Triggers of GERD symptoms were boiled beans 19%, spicy food 11%, sour/fermented meals 10%, roasted tomato 9%, silver cyprinid fish (dagaa) 5%, beans with cooked green banana (matoke) 2% and fermented milk 1%. Most of the studied patients had normal body mass index (52%), and 25% admitted to be consuming alcohol though they didn't associate it with their GERD symptoms. The most common endoscopy finding was “loose lower oesophageal sphincter” (85%). Conclusion Most GERD patients referred for endoscopy at KCMC were found to have water brash and “loose lower oesophageal sphincters” as described by endoscopists to denote mechanical abnormality of the lower oesophageal sphincter. GERD symptoms were precipitated by common locally available food and spices.
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Affiliation(s)
| | | | | | | | - Kajiru Gad Kilonzo
- Kilimanjaro Christian Medical Centre, Tanzania P.O.Box 3010, Moshi, Tanzania
| | - Sarah Japhet Urasa
- Kilimanjaro Christian Medical Centre, Tanzania P.O.Box 3010, Moshi, Tanzania
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Riegler M, Schoppman SF, Bonavina L, Ashton D, Horbach T, Kemen M. Magnetic sphincter augmentation and fundoplication for GERD in clinical practice: one-year results of a multicenter, prospective observational study. Surg Endosc 2014; 29:1123-9. [PMID: 25171881 DOI: 10.1007/s00464-014-3772-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 07/21/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND The techniques available for antireflux surgery have expanded with the introduction of the magnetic sphincter augmentation device (MSAD) for gastroesophageal reflux disease (GERD). METHODS A prospective, multicenter registry evaluated MSAD and laparoscopic fundoplication (LF) in clinical practice (ClinicalTrials.gov identifier: NCT01624506). Data collection included baseline characteristics, reflux symptoms, proton-pump inhibitor (PPI) use, side effects, and complications. Post-surgical evaluations were collected at one year. RESULTS At report, 249 patients (202 MSAD patients and 47 LF patients) had completed one-year follow-up. The LF group was older and had a greater frequency of large hiatal hernias and Barrett's esophagus than the MSAD group (P < 0.001). The median GERD-health related quality of life score improved from 20.0 to 3.0 after MSAD and 23.0 to 3.5 after LF. Moderate or severe regurgitation improved from 58.2 to 3.1% after MSAD and 60.0 to 13.0% after LF (P = 0.014). Discontinuation of PPIs was achieved by 81.8% of patients after MSAD and 63.0% after LF (P = 0.009). Excessive gas and abdominal bloating were reported by 10.0% of patients after MSAD and 31.9% following LF (P ≤ 0.001). Following MSAD, 91.3% of patients were able to vomit if needed, compared with 44.4% of those undergoing LF (P < 0.001). Reoperation rate was 4.0% following MSAD and 6.4% following LF. CONCLUSION Antireflux surgery should be individualized to the characteristics of each patient, taking into consideration anatomy and propensity and tolerance of side effects. Both MSAD and LF showed significant improvements in reflux control, with similar safety and reoperation rates. In the treatment continuum of antireflux surgery, MSAD should be considered as a first-line surgical option in appropriately selected patients without Barrett's esophagus or a large hiatal hernia in order to avoid unnecessary dissection and preserve the patient's native gastric anatomy. MSAD is an important treatment option and will expand the surgeon's role in treating GERD.
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Affiliation(s)
- Martin Riegler
- Department of Surgery, Medical University Vienna, 1090, Vienna, Austria,
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Ribeiro MCB, Tercioti-Júnior V, Souza-Neto JCD, Lopes LR, Morais DJ, Andreollo NA. Identification of preoperative risk factors for persistent postoperative dysphagia after laparoscopic antireflux surgery. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2014; 26:165-9. [PMID: 24190371 DOI: 10.1590/s0102-67202013000300002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 05/14/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Postoperative dysphagia is common after antireflux surgery and generally runs a self-limiting course. Nevertheless, part of these patients report long-term dysphagia. Inadequate surgical technique is a well documented cause of this result. AIM This retrospective study evaluated the preoperative risk factors not surgery-related for persistent dysphagia after primary laparoscopic antireflux surgery. METHODS Patients who underwent laparoscopic antireflux surgery by the modified technique of Nissen were evaluated in the preoperative period retrospectively. Postoperative severity of dysphagia was evaluated prospectively using a stantardized scale. Dysphagia after six weeks were defined as persistent. Statistical tests of association and logistic regression were used to identify risk factors associated with persistent dysphagia. RESULTS A total of 55 patients underwent primary antireflux surgery by a single surgeon team. Of these, 25 patients had preoperative dysphagia (45,45%). Persistent postoperaive dysphagia was reported by 20 (36,36%). Ten patients (18,18%) required postoperative endoscopic dilatation for dysphagia. There was statistical association between satisfaction with surgery and postoperative dysphagia and requiring the use of antireflux medication after the procedure; and between preoperative dysphagia and postoperative dysphagia. Logistic regression identified significant preopertive dysphagia as risk factor for persistent postoperative dysphagia. No correlations were found with preoperative manometry. CONCLUSIONS Patients with significant preoperative dysphagia were more likely to report persistent postoperative dysphagia. This study confirms that the current manometric criteria used to define esophageal dysmotility are not reliable to identify patients at risk for post-fundoplication dysphagia. Minucious review of the clinical history about the presence and intensity of preoperative dysphagia is important in the selection of candidates for antireflux surgery.
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Herbella FAM, Aprile LRO, Patti MG. High-resolution manometry for the evaluation of gastric motility. Updates Surg 2014; 66:177-81. [PMID: 25106472 DOI: 10.1007/s13304-014-0261-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 07/25/2014] [Indexed: 12/12/2022]
Abstract
This review focus on the utility of HRM for the evaluation of gastric motility. The evaluation of gastric motility has clinical implications for the study of a myriad of diseases. Disordered motility represents a spectrum of dysfunction ranging from delayed gastric emptying to abnormally rapid gastric transit. Gastric motility may be measured by a variety of methods with different efficacy and different variables that may be obtained. High-resolution manometry was created and added to the diagnostic armamentarium. The methods and outcomes for the study of proximal motility that may be useful to assess the thoracoabdominal pressure gradient, gastric filling and accommodation are described. Also, studies on antroduodenal manometry are reviewed. High-resolution manometry allows gastric manometry without technical limitations found on conventional manometry; however, studies are still on the phase of understanding the normal findings.
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Affiliation(s)
- Fernando Augusto Mardiros Herbella
- Department of Surgery, Escola Paulista de Medicina, Division of Esophagus and Stomach, Surgical Gastroenterology, Federal University of Sao Paulo, Hospital Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil,
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Abstract
There has been a marked decline over the last several years in drug development for gastroesophageal reflux disease and specifically for nonerosive reflux disease (NERD), despite there being many areas of unmet need. In contrast, we have seen a proliferation, during the same period of time, in development of novel, nonmedical therapeutic strategies for NERD using cutting-edge technology. Presently, compliance and lifestyle modifications are readily available noninvasive therapeutic interventions for NERD. Other nonmedical therapies include, the Stretta procedure, transoral incisionless fundoplication, and the magnetic sphincter augmentation device (LINX). Antireflux surgery, in experienced hands, has been repeatedly shown to be efficacious in resolving NERD-related symptoms. Psychological therapeutic interventions and alternative medicine techniques, such as acupuncture, continue to show promise, especially in NERD patients who failed antireflux treatment.
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