Endoscopic assessment of hiatal hernia repair

Prevalence of reflux esophagitis in obese Japanese undergoing bariatric surgery

Background

Currently, the data on the relationship between obesity and gastroesophageal reflux disease (GERD) in Asian populations are scarce.

Methods

The aim of this study is to investigate the prevalence of reflux esophagitis (RE) among obese Japanese patients in each body mass index (BMI) range group. In addition, we aim to investigate the risk factors for RE in obese Japanese patients. The present retrospective cohort study included 674 obese Japanese patients who underwent bariatric surgery between January 2003 and April 2016. The patients were stratified into five groups based on BMI range.

Results

The mean BMI was 42.7 ± 9.24 kg/m². The prevalence of RE among each of the groups was as follows: Group 1 (BMI 30–34.9) = 20.7%; Group 2 (BMI 35–39.9) = 24.0%; Group 3 (BMI 40–44.9) = 25.2%; Group 4 (BMI 45–49.9) = 26.7%; and Group 5 (BMI ≥50) = 24.8%. Overall, the prevalence of RE was 24.2% in our study. Furthermore, no significant difference in BMI was noted between the RE and non‐RE groups (43.4 ± 9.3 kg/m² and 42.5 ± 10.2 kg/m², respectively; p = 0.24). According to the multivariate logistic regression model, gender, Helicobacter pylori infection status, GERD‐related symptoms, and hiatal hernia were significantly correlated with RE.

Conclusion

Our study shows that the prevalence of RE in severely obese Japanese patients was significantly higher than the average prevalence of RE in Japan. However, the prevalence of RE did not increase with BMI in our cohort.

How Should We Report Endoscopic Results in Patient's with Barrett's Esophagus?

Barrett's esophagus is the only known pre-cancerous lesion for esophageal adenocarcinoma and is diagnosed by high-definition white light endoscopy demonstrating a columnar-lined esophagus along with biopsy evidence of intestinal metaplasia. With accurate performance and reporting of the endoscopic procedure, an evidence-based management strategy can be developed for treatment of Barrett's dysplasia. However, cross-sectional data demonstrate that there is still inconsistency among gastroenterologists in performance and reporting of endoscopic findings in patients with Barrett's esophagus. Here, we present an evidence-based review of how to report endoscopic findings in Barrett's esophagus.

Gender differences in the association of non-alcoholic fatty liver disease and metabolic syndrome with erosive oesophagitis: a cross-sectional study in a Taiwanese population

OBJECTIVES

Although metabolic syndrome correlates with erosive oesophagitis, few studies have examined the association between non-alcoholic fatty liver disease (NAFLD), associated with obesity and insulin resistance as metabolic syndrome, and erosive oesophagitis. The possible gender differences in risk factors of erosive oesophagitis should be considered. This study aimed to determine the concomitant effects of NAFLD and metabolic syndrome on erosive oesophagitis with respect to gender.

DESIGN, SETTING, PARTICIPANTS AND OUTCOME MEASURES

This cross-sectional study, conducted between January 2000 and August 2009, included 12 090 participants from the health examination center of a tertiary hospital. NAFLD was diagnosed according to ultrasonographic findings after excluding participants with excessive alcohol consumption or other liver diseases. Metabolic syndrome was determined using the revised National Cholesterol Education Program Adult Treatment Panel III criteria. Erosive oesophagitis was defined according to the Los Angeles classification by oesophagogastroduodenoscopy.

RESULTS

On the basis of the oesophagogastroduodenoscopic findings, the prevalence of erosive oesophagitis was 20.1% (n=1427/7110) and 9.9% (n=477/4842) in males and females, respectively. After adjusting for other variables, metabolic syndrome (OR 1.26; 95% CI 1.09 to 1.45) but not NAFLD (OR 1.14; 95% CI 0.98 to 1.30) significantly correlated with erosive oesophagitis in males, while NAFLD (OR 1.50; 95% CI 1.21 to 1.86) but not metabolic syndrome (OR 1.24; 95% CI 0.94 to 1.63) positively correlated with erosive oesophagitis in females.

CONCLUSIONS

The detrimental effect on erosive oesophagitis is greater by metabolic syndrome than by NAFLD in males but greater by NAFLD than by metabolic syndrome in females.

Laparoscopic Nissen fundoplication with gastric plication as a potential treatment of morbidly obese patients with GERD, first experience and results

BACKGROUND

Laparoscopic Nissen fundoplication is an effective treatment for gastroesophageal reflux disease (GERD). However, there is no consensus for the surgical treatment of GERD in morbidly obese patients.

METHODS

Twenty-five morbidly obese patients with GERD underwent our novel procedure, laparoscopic Nissen fundoplication with gastric plication (LNFGP), and were monitored for 6 to 18 months. Operative complication, weight loss, and GERD symptoms were monitored.

RESULTS

The study subjects consisted seven males and 18 females. The average age was 38.2 years (from 18 to 58), and the mean BMI was 37.9 kg/m(2) (from 31.5 to 56.4). The mean operative time was 145.6 min (from 105 to 190). All procedures were performed via laparoscopic surgery. Two patients (8%) displayed a major 30-day perioperative complication. The first patient had an acute leak on the second postoperative day. The patient received a laparoscopic revision sleeve gastrectomy and was discharged 5 days later after an uneventful recovery. Another patient developed an intra-abdominal abscess 3 weeks after surgery and received laparoscopic drainage and a revision sleeve gastrectomy. Upon follow-up, only four (16%) patients experienced occasional acid regurgitation symptoms; however, no anti-acid medication was required. A significant decrease in the prevalence of erosive esophagitis (80 vs. 17%) after LNFGP was observed. The mean weight loss was 9.7, 14.1, 17.9, and 18.1% at 1, 3, 6 and 12 months, respectively. The mean BMI decreased to 30.8 kg/m(2) 1 year post surgery with a mean body weight loss of 25 kg.

CONCLUSIONS

LNFGP appears to be an acceptable treatment option for treating GERD in morbidly obese patients who refuse Roux-en-Y gastric bypass. However, further study is indicated to verify this novel procedure.

Nonalcoholic fatty liver disease vs. obesity on the risk of erosive oesophagitis

BACKGROUND

Erosive oesophagitis (EE) may be complicated by oesophageal ulcers, peptic stricture, Barrett's oesophagus and oesophageal adenocarcinoma. There have been few studies examining the influence of nonalcoholic fatty liver disease (NAFLD) on EE, and even fewer exploring the simultaneous effects of NAFLD, general and central obesity on EE. We thus aim to clarify the relationship between NAFLD and EE when general and/or central obesity are considered simultaneously.

MATERIALS AND METHODS

In this cross-sectional study, we enrolled 12 090 subjects who underwent a health check-up at the Health Examination Center of a university hospital between January 2000 and August 2009 for analysis. NAFLD was diagnosed using liver ultrasound and EE was defined according to the Los Angeles classification by oesophagogastroduodenoscopy.

RESULTS

Subjects with EE (1922; 15·9%) had a higher proportion of NAFLD, general and central obesity. With adjustment for age, gender, hypertension, diabetes mellitus, hiatal hernia, hypertriglyceridemia, high-density lipoprotein cholesterol, alcohol consumption, tea drinking, smoking and habitual exercise, the results of the multivariate analyses showed that general obesity, central obesity and NAFLD were all significantly associated with EE in their separate models. When considering general obesity, central obesity and NAFLD simultaneously, NAFLD, but neither general nor central obesity, remained positively correlated to EE. In addition, male gender, hiatal hernia and hypertriglyceridemia were all significantly associated with EE.

CONCLUSION

In addition to general and central obesity, NAFLD is independently associated with increased risk of EE, and the detrimental effect of NAFLD on EE might be greater than those of general and central obesity.

Increase in gastroesophageal reflux disease symptoms and erosive esophagitis 1 year after laparoscopic sleeve gastrectomy among obese adults

BACKGROUND

Although laparoscopic sleeve gastrectomy (LSG) is an effective treatment for morbid obesity, the effects of LSG on gastroesophageal reflux disease (GERD) are controversial. This study evaluated the changes of GERD symptoms and erosive esophagitis (EE) in severely obese patients who underwent LSG.

METHODS

Forty-seven severely obese women and 19 severely obese men (mean age of 37.2 ± 12.7 years) who underwent LSG between August 2007 and November 2009 were enrolled. All patients completed the Reflux Disease Questionnaire and underwent esophagogastroduodenoscopy preoperatively and at least 1 year after LSG.

RESULTS

The median follow-up period was 12 months (range, 12-21). After surgery, significant decreases were reported in mean body mass index (36.3 ± 4.1 vs. 25.8 ± 2.9 kg/m(2)), mean waist circumference (109.5 ± 12.8 vs. 85.7 ± 9.5 cm), and prevalence of metabolic syndrome (54.5 vs. 7.6 %; P < 0.001 for both). Conversely, a significant increase was observed in the prevalence of GERD symptoms (12.1 vs. 47 %) and EE (16.7 vs. 66.7 %) after LSG (P < 0.001 for both). The prevalence of hiatal hernias also increased significantly (6.1 vs. 27.3 %; P < 0.001) after LSG, and it was significantly higher in patients with than those without EE after LSG (9.1 vs. 36.4 %, respectively; P = 0.02).

CONCLUSIONS

Although LSG can achieve significant weight loss and improvement of comorbidities in severely obese patients, the prevalence and severity of GERD symptoms and EE increase after the operation. The occurrence of EE after LSG is related to the presence of a hiatal hernia after the operation.

Barrett's esophagus: surveillance and reversal

The following on surveillance and reversal of Barrett's esophagus (BE) includes commentaries on criteria for surveillance even when squamous epithelium stains normally with a variety of biomarkers; the long-term follow-up of surgery versus endoscopic ablation of BE; the recommended surveillance intervals in patients without dysplasia; the sampling problems related to anatomic changes following fundoplication; the value of tissue spectroscopy and optical coherence tomography; the cost-effectiveness of biopsy protocols for surveillance; the quality of life of Barrett's patients; and risk stratification and surveillance strategies.

The relationship between visceral adiposity and the risk of erosive esophagitis in severely obese Chinese patients

A higher prevalence of erosive esophagitis is found in obese than in nonobese patients; however, it remains unclear why some obese patients develop this disease, whereas others do not. Accordingly, we elucidated the risk factors associated with erosive esophagitis in severely obese Chinese patients. Between June 2007 and January 2009, a total of 260 Chinese patients with morbid obesity referred for bariatric surgery were enrolled in this cross-sectional study. All patients received preoperative endoscopy for evaluation of the presence and severity of erosive esophagitis. Demographic variables, anthropometric measurements, and metabolic factors were included in a logistic regression model to identify the factors predictive of erosive esophagitis. The prevalence of erosive esophagitis was 32.3%. Multiple logistic regression showed that increased waist circumference (odds ratio (OR) = 1.03, 95% confidence interval (CI) = 1.01-1.04), increased insulin resistance (OR = 1.57, 95% CI = 1.06-2.31), and presence of reflux symptoms (OR = 2.40, 95% CI = 1.22-4.74) were independent risk factors associated with erosive esophagitis. In conclusion, among Chinese patients with morbid obesity, increased waist circumference and insulin resistance were risk factors for erosive esophagitis, which highlights the critical role of visceral adiposity in the pathogenesis of erosive esophagitis.

[Clinical and endoscopic outcome after Nissen fundoplication for gastroesophageal reflux disease]

CONTEXT

The surgical treatment of gastroesophageal reflux disease is indicated in patients with a chronic condition when proton pump inhibitors therapy is ineffective or when symptoms are persistently recurrent. Fundoplication failure occurrence has been detected in some patients and highlights a needing of monitoring esophageal post-surgical condition since that clinical symptoms are not sensitive enough for indicating fundoplication failure.

AIMS

To identify the frequency of a disrupted wrap in the postoperative period and to evaluate esophageal complications related with gastroesophageal reflux recurrence in children and adolescents.

METHODS

The study was cross-sectional, prospective and descriptive, including 45 patients (16 months-16.9 years) who had undergone Nissen fundoplication in a school hospital. Twenty six patients (57.8%) were neurologically impaired. Upper gastrointestinal endoscopy was performed in order to determine fundoplication integrity, endoscopic and histopathological esophageal condition. Upper gastrointestinal endoscopies were performed from 12 up to 30 months after surgery.

RESULTS

Patent wrap was identified in 41 patients (91.1%). Recurrent peptic esophagitis was found in 6 of 45 patients, 2 of which required a second fundoplication and other two had Barrett esophagus. Endoscopic peptic esophagitis was associated with a defective wrap (P = 0.005). Conclusions - Fundoplication was effective for treating esophagitis, even in patients with previous esophageal stenosis. Endoscopic follow up may detect surgery failure in children undergone anti-reflux surgery even in asymptomatic patients.

The effect of Roux-en-Y gastric bypass on gastroesophageal reflux disease in morbidly obese Chinese patients

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) is increasing in Eastern and Western countries. Obesity is recognized as a risk factor of gastroesophageal reflux disease. However, little information is available on the prevalence of gastroesophageal reflux disease in morbidly obese Chinese patients. The aim of this study was to compare the prevalence of GERD in Chinese patients with morbid obesity and age- and sex-matched controls, and we also assessed the effect of Roux-en-Y gastric bypass on reflux symptoms and erosive esophagitis.

METHODS

Between November 2006 and February 2008, 150 morbidly obese Chinese patients underwent laparoscopic Roux-en-Y gastric bypass. Gastroesophageal reflux disease questionnaires and esophagogastroduodenoscopy results were assessed in all cases before surgery. The prevalence of reflux symptoms and erosive esophagitis was compared with the prevalence in a database of 300 age- and sex-matched controls. We also compared baseline and postoperative characteristics at 12 months after operation.

RESULTS

Patients with morbid obesity had higher frequencies of reflux symptoms (16% vs. 8%, P = 0.01) and erosive esophagitis (34% vs. 17%, P < 0.01) than those of controls. Twelve months after laparoscopic Roux-en-Y gastric bypass, 26 patients received follow-up evaluations. In addition to substantial weight loss, the prevalence of reflux symptoms and erosive esophagitis decreased significantly after operation (19.2% vs. 0%, P = 0.05, and 42.3% vs. 3.8%, P < 0.01, respectively).

CONCLUSIONS

Gastroesophageal reflux disease is pervasive in Chinese patients with morbid obesity and Roux-en-Y gastric bypass substantially improves not only the reflux symptoms but also the erosive esophagitis.

Metabolic syndrome is associated with erosive esophagitis

AIM

To clarify whether insulin resistance and metabolic syndrome are risk factors for erosive esophagitis.

METHODS

A case-control study was performed using the database of the Kangbuk Samsung Hospital Medical Screening Center.

RESULTS

A total of 1679 cases of erosive esophagitis and 3358 randomly selected controls were included. Metabolic syndrome was diagnosed in 21% of the cases and 12% of the controls (P < 0.001). Multiple logistic regressions confirmed the association between erosive esophagitis and metabolic syndrome (Odds ratio, 1.25; 95% CI, 1.04-1.49). Among the components of metabolic syndrome, increased waist circumference, elevated serum triglyceride levels and hypertension were significant risk factors for erosive esophagitis (all P < 0.01). Furthermore, increased insulin resistance (Odds ratio, 0.91; 95% CI, 0.85-0.98) and fatty liver, as diagnosed by ultrasonography (Odds ratio, 1.39; 95% CI, 1.20-1.60), were also related to erosive esophagitis even after adjustment for a series of confounding factors.

CONCLUSION

Metabolic syndrome and increased insulin resistance are associated with an increased risk of developing erosive esophagitis.

Abdominal obesity is an independent risk factor for erosive esophagitis in a Korean population

BACKGROUND

The relationship between obesity and gastroesophageal reflux disease (GERD) is controversial. The aim of the present study was to investigate the potential roles of body mass index (BMI) and waist circumference on GERD in a Korean population.

METHODS

A total of 2457 subjects who visited the Kangbuk Samsung Hospital medical screening center for esophagogastroduodenoscopy from September 2004 to April 2005 were enrolled. All participants were given a questionnaire to determine reflux symptoms. Abdominal obesity was defined as a waist circumference > or =80 cm in women and > or =90 cm in men.

RESULTS

The proportion of subjects in each BMI group was 68.9%, 28.7% and 2.4% for BMI <25, 25-30 and >30, respectively. The prevalence of abdominal obesity was 24.2%. The prevalence of reflux symptoms was 8.2%. Neither BMI nor abdominal obesity was significantly associated with reflux symptoms after adjustment. The prevalence of erosive esophagitis was 6.6%. There was a clear dose-response relationship between prevalence of erosive esophagitis and BMI (5.6%, 8.1% and 15.5% for BMI <25, 25-30 and >30, respectively, P = 0.002). Abdominal obesity was also associated with erosive esophagitis (odds ratio, 2.3; 95% confidence interval, 1.6-3.1). However, only the association between abdominal obesity and erosive esophagitis remained strong after adjustments.

CONCLUSIONS

Abdominal obesity rather than BMI is an independent risk factor for erosive esophagitis in the Korean population.

The management of patients who have "failed" antireflux surgery

Gastroenterologists may be called upon to manage patients who have had antireflux surgery that failed. The available literature on this topic comprises predominantly reports on retrospective, observational studies written by surgeons who often have focused on how technical deficiencies in performing the operation led to the failure. Such reports are of limited value to the gastroenterologist seeking guidance on patient management. Furthermore, comparisons among the reports are confounded by the lack of a standardized definition for failed antireflux surgery. This report critically reviews the available literature, and suggests a practical approach to the management of patients who have symptoms that were not completely relieved, that reappeared later, or that were caused by antireflux surgery.

Surgical and endoscopic treatment of gastroesophageal reflux disease

There is no evidence to advocate medical or surgical therapy as the best therapy for GERD. The decision to have antireflux surgery must be individualized. All patients taking long-term medications for GERD should receive advice on the safety and wisdom of staying on that therapy and information on antireflux surgery. Fundoplication should be considered in three circumstances [4]: 1. Patients who are intolerant of PPI therapy because of side effects should be considered for surgery. This situation will be less common now with five PPIs, however. 2. Patients who are poorly responsive to PPI therapy should be considered for surgery. This situation is probably not common, given the effectiveness of the currently available PPIs. It is more common in patients with atypical GERD. The gastroenterologist should be as certain as possible that the patient not only has GERD, but also that the patient's symptoms are reflux related. 3. Surgery should be considered when patients desire a permanent solution to free them of the need to take medications. These patients must be warned about the potential suboptimal results, including the frequent need for medication within a few years of having the procedure and the small but real possibility of becoming worse after the operation. Even in experienced hands, 1% to 2% of patients are worse after the procedure. A careful preoperative evaluation to ensure that the patient's symptoms are reflux related and that the right operative procedure is performed offers the patient the best opportunity for success. Widespread use of endoscopic therapy for GERD is probably still several years away. The best endoscopic therapy is yet to be determined, but it will need to be safe, effective, and easy to use.

Post-fundoplication symptoms: the role for endoscopic assessment of fundoplication integrity

BACKGROUND

Fundoplication is now almost exclusively a laparoscopic procedure. The aim of this study was the comparison of the diagnostic usefulness of endoscopy and barium esophagram in the detection of fundoplication abnormalities.

METHODS

Twenty-two patients presented with symptoms post-laparoscopic (Nissen) fundoplication that included dysphagia (14 patients), heartburn (5 patients), dyspepsia (2 patients), and chest pain (1 patient). Barium esophagram and upper endoscopy were performed in all patients and the results were compared. Key features included presence of esophagitis, resistance to endoscope passage, location of the wrap relative to the diaphragmatic hiatus, location of squamocolumnar junction greater than 1 cm proximal to the wrap zone, and the appearance of the wrap (intact, loose, disrupted, or tight).

RESULTS

The key features explained symptoms in 20 of 22 patients. Endoscopy detected twice as many key features as radiography. Disruption of the wrap or excessive proximal location of the squamocolumnar junction proximal to the wrap zone were the most incriminating endoscopic findings. Resistance to endoscope passage was rarely encountered and the esophagram was more accurate in detecting an overly tight wrap.

CONCLUSIONS

Endoscopic evaluation is more accurate than barium esophagram in detecting post-fundoplication abnormalities. The appearance of the fundoplication wrap and an abnormal proximal location of the squamocolumnar junction appear to be major endoscopic clues in diagnosis of post-fundoplication problems.