Gastroesophageal reflux after sleeve gastrectomy. Fact or fiction?

BACKGROUND

One of the most controversial issues surrounding laparoscopic sleeve gastrectomy is the development of gastroesophageal reflux disease following surgery. The aim of the study was to evaluate the occurrence of gastroesophageal reflux disease after laparoscopic sleeve gastrectomy and to analyze patients' weight loss, comorbidities, and quality of life after surgery.

METHODS

The clinical records of 52 patients submitted to laparoscopic sleeve gastrectomy between January and November 2018, with 3 years of follow-up, were retrospectively reviewed. At the end of the follow-up period, the patients underwent screening endoscopy, and those with postoperative esophagitis were submitted to endoscopic biopsies and pH-impedance monitoring (MII-pH). The presence of gastroesophageal reflux disease symptoms was assessed using the modified clinical DeMesteer score questionnaire. The Bariatric Analysis and Reporting Outcome System score and 36-Item Short Form Health Survey were used to assess the postoperative quality of life.

RESULTS

In the preoperative work-up, only 7.6% of patients had signs of esophagitis at esophagogastroduodenoscopy, whilst at 3-year follow-up, 50% of them had endoscopic signs of gastroesophageal reflux disease. Twenty-one out of 26 patients with signs of esophagitis agreed to undergo MII-pH. The median DeMesteer score questionnaire was 4.5, with only 4 patients (19%) exhibiting a value greater than the pH cut-off value (14.72), indicative of gastroesophageal reflux disease. MII-pH data analysis showed the presence of gastroesophageal reflux disease in 5 patients. An excellent outcome on the Bariatric Analysis and Reporting Outcome System score was reported in 50% of patients, and all 8 domains from the 36-Item Short Form Health Survey improved significantly.

CONCLUSION

This study showed an improvement in these patients' quality of life and the limited refluxogenic nature of laparoscopic sleeve gastrectomy at 3-year follow-up when diagnosis of gastroesophageal reflux disease is based on the Lyon consensus.

Differences in dietary habits between patients with inflammatory bowel disease in clinical remission and a healthy population

BACKGROUND

Although patients with active inflammatory bowel disease (IBD) change their dietary habits according to suggestions from their healthcare team, no restriction is required in the remission phase. Accordingly, we compared eating patterns in IBD patients with drug-induced clinical remission with those in healthy subjects.

METHODS

A total of 150 IBD patients, 84 with Crohn's disease (CD) and 66 with ulcerative colitis (UC), in clinical remission, receiving immunomodulator/biologic therapy, and 100 healthy volunteers (controls) were enrolled. The IBD diagnosis had previously been established by a combined assessment of symptoms, endoscopy, histology and abdominal imaging. Clinical remission was defined as a Harvey Bradshaw index <5 for CD and a partial Mayo score <2 for UC. An experienced nutritionist guided the compilation of a food diary for 7 days according to current guidelines. Macronutrient and fiber intake was evaluated using dedicated software. Comparison between continuous variables was performed using Student's t-test or analysis of variance plus Bonferroni post-hoc analysis. Categorical variables were tested with the χ² test.

RESULTS

No difference in protein and carbohydrate intake was observed. IBD patients ate more calories (1970.7±348.4 vs. 1882.1±280.2 kcal/day, P=0.03), more lipids (68.9±15.2 vs. 59.4±19.0 g/day, P<0.001) and less fibers (11.9±4.7 vs. 15.5±8.3 g/day, P<0.001) than controls. No significant difference in total calories, proteins, lipids, carbohydrates or fibers was seen between CD and UC patients.

CONCLUSION

IBD patients have a different macronutrient and fiber intake compared to healthy subjects, even when clinical remission and no symptoms do not dictate dietary restrictions. Therefore, psychological issues may be involved.

Transanal Tube NO COIL® after Rectal Cancer Proctectomy. The “G. Paolo II” Cancer Centre Experience

Aims and background

Covering stoma is the main method used to protect low-lying anastomosis after cancer proctectomy. Intraluminal rectal pressure could be a potential risk factor for anastomotic leakage. We present our personal experience with an alternative and original device, the transanal tube NO COIL®, evaluating its feasibility and safety based on a preliminary manometric study.

Methods

From May 1998 to March 1999, an experimental manometric study on 35 subjects was performed to assess the pathophysiological basis of intraluminal rectal pressure with or without the transanal tube. Subsequently, from April 1999 to December 2009, 184 patients (107 males, 77 females, average age 68.2 ± 10 years) with primary adenocarcinoma of the rectum (≤12 cm from anal verge) were selected. Eighty-two underwent total proctectomy and 102 subtotal proctectomy. No stoma were fashioned. At the end of the operation, the silicone transanal tube NO COIL®, 60–80 mm long, 2 mm thick with a calibre of up to 2 cm, was applied and secured to the perineal skin by two stitches, then removed on the seventhpostoperative day if no signs of leakage occurred.

Results

The intraluminal rectal pressure with transanal tube was strongly reduced from 13.8 + 8.5 mmHg to 4.8 + 3.7 mmHg (P <0.01). Nine patients (4.8%) developed an anastomotic leakage, 2 males and 7 females. In 10 patients, the transanal tube NO COIL® did not remain in situ for the planned seven days, and 18 patients suffered from ulcers in the perianal skin. Leakage subsided with conservative treatment in 4 patients, whereas 5 patients required loop colostomy. The stoma rate was 2.7%. No leakage-related deaths occurred, and overall mortality was 1.3%.

Conclusions

The transanal tube NO COIL® does not abolish the risk of anastomotic leakage but could be an alternative option to covering stoma after cancer proctectomy in selected patients. In our experience, this simple and cheap device could reduce the rate of stoma without leakage-related mortality. Further studies within a randomized controlled trial are required to better define our results.

Tailored therapy guided by multichannel intraluminal impedance pH monitoring for refractory non-erosive reflux disease

A relevant percentage of non-erosive reflux disease (NERD) is refractory to proton pump inhibitors (PPIs) treatment. Multichannel intraluminal impedance pH (MII-pH) monitoring should give useful pathophysiological information about refractoriness. Therefore, our aim was to assess whether this technique could be useful to guide a 'tailored' therapy in refractory NERD. We retrospectively recruited NERD patients undergoing MII-pH monitoring for unsuccessful treatment. All patients had undergone upper endoscopy, and those with erosive esophagitis were excluded. No patient received PPI during MII-pH monitoring. Subjects were subgrouped into three categories: acid reflux, non-acid reflux and functional heartburn. MII-pH-guided therapy was performed for 4 weeks as follows: patients with acid reflux received PPI at double dose, patients with non-acid reflux PPI at full dose plus alginate four times a day and patients with functional heartburn levosulpiride 75 mg per day. A visual analog scale (VAS) ranging from 0 to 100 mm was administered before and after such tailored therapy to evaluate overall symptoms. Responders were defined by VAS improvement of at least 40%. Sixty-nine patients with refractory NERD were selected (female-male ratio 43 : 26, mean age 47.6±15.2 years). Overall effectiveness of tailored therapy was 84% without statistical difference among subgroups (88.5% acid reflux, 92% non-acid reflux, 66.6% functional heartburn; P=0.06). Univariate analysis showed that therapy failure directly correlated with functional heartburn diagnosis (OR=4.60) and suggested a trend toward a negative correlation with smoking and a positive one with nausea. However, at multivariate analysis, these parameters were not significant. Functional heartburn experienced a lower median percent VAS reduction than acid reflux (52.5% versus 66.6%, P<0.01) even if equal to non-acid reflux (66.6%). In conclusion, a tailored approach to refractory NERD, guided by MII-pH monitoring, demonstrated to be effective and should be promising to cure symptom persistence after conventional therapy failure. Nevertheless, standardized guidelines are advisable.

Acute pancreatitis in elderly patients: A retrospective evaluation at hospital admission

BACKGROUND AND AIMS

Acute pancreatitis (AP) in elderly may have an aggressive course due to co-morbidity high rate and severe presentation. We retrospectively evaluated AP severity and its underlying factors in a group of elderly patients compared with an adult population sample.

METHODS

Forty-two elderly patients (65-102years) and 48 controls (19-64years) admitted at our Unit for biliary or alcoholic AP were retrospectively enrolled. AP severity was evaluated by the Atlanta classification and Ransom score. Laboratory investigations and demographic data were collected. Comparison between the two groups was performed by t-test, ANOVA or Fisher's exact test. A multinomial logistic regression was used to determine factors affecting AP severity.

RESULTS

Elderly patients showed more severe Atlanta (1.81±0.75 vs 1.29±0.46; p=0.007) and higher Ransom (2.52±1.57 vs 0.75±0.73; p<0.0001) scores. No death was observed. Elderly patients consumed more drugs than controls, had higher rates of cardiovascular, pulmonary and renal co-morbidity, showed higher creatinine (1.09±0.41 vs 0.81±0.18; p=0.004) and lower calcium levels (8.43±0.48 vs 8.88±0.44; p=0.002). We observed only one case of fluid necrosis in an old patient. Non-necrotic fluid collections were more common in the elderly (40.5% vs 12.5%; p=0.003). At multivariate analysis, AP severity was influenced by white blood cell-count (WBC: OR=1.94; p=0.048), aspartate-transaminase-levels (AST: OR=1.97; p=0.02), serum lactate-dehydrogenase (LDH: OR=1.07; p=0.047) and Ransom score (OR=70.4; p=0.036) in elderly, while only Ransom score correlated in controls (OR=66.04; p<0.001). The etiology (biliary/alcoholic) did not influence the severity.

CONCLUSIONS

Elderly patients usually undergo a severe AP course, but without increase of mortality. High WBC, LDH, AST and Ransom score at the onset may predict AP severity.

Transanal tube NO COIL® after rectal cancer proctectomy. The "G. Paolo II" Cancer Centre experience

AIMS AND BACKGROUND

Covering stoma is the main method used to protect low-lying anastomosis after cancer proctectomy. Intraluminal rectal pressure could be a potential risk factor for anastomotic leakage. We present our personal experience with an alternative and original device, the transanal tube NO COIL®, evaluating its feasibility and safety based on a preliminary manometric study.

METHODS

From May 1998 to March 1999, an experimental manometric study on 35 subjects was performed to assess the pathophysiological basis of intraluminal rectal pressure with or without the transanal tube. Subsequently, from April 1999 to December 2009, 184 patients (107 males, 77 females, average age 68.2 ± 10 years) with primary adenocarcinoma of the rectum (≤12 cm from anal verge) were selected. Eighty-two underwent total proctectomy and 102 subtotal proctectomy. No stoma were fashioned. At the end of the operation, the silicone transanal tube NO COIL ®, 60-80 mm long, 2 mm thick with a calibre of up to 2 cm, was applied and secured to the perineal skin by two stitches, then removed on the seventh postoperative day if no signs of leakage occurred.

RESULTS

The intraluminal rectal pressure with transanal tube was strongly reduced from 13.8 + 8.5 mmHg to 4.8 + 3.7 mmHg (P <0.01). Nine patients (4.8%) developed an anastomotic leakage, 2 males and 7 females. In 10 patients, the transanal tube NO COIL® did not remain in situ for the planned seven days, and 18 patients suffered from ulcers in the perianal skin. Leakage subsided with conservative treatment in 4 patients, whereas 5 patients required loop colostomy. The stoma rate was 2.7%. No leakage-related deaths occurred, and overall mortality was 1.3%.

CONCLUSIONS

The transanal tube NO COIL® does not abolish the risk of anastomotic leakage but could be an alternative option to covering stoma after cancer proctectomy in selected patients. In our experience, this simple and cheap device could reduce the rate of stoma without leakage-related mortality. Further studies within a randomized controlled trial are required to better define our results.