The role of hiatus hernia in gastro-oesophageal reflux disease

Hiatal Hernia Repair With Tension-Free Mesh or Crural Sutures Alone in Antireflux Surgery: A 13-Year Follow-Up of a Randomized Clinical Trial

Importance

Antireflux surgery is an effective treatment of gastroesophageal reflux disease (GERD), but the durability of concomitant hiatal hernia repair remains challenging. Previous research reported that the use of a mesh-reinforced, tension-free technique was associated with more dysphagia for solid foods after 3 years without reducing hiatal hernia recurrence rates compared with crural sutures alone, but the long-term effects of this technique have not been assessed.

Objective

To assess the long-term anatomical and functional outcomes of using a mesh for hiatal hernia repair in patients with GERD.

Design, Setting, and Participants

A double-blind, randomized clinical trial was performed at a single center (Ersta Hospital, Stockholm, Sweden) from January 11, 2006, to December 1, 2010. A total of 159 patients were recruited and randomly assigned. Data for the current analysis were collected from September 1, 2021, to March 31, 2022. All analyses were conducted with the intention-to-treat population.

Interventions

Closure of the diaphragmatic hiatus with crural sutures alone vs a tension-free technique using a nonabsorbable polytetrafluoroethylene mesh (Bard CruraSoft).

Main Outcomes and Measures

The primary outcome was radiologically verified recurrent hiatal hernia after more than 10 years. Secondary outcomes were dysphagia scores (ranging from 1 to 4, with 1 indicating no episodes of dysphagia and 4 indicating more than 3 episodes of dysphagia per day) for solid and liquid foods, generic 36-Item Short Form Health Survey and disease-specific Gastrointestinal Symptom Rating Scale symptom assessment scores, proton pump inhibitor consumption, and reoperation rates. Intergroup comparisons of parametric data were performed using t tests; for nonparametric data, Mann-Whitney U, χ2, or Fisher exact tests were used. For intragroup comparisons vs the baseline at follow-up times, the Friedman test was used, and post hoc analysis was performed using Wilcoxon matched pairs.

Results

Of 145 available patients, follow-up data were obtained from 103 (response rate 71%; mean [SD] age at follow-up, 65 [11.3] years; 55 [53%] female), with 53 initially randomly assigned to mesh reinforcement, and 50 to crural suture alone. The mean (SD) follow-up time was 13 (1.1) years. The verified radiologic hiatal hernia recurrence rates were 11 of 29 (38%) in the mesh group vs 11 of 35 (31%) in the suture group (P = .61). However, 13 years postoperatively, mean (SD) dysphagia scores for solids remained significantly higher in the mesh group (mean [SD], 1.9 [0.7] vs 1.6 [0.9]; P = .01).

Conclusions and Relevance

Findings from this long-term follow-up of a randomized clinical trial suggest that tension-free crural repair with nonabsorbable mesh does not reduce the incidence of hiatal hernia recurrence 13 years postoperatively. This finding combined with maintained higher dysphagia scores does not support the routine use of tension-free polytetrafluoroethylene mesh closure in laparoscopic hiatal hernia repair for treatment of GERD.

Trial Registration

ClinicalTrials.gov Identifier: NCT05069493.

Measurement of oesophageal hiatus surface area by multiplanar reconstruction of MDCT: relationship with lower oesophageal sphincter pressure and acid reflux

AIM

To evaluate the relationship between oesophageal hiatus surface area (OHSA) and gastro-oesophageal reflux disease (GERD).

MATERIALS AND METHODS

Patients who underwent 24-h pH monitoring, oesophageal high-resolution manometry, and upper abdominal contrast-enhanced multidetector computed tomography (MDCT) during 2014-2021 were enrolled. Patients with a hiatus hernia (HH) on MDCT or who had a history of gastro-oesophageal surgery were excluded. Multiplanar reconstruction (MPR) of the MDCT image was used for the measurement of OHSA. Correlations of OHSA with acid exposure time (AET) and lower oesophageal sphincter (LOS) pressure of all patients were analysed.

RESULTS

Seventy-eight patients were included in the study. OHSA was much less in the AET <4% group than in the AET >6% group (1.61 ± 0.42 versus 2.09 ± 0.55 cm2, p<0.001). Correlation analysis reveals that OHSA correlated positively with AET (correlation coefficient = 0.47, p<0.001). Receiver operating characteristic (ROC) curve analysis reveals that OHSA can significantly distinguish patients in different groups divided by AET (area under the ROC curve [AUC] = 0.76, 95% confidence interval [CI]: 0.63-0.90). OHSA was not related to LOS pressure (correlation coefficient = -0.268, p=0.051). There was no difference in OHSA between the low LOS pressure group and the normal LOS pressure group (1.84 ± 0.61 versus 1.74 ± 0.50 cm2, p=0.52).

CONCLUSIONS

OHSA significantly correlated with AET but has no relationship with LOS pressure. It may be an independent risk factor of GERD.

Developments in Gastroesophageal Reflux Disease over the Last 40 Years

BACKGROUND

The last 40 years have seen a remarkable change in our understanding of reflux disease.

SUMMARY

These changes encompass disease definition and impact, pathophysiology, diagnostic testing, regulatory oversight of clinical trials, pharmacotherapy, endoscopic, and surgical treatment. We have also seen a number of promising therapies fail.

KEY MESSAGES

The future holds the promise of further advances. Adaptive artificial intelligence will take over diagnostics in manometry and pH impedance testing and patient-driven outcomes may be changed by interactions with artificial intelligence rather than humans. Changes in chip technology will allow higher resolution chips to be carried on smaller devices making extra-esophageal areas where reflux may play a role more accessible to prolonged observation and testing.

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

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

The effect of age and sex on esophageal hiatal surface area among normal North American adults using multidetector computed tomography

The size of the esophageal hiatus is clinically important for preserving the integrity of the lower esophageal sphincter mechanism. The purpose of this study was to systematically establish the mean hiatal surface area (HSA) for normal North American adults under physiologic conditions and assess the relationship between sex and age on HSA. Multi-Detector Computer Tomogram (MDCT) images of the esophageal hiatus in 119 healthy adult subjects (61 males and 58 females with an age range of 24-88 years) were retrospectively analyzed using the multi-planar reconstruction (MPR) technique to directly measure their hiatal length (long axis), width (short axis) and surface area at end inspiration. The mean HSA for males was 2.88 cm², with a standard deviation of 0.74 cm². The mean HSA for females was 2.51 cm², with a standard deviation of 0.68 cm². There was a statistically significant difference in HSA between males and females (p = 0.0053); however, there was no statistically significant difference between the HSA among different age groups (p = 0.8439). Similarly, significant differences between males and females were demonstrated in both the length (p = 0.0263) and width (p = 0.0311) measurements, but there was no evidence of an association of these parameters with age. For the first time, the normal size of the hiatus at end inspiration has been established noninvasively for a population of healthy adults from MDCT images.

Current Advancement on the Dynamic Mechanism of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common clinical disease associated with upper gastrointestinal motility disorders. Recently, with improvements in living standards and changes in lifestyle and dietary habits, the incidence of GERD has been increasing yearly. However, the mechanism of GERD has not been fully elucidated due to its complex pathogenesis, and this had led to unsatisfactory therapeutic outcomes. Currently, the occurrence and development of GERD involve multiple factors. Its pathogenesis is mainly thought to be related to factors, such as lower esophageal sphincter pressure, transient lower esophageal sphincter relaxation, crural diaphragmatic dysfunction, hiatus hernia, and impaired esophageal clearance. Therefore, explaining the pathogenesis of GERD more clearly and systematically, exploring potential and effective therapeutic targets, and choosing the best treatment methods have gradually become the focus of scholars' attention. Herein, we reviewed current advancements in the dynamic mechanism of GERD to better counsel patients on possible treatment options.

Neutrophils, eosinophils, and intraepithelial lymphocytes in the squamous esophagus in subjects with and without gastroesophageal reflux symptoms

Whilst intraepithelial lymphocytes (IELs) are considered normal within the distal esophageal mucosa, they have an increasingly recognised role in the pathogenesis of reflux esophagitis, and IEL quantification establishes the diagnosis of lymphocytic esophagitis. Knowledge regarding the upper limit of a normal IEL count in health is lacking. We studied 117 non-healthcare seeking adult volunteers from a random community sample (the Kalixanda study) with esophageal biopsies 2 cm above the gastroesophageal junction. Subjects were divided into four groups based on the presence or absence of gastro-esophageal reflux symptoms and/or esophagitis on endoscopy. Asymptomatic subjects with no endoscopic esophagitis were selected as controls, and the cell counts in this group were used to define the upper limit of normal of IELs, eosinophils and neutrophils. The entire sample was used to identify independent predictors of increased cellular counts by logistic regression analysis. None of the healthy controls had an IEL count of more than three per five high power fields (HPF), and therefore this was considered as the upper limit of normal; no controls had eosinophils or neutrophils in esophageal biopsies. Independent predictors of an elevated IEL count were spongiosis on histology (OR 11.17, 95% CI 3.32-37.58, P < 0.01) and current smoking (OR 4.84, 95% CI 1.13-2.71, P = 0.03). A receiver operating characteristics analysis concluded that a threshold of 3 IELs/5HPFs performs best in predicting reflux symptoms when a normal esophageal mucosa is visualized on endoscopy (sensitivity = 100.0%, specificity = 35.2%). The healthy esophageal mucosa does not contain more than three IELs per five HPF in the distal esophagus.

A SIGE-SINGEM-AIGO technical review on the clinical use of esophageal reflux monitoring

Patients with esophageal symptoms potentially associated with gastroesophageal reflux disease such as heartburn, regurgitation, chest pain, or cough represent one of the most frequent reasons for referral to gastroenterological evaluation. The utility of esophageal reflux monitoring in clinical practice is: (1) to accurately define reflux burden, (2) to segregate patients according to reflux monitoring results as true GERD, reflux hypersensitivity and functional heartburn, and (3) to establish a treatment plan. With this in mind, in the last decade, investigations and technical advances, with the introduction of impedance-pH monitoring and wireless pH capsule, have enhanced our understanding and management of GERD. The following recommendations were discussed and approved after a comprehensive review of the medical literature pertaining to reflux testing techniques and their recent application. This review created under the auspices of the Società Italiana di Gastroenterologia ed Endoscopia Digestiva (SIGE), Società Italiana di Neuro-Gastro-Enterologia e Motilità (SINGEM) and Associazione Italiana Gastroenterologi ed Endoscopisti Digestivi Ospedalieri (AIGO) is intended to help clinicians in applying reflux studies in the most fruitful manner within the context of their patients with esophageal symptoms.

Mechanism and Pathophysiology of Gastroesophageal Reflux Disease

Gastroesophageal reflux (GER) describes a process in which gastric contents travel retrograde into the esophagus. GER can be either a physiologic phenomenon that occurs in asymptomatic individuals or can potentially cause symptoms. When the latter occurs, this represents GER disease (GERD). The process by which GER transforms into GERD begins at the esophagogastric junction. Impaired clearance of the refluxate also contributes to GERD. Reflux causes degradation of esophageal mucosal defense. The refluxate triggers sensory afferents leading to symptom generation.

Anti-reflux mucosal ablation (ARMA) as a new treatment for gastroesophageal reflux refractory to proton pump inhibitors: a pilot study

Background  The incidence of proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD) has been increasing. While surgical intervention with Laparoscopic Nissen Fundoplication remains the gold standard, less invasive anti-reflux interventions are desired. We have developed a minimally invasive anti-reflux mucosal ablation (ARMA) treatment. Herein, we report its technical details and describe its feasibility, safety, and efficacy in PPI-refractory GERD. Methods  We conducted a prospective single-center single-arm interventional trial evaluating the outcome of ARMA in 12 patients with PPI-refractory GERD. GERD-Health Related Quality of Life Questionnaire (GERD-HRQL) evaluation, Frequency Scale for the Symptoms of GERD (FSSG) assessment, and impedance-pH monitoring were performed at baseline and at 2 months post-ARMA. Results  A total of 12 patients underwent ARMA with a median follow-up duration of 9 months (range: 6 - 14 months). Median GERD-HRQL score significantly improved from 30.5 to 12 ( P  = 0.002); median FSSG score significantly improved from 25 to 10.5 ( P  = 0.002), and median DeMeester score decreased from 33.5 to 2.8 ( P  = 0.049) at 2 months follow-up. No immediate complications were observed. Conclusion  Our pilot study has shown that ARMA, a new endoscopic treatment for PPI-refractory GERD, is simple, safe, and improves GERD-related symptoms and objective acid reflux parameters.

Analysis of risk factors for reflux esophagitis based on clinical big data platform

BACKGROUND

In recent years, with the changes in people's lives and dietary habits, the incidence of reflux esophagitis (RE) has increased year by year, seriously affecting people's quality of life. The risk factors related to the incidence of RE and the relationship of Helicobacter pylori (H. pylori) infection and eradication with RE are now hot research topics.

AIM

To explore the risk factors for RE and the relationship between H. pylori infection and RE through a big data platform.

METHODS

A retrospective analysis was conducted to screen and group inpatients who underwent digestive endoscopy at Chaoyang Hospital from March 2010 to December 2018 in the study. The patients were divided into either an RE group or a control group. The RE group consisted of patients diagnosed with RE by digestive endoscopy with clear Los Angeles (LA) grading results and H. pylori results, and they were further divided into two subgroups: Mild RE (LA-A) and severe RE (LA-B, LA-C, and LA-D). The control group was confirmed as having no RE (endoscopic diagnosis of chronic superficial gastritis) by digestive endoscopy with H. pylori test results, and patients with gastroesophageal reflux symptoms were excluded. Both groups were analyzed through a big data platform, including gender, age, body mass index (BMI), blood lipids, blood glucose, smoking, drinking, hypertension, fatty liver, diabetes, hyperlipidemia, hiatal hernia, H. pylori infection and so on.

RESULTS

Univariate logistic regression analysis demonstrated that male gender, high BMI, smoking, and esophageal hiatal hernia were risk factors for RE. High-density lipoprotein cholesterol was found to be a protective factor. In addition, previous hypertension and hyperlipidemia are risk factors for severe RE, and elevated triglycerides are a risk factor for mild RE. Multivariate logistic regression analysis showed that male gender, high BMI, and esophageal hiatus hernia were independent risk factors for RE regardless of the severity of RE, and H. pylori infection was found to an independent protective factor for RE.

CONCLUSION

The occurrence and development of RE are closely related to some lifestyles, basic diseases, and H. pylori infection.

Endoscopic techniques for treating gastroesophageal reflux

PURPOSE OF REVIEW

Nearly, a third of patients with medically refractory gastroesophageal reflux disease (GERD) will desire an additional nonsurgical treatment option. Recently, endoscopic therapy has been reintroduced as a minimally invasive antireflux barrier treatment, after addressing prior efficacy and safety concerns. Over the last two decades, additional experience and new technologies have resulted in devices and protocols with favorable short-term outcomes and safety profiles. The current literature in endoscopic antireflux therapies covers new devices, long-term follow-up data and further safety experience. This review discusses the endoscopic antireflux devices on the market and most recent studies in this area.

RECENT FINDINGS

Quality of life and reflux symptom score improvement is observed in 73-90% of patients through a 36-48 month follow-up period, with 41-77% remaining off all reflux medicines. Composite data from several thousand cases indicate a low rate (0.93-2.4%) of serious complications and no late adverse effects, including gas-bloat syndrome.

SUMMARY

In this review, we describe the four endoscopic antireflux devices on market and summarize the current data in the literature. The short and long-term data demonstrate durable symptom improvement and favorable safety profile. Endoscopic antireflux treatment should be considered in the management of GERD.

Hiatal Hernia on Chest High-Resolution Computed Tomography and Exacerbation Rates in COPD Individuals

Background: Gastroesophageal reflux disease (GERD) is associated with frequent chronic obstructive pulmonary disease (COPD) exacerbations. Hiatal hernia (HH) contributes to GERD pathogenesis and is identifiable on chest high-resolution computed tomography (HRCT). We hypothesize that the presence of an HH on HRCT identifies those at increased risk for acute exacerbation of COPD. Methods: We retrospectively reviewed a prospectively enrolled cohort of smokers with and without airflow obstruction. HHs were identified visually on inspiratory HRCT. Individuals' demographic and clinical information was compared with secondary analysis performed using a propensity score generated matched cohort. Results: There were 523 COPD individuals and 607 unobstructed smokers. COPD individuals had more HHs than unobstructed smokers, (11.6% versus 6.1%, p < 0.001). COPD individuals with hernias were older, female, overweight and GERD positive as compared to those without hernia. There was no difference in self-reported exacerbation rates or hospitalizations per year, but similar severity of obstruction, smoking rates and long-term oxygen use. Analysis with the matched cohort revealed no significant difference in exacerbation rates. Conclusions: Presence of HHs on inspiratory HRCT scan did not predict worse symptoms or exacerbation rate in COPD individuals. Those with HHs were older, more obese, and predominantly female compared to those without HHs.

Pathophysiology of gastroesophageal reflux disease: new understanding in a new era

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) has increased in the last decades and it is now one of the most common chronic diseases. Throughout time our insight in the pathophysiology of GERD has been characterized by remarkable back and forth swings, often prompted by new investigational techniques. Even today, the pathophysiology of GERD is not fully understood but it is now recognized to be a multifactorial disease. Among the factors that have been shown to be involved in the provocation or increase of reflux, are sliding hiatus hernia, low lower esophageal sphincter pressure, transient lower esophageal sphincter relaxation, the acid pocket, obesity, increased distensibility of the esophagogastric junction, prolonged esophageal clearance, and delayed gastric emptying. Moreover, multiple mechanisms influence the perception of GERD symptoms, such as the acidity of the refluxate, its proximal extent, the presence of gas in the refluxate, duodenogastroesophageal reflux, longitudinal muscle contraction, mucosal integrity, and peripheral and central sensitization. Understanding the pathophysiology of GERD is important for future targets for therapy as proton pump inhibitor-refractory GERD symptoms remain a common problem.

PURPOSE

In this review we provide an overview of the mechanisms leading to reflux and the factors influencing perception, in the light of historical developments. It is clear that further research remains necessary despite the recent advances in the understanding of the pathophysiology of GERD.

Atypical symptoms and health-related quality of life of patients with asymptomatic reflux esophagitis

BACKGROUND AND AIM

Asymptomatic reflux esophagitis (RE) is simply regarded as RE without the typical reflux symptoms, but it is unknown whether patients with asymptomatic RE have atypical symptoms. The aim of this study was to examine the clinical characteristics and health-related quality of life (HRQOL) of patients with asymptomatic RE.

PATIENTS AND METHODS

Consecutive patients with RE were enrolled during January 2010 to August 2012, and of them, 41 who had taken acid-suppressing drugs were excluded, leaving 280 patients as the study group. The patients' symptoms were evaluated using a self-completed questionnaire (modified Frequency Scale for the Symptoms of gastroesophageal reflux disease [FSSG]), as well as an HRQOL questionnaire (SF-8). We defined the typical symptoms of RE as heartburn and regurgitation. Asymptomatic RE was defined if the total symptom score was 0 or the minimum (1 point) for typical reflux symptoms in the modified FSSG.

RESULTS

Of the 280 RE patients, 71.8% (n = 201) were symptomatic and 28.2% (n = 79) were asymptomatic. The atypical symptom scores were significantly lower in asymptomatic RE (2.2 ± 2.2) than in symptomatic RE patients (6.9 ± 5.2) (P < 0.0001), and the HRQOL scores were significantly higher in asymptomatic RE than in symptomatic RE (P < 0.0001). Sleep was significantly less disturbed and chronic cough less frequent in asymptomatic RE than in symptomatic RE.

CONCLUSION

Frequency and severity of atypical symptoms in patients with asymptomatic RE were significantly less than in patients with symptomatic RE, and the HRQOL score was significantly higher in those patients. These observations suggest a specific patient cohort that is truly unlikely to manifest symptoms.

An alginate-antacid formulation localizes to the acid pocket to reduce acid reflux in patients with gastroesophageal reflux disease

BACKGROUND & AIMS

Alginate rafts (polysaccharide polymers that precipitate into a low-density viscous gel when they contact gastric acid) have been reported to form at the acid pocket, an unbuffered pool of acid that floats on top of ingested food and causes postprandial acid reflux. We studied the location of an alginate formulation in relation to the acid pocket and the corresponding effects on reflux parameters and acid pocket positioning in patients with gastroesophageal reflux disease (GERD).

METHODS

We randomly assigned patients with symptomatic GERD and large hiatal hernias to groups who were given either (111)In-labeled alginate-antacid (n = 8, Gaviscon Double Action Liquid) or antacid (n = 8, Antagel) after a standard meal. The relative positions of labeled alginate and acid pocket were analyzed for 2 hours by using scintigraphy; reflux episodes were detected by using high-resolution manometry and pH-impedance monitoring.

RESULTS

The alginate-antacid label localized to the acid pocket. The number of acid reflux episodes was significantly reduced in patients receiving alginate-antacid (3.5; range, 0-6.5; P = .03) compared with those receiving antacid (15; range, 5-20), whereas time to acid reflux was significantly increased in patients receiving alginate-antacid (63 minutes; range, 23-92) vs those receiving antacid (14 minutes; range, 9-23; P = .01). The acid pocket was located below the diaphragm in 71% of patients given alginate-antacid vs 21% of those given antacid (P = .08). There was an inverse correlation between a subdiaphragm position of the acid pocket and acid reflux (r = -0.76, P < .001).

CONCLUSIONS

In a study of 16 patients with GERD, we observed that the alginate-antacid raft localizes to the postprandial acid pocket and displaces it below the diaphragm to reduce postprandial acid reflux. These findings indicate the importance of the acid pocket in GERD pathogenesis and establish alginate-antacid as an appropriate therapy for postprandial acid reflux.

Four-year follow-up of endoscopic gastroplication for the treatment of gastroesophageal reflux disease

AIM: To evaluate the long-term effect of Endocinch treatment for gastroesophageal reflux disease (GERD).

METHODS: After unblinding and crossover, 50 patients (32 males, 18 females; mean age 46 years) with pH-proven chronic GERD were recruited from an initial randomized, placebo-controlled, single-center study, and included in the present prospective open-label follow-up study. Initially, three gastroplications using the Endocinch device were placed under deep sedation in a standardized manner. Optional retreatment was offered in the first year with 1 or 2 extra gastroplications. At baseline, 3 mo after (re) treatment and yearly proton pump inhibitor (PPI) use, GERD symptoms, quality of life (QoL) scores, adverse events and treatment failures (defined as: patients using > 50% of their baseline PPI dose or receiving alternative antireflux therapy) were assessed. Intention-to-treat analysis was performed.

RESULTS: Median follow-up was 48 mo [interquartile range (IQR): 38-52]. Three patients were lost to follow-up. In 44% of patients retreatment was done after a median of 4 mo (IQR: 3-8). No serious adverse events occurred. At the end of follow-up, symptom scores and 4 out of 6 QoL subscales were improved (all P < 0.01 compared to baseline). However, 80% of patients required PPIs for their GERD symptoms. Ultimately, 64% of patients were classified as treatment failures. In 60% a post-procedural endoscopy was carried out, of which in 16% reflux esophagitis was diagnosed.

CONCLUSION: In the 4-year follow-up period, the subset of GERD patients that benefit from endoscopic gastroplication kept declining gradually, nearly half opted for retreatment and 80% required PPIs eventually.

Arm span-height difference is correlated with gastroesophageal reflux symptoms in aged Japanese subjects

Previous studies have indicated an association between the symptoms of gastroesophageal reflux disease (GERD) and aging plus height. In this study we investigated whether the arm span–height difference was related to GERD symptoms with a focus on aged subjects in the general population, since the arm span reflects the height in young adulthood before decreasing due to vertebral deformities from aging. A total of 285 elderly individuals (105 females) who visited nursing homes for the elderly in Japan were enrolled in this study. The GERD symptoms were evaluated by the Frequency Scale for the Symptoms of GERD (FSSG). The body weight, height and arm span were measured, and information regarding medications and complications were reviewed in each nursing record. 50.5% of women had more than 3 cm of arm span–height difference. In contrast, only 37.3% of men had more than 3 cm of arm span–height difference. The FSSG scores indicated more than 70% of subjects complained of any GERD symptoms. There was a significant correlation between the FSSG score and the arm span–height difference in the subjects with more than 3 cm of arm span-height difference (r = 0.236; p = 0.012). The correlation between the arm span–height difference and the FSSG score was significant only in women in females in the present study. In conclusion, our findings indicate that vertebral deformity evaluated by the arm span–height difference might have some positive relationship to the pathogenesis of GERD symptoms in elderly Japanese individuals.

Mechanisms of increased gastroesophageal reflux in patients with cystic fibrosis

OBJECTIVES

Up to 80% of patients with cystic fibrosis (CF) may have increased gastroesophageal reflux (GER). It has been suggested that increased GER is due to low basal lower esophageal sphincter (LES) pressure and a high number of transient LES relaxations (TLESRs). The aim of our study was to reassess the mechanisms of GER in adult CF patients using state of the art upper-gastrointestinal physiology techniques: high-resolution manometry impedance (HRM-MII).

METHODS

We studied 12 CF patients (age 32 range (19-58), 5 males/7 females) and 11 age-matched healthy volunteers (age 27 range (20-36), 4 males /7 females). HRM-MII was performed in a semi-recumbent position for 30 min during fasting and for 2 h after a standard meal (1,000 kcal). We measured total reflux and proximal extent of reflux with impedance; basal LES pressure, TLESRs, and gastroesophageal pressure gradient (GEPG) with HRM.

RESULTS

Basal LES pressure was lower in CF patients compared with healthy controls, both in the pre- and postprandial period (preprandial 13 (7-22) vs. 24 (13-26) mm Hg, P = 0.04; postprandial 10 (8-14) vs. 18 (10-31) mm Hg, P = 0.01) and TLESRs were the main mechanism for reflux both in CF and in controls. We could not find a difference in the number of TLESRs in CF patients compared with healthy (14 (10-20) vs. 13 (10-24), P = not significant). However, reflux during TLESRs was more frequent in CF compared with healthy volunteers (80 (70-95) vs. 42 (20-78) %, P = 0.0058). GEPG during TLESRs was significantly higher in CF than in controls during inspiration (13.5 (9.5-15.8) vs. 7 (4-9.9) mm Hg, P = 0.004). This difference was due to a lower inspiratory intra-thoracic pressure in CF patients (-8.2 (-10.2-(-4.6) vs. -0.08 (-5.7-2.7) mm Hg, P = 0.002). Compared with controls, CF patients had significantly higher number of reflux episodes (13 (6-20) vs. 7 (3-9), P = 0.014) and CF patients also showed a higher proportion of reflux episodes with a high proximal extent compared with healthy volunteers (49 (22-50) vs. 0 (0-17) %, P = 0.0028).

CONCLUSIONS

CF patients have increased GER with a high proximal extent. Although we could not find a higher number of TLESRs in CF, there is a higher proportion of TLESRs associated with reflux. Unlike non-CF GER disease patients (with increased intra-abdominal pressure), reflux during TLESRs in CF is probably due to an increased GEPG mainly generated by a greater inspiratory negative intra-thoracic pressure.

Is there a role for dynamic swallowing MRI in the assessment of gastroesophageal reflux disease and oesophageal motility disorders?

OBJECTIVES

To evaluate the diagnostic value of dynamic MRI swallowing in patients with symptoms of Gastroesophageal Reflux Disease (GERD).

METHODS

Thirty-seven patients (17 m/20f) with typical signs of GERD underwent MR swallowing in the supine position at 1.5 T with a phased-array body coil. Using dynamic, gradient echo sequences (B-FFE) in the coronal, sagittal and axial planes, the bolus passages of buttermilk spiked with gadolinium chelate were tracked. MRI, pH-metry and manometry were performed within 31 days and results were compared.

RESULTS

MRI results were concordant with pH-metry in 82% (23/28) of patients diagnosed with abnormal oesophageal acid exposure by pH-metry. Five patients demonstrated typical symptoms of GERD and had positive findings with pH monitoring, but false negative results with MRI. In four of six patients (67%), there was a correct diagnosis of oesophageal motility disorder, according to manometric criteria, on dynamic MRI. The overall accuracy of MRI diagnoses was 79% (27/34). A statistically significant difference was found between the size of hiatal hernia, grade of reflux in MRI, and abnormal acid exposure on pH-monitoring.

CONCLUSIONS

MR fluoroscopy may be a promising radiation-free tool in assessing the functionality and morphology of the GE junction.

KEY POINTS

• Swallowing MRI can assess anatomy and function of the gastroesophageal-junction • Swallowing MRI can help identifying reflux and motility disorders • Definition of the size of hiatal hernias is possible in all three planes in MR. • Short duration of swallowing MRI enables its application in routine clinical practice.

Gastroesophageal reflux disease: From pathophysiology to treatment

This review focuses on the pathophysiology of gastroesophageal reflux disease (GERD) and its implications for treatment. The role of the natural anti-reflux mechanism (lower esophageal sphincter, esophageal peristalsis, diaphragm, and trans-diaphragmatic pressure gradient), mucosal damage, type of refluxate, presence and size of hiatal hernia, Helicobacter pylori infection, and Barrett’s esophagus are reviewed. The conclusions drawn from this review are: (1) the pathophysiology of GERD is multifactorial; (2) because of the pathophysiology of the disease, surgical therapy for GERD is the most appropriate treatment; and (3) the genesis of esophageal adenocarcinoma is associated with GERD.

The effect of gastroesophageal flap valve appearance on the management of patients with symptoms of gastroesophageal reflux disease

PURPOSE

To assess the effectiveness of anti-reflux treatment in gastroesophageal reflux disease patients classified according to esophagogastric junction morphology (Hill classification).

RESULTS

A symptom score and endoscopic grading of gastrooesophageal flap valve appearance were determined in 49 symptomatic patients (female 26, male 23; mean age 49 years, range 21-76 years). Patients received 8 weeks of continuous rabeprazole at a daily dose of 20 mg and, upon symptom control, continued with on-demand treatment for 3 months. The mean symptom score at 8 weeks was significantly reduced in all groups. However, at the end of the on-demand therapy, patients with Hill grade IV had used more rabeprazole tablets than those in the two other groups (II: 10.86 +/- 14.52, III: 14.73 +/- 14.58, IV: 25.78 +/- 15.85; P = 0.002).

CONCLUSIONS

Continuous treatment is effective in all groups of patients with reflux disease. Grading patients according to the gastroesophageal flap valve appearance is useful as a prognostic factor, especially when on-demand therapy is considered to be an option.

[Hiatus hernia and recurrence : the Achilles heel of antireflux surgery?]

Long-term studies show good postoperative results after laparoscopic antireflux surgery, but still approximately 10% of patients suffer from new or recurrent symptoms of gastroesophageal reflux disease. In the majority of cases the symptoms are caused by morphological changes of the fundic wrap or are related to the hiatal closure. Closure of the esophageal hiatus is therefore becoming more and more the key point of antireflux surgery. The aim of this study was to show the problems caused by the esophageal hiatus and to offer possible solutions. Therefore 1,201 laparoscopic antireflux procedures and 240 refundoplications performed in our department between 1993 and 2007 were analyzed with respect to morphologic reasons for failures and the corresponding symptoms. The most common morphological reason for complications after surgery was failure of the hiatal closure with consecutive intrathoracic migration of the fundic wrap, the so-called slipped Nissen. In the past the typical problems after open antireflux surgery were either that the wrap was too loose, a breakdown of the wrap or a so-called telescope phenomenon, all caused by failure of the fundic wrap and now a rarity since laparoscopic surgery. Even after repeated laparoscopic refundoplications the main problem was always the hiatus. This shows the importance of the crural closure and the necessity of a specific definition of size and form of the hiatus.The aim of this study was to initiate a discussion leading to a new definition of the hiatus with the focus on the "hiatal surface area" for a better basis for comparison of the published results of antireflux or hiatal surgery.

Review article: the pathophysiology of gastro-oesophageal reflux disease

BACKGROUND

Gastro-oesophageal reflux disease (GERD) is a common condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications.

AIM

To review the current knowledge on the underlying factors contributing to GERD, with particular emphasis on the most recent research.

METHODS

Literature searches were conducted in Medline and EMBASE. The abstracts from recent large congresses were also reviewed to ensure coverage of the latest findings.

RESULTS

The pathophysiological factors causing GERD can be split into those inducing greater exposure of the oesophagus to stomach contents, and those that provide increased perception of reflux or increased mucosal damage. Transient lower oesophageal sphincter relaxations, which are likely to be triggered by gastric distension, appear to be a key physiological cause of GERD. Excessive reflux may also be provoked by impaired oesophageal or gastric clearance mechanisms. Pre-epithelial, epithelial and post-epithelial defences all normally protect the oesophagus from injury, and may be compromised in individuals with GERD. Heartburn could also be caused by oesophageal hypersensitivity as a result of visceral neural pathway dysfunction.

CONCLUSION

The pathophysiology of GERD is multifactorial, and abnormalities in the gastro-oesophageal junction, the stomach, the oesophagus and the nervous system may all contribute to this disease state.

Gastroesophageal reflux disease: integrating the barium esophagram before and after antireflux surgery

Gastroesophageal reflux disease (GERD) is a common medical problem in the United States. As a result, laparoscopic antireflux surgery is a common surgical procedure. At the authors' institution, the barium esophagram before and after antireflux surgery is a critical examination in patients with GERD. This article summarizes the authors' examination protocol and describes how the findings are integrated in the care of these patients.

Review: what do we mean by GERD?--definition and diagnosis

Gastro-oesophageal reflux disease (GERD) is a condition in which the gastro-oesophageal reflux provokes symptoms or complications. Since the majority of patients with heartburn do not have mucosal breaks, expressions such as 'endoscopy-negative reflux disease' (ENRD), 'non-erosive reflux disease' (NERD), or even 'reflux-like dyspepsia' and 'functional heartburn' are frequently employed despite the lack of consensus concerning their exact meaning. Moreover, definition of a disease does not mean that precise diagnostic criteria exist. Diagnostic approaches to GERD differ considerably between primary and secondary care. The primary care physician's role is to decide, on the basis of symptoms and clinical examination, if it is likely that the patient has some serious problem which requires urgent investigation and intervention. In practice, a symptom-based diagnosis can often be made reliably because heartburn and regurgitation are very specific for GERD. The secondary care physician has to make a full evaluation of an already highly-selected patient and, as far as possible, to make a comprehensive, accurate diagnosis, using whatever investigative tools are required. However, there is no 'gold standard' for the diagnosis of GERD and 24-hour pH monitoring lacks sensitivity in NERD. Recently, impedance-pH monitoring has been introduced and promising results have been reported. However, this new technology needs further validation and technical improvement before being employed in routine clinical investigation.