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Dasarathy D, Vaezi M, Patel D. Optimizing ambulatory reflux monitoring: current findings and future directions. Expert Rev Gastroenterol Hepatol 2024; 18:13-24. [PMID: 38145413 DOI: 10.1080/17474124.2023.2297919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/18/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is the most common diagnosis seen in outpatient gastroenterology clinics. The diagnosis is made by a variable combination of symptoms, response to acid suppressive therapy, endoscopic evaluation, and pH testing. In this review, we evaluate how to utilize various reflux testing in clinical practice based on current evidence. AREAS COVERED Ambulatory reflux monitoring is a recognized diagnostic tool for clinical decision making in patients with/without established GERD, persistent reflux symptoms, and lack of response to proton pump inhibitor (PPI) therapy. Standard evaluation approaches include 24-hour pH or impedance monitoring via transnasal catheter, prolonged (48 to 96 hour) wireless pH monitoring, and the recently developed mucosal integrity testing. Testing using one of these methods allows for measurement of acid exposure, frequency of reflux, and to phenotype patients to personalize treatment recommendations. EXPERT OPINION The primary goal of future studies should be to simplify ambulatory reflux monitoring, reduce diagnostic latency, improve patient tolerance, and to obtain clinical outcomes-based studies. The current paradigm of reflux testing is vastly complex with multiple modalities and shifting cutoffs of pH abnormality that lead to high economic burden on the society.
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Affiliation(s)
- Dhweeja Dasarathy
- School of Medicine, and Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael Vaezi
- School of Medicine, and Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dhyanesh Patel
- School of Medicine, and Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
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Predictive Factors for Developing GERD After Sleeve Gastrectomy: Is Preoperative Endoscopy Necessary? J Gastrointest Surg 2022; 26:1015-1020. [PMID: 34997468 DOI: 10.1007/s11605-021-05207-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 11/16/2021] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Sleeve gastrectomy (SG) is the most common bariatric procedure performed in the USA. There is a concern for new gastroesophageal reflux disease (GERD) and Barrett's esophagus after SG. Endoscopic screening before bariatric surgery is controversial. We sought to identify preoperative endoscopic factors that may predict the development of GERD after SG. METHODS We prospectively evaluated 217 patients undergoing primary robotic-assisted SG. All patients underwent endoscopy before SG and for-cause postoperatively. Patients were followed for the development of GERD, diagnosed by either biopsy-proven reflux esophagitis or a positive esophageal pH test. Patients were separated into 2 groups: Those who developed GERD after surgery (GERD group) and those who did not (No GERD group). Patients with a positive preoperative pH test, LA Grade B or greater esophagitis, or hiatal hernia > 5 cm on preoperative endoscopy were counseled to undergo gastric bypass and excluded. RESULTS There were more males in the No GERD group (25.6% vs. 8.1%; p = 0.02). More patients had preoperative heartburn symptoms in the GERD group (40.5% vs. 23.9%; p = 0.04). Endoscopically identified esophagitis was more common in the GERD group (29.7% vs. 13.3%; p = 0.01), as was biopsy-proven esophagitis (24.3% vs. 11.1%; p = 0.03). There was no significant difference in the incidence or size of hiatal hernia or in the rate of H. pylori infection between the groups. On multivariate analysis, the strongest predictors of GERD after SG were endoscopically identified esophagitis (odds ratio [OR] 2.79; 95% confidence interval [CI]1.17-6.69; p = 0.02) and biopsy-proven esophagitis (OR 2.80; 95% CI 1.06-7.37; p = 0.04). Male patients were less likely to develop GERD after SG (OR 0.23; 95% CI 0.06-0.85; p = 0.03). CONCLUSION Our findings strengthen the rationale for routine preoperative endoscopy and highlight critical clinical and endoscopic criteria that should prompt consideration of alternatives to SG for weight loss.
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Robotic-assisted surgery enhances the learning curve while maintaining quality outcomes in sleeve gastrectomy: a preliminary, multicenter study. Surg Endosc 2021; 35:1970-1975. [PMID: 33398577 DOI: 10.1007/s00464-020-08228-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 12/03/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The frequency of robotic-assisted bariatric surgery has been on the rise. An increasing number of fellowship programs have adopted robotic surgery as part of the curriculum. Our aim was to compare technical efficiency of a surgeon during the first year of practice after completing an advanced minimally invasive fellowship with a mentor surgeon. METHODS A systematic review of a prospectively maintained database was performed of consecutive patients undergoing robotic-assisted sleeve gastrectomy between 2015 and 2019 at a tertiary-care bariatric center (mentor group) and between 2018 and 2019 at a semi-academic community-based bariatric program (mentee 1 group) and 2019-2020 at a tertiary-care academic center (mentee 2 group). RESULTS 257 patients in the mentor group, 45 patients in the mentee 1 group, and 11 patients in the mentee 2 group were included. The mentee operative times during the first year in practice were significantly faster than the mentor's times in the first three (mentee 1 group) and two (mentee 2 group) years (P < 0.05) but remained significantly longer than the mentor's times in the last two (mentee 1 group) and one (mentee 2 group) years (P < 0.05). There was no significant difference in venothromboembolic events (P = 0.89) or readmission rates (P = 0.93). The mean length of stay was 1.8 ± 0.5 days, 1.3 ± 0.5 days, and 1.5 ± 0.5 days in the mentor, mentee 1, and mentee 2 groups, respectively (P < 0.0001). There were no reoperations, conversion to laparoscopy or open, no staple line leaks, strictures, or deaths in any group. CONCLUSIONS This is one of the first series to show that the robotic platform can safely be taught and may translate into outcomes consistent with surgeons with more experience while mitigating the learning curve as early as the first year in practice. Long-term follow-up of mentees will be necessary to assess the evolution of fellowship training and outcomes.
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Yadlapati R, Masihi M, Gyawali CP, Carlson DA, Kahrilas PJ, Nix BD, Jain A, Triggs JR, Vaezi MF, Kia L, Kaizer A, Pandolfino JE. Ambulatory Reflux Monitoring Guides Proton Pump Inhibitor Discontinuation in Patients With Gastroesophageal Reflux Symptoms: A Clinical Trial. Gastroenterology 2021; 160:174-182.e1. [PMID: 32949568 PMCID: PMC7755671 DOI: 10.1053/j.gastro.2020.09.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/29/2020] [Accepted: 09/10/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Proton pump inhibitor (PPI) therapy fails to provide adequate symptom control in up to 50% of patients with gastroesophageal reflux symptoms. Although a proportion do not require ongoing PPI therapy, a diagnostic approach to identify candidates appropriate for PPI cessation is not available. This study aimed to examine the clinical utility of prolonged wireless reflux monitoring to predict the ability to discontinue PPIs. METHODS This double-blinded clinical trial performed over 3 years at 2 centers enrolled adults with troublesome esophageal symptoms of heartburn, regurgitation, and/or chest pain and inadequate PPI response. Participants underwent prolonged wireless reflux monitoring (off PPIs for ≥7 days) and a 3-week PPI cessation intervention. Primary outcome was tolerance of PPI cessation (discontinued or resumed PPIs). Symptom burden was quantified using the Reflux Symptom Questionnaire electronic Diary (RESQ-eD). RESULTS Of 128 enrolled, 100 participants met inclusion criteria (mean age, 48.6 years; 41 men). Thirty-four participants (34%) discontinued PPIs. The strongest predictor of PPI discontinuation was number of days with acid exposure time (AET) > 4.0% (odds ratio, 1.82; P < .001). Participants with 0 days of AET > 4.0% had a 10 times increased odds of discontinuing PPI than participants with 4 days of AET > 4.0%. Reduction in symptom burden was greater among the discontinued versus resumed PPI group (RESQ-eD, -43.7% vs -5.3%; P = .04). CONCLUSIONS Among patients with typical reflux symptoms, inadequate PPI response, and absence of severe esophagitis, acid exposure on reflux monitoring predicted the ability to discontinue PPIs without symptom escalation. Upfront reflux monitoring off acid suppression can limit unnecessary PPI use and guide personalized management. (ClinicalTrials.gov, Number: NCT03202537).
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology, University of California, San Diego School of Medicine, La Jolla, California
| | - Melina Masihi
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | - Dustin A Carlson
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Peter J Kahrilas
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Billy Darren Nix
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | - Anand Jain
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Joseph R Triggs
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Leila Kia
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alexander Kaizer
- Department of Biostatistics and Informatics, University of Colorado, Anschutz Medical Campus, Colorado School of Public Health, Aurora, Colorado
| | - John E Pandolfino
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Bellorin O, Dolan P, Vigiola-Cruz M, Al Hussein Alawamlh O, Pomp A, Dakin G, Afaneh C. Robotic-assisted approaches to GERD following sleeve gastrectomy. Surg Endosc 2020; 35:3033-3039. [PMID: 32572629 DOI: 10.1007/s00464-020-07753-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/16/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Sleeve gastrectomy (SG) is the most common bariatric operation in the United States but increases the incidence of gastroesophageal reflux disease (GERD). The aim of our study was to describe our experience with robotic-assisted management of intractable GERD after SG. METHODS A systematic review of a prospectively maintained database was performed of consecutive patients undergoing robotic-assisted magnetic sphincter augmentation placement after sleeve gastrectomy (MSA-S group) or conversion to Roux-en-Y gastric bypass (RYGB group) for GERD from 2015 to 2019 at our tertiary- care bariatric center. These were compared to a consecutive group of patients undergoing robotic-assisted magnetic sphincter augmentation placement (MSA group) for GERD without a history of bariatric surgery from 2016 to 2019. The primary outcome was perioperative morbidity. Secondary outcomes were operative time (OT), 90-day re-intervention rate, length of stay, symptom resolution and weight change. RESULTS There were 51 patients included in this study; 18 patients in the MSA group, 13 patients in the MSA-S group, and 20 patients in the RYGB group. There was no significant difference in age, gender, ASA score, preoperative endoscopic findings, or DeMeester scores (P > 0.05). BMI was significantly higher in patients undergoing RYGB compared to MSA or MSA-S (P < 0.0001). There were significant differences in OT between the MSA and RYGB groups (P < 0.0001) and MSA-S and RYGB groups (P = 0.009), but not MSA group to MSA-S group (P = 0.51). There was no significant difference in intraoperative and postoperative morbidity (P = 1.0 and P = 0.60, respectively). 30-day morbidity: 5.6% (MSA), 15.4% (MSA-S) and 15% (RYGB). There was no difference on PPI discontinuation among groups, with more than 80% success rate in all. CONCLUSIONS The use of the robotic platform in the different approaches available for treatment of GERD after SG appears to be a feasible option with low morbidity and high success rate. Further data is needed to support our findings.
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Affiliation(s)
- Omar Bellorin
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St., Box 294, New York, NY, 10065, USA
| | - Patrick Dolan
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St., Box 294, New York, NY, 10065, USA
| | - Mariana Vigiola-Cruz
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St., Box 294, New York, NY, 10065, USA
| | | | - Alfons Pomp
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St., Box 294, New York, NY, 10065, USA
| | - Gregory Dakin
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St., Box 294, New York, NY, 10065, USA
| | - Cheguevara Afaneh
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St., Box 294, New York, NY, 10065, USA.
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Moore MD, Gray KD, Panjwani S, Finnerty B, Ciecerega T, Afaneh C, Fahey TJ, Crawford CV, Zarnegar R. Impact of procedural multimedia instructions for pH BRAVO testing on patient comprehension: a prospective randomized study. Dis Esophagus 2020; 33:5532834. [PMID: 31313807 DOI: 10.1093/dote/doz068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 06/12/2019] [Accepted: 06/27/2019] [Indexed: 12/11/2022]
Abstract
The positive impact on patient comprehension and improved procedural outcomes when multimedia is utilized to convey instructions preprocedurally has been previously shown for gastrointestinal procedures such as colonoscopy. However, in gastroesophageal reflux testing (GERD), we continue to utilize verbal and written instructions to establish this diagnosis when we use BRAVO pH testing. This is arguably a more complex procedure involving stopping medications, placement of a device, and maintaining an accurate diary for the duration of the testing. We hypothesize that by utilizing multimedia to relay complex textual information, patients will have improved comprehension of periprocedural instructions thereby improving data entry and satisfaction of expectations during the procedure. Prospective randomized study of 120 patients undergoing endoscopic placement of the BRAVO pH monitoring capsule for evaluation of GERD receive either written preoperative instructions (control) or written plus video instructions (video group). A composite comprehension score was calculated using procedure-specific parameters of data entry over the 48-hour monitoring period. Patient satisfaction was evaluated on the basis of a five-point Likert scale. Extent of patient satisfaction was defined by the fulfillment of patient expectations. Exclusion criteria included patients who did not have access to the video or did not complete follow-up. Seventy-eight patients completed all follow-up evaluations. The video group (n = 44) had a significantly higher mean comprehension score when compared to the control group (n = 34) (9.6 ± 1.4 vs. 7.4 ± 2.0, P = 0.01). Overall satisfaction with instructions was significantly higher in the intervention group (91% vs. 47%, p 0.01). We detected no significant difference in comprehension or satisfaction scores in subgroup analyses of the video group comparing patients <65 and ≥65 years of age and by education level. Compared to standard written instructions, video instructions improved patient comprehension based on data evaluation, and satisfaction. Therefore, clinicians should consider incorporation of multimedia instructions to enhance patient periprocedural expectations and understanding of reflux pH testing using the BRAVO procedure.
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Affiliation(s)
- M D Moore
- Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - K D Gray
- Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - S Panjwani
- Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - B Finnerty
- Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - T Ciecerega
- Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - C Afaneh
- Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - T J Fahey
- Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - C V Crawford
- Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - R Zarnegar
- Department of Surgery, Weill Cornell Medical College, New York, New York, USA
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Use of Esophageal pH Monitoring to Minimize Proton-Pump Inhibitor Utilization in Patients with Gastroesophageal Reflux Symptoms. Dig Dis Sci 2018; 63:2673-2680. [PMID: 29959725 DOI: 10.1007/s10620-018-5183-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/23/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Due to concerns about long-term PPI use in patients with acid reflux, we aimed at minimizing PPI use, either by avoiding initiating therapy, downscaling to other therapies, or introducing endoscopic or surgical options. AIMS To examine the role of esophageal ambulatory pHmetry in minimizing PPI use in patients with heartburn and acid regurgitation. METHODS Retrospective cohort analysis of patients with reflux symptoms, who underwent endoscopy, manometry, and ambulatory pHmetry to define the need for PPI. Patients were classified as: (1) never users; (2) partial responders to PPI; (3) users with complete response to PPI. Patients were then managed as: (1) PPI non-users; (2) PPI-initiated, and (3) PPI-continued. RESULTS Of 286 patients with heartburn and regurgitation, 103 (36%) were found to have normal and 183 (64%) abnormal esophageal acid exposure (AET). In the normal AET group, 44/103 had not been treated and were not initiated on PPI. Of the 59 who had previously received PPI, 52 stopped and 7 continued PPI. Hence, PPI were avoided in 96/103 patients (93%). In the abnormal AET group, 61/183 had not been treated and 38 were initiated on PPI and 23 on other therapies. In the 122 patients previously treated with PPI, 24 were not treated with PPI, but with H2RAs, prokinetics, endoscopic, or surgical therapy. Hence, PPI therapy was avoided in 47/183 patients (26%). CONCLUSIONS In patients with GER symptoms, esophageal pHmetry may avert PPI use in 50%. In the era of caution regarding PPIs, early testing may provide assurance and justification.
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