Endoscopic grading of the gastroesophageal valve in patients with symptoms of gastroesophageal reflux disease (GERD)

Correlation of the Endoscopic Gastroesophageal Flap Valve with Pathologic Reflux

BACKGROUND

The Hill classification characterizes the geometry of gastroesophageal junction and Hill grades (HGs) III and IV have a high association with pathologic reflux. This study aimed to understand the use of the Hill classification and correlate the prevalence of pathologic reflux across different HGs.

STUDY DESIGN

A retrospective review of 477 patients who underwent upper endoscopy and BRAVO pH monitoring between August 2018 and October 2021 was performed. These charts were reviewed for endoscopic findings for hiatal hernia and association of HGs with pathologic reflux, defined as an abnormal esophageal acid exposure time (AET) of ≥4.9%.

RESULTS

Of 477 patients, 252 (52.8%) had an HG documented on the endoscopy report. Of the 252 patients, 61 had HG I (24.2%), 100 had HG II (39.7%), 61 had HG III (24.2%), and 30 had HG IV (11.9%). The proportion of patients with abnormal AET increases with increasing HGs (p < 0.001) as follows: I (39.3%), II (52.5%), III (67.2%), and IV (79.3%). The mean overall AET is as follows: HG I (5.5 ± 6%), HG II (7.0 ± 5.9%), HG III (10.2 ± 10.3%), and HG IV (9.5 ± 5.5%). The proportion of patients with hiatal hernia was 18% for HG I, 28% for HG II, 39.3% for HG III, and 80% for HG IV.

CONCLUSIONS

Use of the Hill classification in clinical practice is low. There is an association of increasing HGs with increasing proportion of patients with abnormal AET. There is a high proportion of patients within HGs I and II with documented pathologic reflux and the presence of a hiatal hernia as observed on endoscopic examination. Our study suggests that endoscopic grading of the gastroesophageal junction may not adequately differentiate between normal vs abnormal reflux status, particularly for HGs I and II.

Relationship between endoscopic gastroesophageal valve grading and mean nocturnal baseline impedance and postreflux swallow-induced peristaltic wave index in patients with gastroesophageal reflux disease

This study aimed to investigate the relationship between endoscopic gastroesophageal valve grading and mean nocturnal baseline impedance (MNBI) and postreflux swallow-induced peristaltic wave index (PSPWI) in patients with gastroesophageal reflux disease (GERD). A total of 120 patients diagnosed with GERD disease were included in the study. According to the classification of endoscopic gastroesophageal valves, the patients were divided into 5 groups, group 1 as baseline group, and Group 2-4 as Hill grade I-IV. Basic information about the patients was collected, including age and gender. The mean nocturnal baseline impedance and creep wave index induced by swallowing after rumination were measured by high resolution creep measurement technique. Through statistical analysis, the relationship between valve classification and observation index was discussed. In terms of MNBI, impedance values gradually decreased with increasing valve classification. The average impedance of the Grade 1 group was 23.5 mm Hg/cm2, while the average impedance of the Grade 5 group was 15.2 mm Hg/cm2. This reduction showed a significant decreasing trend (P < .001). In addition, in terms of the peristaltic wave index caused by swallowing after regurgitation, the peristaltic wave index gradually increased with the increase of valve classification. The mean index in the Grade 1 group was 1.8 beats/min, while the mean index in the Grade 5 group was 3.6 beats/min. This increase showed a significant positive relationship (P < .001). Endoscopic gastroesophageal valve grading was significantly correlated with MNBI and PSPWI in patients with GERD. These observations can serve as useful tools for assessing the severity of GERD and monitoring disease progression.

Relationship of Gastroesophageal Flap Valve with Gastroesophageal Reflux Disease Assessed Based on GerdQ Scores and Endoscopic Images

Background: Gastroesophageal reflux disease (GERD) is a condition where reflux of stomach contents causes troublesome symptoms or complications. The gastroesophageal flap valve (GEFV) is one of the protective structures against esophageal reflux. This study aimed to determine the relationship between GEFV, measured by Gastroesophageal Reflux Disease Questionnaire (GerdQ) scores, and the endoscopic features of GERD patients. Method: This observational cross-sectional study was performed at Wahidin Sudirohusodo Hospital Makassar from August 2021 to October 2021. The participants were GERD patients who met the inclusion criteria. They were diagnosed using GerdQ scores and endoscopic features based on the Los Angeles criteria. The GEFV was assessed using retroflection endoscopy according to Hill’s criteria. Data analysis used SPSS version 25. The Kolmogorov–Smirnov test was used to assess data normality, along with the Chi-square test and calculation of odds ratio (OR). The results of the statistical tests were significant if p<0.05. Results: This study included 100 GERD patients: 49 men and 51 women. They had a mean age of 40.5±12.8 years and a mean body mass index of 22.4±3.8 kg/m2. Abnormal GEFV was a risk for a GerdQ score of ≥8 compared to <8 (OR 4.56; 95% CI 1.53–13.52). Both normal and abnormal GEFV in esophagitis reflux were higher than in non-erosive reflux disease (p=0.943). Conclusion: Abnormal GEFV was a risk factor for GERD based on a GerdQ score of 8, at 4.56 times higher than with normal GEFV. No statistically significant relationship existed between GEFV and endoscopic images.

Association Between Gastroesophageal Flap Valve and Endoscopically Diagnosed Gastroesophageal Reflux Disease According to Lyon Consensus: A Meta-analysis of Asian Studies

BACKGROUND

Lyon Consensus altered the previous understanding of endoscopic gastroesophageal reflux disease (GERD) and pointed out that only high-grade reflux esophagitis (RE) [Los Angeles (LA) grades C or D], Barrett's esophagus or peptic stricturing were considered confirmatory evidence for GERD but low-grade RE (LA grades A or B) was regarded as suspected GERD. We aimed to summarize the possible relationship between gastroesophageal flap valve (GEFV) and endoscopic GERD according to Lyon Consensus using meta-analysis of studies done in Asia.

MATERIALS AND METHODS

Comprehensive searches of PubMed, WOS, Embase, SinoMed, and CNKI databases were completed to identify eligible studies published before September 22, 2019. A total of 237 articles have been reviewed and 2 reviewers independently evaluated the eligibility for inclusion, extracted, and analyzed the statistical data. The pooled risk ratios (RRs) with 95% confidence intervals (CI) were measured for the association. Random-effects models were used when observing significant heterogeneity.

RESULTS

A total of 15 studies were included and we found that abnormal GEFV (III and IV) could be associated with RE and the correlation become stronger as the grade increases (RE-A vs. controls-RR: 2.186, 95% CI: 1.560-3.064, P<0.001; RE-B vs. RE-A-RR: 1.268, 95% CI: 1.128-1.425, P<0.001; RE-C vs. RE-B-RR: 1.181, 95% CI: 1.000-1.395, P=0.049; RE-D vs. RE-C-RR: 1.471, 95% CI: 1.151-1.879, P=0.002). Both suspected GERD (RR: 2.400, 95% CI: 1.761-3.271, P<0.001) and endoscopic GERD (RR: 1.388, 95% CI: 1.127-1.711, P=0.002) were related to abnormal GEFV.

CONCLUSION

Abnormal GEFV could provide useful information for reflux conditions, but it could not distinguish confirmatory GERD from low-grade RE under the upper endoscopy.

Adequacy of EGD Reporting: a Review of 100 Reports from 100 Endoscopists

INTRODUCTION

Esophagogastroduodenoscopy (EGD) is commonly performed in patients with gastroesophageal reflux disease (GERD). An EGD report should document pertinent findings such as esophagitis, a columnar-lined esophagus (CLE), the location of the squamo-columnar and gastroesophageal junctions, the size and type of a hiatal hernia and the number and location of any biopsies. The aim of this study was to evaluate how commonly these findings were noted in the EGD reports of patients referred for antireflux surgery.

METHODS

A retrospective review was performed of patient charts from 2012 to 2015 to identify 100 consecutive EGD reports from different endoscopists in different patients. Each EGD report was reviewed for pertinent findings and the use of a classification system for esophagitis (Savory-Miller or Los Angeles) and for reporting a CLE (Prague).

RESULTS

In 100 EGD reports, esophagitis was noted in 33 patients, but was graded in only 14 (42%). A CLE was noted in 28 patients, but the length was reported in only 16 (57%) and no report used the Prague classification system. A hiatal hernia was noted in 61 patients, measured in 31 (51%) and the type classified in 26%. A biopsy was taken in 93 patients and the location noted in 86 patients (93%). The number of biopsies was recorded in only 20 patients (22%). In 12 patients the EGD was for Barrett's surveillance, yet a Seattle biopsy protocol was reported to be used in only 3 patients.

CONCLUSION

Endoscopy reports frequently do not include the use of a grading system for esophagitis or the Prague system for CLE. This hampers the assessment of change with therapy or over time. The size of a hiatal hernia was typically reported in a subjective fashion and only infrequently was the type specified. Lack of clarity about the presence of a paraesophageal hernia can impede evaluation of acute symptoms. In patients with Barrett's esophagus a standard biopsy protocol was infrequently reported to be used. These findings raise concern about the quality of upper endoscopy, both in the performance of the procedure and the documentation of findings. A consistent reporting system is recommended for routine use with upper endoscopy.

Usefulness of Endoscopic Hill Grade in Evaluating Children Suspected of Having Gastroesophageal Reflux Disease

Background/Aims

This study aim to evaluate the relationship between the Hill grade confirmed by esophagogastroduodenoscopy (EGD) and the degree of gastroesophageal reflux (GER) by 24-hour multichannel intraluminal impedance-pH monitoring (MII-pH) in children suspected of having gastroesophageal reflux disease (GERD).

Methods

A retrospective review of 105 children and adolescents who underwent EGD and MII-pH for the evaluation of GERD from March 2013 to July 2019 was performed. Clinical features and results of EGD and 24-hour MII-pH were collected and statistically analyzed.

Results

Hill grades 1, 2, 3, and 4 were identified using EGD in 56 (53.3%), 22 (22.0%), 16 (15.2%), and 11 (10.5%) patients, respectively. As the Hill grade increased, the proportion of neurological diseases (P < 0.001) and endoscopic erosive esophagitis (P < 0.001) increased significantly. The acid exposure index, bolus exposure index, number of reflux episodes, and number of GER reaching proximal extent on MII-pH increased significantly as the endoscopic Hill grade increased (all P < 0.001). Linear regression analysis revealed an increase in the Hill grade by 1 increased the acid exposure index by 2.0%, bolus exposure index by 0.7%, number of reflux episodes by 18.9 episodes, and the number of GER reaching the proximal esophagus increased by 10.5 episodes on average (all P < 0.001).

Conclusions

Hill grade on EGD was associated with GER in children. Estimating the degree of GER by applying Hill grade in the retroflexion view may be useful in practice when evaluating children suspected with GERD.

Esophagogastric Junction Morphology on Hill's Classification Predicts Gastroesophageal Reflux with Good Accuracy and Consistency

INTRODUCTION

Hill's classification provides a reproducible endoscopic grading system for esophagogastric junction morphology and competence, specifically whether the gastroesophageal flap valve (GEFV) is normal (grade I/II) or abnormal (grades III/IV). However, it is not routinely used in clinical practice. We report a systematic review and meta-analysis to determine association between abnormal GEFV and gastroesophageal reflux disorder (GERD).

METHODS

A comprehensive literature search of MEDLINE and Scopus databases was conducted to identify studies that reported the association between abnormal GEFV and GERD. The search and quality assessment were performed independently by two authors. Fixed- and random-effects meta-analyses were conducted using symptomatic GERD and erosive esophagitis as outcomes.

RESULTS

A total of 11 studies met inclusion criteria that included a total of 5054 patients. In the general population, patients with abnormal GEFV had greater risk of symptomatic GERD compared to patients with a normal GEFV (risk ratio [RR] 1.88, 95% CI 1.57-2.24). Further, in patients with symptomatic GERD, patients with abnormal GEFV had greater risk of erosive esophagitis compared to patients with normal GEFV (RR 2.17, 95% CI 1.40-3.36). Finally, the specificity of abnormal GEFV for symptomatic GERD was 73.3% (95% CI 69.3-77.0%) and 75.7% (95% CI 65.9-83.4%) for erosive esophagitis in symptomatic GERD.

CONCLUSION

Our systematic review and meta-analysis showed consistent association between abnormal GEFV indicated by Hill's classification III/IV and symptomatic GERD and erosive esophagitis. Our recommendation is to include Hill's classification in routine endoscopy reports and workup for GERD.

Novel Interdisciplinary Approach to GERD: Concomitant Laparoscopic Hiatal Hernia Repair with Transoral Incisionless Fundoplication

BACKGROUND

Transoral incisionless fundoplication (TIF) is an endoscopic alternative for the treatment of GERD. However, TIF does not address the hiatal hernia (HH). We present a novel approach with a laparoscopic HH repair followed by same-session TIF, coined concomitant transoral incisionless fundoplication (cTIF). The aim of this study was to assess the efficacy, safety, and feasibility of cTIF in a collaborative approach between Gastroenterology and surgery.

STUDY DESIGN

Patients with confirmed GERD and >2 cm HH who underwent cTIF between 2018 and 2020 were included. Symptoms were assessed using the Reflux Disease Questionnaire, GERD Health-Related Quality of Life Index, and the Reflux Symptom Index pre and post cTIF. One-way ANOVA and paired samples t-test were used for statistical analysis.

RESULTS

Sixty patients underwent cTIF (53% were men, mean age was 59.3 years) with 100% technical success. Mean ± SD HH measurement on endoscopy was 2.9 ± 1.5 cm. Scores on Reflux Disease Questionnaire for symptom frequency and symptom severity improved significantly from before to 6 months after cTIF (17.4 to 4.72; p < 0.01 and 16.7 to 4.56; p < 0.05, respectively). According to the GERD Health-Related Quality of Life Index, significant decreases were seen post cTIF in heartburn (23.26 to 7.37; p < 0.01) and regurgitation (14.26 to 0; p = 0.05). Reflux Symptom Index similarly decreased after cTIF (17.7 to 8.1 post cTIF; p < 0.01). Mean DeMeester score decreased from 43.7 to 4.9 and acid exposure time decreased from 12.7% to 1.28% post cTIF (p = 0.06).

CONCLUSIONS

We present a novel multidisciplinary approach to GERD using a combined endoscopic and surgical approach with close collaboration between Gastroenterology and surgery. Our results suggest that cTIF is safe and effective in reducing reflux symptoms in a large spectrum of GERD patients.

Does anti-reflux surgery disrupt the pathway of Barrett's esophagus progression to cancer?

In patients with Barrett's esophagus (BE), anti-reflux surgery aims to sustainable control reflux symptoms and heal reflux induced esophageal mucosal inflammation and prevent progression of BE to adenocarcinoma. There is growing evidence that beside gastric acid, bile salts in refluxed duodenal juice are responsible for the development and progression of BE. However, the pathogenesis of BE progression and the metaplasia-dysplasia-carcinoma sequence of the adenocarcinoma of the esophagus (EAC) is multifactorial and occurs over long natural time course. After anti-reflux surgery significant levels of regression from metaplastic Barrett's to non-metaplastic epithelium as well as from dysplastic to non-dysplastic BE have been observed and a randomized trial showed that sufficient surgical reflux control reduces the risk of Barrett's progression significantly when compared to medical treatment. Thus, large cohort studies show significant reduced risk of EAC in patients suffering from gastroesophageal reflux disease (GERD) with and without BE after anti-reflux surgery. Even after anti-reflux surgery the risk for EAC remains elevated in patients with BE and the right moment of intercepting the progressive nature of GERD has to be discussed in future. The paper also addresses the impact of anti-reflux surgery, endoscopic ablation and life style therapies for the management of GERD, BE and cancer prevention.

Analysis of computed tomographic findings according to gastroesophageal flap valve grade

BACKGROUND/AIMS

The gastroesophageal junction is an important barrier against gastroesophageal ref lux. Endoscopic grading of gastroesophageal f lap valve is simple, reproducible, and may predict reflux activity. We investigated the correlation between gastroesophageal flap valve grade and the gastroesophageal junction's structural properties using abdominal computed tomography.

METHODS

A total of 138 patients with early gastric cancer who underwent both pre-treatment esophagogastroduodenoscopy and water-distended stomach two-phase computed tomography were enrolled. Endoscopic gastroesophageal f lap valve grade and abdominal computed tomography findings were analyzed to assess anatomical factors including the gastroesophageal junction and related organs.

RESULTS

The angle of His increased significantly with gastroesophageal flap valve grade (grade I, 65.2˚ ± 19.6˚; grade II, 66.6˚ ± 19.8˚; grade III, 76.7˚ ± 11.9˚; grade IV, 120.0˚ ± 30.3˚; p < 0.001), as did the size of the diaphragmatic hiatus (grade I, 213.0 ± 53.8 mm² ; grade II, 232.6 ± 71.0 mm² ; grade III, 292.3 ± 99.2 mm² ; grade IV, 584.4 ± 268.3; p < 0.001). The length of the abdominal esophagus decreased as gastroesophageal flap valve grade increased (grade I, 34.6 ± 5.8 mm; grade II, 32.0 ± 6.5 mm; grade III, 24.6 ± 7.8 mm; grade IV, -22.6 ± 38.2 mm; p < 0.001). There was no significant relationship between gastroesophageal flap valve grade and visceral and subcutaneous fat areas (p = 0.877 and p = 0.508, respectively).

CONCLUSIONS

Endoscopic grading of the gastroesophageal flap valve is well correlated with anatomical changes around the gastroesophageal junction on abdominal computed tomography, and it can provide useful information about the anti-reflux barrier.

Endoscopic Evaluation of Post-Fundoplication Anatomy

PURPOSE OF REVIEW

We aim to review the endoscopic evaluation of post-fundoplication anatomy and its role in assessment of fundoplication outcomes and in pre-operative planning for reoperation in failed procedures.

RECENT FINDINGS

There is no universally accepted system for evaluating post-fundoplication anatomy endoscopically. However, multiple reports described the usefulness of post-operative endoscopy as a quality control measure and in the evaluation of complex cases such as repeat procedures and paraesophageal hernias (PEH). Endoscopic evaluation of post-fundoplication anatomy has an important role in assessing the outcomes of operative repair and pre-operative planning for failed fundoplications. Attempts have been made to characterize the appearance of the newly formed gastroesophageal valve after successful repairs and to standardize endoscopic reporting and classification of anatomic descriptions of failed fundoplications. However, there is no consensus. More studies are needed to evaluate the applicability and reproducibility of proposed endoscopic evaluation systems in order for such tools to become widely accepted.

Hill classification is superior to the axial length of a hiatal hernia for assessment of the mechanical anti-reflux barrier at the gastroesophageal junction

BACKGROUND AND STUDY AIMS

The pathogenesis of gastroesophageal reflux disease (GERD) is multifactorial, including the mechanical anti-reflux barrier of the gastroesophageal junction. This barrier can be evaluated endoscopically in two ways: by measuring the axial length of any hiatal hernia present or by assessing the gastroesophageal flap valve. The endoscopic measurement of axial length is troublesome because of the physiological dynamics in the area. Grading the gastroesophageal flap valve is easier and has proven reproducible. The aim of the present study was to compare the two endoscopic grading methods with regard to associations with GERD.

PATIENTS AND METHODS

Population-based subjects underwent endoscopic examination assessing the axial length of hiatus hernia, the gastroesophageal flap valve using the Hill classification, esophagitis using the Los Angeles (LA) classification, and columnar metaplasia using the Z-line appearance (ZAP) classification. Biopsies were taken from the squamocolumnar junction to assess the presence of intestinal metaplasia. Symptoms were recorded with the validated Abdominal Symptom Questionnaire. GERD was defined according to the Montreal definition.

RESULTS

In total, 334 subjects were included in the study and underwent endoscopy; 86 subjects suffered from GERD and 211 presented no symptoms or signs of GERD. Based on logistic regression, the estimated area under the curve statistic (AUC) for Hill (0.65 [95 %CI 0.59 - 0.72]) was higher than the corresponding estimate for the axial length of a hiatal hernia (0.61 [95 %CI 0.54 - 0.68]), although the difference was not statistically significant (P = 0.225).

CONCLUSION

From our data, and in terms of association with GERD, the Hill classification was slightly stronger compared to the axial length of a hiatal hernia, but we could not verify that the Hill classification was superior as a predictor. The Hill classification may replace the axial length of a hiatal hernia in the endoscopic assessment of the mechanical anti-reflux barrier of the gastroesophageal junction.

Altered Esophageal Mucosal Structure in Patients with Celiac Disease

Background/Aim. Reflux symptoms (RS) are common in patients with celiac disease (CD), a chronic enteropathy that affects primarily the small intestine. We evaluated mucosal integrity and motility of the lower esophagus as mechanisms contributing to RS generation in patients with CD. Methods. We enrolled newly diagnosed CD patients with and without RS, nonceliac patients with classical reflux disease (GERD), and controls (without RS). Endoscopic biopsies from the distal esophagus were assessed for dilated intercellular space (DIS) by light microscopy and electron microscopy. Tight junction (TJ) mRNA proteins expression for zonula occludens-1 (ZO-1) and claudin-2 and claudin-3 (CLDN-2; CLDN-3) was determined using qRT-PCR. Results. DIS scores were higher in patients with active CD than in controls, but similar to GERD patients. The altered DIS was found even in CD patients without RS and normalized after one year of a gluten-free diet. CD patients with and without RS had lower expression of ZO-1 than controls. The expression of CLDN-2 and CLDN-3 was similar in CD and GERD patients. Conclusions. Our study shows that patients with active CD have altered esophageal mucosal integrity, independently of the presence of RS. The altered expression of ZO-1 may underlie loss of TJ integrity in the esophageal mucosa and may contribute to RS generation.

Stomach intestinal pylorus sparing surgery (SIPS) with laparoscopic fundoplication (LF): a new approach to gastroesophageal reflux disease (GERD) in the setting of morbid obesity

The increase in the prevalence of obesity and gastroesophageal reflux disease (GERD) has paralleled one another. Laparoscopic fundoplication (LF) (Nissen or Toupet) is a minimally invasive form of anti-reflux surgery. The duodenal switch is a highly effective weight loss surgery with a proven record of long term weight loss success. However, fundoplication alone does not give satisfactory results when used for GERD in morbidly obese patients. Here we present a novel approach combining stomach intestinal pylorus sparing surgery (SIPS) with LF for morbidly obese patients with GERD. The data from patients who underwent the SIPS procedure along with LF in past year was retrospectively analyzed. The variables collected were age, sex, height, weight, intra-operative and post-operative complications, length of stay, operative time, and estimated blood loss. All revisions were excluded. Descriptive statistics such as mean and standard deviation were used to analyze the data. The total sample size of the study was 5 patients, with a mean age of 59.6 ± 16.4 years, a mean weight of 292.1 ± 73.6 lbs., and a mean body mass index (BMI) of 43.4 ± 6.3. Weight loss patterns were the same as those without LF. All the 5 patients had resolution or improvement in their GERD symptoms within 6 months. SIPS with LF provides substantial and sustained weight loss and GERD resolution. Long term follow ups and further study on this novel surgical technique is recommended.

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.

Efficacy of transoral fundoplication for treatment of chronic gastroesophageal reflux disease incompletely controlled with high-dose proton-pump inhibitors therapy: a randomized, multicenter, open label, crossover study

Background

The aim of this randomized, crossover study was to determine if transoral fundoplication (TF) could further improve clinical outcomes in partial responders to high-dose (HD) proton-pump inhibitor (PPI) therapy and to evaluate durability of TF.

Methods

In seven United States centers, patients with hiatal hernia ≤2 cm and abnormal esophageal acid exposure (EAE) were randomized to TF (n = 40) or HD PPIs (n = 23) group. At 6-month follow-up, PPI patients underwent crossover. We assessed clinical outcomes 6-month post TF in crossover patients (COP), as compared to 6-month of HD PPI therapy, and 12-month outcomes in patients initially randomized to TF. The primary outcome was symptom control evaluated by Reflux Disease Questionnaire and Reflux Symptom Index. Secondary outcomes included healing of esophagitis, normalization of EAE and PPI use after TF. We analyzed 21 COP and 39 TF patients. McNemar’s test or Fisher exact test was used to compare proportions.

Results

Of 63 randomized patients, 3 were lost to follow-up, leaving 39 TF and 21 COP for analyses. In the COP, TF further improved control of regurgitation and of atypical symptoms achieved after six months of HD PPIs. Of 20 patients with GERD symptoms after six months of high-dose PPI therapy, 65% (13/20) reported global elimination of troublesome regurgitation and atypical symptoms post TF off PPIs; 67% (6/9) reported no troublesome regurgitation. Esophagitis further healed in 75% (6/8) of patients. Seventy-one percent of COP patients were off PPIs six months following TF. Normalization of EAE decreased from 52% after HD PPIs (on PPIs) to 33% after TF (off PPIs), p =0.388. In the original TF group, 12-month post TF, 77% of patients achieved complete symptom control, 82% ceased PPI therapy, 100% healed esophagitis and 45% normalized EAE.

Conclusions

The results of this study indicate that in patients with incomplete symptom control on high-dose PPI therapy TF may provide further elimination of symptoms and esophagitis healing. In the original TF group, the clinical outcomes of TF remained stable between 6- and 12-month follow-up.

Trail registration

Clinicaltrials.gov: NCT01647958.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-230X-14-174) contains supplementary material, which is available to authorized users.

Impacts of endoscopic gastroesophageal flap valve grading on pediatric gastroesophageal reflux disease

BACKGROUND

Gastroesophageal flap valve (GEFV) endoscopic grading is reported to be associated with gastroesophageal reflux disease (GERD) in adults; however its role in pediatric groups remains unknown. This study aimed to investigate the significance of GEFV grading and the associations to multichannel intraluminal impedance and pH monitoring (MII-pH) in children with GERD.

METHODS

A total of 48 children with GERD symptoms who received esophagogastroduodenoscopy and MII-pH monitoring were enrolled. The degree of GEFV was graded from I to IV according to the Hill classification, and classified into two groups: normal GEFV (Hill grades I and II), and abnormal GEFV (Hill grades III and VI). Endoscopic findings and MII-pH monitoring were analyzed among the groups.

RESULTS

Thirty-six patients had normal GEFV while 12 had abnormal GEFV. The presence of erosive esophagitis was significantly more common in the patients with abnormal GEFV (p = 0.037, OR 9.84, 95% CI 1.15-84.42). Pathological acidic gastroesophageal reflux (GER) determined by MII-pH was more prevalent in the patients with loosened GEFV geometry (p = 0.01, OR 7.0, 95% CI 1.67-27.38). There were significant positive correlations between GEFV Hill grading I to IV and the severity of erosive esophagitis (r = 0.49, p<0.001), percentage of supine acid reflux (r = 0.37, p = 0.009), percentage of total acid reflux (r = 0.3284, p = 0.023), and DeMeester score (r = 0.36, p = 0.01) detected by pH monitoring. In the impedance study, GEFV Hill grading also positively correlated to median number of acid reflux events (r = 0.3015, p = 0.037).

CONCLUSIONS

GEFV dysfunction highly associated with acid GER and severe erosive esophagitis. An abnormal GEFV is a sign of acid GER in children.

Association of reflux symptom index scores with gastroesophageal flap valve status

OBJECTIVE

Gastroesophageal reflux disease is a chronic symptom of mucosal damage caused by gastric acid reflux. Impaired gastroesophageal flap valve (GEFV) is one of the common etiologic factors of gastroesophageal reflux. The aim of this study was to investigate the association between GEFV, RSI, and GER in patients who underwent gastroesophageal endoscopy.

METHODS

Two hundred and fifty seven consecutive patients with reflux symptoms (151 men and 106 women, mean age was 50.22 years) who underwent routine upper gastrointestinal endoscopy were enrolled to our study. GEFV was graded as I through IV according to the Hill's classification. Symptoms of laryngopharyngeal and upper gastrointestinal disease and endoscopic severity of esophageal injury were correlated with GEFV status. The GEFV was classified into two groups: normal GEFV group (grade I) and the abnormal GEFV group (grades II-III and IV). The reflux symptom index (RSI) was used as a diagnostic tool for LPR.

RESULTS

Age, male gender, and body mass index were significantly related to an abnormal GEFV. The rate of abnormal grades of GEFV (Grade II+III+IV) was 31%. Age of normal and abnormal grades of GEFV (49.0/50.8 vs 52.9) and values of BMI (26.2/26.7 vs 26.5) were similar. RSI scores were correlated with gastroesophageal flap valve grades but RSI scores were not correlated with Los Angeles gastroesophageal reflux (GER) Classification. Moreover, gastroesophageal reflux grade of Los Angeles Classification was positively correlated with gastroesophageal flap valve grades.

CONCLUSION

Endoscopic grading of GEFV is a simple and useful technique which may provide an accurate diagnosis of laryngopharyngeal and gastroesophageal reflux. Also, reflux symptom index (RSI) is a simple, economic and noninvasive diagnostic tool for gastroesophageal reflux. However, in this research, we did not find any correlation between reflux symptom index and degree of esophageal mucosal injury which was classified according to LA classification.

Barrett's esophagus is frequently overdiagnosed in clinical practice: results of the Barrett's Esophagus Endoscopic Revision (BEER) study

BACKGROUND

The published prevalence of Barrett's esophagus (BE) varies from 0.9% to 25%, in part because of differences in the endoscopic interpretation of the disease.

OBJECTIVE

We studied the accuracy of diagnosis in 130 patients previously labeled as having BE. Our aim was to determine the interobserver consistency of endoscopic findings and assess the percentage of patients with confirmed BE versus those with a revised diagnosis.

DESIGN/SETTING/PATIENTS

Patients previously diagnosed with BE of any length and due for surveillance endoscopy were eligible for study.

INTERVENTIONS

After intensive consensus anatomic and endoscopic review, study patients underwent endoscopy and biopsy by 1 of 3 endoscopists. BE was defined as any length of columnar-lined esophagus with goblet cells.

MAIN OUTCOME MEASUREMENTS

Patients were photographed/videotaped for review by the other 2 endoscopists, and BE was either confirmed or revised.

RESULTS

Eighty-eight patients (67.7%) had confirmed BE, and 42 (32.3%) had their diagnosis revised to no BE (95% confidence interval, 24.4%-41.1%) because there was no visible columnar-lined esophagus proximal to the gastric folds or no goblet cells were found on biopsy. BE length, site of previous endoscopy, age, sex, and hiatal hernia size were predictors of revision. All 3 endoscopists agreed on all confirmed BE cases and 38 of 42 of those revised.

LIMITATIONS

Retrospective analysis, possible sampling error.

CONCLUSIONS

BE is overdiagnosed in clinical practice with important implications for patient care including increased costs, reduced insurability, and psychological stress. The true BE cancer risk may also be underestimated. This study suggests the need for a better definition of the gastroesophageal junction, stricter accountability for BE diagnosis, and improved endoscopic education.

Acta from the EndoFLIP® Symposium

Laparoscopic fundoplication (LF) is a surgical treatment for gastroesophageal reflux disease (GERD) that has been performed for more than 20 years. High-volume centers of excellence report long-term success rates greater than 90% with LF. On the other hand, general population-based outcomes are reported to be markedly worse, leading to a nihilistic perception of the procedure on the part of the medical referral population. The lack of standardization of the technique and the lack of tools to calibrate objectively the repairs are probably among the causes of variability in the outcomes and may explain the decline in the number of LF procedures in recent years. The functional lumen imaging probe (EndoFLIP(®)) device is essentially a "smart bougie" in the form of a balloon catheter that measures shape and compliance of the gastroesophageal junction (GEJ) during surgery using impedance planimetry. With approximately 3 years of international experience gained with this tool, a symposium was convened in October 2012 in Strasbourg, France, with the aim of determining if intraoperative EndoFLIP use could provide standardization of surgical treatment of GERD through the understanding of physiological changes occurring to the GEJ during fundoplication. This article provides a brief history of the EndoFLIP system and reviews data previously published on the use of EndoFLIP to characterize the GEJ in normal subjects. It then summarizes the data from the 5 high-volume international sites with expert surgeons performing LF presented in Strasbourg to objectively profile the characteristics of a normal postoperative GEJ.

Endoscopic grading of the gastroesophageal flap valve is correlated with reflux activity and can predict the size of the esophageal hiatus in patients with gastroesophageal reflux disease

BACKGROUND

Endoscopic grading of the gastroesophageal flap valve (GEFV) is simple, reproducible, and suggested to be a good predictor of reflux activity. This study aimed to investigate the potential correlation between grading of the GEFV and quality of life (QoL), gastroesophageal reflux disease (GERD) symptoms, esophageal manometry, multichannel intraluminal impedance monitoring (MII) data, and size of the hiatal defect.

METHODS

The study included 43 patients with documented chronic GERD who underwent upper gastrointestinal endoscopy, esophageal manometry, and ambulatory MII monitoring before laparoscopic fundoplication. The GEFV was graded 1-4 using Hill's classification. QoL was evaluated using the Gastrointestinal Quality-of-Life Index (GIQLI), and gastrointestinal symptoms were documented using a standardized questionnaire. The size of the esophageal hiatus was measured during surgery by calculating the hiatal surface area (HSA). Analysis of the correlation between QoL, GERD symptoms, esophageal manometry, MII data, HSA size, and GEFV grading was performed. Statistical significance was set at a p value of 0.05.

RESULTS

A significant positive correlation was found between increased GEFV grade and DeMeester score, total number of acid reflux events, number of reflux events in the supine position, and number of reflux events in the upright position. Additionally, a significant positive correlation was found between HSA size and GEFV grading. No significant influence from intensity of GERD symptoms, QoL, and the GEFV grading was found. The mean LES pressures were reduced with increased GEFV grade, but not significantly.

CONCLUSIONS

The GEFV plays a major role in the pathophysiology of GERD. The results underscore the importance of reconstructing a valve in patients with GERD and an altered geometry of the gastroesophageal junction when they receive a laparoscopic or endoscopic intervention.

Pathophysiology of gastroesophageal reflux disease

The gastroesophageal junction is structurally complex and functionally designed to ensure the acid secreted by the most proximal gastric mucosa flows towards the stomach and not up onto the oesophageal squamous mucosa. The pattern and mechanism of reflux vary with the severity of reflux disease and this probably represents different ends of a spectrum rather than distinct pathophysiological mechanisms. Nearly all patients with severe reflux disease have hiatus hernia, however, a substantial proportion of patients with mild reflux disease do not, and this may be a result of intermittent or partial hiatus hernia undetectable by current available tools. The acid pocket is an area of post-prandial unbuffered gastric acidity immediately distal to the gastroesophageal junction and which is enlarged in patients with hiatus hernia. The acid pocket provides a reservoir of acid available to reflux when the intrinsic sphincter fails. Central obesity is an important factor in the aetiology of reflux and does this by the increased abdomino-thoracic pressure gradient inducing hiatus hernia and increasing the rate of flow of reflux when sphincter opens. Central obesity also induces short segment intrasphincteric reflux and thereby columnar metaplasia of the most distal oesophagus.

Waist-to-hip ratio, but not body mass index, is associated with an increased risk of Barrett's esophagus in white men

BACKGROUND & AIMS

Abdominal obesity increases the risk of gastroesophageal reflux disease (GERD) and also might contribute to the development of Barrett's esophagus (BE), although results are inconsistent. We examined the effects of waist-to-hip ratio (WHR) and body mass index (BMI) on the risk of BE and investigated whether race, GERD symptoms, or hiatus hernia were involved.

METHODS

We conducted a case-control study using data from eligible patients who underwent elective esophagogastroduodenoscopy; 237 patients had BE and the other 1021 patients served as endoscopy controls. We also analyzed data and tissue samples from enrolled patients who were eligible for screening colonoscopies at a primary care clinic (colonoscopy controls, n = 479). All patients underwent esophagogastroduodenoscopy, completed a survey, and had anthropometric measurements taken. WHR was categorized as high if it was 0.9 or greater for men or 0.85 or greater for women. Data were analyzed with logistic regression.

RESULTS

There was no association between BMI and BE. However, more patients with BE had a high WHR (92.4%) than endoscopy controls (79.5%) or colonoscopy controls (84.6%) (P < .001 and P = .008, respectively). In adjusted analysis, patients with BE were 2-fold more likely to have a high WHR than endoscopy controls (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.1-3.5), this association was stronger for patients with long-segment BE (OR, 2.81; 95% CI, 1.0-7.9). A high WHR was associated significantly with BE only in whites (OR, 2.5; 95% CI, 1.2-5.4), but not in blacks or Hispanics. GERD symptoms, hiatus hernia, or gastroesophageal valve flap grade could not account for the association.

CONCLUSIONS

High WHR, but not BMI, is associated with a significant increase in the risk of BE, especially long-segment BE and in whites. The association is not caused by GERD symptoms or hiatus hernia.

Correlation of the gastroesophageal flap valve grade with the surgery rate in patients with gastroesophageal reflux disease

BACKGROUND

The importance of endoscopic evaluation and grading of the gastroesophageal flap valve (GEFV) in patients with gastroesophageal reflux disease (GERD) was previously demonstrated with increased acid exposure and high grades of esophagitis in those with high-grade valves. On the other hand, no data exist on the relationship between GEFV appearance and surgical rate.

METHODS

For 453 patients with symptoms suggestive of GERD, GEFV grading and 24-h ambulatory pH monitoring were performed. Surgery was performed for 82 of these patients who failed medical management or had disease complications.

RESULTS

The GEFV grade 4 patients were younger than the patients with normal GEFV (grades 1 [p = 0.017] and 2 [p < 0.001]) and showed significant male predominance. The prevalence of hiatal hernia, the degree of esophageal acid exposure, and the prevalence and degree of erosive esophagitis significantly increased with GEFV grade (p < 0.001 for all). No GEFV grade 1 patients underwent surgery compared with 4.9 % of the grade 2 patients, 20.5 % of the grade 3 patients, and 63.6 % of the grade 4 patients who had surgery for various indications (p < 0.001).

CONCLUSIONS

Esophagogastric opening estimated by endoscopic grading of the GEFV was strongly correlated with surgery rate in GERD patients. In particular, patients with grade 4 valves showed the highest rates of erosive esophagitis and axial hiatal hernia and frequently underwent surgery for either failed medical management or disease complications.

Is the course of gastroesophageal reflux disease progressive? A 21-year follow-up

OBJECTIVE. We re-evaluated a cohort of patients referred for reflux symptoms and objectively diagnosed with pathological reflux, with the purpose of clarifying the course of conservatively treated gastroesophageal reflux disease (GERD). MATERIAL AND METHODS. All consecutive patients with GERD diagnosed between 1984 and 1988 showing pathologic 24-h pH-metry in the interval 3.8-10% and without any previous surgery in the gastroesophageal tract were assessed for further follow-up. A total of 40 evaluable patients were followed in the years 2007-08 with endoscopy, manometry, 24-h pH-metry, Helicobacter pylori assessment and the self-administered questionnaires the GERD Impact Scale, the Reflux Disease Questionnaire, the Quality of Life in Reflux and Dyspepsia and the Medical Outcome Study Short Form-36 Health Survey. Baseline data from the 1980s were retrieved and compared with the evaluations conducted at follow-up. RESULTS. At follow-up 20.7 years (range 18.8-23.5 years) after referral, the study population showed more use of acid suppressants (p = 0.007) and increasing prevalences of esophagitis (p = 0.001) and Barrett's esophagus (p = 0.002). Esophagitis was seen in 16/40 patients (40%) at baseline and in 29/40 (72.5%) at follow-up. No significant deterioration was seen at follow-up in manometry data and in most pH data. Patients with esophagitis (ERD) were less likely to have a positive H. pylori test (hazard ratio 0.054; p = 0.002) than non-erosive (NERD) patients. Symptom evaluations showed significantly lower quality of life in the ERD group. CONCLUSIONS. After 20 years a considerable part of the cohort still experienced symptoms of reflux and showed endoscopic progression, although no significant deteriorations were seen in manometry data and in most pH-metry data. H. pylori infection was inversely associated with erosive esophagitis and this supports the hypothesis that H. pylori colonization is a protective factor against GERD.

Barrett's esophagus and endoscopically assessed esophagogastric junction integrity in 1000 consecutive Turkish patients undergoing endoscopy: a prospective study

Barrett's esophagus (BE) appears to be more common in Western than in Asian countries. BE is a complication of gastroesophageal reflux disease (GERD). Anatomical abnormalities of the esophagogastric junction (EGJ) are an important factor in the pathogenesis of GERD. We aimed to determine the prevalence of BE in Turkey, which is geographically located between Europe and Asia, and to investigate the frequency of BE according to the degree of anatomical disruption in the EGJ. This prospective study was performed on 1000 consecutive patients referred for endoscopy for any clinical indication. All patients underwent a structured interview that assessed major symptoms of GERD (regurgitation and heartburn). BE was diagnosed when specialized intestinal metaplasia was detected histologically in the esophageal biopsy specimens. Endoscopically assessed integrity of the EGJ was classified as one of three types, as follows: 1 Normal EGJ. The endoscope shaft was gripped tightly by the cardia in retroflexed endoscopy, or it was gripped less tightly but the cardia was seen to open and close with respiration. 2 Widened EGJ. The cardia was open during all phases of respiration in retroflexed endoscopy, but there was no endoscopic evidence of hiatal hernia (HH) on the antegrade view. 3 HH. The axial length from the EGJ to the diaphragmatic hiatus was at least 2 cm. BE was found in 12 patients (1.2%). Normal EGJ was seen in 90.7% of patients, widened EGJ in 4.3%, and HH in 5%. Patients with widened EGJ had a significantly higher incidence of major reflux symptoms and erosive esophagitis compared with those with normal EGJ (P= 0.001). BE was found in 14% of patients with HH and in 0.5% of patients with a normal EGJ (P= 0.001). None of the patients with widened EGJ had BE. In terms of BE frequency, these patients did not differ significantly from those with normal EGJ (P= 0.793) but did differ significantly from those with HH (P= 0.014). The prevalence of BE was 1.2% in a Turkish population undergoing endoscopy for any reason. In terms of EGJ integrity, comparison of the groups showed that even in the absence of HH, patients with widening of the EGJ had an increased prevalence of major reflux symptoms and erosive esophagitis. However, histologically confirmed BE was not seen among patients with widened EGJ.

Endoscopic therapies for the treatment of reflux disease

Endoscopic techniques for the treatment of reflux disease were first introduced in 2000 as an alternative to laparoscopic antireflux operations. Because of reports of long-term treatment failure with laparoscopic fundoplication and the fact that surgery is increasingly being reserved for the relatively small proportion of patients with complicated reflux disease, attempts to develop safe, effective, and durable endoscopic approaches to antireflux surgery continue. Techniques include radiofrequency ablation, injection therapy, and suturing/stapling techniques. Of these, the suturing/stapling techniques are most similar to the anatomic restructuring of the gastroesophageal junction provided by fundoplication. While early attempts at endoscopic suturing have been disappointing, significant advances in endoscopic instrumentation, a more complete understanding of the gastroesophageal junction anatomy, and improvements in the technical skills of the endoscopic surgeon have been realized. As a result, techniques now being tested, such as the endoluminal fundoplication, may prove more effective and durable than previous endoscopic antireflux procedures.

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.

Endoscopic grading of gastroesophageal flap valve and atrophic gastritis is helpful to predict gastroesophageal reflux

BACKGROUND AND AIM

The endoscopic grading of the gastroesophageal flap valve (GEFV) has been suggested to be a good predictor of reflux status. Atrophic gastritis is inversely associated with reflux esophagitis. The aim of the present study was to investigate the association between GEFV, atrophic gastritis and gastroesophageal reflux.

METHODS

A total of 608 patients (252 men and 356 women; mean age 51.1 years) who underwent endoscopy, esophageal manometry and ambulatory 24-h pH monitoring were included. GEFV was graded I through IV using Hill's classification: the GEFV was largely classified into two groups: the normal GEFV group (grades I and II) and the abnormal GEFV group (grades III and IV). Atrophic gastritis was classified into two groups by endoscopic atrophic border: closed-type (C-type) and open-type (O-type). Findings of endoscopy, esophageal manometry and ambulatory pH monitoring were compared among the groups.

RESULTS

The incidence of reflux esophagitis and gastroesophageal reflux disease was associated with an abnormal GEFV grade and was inversely associated with open-type atrophic gastritis. The patients with a coexisting abnormal GEFV and closed-type atrophic gastritis showed a significantly higher incidence of reflux esophagitis and gastroesophageal reflux disease than the patients with a coexisting normal GEFV and open-type atrophic gastritis (OR, 20.6 [95% CI, 6.2-68.4], 11.4 [95% CI, 6.3-20.7], respectively).

CONCLUSIONS

Endoscopic grading of GEFV and atrophic gastritis is simple and provides useful information on the status of gastroesophageal reflux.

Gastroesophageal flap valve is associated with gastroesophageal and gastropharyngeal reflux

BACKGROUND

The endoscopic grade of the gastroesophageal flap valve (GEFV) is suggested to be a good predictor of reflux status. The aim of this study was to investigate the association of the GEFV and gastroesophageal and gastropharyngeal reflux.

METHODS

A total of 364 patients (151 men and 233 women; mean age, 52.2 years) who underwent endoscopy, esophageal manometry, and ambulatory 24-h dual-probe pH monitoring were included. GEFV was graded I through IV using Hill's classification; then, GEFV was classified into two groups: a normal GEFV group (grades I and II) and an abnormal GEFV group (grades III and IV). Findings of endoscopy, esophageal manometry, and ambulatory pH monitoring were compared between the groups.

RESULTS

Increased GEFV grade was significantly associated with an increased prevalence of both reflux esophagitis and Barrett's epithelium (P < 0.001). Lower esophageal sphincter pressure was significantly lower in the abnormal GEFV group than in the normal GEFV group (P < 0.001). All variables showing gastroesophageal reflux in the distal probe were significantly higher in the abnormal GEFV group than in the normal GEFV group (P < 0.001). In addition, all variables, except the supine time of pH < 4, showing gastropharyngeal reflux in the proximal probe were significantly higher in the abnormal GEFV group than in the normal GEFV group (P < 0.001). The frequency of gastroesophageal reflux disease and of gastropharyngeal reflux disease was significantly higher in the abnormal GEFV group than in the normal GEFV group (P < 0.001).

CONCLUSION

Endoscopic grading of the GEFV is easy and provides useful information about the status of gastroesophageal and gastropharyngeal reflux.

Abnormal gastroesophageal flap valve is highly associated with gastroesophageal reflux disease among subjects undergoing routine endoscopy in Taiwan

OBJECTIVE

Gastroesophageal flap valve (GEFV) grade predicts severe gastroesophageal reflux disease in Caucasians, but its role in other populations is unclear. This study evaluated the significance of endoscopic grading of the GEFV in Taiwanese subjects.

METHODS

Five hundred and six consecutive patients undergoing routine check-ups at the National Taiwan University Hospital were enrolled. Symptoms of upper gastrointestinal disease and endoscopic severity of esophageal mucosal injury were correlated to GEFV grades according to the Hill classification.

RESULTS

The frequency of abnormal valves (Hill grades III or IV) was 27.3%. Of these, 42.7% had erosive esophagitis (EE). The majority of patients with EE were classified as Los Angeles grades A and B (79.7 and 16.9%, respectively). The prevalence of EE, hiatal hernia and, to a lesser degree, non-erosive reflux disease, increased with altered GEFV. Patients with abnormal valves were younger and more likely to be male, overweight, and to have atypical and extraesophageal symptoms.

CONCLUSIONS

Taiwanese patients with abnormal GEFVs share similar characteristics and risk factors with the patients who have EE. Endoscopic grading of the GEFV is highly associated with GERD, and in particular EE, in subjects undergoing routine endoscopy.

Fetus support manipulator with flexible balloon-based stabilizer for endoscopic intrauterine surgery

A novel manipulator is described for stabilizing fetus and preventing it from free-floating during the endoscopic intrauterine surgery. Minimally invasive endoscopic fetal surgery enables intrauterine intervention with reduced risk to the mother and fetus. We designed and fabricated a prototype of a fetus supporting manipulator equipped with a flexible bending/curving mechanisms and a soft balloon-based stabilizer. The flexible bending and curving mechanisms enable the stabilizer to reach the target sites within the uterus under an ultrasound-guidance. The balloon-based stabilizer could be inserted into the uterus with a small incision for entry. The accuracy evaluation showed that the maximum error of the curving mechanism was as small as 7 mm and the standard deviation of the bending mechanism was just 1.6 degrees. In the experiments using a fetus model, the manipulator could be well controlled under ultrasound guidance and its curving mechanism with the balloon-based stabilizer could be clearly visualized during the implementation of fetus model supporting. The manipulator has the potential to be used in minimally invasive intrauterine surgery, though further improvements and experiments remain to be carried out.

Endoscopic measurement of cardia circumference as an indicator of GERD

BACKGROUND

It is theorized that repeated gastric distention leads to dilatation of the cardia and the development of GERD. We hypothesize that cardia circumference correlates with the presence and the severity of GERD, and we developed software to measure cardia circumference from static endoscopic images. Our aims were to validate the software and to quantify cardia circumference along the spectrum of GERD.

METHODS

Software-based measurements were compared with actual measurements in animal and mechanical models. A retrospective review of an endoscopic database and patient charts produced 273 subjects, grouped as follows: controls, GERD, < or = 3-cm Barrett's esophagus, or > 3-cm Barrett's esophagus. A blinded abstractor measured cardia circumference by using images from the database.

RESULTS

Software and actual measurements correlated closely and were reproducible among observers. Median cardia circumference for each group was the following: control, 31.8 mm; GERD, 37.8 mm; < or = 3-cm Barrett's esophagus, 38.4 mm; and > 3-cm Barrett's esophagus, 45.0 mm (p < 0.001). By using 34.3 mm as a cutoff, cardia circumference was 85.3% sensitive and 89.6% specific for the diagnosis of GERD.

CONCLUSIONS

There was a direct relationship between cardia circumference and the presence of GERD. This finding augments our understanding of the anatomic contributions of the esophagogastric junction in the pathogenesis of GERD. Cardia measurement may prove to be a useful diagnostic tool.

A prospective study of the prevalence of gastroesophageal reflux disease and confounding factors

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) has reportedly risen in recent years. Difficulties associated with endoscopic diagnosis mean it is not easy to determine its precise prevalence. A prospective study of the prevalence of endoscopy-positive GERD (EP-GERD) was conducted at Higuchi Hospital, a general hospital in Northwestern Kyushu, Japan. The study also correlated factors that might affect prevalence (age, sex, and functions of the gastroesophageal junction).

METHODS

From consecutive patients undergoing endoscopic examination at Higuchi Hospital between January 2000 and April 2003, 1234 patients without severe complications were examined for the possible presence of GERD. Patients were stratified by age and sex, and the prevalence in each group ascertained. EP-GERD was defined on the four-level scale of the Los Angeles classification. Endoscopic classification of gastroesophageal flap valve ([GEFV] functional anomalie; using a four-level scale), was done as proposed by Hill et al. in 1996, to assess flap-valve morphology. Six items were evaluated: (1) symptoms and primary diseases; (2) prevalence of development of EP-GERD classified by age and sex; (3) endoscopic morphology of the GEFV as an expression of the functions of the gastroesophageal junction, and its prevalence by age and sex; (4) regression analysis and Spearman's rank correlation of GEFV and EP-GERD grades; (5) prevalence of EP-GERD and GEFV stratified by age and analyzed; and (6) multiple regression analysis of EP-GERD and explanatory variables (age, sex, and GEFV).

RESULTS

The overall prevalence of EP-GERD was 5.8% (72/1234) and this patient group was dominated by men. Aging had minimal effect on prevalence in men, but the prevalence rose among women as they aged. The age-stratified prevalence of GEFV functional anomalies was similar to the age-stratified prevalence of EP-GERD in both sexes. The correlation between EP-GERD and GEFV functional anomalies was high regardless of sex.

CONCLUSIONS

We postulate that the mechanisms leading to the development of GEFV functional anomalies in men are different from those in women. Future evaluations of EP-GERD should also observe GEFV function.

[Antireflux therapy--more than acid reduction?]

Because gastroesophageal reflux disease (GERD) is a motility disorder, acid reduction with proton pump inhibitors (PPI) remains a symptomatic therapy with a recurrence rate of over 90% after discontinuation of acid suppression. This "therapeutic dilemma" becomes obvious in patients not responding sufficiently to the conventional medication (therapy resistance, necessity of high PPI doses, volume reflux). In this manuscript we analyze additional factors that may play a role in the pathogenesis and interpretation of GERD. These additional factors include gastroesophageal motility and esophageal barrier functions as well as duodenogastroesophageal reflux and Helicobacter pylori infection. In addition, basic problems in interpretation of therapeutic success such as placebo effect, spontaneous remission of GERD, the role of sensory function and subjective interpretation of symptoms and the overlap between physiological and pathological reflux as well as functional disorders will be discussed.

Effect of straining on diaphragmatic crura with identification of the straining-crural reflex. The "reflex theory" in gastroesophageal competence

BACKGROUND

The role of the crural diaphragm during increased intra-abdominal pressure is not exactly known. We investigated the hypothesis that the crural diaphragm undergoes reflex phasic contraction on elevation of the intra-abdominal pressure with a resulting increase of the lower esophageal pressure and prevention of gastro-esophageal reflux.

METHODS

The esophageal pressure and crural diaphragm electromyographic responses to straining were recorded in 16 subjects (10 men, 6 women, age 36.6 +/- 11.2 SD years) during abdominal hernia repair. The electromyogram of crural diaphragm was recorded by needle electrode inserted into the crural diaphragm, and the lower esophageal pressure by a saline-perfused catheter. The study was repeated after crural anesthetization and after crural infiltration with saline.

RESULTS

The crural diaphragm exhibited resting electromyographic activity which showed a significant increase on sudden (coughing, p < 0.001) or slow sustained (p < 0.01) straining with a mean latency of 29.6 +/- 4.7 and 31.4 +/- 4.5 ms, respectively. Straining led to elevation of the lower esophageal pressure which was coupled with the increased electromyographic activity of the crural diaphragm. The crural response to straining did not occur during crural diaphragm anesthetization, while was not affected by saline infiltration. The lower esophageal pressure declined on crural diaphragm anesthetization.

CONCLUSIONS

Straining effected an increase of the electromyographic activity of the crural diaphragm and of the lower esophageal pressure. This effect is suggested to be reflex in nature and to be mediated through the "straining-crural reflex". The crural diaphragm seems to play a role in the lower esophageal competence mechanism. Further studies are required to assess the clinical significance of the current results in gastro-esophageal reflux disease and hiatus hernia.

Esophagogastric junction morphology predicts susceptibility to exercise-induced reflux

BACKGROUND AND AIM

Although strenuous exercise has been reported to increase gastroesophageal reflux, there are few data exploring the mechanism behind this relationship. The aim of this study was to use vigorous exercise as a provocation for strain-induced reflux and examine the correlation between endoscopically assessed EGJ integrity and exercise-induced reflux.

METHODS

Ten controls and 10 GERD patients were studied for a 2-day period using the wireless Bravo pH monitoring system. The subjects were randomly assigned to perform 60 min of exercise on day 1 or 2 consuming the same diet on both days. Exercise consisted of 30 min of running and 30 min of 5 resistance exercises. Subjects underwent endoscopy to grade the EGJ "flap valve" and manometry to measure basal LES pressure.

RESULTS

Nineteen subjects completed the 2-day study with 100% data capture during exercise. Median acid exposure was increased more than threefold for both controls and GERD patients during exercise when compared to nonexercise periods. In addition, a strong correlation existed between EGJ grade and % time pH < 4 during exercise while there was not a significant correlation between LES pressure and EGJ grade. These findings were present even after exclusion of hiatus hernia patients (flap valve grade 4).

CONCLUSIONS

Exercise caused a threefold increase in esophageal acid exposure in both controls and GERD patients. The degree of exercise-induced reflux is strongly correlated with EGJ morphology and this supports the hypothesis that anatomical integrity of the EGJ is of cardinal importance in preventing strain-induced reflux.

Endoscopic appraisal of the gastroesophageal valve after antireflux surgery

OBJECTIVES

Little consensus exists regarding the endoscopic assessment of the esophagogastric junction after antireflux surgery. The purpose of this report is to characterize the gastroesophageal valve appearance unique to each type of antireflux procedure and to introduce an endoscopic lexicon by which to describe this anatomic region.

METHODS

Endoscopic images were obtained from patients who had undergone any one of the following procedures: Nissen, Collis-Nissen, Toupet, and Dor fundoplications and Hill repair. Images were excluded if patients had any symptoms of heartburn, regurgitation, dysphagia, chest pain, or gas bloat or if they were using antisecretory medication. Seven photographs per operation type were evaluated by experienced surgeons and gastroenterologists tasked with describing defining characteristics of each procedure.

RESULTS

Ten valve criteria were developed to uniquely identify and quantify the ideal endoscopic appearance of each procedure. Illustrations were created to clearly depict those traits.

CONCLUSIONS

Using 10 gastroesophageal valve criteria, the key components of a successful functional repair of the esophagogastric junction were defined. These criteria can be employed when evaluating upper gastrointestinal complaints after antireflux surgery and may ultimately serve as a dependable outcome measure.

In utero surgery for cleft lip/palate: minimizing the "Ripple Effect" of scarring

Surgical intervention is currently performed on highly selected fetuses with anatomical deformities that have a high mortality or severe morbidity when treated postnatally. In the future, in utero surgical intervention for non-life-threatening disease may become possible as fetal surgery becomes safer for the mother and fetus. Fetal cleft repair is an attractive intervention for plastic surgeons because it affords the potential to provide a scarless repair and correct the primary deformity. Furthermore, scarless fetal lip and palate repairs may prevent the ripple effect of postnatal scarring with its resultant secondary dentoalveolar and midface growth deformities. These potential benefits can dramatically reduce the number of postnatal reconstructive procedures in children with facial clefts. The rationale for a prenatal treatment approach to the patient with cleft lip/palate and the experimental evidence to support in utero intervention are discussed in this article.

Vascular closure staples-a new technique for biliary reconstruction: prospective randomized comparison with manual suture in an animal model

BACKGROUND

In orthotopic liver transplantation the incidence of biliary complications is up to 49%. In view of the relative frequency of such complications despite seemingly good preconditions, method-related disadvantages of conventional suture must also be considered as a possible cause. These include perforating needle injury of the choledochal wall with at least temporary exposure of suture material in the lumen, suboptimal approximation of the mucosa, and an additional decrease in blood flow in the choledochal stumps as a result of suture-related tissue strangulation. Hence the search for alternative anastomosis techniques.

METHODS

To evaluate the surgical suitability of extramucosal titanium clips (Vascular Closure Staples; VCS) in comparison with conventional manual suture, a study was performed in 36 pigs, which were randomly assigned to 4 groups, each containing 9 animals. Choledochal excision was performed in 18 pigs and transection in the other 18 pigs; end-to-end anastomosis was then carried out, using a VCS stapler in half of the animals in each of these two groups and conventional manual suture in the other half. Pre- and postanastomotic blood flow was measured during the surgery with the aid of a laser Doppler flow meter. The long-term behavior of the closure techniques was ascertained by regular laboratory checks over the ensuing 6-month observation period, after which the pigs were killed so that the specimens could be harvested.

RESULTS

Using medium-sized VCS clips, we were able to create a tension-free, everted biliary anastomosis with exact mucosal approximation and no narrowing of the lumen, and without any technical problems during the performance of the procedure. Measurements with the laser Doppler flow meter showed well-preserved anastomotic blood flow after clip reconstruction, with significantly higher perfusion values than after manual suture. The postoperative courses of the investigated laboratory parameters did not reveal any significant differences between the two methods. In contrast, histomorphometric evaluation showed wall thickness and thus fibrosis in the anastomosis region to be less in the clip group than in the suture group (median: 510 microm versus 660 microm, P<0.001). In the pigs in which clip anastomosis was used, there were no detectable anastomotic stenoses; in the pigs in which conventional suture was used, however, ultrasonography revealed five anastomoses with varying degrees of narrowing.

CONCLUSIONS

Extramucosal VCS clip anastomosis not only offers potential advantages with respect to nonpenetrating and optimal mucosal contact, investigations in animals also show it to be superior to conventional manual suture as regards anastomotic blood flow and medium-term fibrosis formation. We believe that our data and the available literature warrant a clinical evaluation of this technique in appropriate studies.

The Crura and Crura-Sphincter Pressure Dynamics in Patients with Isolated Upright and Isolated Supine Reflux

The reason why patients with isolated supine reflux do not reflux in the upright position and patients with isolated upright reflux do not reflux in the supine position is unknown. Our objective was to determine the characteristics of the crura, lower esophageal sphincter, crurasphincter dynamics, and esophageal body on manometry, endoscopy, and X-ray in patients with isolated upright and isolated supine reflux. Eighty consecutive patients with isolated upright reflux were compared with 82 consecutive patients with isolated supine reflux. Manometrically there was no difference in lower esophageal sphincter characteristics and esophageal contractions between the two groups. The prevalence of a hiatal hernia on manometry was similar between upright and supine refluxers (88% vs 88%). Upright refluxers had shorter hiatal hernias [median (interquartile range) 1.1 (0.65–1.8) vs 1.2 (1–2.3), P < 0.046)]. The median crural pressure, crura-sphincter pressure gradient, and crura-sphincter pressure ratio in upright refluxers was 14.96 (9.5–21.27), 3.28 (1.7–12.2), and 1.33 (0.87–2.8) mm Hg, respectively. These values were significantly higher ( P < 0.001) in supine refluxers at 21.43 (16.6–29.9), 10.66 (4.3–19.7), and 2.1 (1.3–4.2) mm Hg, respectively. We conclude that the significantly higher crural pressure in patients with supine reflux acts as a mechanical ring and as a physiologic protector against the unfolding of the sphincter in the postprandial and upright periods. Higher crura-sphincter pressure gradient and larger-size hiatal hernias in patients with supine reflux results in pressurization of the hernia sac and subsequent reflux when these patients are in a supine position.

Laparoscopic esophageal surgery

In its 9-year history, laparoscopic esophageal surgery has become second only to gallbladder surgery in the frequency of minimally invasive procedures performed in routine surgical practice. Laparoscopic fundoplication has assumed a central role in the surgical treatment of gastroesophageal reflux. Laparoscopic myotomy has emerged as the optimal form of therapy for achalasia, and staging laparoscopy has been identified as an important adjunct to the preoperative evaluation of esophageal and gastroesophageal junction carcinoma. Laparoscopic paraesophageal hernia repair and remedial laparoscopic antireflux surgery currently are gaining acceptance. Laparoscopic gastroplasty, esophagectomy, and diverticulectomy are undergoing clinical trials, and their roles remain to be defined.