The mechanisms associated with reflux episodes in ambulant subjects with gastro-esophageal reflux disease

BACKGROUND

The mechanisms associated with gastro-esophageal reflux (GER) episodes were studied using combined High-resolution Impedance Manometry (HRIM) and pH monitoring in ambulant subjects with different patterns of GERD.

METHODS

Sixteen subjects with mild-moderate esophagitis (Los Angeles (LA) grade A&B) (group A) and 11 subjects with severe esophagitis (LA grade C&D) or Barrett's esophagus (BE) were studied before and after a meal, resting, while walking, and during standardized exercise, using a HRIM and a pH probe.

KEY RESULTS

Post-prandial acid GER episodes were more common in group B (median 10 range (3-18) vs A (6.5 (0-18), p = 0.048). Postprandial acid clearance time was much longer in group B (median 0.71( 0.07-2.66 min) vs A (0.17 (0.04-2.44 min), p = 0.02). Transient lower esophageal sphincter relaxation (TLESR) was the most frequent mechanism associated with GER episodes in both groups. Post-prandial TLESRs with GER were more common in group B (median 17 (9-24) vs A 13.5 (7-34), p = 0.014), particularly during exercise (B 8 (6-9) vs A 6 (5-6.8), p = 0.007). Post-prandially TLESR with acid reflux increased during exercise in both groups (A rest median 2.4 (0-6.4) per hour vs exercise 4.7 (0-17.3), p = 0.005 and B 4 (0.8-9.6) vs 5.3 (2.7-13.3) per hour, p = 0.045).

CONCLUSIONS AND INFERENCES

TLESR was the most common mechanism associated with reflux episodes in all subjects. Acid reflux episodes were more common in subjects with severe esophagitis or BE and esophageal acid clearance was much slower. Post-prandial exercise increased TLESR with acid reflux and GERD patients should be encouraged to avoid exercise immediately after a meal.

The not-so-rare absent RAIR: Internal anal sphincter achalasia in a review of 1072 children with constipation undergoing high-resolution anorectal manometry

BACKGROUND

Our objective is to describe the prevalence of patients with internal anal sphincter achalasia (IASA) without Hirschsprung disease (HD) among children undergoing anorectal manometry (ARM) and their clinical characteristics.

METHODS

We performed a retrospective review of high-resolution ARM studies performed at our institution and identified patients with an absent rectoanal inhibitory reflex (RAIR). Clinical presentation, medical history, treatment outcomes, and results of ARM and other diagnostic tests were collected. We compared data between IASA patients, HD patients, and a matched control group of patients with functional constipation (FC).

KEY RESULTS

We reviewed 1,072 ARMs and identified 109 patients with an absent RAIR, of whom 28 were diagnosed with IASA. Compared to patients with FC, patients with IASA had an earlier onset of symptoms and were more likely to have abnormal contrast enema studies. Compared to patients with HD, patients with IASA were more likely to have had a normal timing of meconium passage, a later onset of symptoms, and were diagnosed at an older age. At the latest follow-up, the majority of patients diagnosed with IASA (54%) were only using oral laxatives. Over half of patients with IASA had been treated with anal sphincter botulinum toxin injection, and 55% reported a positive response.

CONCLUSIONS AND INFERENCES

Patients diagnosed with IASA may represent a more severe patient population compared to patients with FC, but have a later onset of symptoms compared to patients with HD. They may require different treatments for their constipation and deserve further study.

Upper Esophageal Sphincter Motility and Thoracic Pressure are Determinants of Pressurized Waves in Achalasia Subtypes According to the Chicago Classification

BACKGROUND

Phenotypes of achalasia are based on esophageal body pressurization during swallow. The reasons that lead to pressurized waves are still unclear. This study aims to evaluate manometric parameters that may determine pressurized waves in patients with achalasia.

METHODS

A total of 100 achalasia high-resolution manometry tests were reviewed. We measured before each swallow: upper esophageal sphincter (UES) basal pressure, esophageal length, lower esophageal sphincter (LES) basal pressure, LES length, gastric and thoracic pressure, transdiaphragmatic pressure gradient and the LES retention pressure (LES basal pressure-TPG); during swallow: UES pressure, UES residual pressure, UES recovery time, LES relaxation pressure, gastric and thoracic pressure, transdiaphragmatic pressure gradient and after swallow: esophageal length, LES length, wave pressure, gastric and thoracic pressure and transdiaphragmatic gradient pressure.

RESULTS

Univariate analysis showed in pressurized waves before swallow: higher thoracic, UES and LES basal pressure, longer LES length and decrease in LES retention pressure; during swallow: higher thoracic, gastric and UES pressure, higher UES and LES relaxation pressure and after swallow: higher thoracic and gastric pressure. Multivariate analysis in pressurized waves showed as significant before swallow: thoracic and UES basal pressure; during swallow: thoracic, gastric and UES pressure, UES residual pressure and UES recovery time and after swallow: thoracic pressure.

CONCLUSIONS

Basal esophageal pressurization and the UES are independent variables that may be associated with pressurized waves.

EndoFLIP in the Esophagus: Assessing Sphincter Function, Wall Stiffness, and Motility to Guide Treatment

The functional luminal imaging probe (FLIP) uses high-resolution planimetry to provide a three-dimensional image of the esophageal lumen by measuring diameter, volume, and pressure changes. Literature surrounding use of FLIP has demonstrated its clinical utility as a diagnostic tool and as a device to guide and measure response to therapy. FLIP can assess and guide treatments for esophageal disease states including gastroesophageal reflux disease, achalasia, and eosinophilic esophagitis. FLIP may become the initial test for patients with undifferentiated dysphagia at their index endoscopy. This article summarizes use of FLIP in assessing sphincter function, wall stiffness, and motility to guide treatments.

Pathophysiology of Gastroesophageal Reflux Disease in Infants and Nonpharmacologic Strategies for Symptom Management

Gastroesophageal reflux is common in young infants, particularly those born prematurely or with a history of medical complexity. The most recent clinical practice guidelines recommend the use of nonpharmacologic management strategies because of concerns about the safety of acid-reducing medications and a lack of evidence of their effectiveness. Our purpose in this article is to holistically review the pathophysiology of gastroesophageal reflux disease, identify symptom management targets, and describe nonpharmacologic strategies that nurses can implement and/or teach to parents to manage symptoms of gastroesophageal reflux. Strategies targeting stress, dysbiosis, food intolerances, feeding difficulties, and positioning are discussed. Nurses can work with families to identify factors contributing to gastroesophageal reflux disease and determine individualized strategies that can be used in lieu of, or in addition to, medication.

Use of Impedance Planimetry (Endoflip) in Foregut Surgery Practice: Experience of More than 400 Cases

BACKGROUND

We provide a comprehensive report of our institution's experience with the endoluminal functional lumen imaging probe (Endoflip) impedance planimetry system, a device that can be used intraoperatively to objectively evaluate the distensibility of any sphincter of the gastrointestinal tract. We aim to describe the variety of ways in which the Endoflip can be used in a foregut surgeon's practice.

STUDY DESIGN

This is a retrospective review of a prospectively maintained quality database of all patients in which the functional lumen imaging probe (FLIP) system was used between February 2013 and June 2019.

RESULTS

During the study period, 402 FLIP cases were performed: 226 fundoplications, 94 peroral endoscopic myotomies, 15 peroral pyloromyotomies, 12 antireflux mucosectomies, 11 magnetic sphincter augmentations, 9 laparoscopic Heller myotomies, 8 pre-esophagectomy esophagogastroduodenoscopies (EGDs), 4 diagnostic EGDs, 8 endoscopic Zenker's diverticulotomies, 5 post-peroral endoscopic myotomy EGDs, 8 EGDs with dilations, and 2 transoral incisional fundoplications.

CONCLUSIONS

Within a foregut surgeon's practice, the FLIP can be used to measure the upper esophageal sphincter, lower esophageal sphincter, and pylorus in a variety of clinical scenarios and settings.

Stretta procedure versus proton pump inhibitors for the treatment of nonerosive reflux disease: A 6-month follow-up

To compare the Stretta procedure with proton pump inhibitors for the treatment of nonerosive reflux disease (NERD).From July 2018 to April 2019, patients diagnosed with NERD and referred for treatment were enrolled. They were treated with either Stretta procedure or proton pump inhibitor (PPI) medication and followed-up for 6 months. The symptom control, quality of life, lower esophageal sphincter (LES) pressure, 24-hour pH parameters, PPI usage and satisfaction rate were evaluated. The complications were assessed. The outcomes of the 2 groups were analyzed and compared.Twenty-eight patients in the Stretta group and 21 patients in the PPI group completed the 6-month follow-up. No severe adverse events occurred in both groups. Both interventions were effective in improvement of symptom and quality of life. The symptom score improvement was significantly superior in the Stretta group compared to the PPI group (6.3 ± 3.4 vs 8.5 ± 4.1, P = .03). LES pressure increased significantly in the Stretta group compared to the PPI group (14.2 ± 4.4 mm Hg vs 10.0 ± 4.0 mm Hg, P < .01). Although both interventions improved 24-hour pH parameters, including number of acid episodes (P = .27), acid exposure time (P = .39), and DeMeester score (P = .28), no difference was found between the 2 groups. Complete PPI cessation rate (82% vs 52%, P = .03) as well as satisfaction rate (89% vs 57%, P = .02) was much higher in Stretta group than those in the PPI groupThe Stretta procedure was safe and effective in the short term for the management of NERD. The Stretta procedure resulted in higher LES pressure and achieved better improvement of symptom control and PPI cessation than did PPI in the short term.

Achalasia in a Patient with Myotonic Dystrophy

Myotonic dystrophy is a progressive disorder mainly affecting the voluntary muscles. We herein report a rare case of myotonic dystrophy complicated with high-resolution manometry-defined achalasia, the pathology of which is absent relaxation of the smooth muscles of lower esophageal sphincter (LES). In the present case, achalasia was considered a complication of myotonic dystrophy instead of sporadic achalasia, as on performing high-resolution manometry, the finding of an impaired LES relaxation (myotonic phase) changed to a totally emaciated LES function (muscle weakness phase) as myotonic dystrophy progressed.

Gastroesophageal Reflux Disease in the Neonatal Intensive Care Unit Infant: Who Needs to Be Treated and What Approach Is Beneficial?

Gastroesophageal reflux (GER) and GER disease (GERD) pertaining to infants in the neonatal intensive care unit (NICU) are reviewed, based on research in this specific population. The developmental biology of the gastroesophageal junction, physiology of GER, and pathophysiology of GERD in this setting are summarized, and risk factors for GER and GERD identified. The epidemiology, economic burden, and controversies surrounding GERD in NICU infants are addressed, and an approach to GER and GERD in these patients formulated. Recent advancements in individual assessment of GER and GERD in the NICU infant are examined, and evidence-based guidelines for their adoption provided.

A Rare Case Involving the Inability to Belch

A 17-year-old girl was referred to our hospital with an inability to belch, while experiencing chest gurgling noises, and severe abdominal bloating. She reported having these symptoms all her life. A timed barium esophagogram revealed a moderate amount of bubbles in the esophagus and gastric fundus, which significantly increased after the examination. High resolution manometry revealed that the basal upper esophageal sphincter pressure increased with a rise in the cervical esophageal pressure. A pathological inability to belch is rare; at present, no specific name exists to describe the disorder. Further research is needed in this unexplored field.

Unexpected appearance of esophageal spastic activity after pneumatic dilatation in a patient with type II achalasia

.

Electrical lower esophageal sphincter augmentation in patients with GERD and severe ineffective esophageal motility-a safety and efficacy study

Background

Laparoscopic fundoplication (LF), even if performed in specialized centers, can be followed by long-term side effects such as dysphagia, gas bloating or inability to belch. Patients with an ineffective esophageal motility (IEM) and concurrent GERD are prone to postoperative dysphagia after LF. The aim of this study is to evaluate the safety and efficacy of electrical lower esophageal sphincter stimulation in patients with IEM and GERD.

Methods

This is a prospective, open-label single center study. Patients with PPI-refractory GERD and ineffective esophageal motility were included for lower esophageal sphincter electrical stimulation (LES-EST). Patients underwent prospective follow-up including physical examination, interrogation of the device and were surveyed for changes in the health-related quality of life score.

Results

According to power analysis, 17 patients were included in this study. Median distal contractile integral (DCI) was 64 mmHg s cm (quartiles 11.5–301). Median total % pH < 4 was 8.9 (quartiles 4–21.6). Twelve patients (70.6%) underwent additional hiatal repair. At 1-month follow-up, none of the patients showed any clinical or radiological signs of dysphagia. There were no procedure related severe adverse events. Mean total HQRL improved from baseline 37.53 (SD 15.07) to 10.93 (SD 9.18) at follow-up (FUP) (mean difference 24.0 CI 15.93–32.07) p < 0.001.

Conclusions

LES-EST was introduced as a potential technique to avoid side effects of LF. LES-EST significantly improved health related quality of life and does not impair swallowing in patients with GERD and ineffective esophageal motility.

Fiber-enriched diet helps to control symptoms and improves esophageal motility in patients with non-erosive gastroesophageal reflux disease

AIM

To investigate the effect of dietary fiber on symptoms and esophageal function testing parameters in non-erosive gastroesophageal reflux disease (GERD) (NERD) patients.

METHODS

Thirty-six NERD patients with low (< 20 g/d) dietary fiber intake were enrolled in the study. They were examined with the use of symptom questionnaire (GERD-Q), high-resolution esophageal manometry, 24-h esophageal pH-impedance examinations, and food frequency questionnaire before and after 10 d of usual diet supplemented by psyllium 5.0 g TID. Complete data of 30 patients were available to the final analysis. The obtained results were analyzed with the use of non-parametric statistics (Wilcoxon matched pairs test).

RESULTS

The number of patients experiencing heartburn was less (93.3% at baseline vs 40% at the end of the study, P < 0.001) and the GERD-Q score decreased (mean ± SD: 10.9 ± 1.7 vs 6.0 ± 2.3, P < 0.001) after the treatment period. Minimal resting lower esophageal sphincter (LES) pressure increased from 5.41 ± 10.1 to 11.3 ± 9.4 mmHg (P = 0.023), but no change in residual LES pressure and mean resting pressure was found. Total number of gastroesophageal refluxes (GER) decreased from 67.9 ± 17.7 to 42.4 ± 13.5 (P < 0.001) predominantly by acid and weak acid types of GERs. No significant change in mean esophageal pH and % of time pH < 4 was registered. Maximal reflux time decreased from 10.6 ± 12.0 min to 5.3 ± 3.7 min (P < 0.05).

CONCLUSION

Fiber-enriched diet led to a significant increase of minimal lower esophageal sphincter resting pressure, a decrease of number of gastroesophageal refluxes, and a decrease of heartburn frequency per week in NERD.

GERD: Presence and Size of Hiatal Hernia Influence Clinical Presentation, Esophageal Function, Reflux Profile, and Degree of Mucosal Injury

A hiatal hernia (HH) is a frequent finding in patients with gastroesophageal reflux disease (GERD). We examined a consecutive series of patients with GERD diagnosed by a 24-hour pH monitoring. Based on the presence and size of HH on barium swallow, patients were divided into the following groups: no HH, HH <3 cm, HH 3-5 cm and HH >5 cm. A total of 175 patients were included: 43 with no HH, 86 with HH <3 cm, 34 with HH 3-5 cm, and 12 with HH >5 cm. Patients with larger HH had more frequent episodes of coughing and wheezing associated with episodes of reflux. High-resolution manometry showed that the increasing size of the HH was associated with decreasing pressure of the lower esophageal sphincter and weaker peristalsis. Ambulatory pH monitoring revealed that patients with larger HH had more acid reflux, in both the distal and proximal esophagus. Endoscopy showed that patients with larger HH had more severe esophagitis. Fifty per cent of patients with HH >5.0 cm had Barrett's esophagus. These findings should guide gastroenterologists and surgeons in choosing the appropriate therapy in patients with GERD and large HH.

Association of oral Helicobacter pylori with gastric complications

AIM

This study was aimed to identify the presence of Helicobacter pylori (H. pylori) genes in oral mucosa and find out their relationship between oral H. pylori infection and gastric complications.

METHODS

This study is a case control study consists of 567 subjects with periodontal infection (278 gastric complication cases and 289 controls normal gastric intestinal mucosa) with age range of 20-80 years. Oral health status was recorded by calculating oral hygiene index (OHI), probing depths (PD) and clinical attachment loss (CAL). Each participant provided gastric biopsy and plaque samples which were subjected to H. pylori detection. Polymerase chain reaction (PCR) with different primers specifically β globulin, 16SrRNA, babA, cagA, ureA, ureC and vacA gene was performed which were then analyzed using gel electrophoresis.

RESULTS

No significant differences (χ² = 11.873, p value > 0.05) were observed between oral H. pylori and gastric infections/complications. However, H. pylori increase the risk of developing gastro-esophageal reflux grade II (OR = 1.458, 95%CI = 0.659-3.226), normal upper GIT mucosa with lax esophageal sphincters (OR = 1.215, 95%CI = 0.285-5.181) and duodenal ulcer/duodenitis (OR = 2.187, 95%CI = 0.225-21.278). This study also showed a significant increased risk of gastritis with babA gene.

CONCLUSION

Oral pathogenic H. pylori genes may enhance the severity of the gastric infection.

Pathophysiology of Gastroesophageal Reflux Disease

The pathogenesis of gastroesophageal reflux disease (GERD) is complex and involves changes in reflux exposure, epithelial resistance, and visceral sensitivity. The gastric refluxate is a noxious material that injures the esophagus and elicits symptoms. Esophageal exposure to gastric refluxate is the primary determinant of disease severity. This exposure arises via compromise of the anti-reflux barrier and reduced ability of the esophagus to clear and buffer the refluxate, leading to reflux disease. However, complications and symptoms also occur in the context of normal reflux burden, when there is either poor epithelial resistance or increased visceral sensitivity. Reflux therefore develops via alterations in the balance of aggressive and defensive forces.

High Resolution Manometry and pH step-up method on the localisation of the lower esophageal sphincter

.

Is Heller myotomy better than balloon dilation? A meta-analysis

BACKGROUND AND AIM

Endoscopic balloon dilation (EBD) and laparoscopic Heller myotomy (LHM) are the most commonly performed treatment options for achalasia. Decision between these treatment options is difficult. The aim of this meta-analysis was to evaluate the efficacy of EBD compared to LHM.

METHODS

The electronic databases PubMed, Embase and Cochrane Controlled Trials Registry were systematically searched for the period between January 1, 1976 and December 31, 2015. Meta-analysis was performed using the PICOS (problem, intervention, comparison, outcome, study design) format. Efficacy and safety of EBD were compared to LHM. Forest plot analyses were used to illustrate the success rate, perforation rate and post-procedural gastroesophageal reflux.

RESULTS

Using the search strategy, eight studies met the selection criteria and were included in the meta-analysis. The total number of patients included was 749 (360 in the EBD group and 389 in the LHM group). The success rate was lower in the EBD group than in the LHM group (OR=0.486; CI: 0.304-0.779; p=0.003). The rate of perforation did not differ significantly between the EBD and LHM group (RR= 0.635, CI: 0.340-1.186, p=0.154). The incidence of post-procedural symptomatic gastroesophageal reflux did not differ between the two treatment groups (RR=0.663, CI: 0.328-1.343, p=0.254).

CONCLUSION

Our data suggest that the efficacy of LHM is superior to that of EBD, while there is no difference in safety between the two treatment groups.

Long-term outcomes of peroral endoscopic myotomy for patients with achalasia: a retrospective single-center study

Peroral endoscopic myotomy (POEM) has been widely applied to the treatment of achalasia. The aim of this study is to retrospectively investigate the long-term outcome of POEM in patients with achalasia. Patients undergoing POEM at our center with a minimum follow-up of 3 years were enrolled in this study. Relief of patients' symptom was defined as the primary outcome. Secondary outcomes included lower esophageal sphincter pressure, esophageal emptying, symptoms relapse, and clinical reflux adverse events. The Chi-square test was performed to determine the potential predictors of surgical failure. Sixty-seven patients (aged 40.7 ± 15.3 years) were recruited in the study, with a mean follow-up period of 40.1 ± 2.8 months. At the final follow-up, the median Eckardt score reduced from 7.6 ± 2.3 preoperatively to 1.9 ± 1.7 (P < 0.001), the lower esophageal sphincter pressure was reduced from 35.4 ± 13.7 mmHg preoperatively to 8.9 ± 4.1 mmHg (P < 0.001), and the height of the barium column at 5 min after barium swallowed was reduced from 9.7 ± 1.6 cm preoperatively to 2.9 ± 2.1 cm (P < 0.001). Eight patients had symptoms relapse and nine patients developed reflux esophagitis. Type III achalasia was found to be indicative of surgical failure. POEM was a promising treatment for patients with achalasia, which can yield a long-term relief of the symptom and a low rate of clinical reflux adverse events.

Peroral endoscopic myotomy for treatment of Guillain-Barre syndrome-associated achalasia: A rare case

Guillain-Barre syndrome (GBS)-associated achalasia is a very rare disease of uncertain cause. We report the case of a patient diagnosed with GBS-associated type I achalasia who was successfully treated with peroral endoscopic myotomy (POEM). A 30-year-old man who was diagnosed with GBS 3 mo before was referred to our department with dysphagia and meal-related regurgitation. The results of esophagography, endoscopy, and high-resolution manometry (HRM) revealed type I achalasia. POEM that utilized a submucosal tunneling technique was performed to treat the GBS-associated type I achalasia. After POEM, smooth passage of a contrast agent into the stomach was shown in follow-up esophagography, and follow-up HRM revealed a decrease in the mean integrated relaxation pressure 22.9 mmHg to 9.6 mmHg. The patient remained without dysphagia for 7 mo, even though the patient’s neurological problems were not fully resolved. POEM may be a safe and effective treatment for GBS-associated type I achalasia.

Esophagogastric Junction Morphology and Distal Esophageal Acid Exposure

BACKGROUND

The Chicago classification has recently added a morphological subclassification for the esophagogastric junction (EGJ). Our aim was to assess the distal esophageal acid exposure in patients with this new Chicago EGJ-type IIIa and IIIb classification.

STUDY DESIGN

From a prospectively collected high-resolution manometry (HRM) database, we identified patients who underwent 24-h pH study between October 2011 and June 2015 and were diagnosed with EGJ-type III based on HRM. Chicago EGJ-type III is defined as the inter-peak nadir pressure ≤gastric pressure and a lower esophageal sphincter (LES)-crural diaphragm (CD) separation >2 cm [IIIa-pressure inversion point (PIP) remains at CD level and IIIb-PIP remains at LES level]. We classified the patients into reflux group [DeMeester score >14.72 or Fraction time pH (<4) > 4.2 %] and non-reflux group based on 24-h pH study.

RESULTS

Fifty patients were identified that satisfied the study criteria, of which 37 patients (74 %) were EGJ-type IIIa. In those with EGJ-type IIIb, abdominal LES length (AL) in reflux group was significantly shorter than the non-reflux group (0.8 vs. 1.8, p < 0.05). EGJ-type IIIa patients showed significantly higher value for DeMeester score and Fraction time pH and more often had a positive pH study than EGJ-type IIIb patients (DeMeester score: 26.7 vs. 11.7, p < 0.05; Fraction time pH: 7.9 vs. 2.6, p < 0.05; positive pH study: 81.1 vs. 30.8 %, p < 0.001). Reflux was more common in LES-CD ≥ 3 cm than that in LES-CD < 3 cm (85 vs. 56.7 %, p < 0.05).

CONCLUSION

A subset of patients with >2-cm LES-CD separation (type IIIb) maintain a physiological intra-abdominal location of the EGJ and are less likely to have reflux. A LES-CD ≥ 3 cm seems to discern a hiatus hernia of clinical significance.

Esophagogastric anastomosis in rats: Improved healing by BPC 157 and L-arginine, aggravated by L-NAME

AIM

To cure typically life-threatening esophagogastric anastomosis in rats, lacking anastomosis healing and sphincter function rescue, in particular.

METHODS

Because we assume esophagogastric fistulas represent a particular NO-system disability, we attempt to identify the benefits of anti-ulcer stable gastric pentadecapeptide BPC 157, which was in trials for ulcerative colitis and currently for multiple sclerosis, in rats with esophagocutaneous fistulas. Previously, BPC 157 therapies have promoted the healing of intestinal anastomosis and fistulas, and esophagitis and gastric lesions, along with rescued sphincter function. Additionally, BPC 157 particularly interacts with the NO-system. In the 4 d after esophagogastric anastomosis creation, rats received medication (/kg intraperitoneally once daily: BPC 157 (10 μg, 10 ng), L-NAME (5 mg), or L-arginine (100 mg) alone and/or combined or BPC 157 (10 μg, 10 ng) in drinking water). For rats underwent esophagogastric anastomosis, daily assessment included progressive stomach damage (sum of the longest diameters, mm), esophagitis (scored 0-5), weak anastomosis (mL H₂O before leak), low pressure in esophagus at anastomosis and in the pyloric sphincter (cm H₂O), progressive weight loss (g) and mortality. Immediate effect assessed blood vessels disappearance (scored 0-5) at the stomach surface immediately after anastomosis creation.

RESULTS

BPC 157 (all regimens) fully counteracted the perilous disease course from the very beginning (i.e., with the BPC 157 bath, blood vessels remained present at the gastric surface after anastomosis creation) and eliminated mortality. Additionally, BPC 157 treatment in combination with L-NAME nullified any effect of L-NAME that otherwise intensified the regular course. Consistently, with worsening (with L-NAME administration) and amelioration (with L-arginine), either L-arginine amelioration prevails (attenuated esophageal and gastric lesions) or they counteract each other (L-NAME + L-arginine); with the addition of BPC 157 (L-NAME + L-arginine + BPC 157), there was a marked beneficial effect. BPC 157 treatment for esophagogastric anastomosis, along with NOS-blocker L-NAME and/or NOS substrate L-arginine, demonstrated an innate NO-system disability (as observed with L-arginine effectiveness). BPC 157 distinctively affected corresponding events: worsening (obtained with L-NAME administration that was counteracted); or amelioration (L-arginine + BPC 157-rats correspond to BPC 157-rats).

CONCLUSION

Innate NO-system disability for esophagogastric anastomoses, including L-NAME-worsening, suggests that these effects could be corrected by L-arginine and almost completely eliminated by BPC 157 therapy.

Gastroesophageal reflux disease. Are we acting in the best interest of our patients?

Oesophageal adenocarcinoma is strictly related to gastroesophageal reflux and cylindrical metaplasia of the epithelium of the distal esophagus (Barrett's esophagus) due to chronic inflammation. Worldwide incidence of oesophageal adenocarcinoma is rising despite the availability of precise international guidelines for the treatment of gastroesophageal reflux disease and the increasing use of proton-pump inhibitors (PPIs). While PPIs can control GERD symptoms in a significant amount of cases, still a large number of patients progress to Barrett's esophagus and adenocarcinoma. Recent investigations have demonstrated that in one-third of the patients their reflux symptoms are due to non-acid reflux, obviously not affected by PPIs. Robust evidences are available to demonstrate the role of non-acid reflux in the development of Barrett's esophagus and adenocarcinoma. Therefore, PPIs are not effective in preventing the worst complications of GERD. It is mandatory to develop new and more effective guidelines on the treatment of GERD; that would take into account the fact that GERD should be considered a "surgical" disease, as it is due, at least in its late stages, to an anatomical defect of the lower oesophageal sphincter. Medical treatment should be considered in early stage GERD, when reflux is due to transient relaxations of the lower oesophageal sphincter, whereas surgery should be considered in late stages, in the presence of a demonstrated mechanical failure of the sphincter.

New insights into the pathophysiology of achalasia and implications for future treatment

Idiopathic achalasia is an archetype esophageal motor disorder, causing significant impairment of eating ability and reducing quality of life. The pathophysiological underpinnings of this condition are loss of esophageal peristalsis and insufficient relaxation of the lower esophageal sphincter (LES). The clinical manifestations include dysphagia for both solids and liquids, regurgitation of esophageal contents, retrosternal chest pain, cough, aspiration, weight loss and heartburn. Even though idiopathic achalasia was first described more than 300 years ago, researchers are only now beginning to unravel its complex etiology and molecular pathology. The most recent findings indicate an autoimmune component, as suggested by the presence of circulating anti-myenteric plexus autoantibodies, and a genetic predisposition, as suggested by observed correlations with other well-defined genetic syndromes such as Allgrove syndrome and multiple endocrine neoplasia type 2 B syndrome. Viral agents (herpes, varicella zoster) have also been proposed as causative and promoting factors. Unfortunately, the therapeutic approaches available today do not resolve the causes of the disease, and only target the consequential changes to the involved tissues, such as destruction of the LES, rather than restoring or modifying the underlying pathology. New therapies should aim to stop the disease at early stages, thereby preventing the consequential changes from developing and inhibiting permanent damage. This review focuses on the known characteristics of idiopathic achalasia that will help promote understanding its pathogenesis and improve therapeutic management to positively impact the patient’s quality of life.

[Transient lower esophageal sphincter relaxation]

Transient lower esophageal sphincter relaxation(TLESR) is the single most common mechanism underlying acid reflux in normal subjects and patients with gastroesophageal reflux disease (GERD). It is also the mechanism underlying the reflux of gas during belching. By definition, TLESRs are not triggered by swallowing. They are of substantially longer duration(10-45 sec) than swallow-induced LES relaxation(5-8 sec). The occurrence of TLESRs is unrelated to basal LES pressure. TLESRs are not always accompanied by acid reflux. In normal subjects about 40-60 % of TLESRs are accompanied by acid reflux, compared with 60-70 % in patients with GERD. The rate of TLESRs is increased by a number of factors. The most important stimulus appears to be gastric distention due to gas or a meal.

Electrical stimulation therapy of the lower esophageal sphincter is successful in treating GERD: long-term 3-year results

BACKGROUND

Electrical stimulation of the lower esophageal sphincter (LES) has been shown to improve outcomes in patients with gastroesophageal reflux disease (GERD) at 2 years. The aim of the study was to evaluate the safety and efficacy of LES stimulation in the same cohort at 3 years.

METHODS

GERD patients with partial response to PPI, with % 24-h esophageal pH < 4.0 for >5 %, with hiatal hernia <3 cm and with esophagitis ≤LA grade C were treated with LES stimulation in an open-label 2-year trial. All patients were on fixed stimulation parameter of 20 Hz, 220 μs, 5 mA delivered in twelve, 30-min sessions. After completing the 2-year open-label study, they were offered enrollment into a multicenter registry trial and were evaluated using GERD-HRQL, symptom diaries and pH testing at their 3-year follow-up.

RESULTS

Fifteen patients completed their 3-year evaluation [mean (SD) age = 56.1 (9.7) years; men = 8] on LES stimulation. At 3 years, there was a significant improvement in their median (IQR) GERD-HRQL on electrical stimulation compared to both their on PPI [9 (6-10) vs. 1 (0-2), p = 0.001] and off PPI [22 (21-24) vs. 1 (0-2), p < 0.001]. Median 24-h distal esophageal acid exposure was significantly reduced from [10.3 (7.5-11.6) % at baseline vs. 3 (1.9-4.5) %, p < 0.001] at 3 years. Seventy-three % (11/15) patients had normalized their distal esophageal acid exposure at 3 years. Remaining four patients had improved their distal esophageal acid exposure by 39-48 % from baseline. All but four patients reported cessation of regular PPI use (>50 % of days with PPI use); three had normal esophageal pH at 3 years. There were no unanticipated device- or stimulation-related adverse events or untoward sensation reported during the 2- to 3-year follow-up.

CONCLUSION

LES-EST is safe and effective for treating patients with GERD over long-term, 3-year duration. There was a significant and sustained improvement in esophageal acid exposure and reduction in GERD symptoms and PPI use. Further, no new GI side effects or adverse events were reported.

Efficacy of peroral endoscopic myotomy vs other achalasia treatments in improving esophageal function

AIM: To assess and compare the esophageal function after peroral endoscopic myotomy (POEM) vs other conventional treatments in achalasia.

METHODS: Chart review of all achalasia patients who underwent POEM, laparoscopic Heller myotomy (LHM) or pneumatic dilation (PD) at our institution between January 2012 and March 2015 was performed. Patient demographics, type of achalasia, prior treatments, pre- and post-treatment timed barium swallow (TBE) and high-resolution esophageal manometry (HREM) findings were compared between the three treatment groups. Patients who had both pre- and 2 mo post-treatment TBE or HREM were included in the final analysis. TBE parameters compared were barium column height, width and volume of barium remaining at 1 and 5 min. HREM parameters compared were basal lower esophageal sphincter (LES) pressures and LES-integrated relaxation pressures (IRP). Data are presented as mean ± SD, median [25^th, 75^th percentiles] or frequency (percent). Analysis of variance, Kruskal-Wallis test, Pearsons χ² test and Fishers Exact tests were used for analysis.

RESULTS: A total of 200 achalasia patients were included of which 36 underwent POEM, 22 underwent PD and 142 underwent LHM. POEM patients were older (55.4 ± 16.8 years vs 46.5 ± 15.7 years, P = 0.013) and had higher BMI than LHM (29.1 ± 5.9 kg/m²vs 26 ± 5.1 kg/m², P = 0.012). More number of patients in POEM and PD groups had undergone prior treatments compared to LHM group (72.2% vs 68.2% vs 44.3% respectively, P = 0.003). At 2 mo post-treatment, all TBE parameters including barium column height, width and volume remaining at 1 and 5 min improved significantly in all three treatment groups (P = 0.01 to P < 0.001) except the column height at 1 min in PD group (P = 0.11) . At 2 mo post-treatment, there was significant improvement in basal LES pressure and LES-IRP in both LHM (40.5 mmHg vs 14.5 mmHg and 24 mmHg vs 7.1 mmHg respectively, P < 0.001) and POEM groups (38.7 mmHg vs 11.4 mmHg and 23.6 mmHg vs 6.6 mmHg respectively, P < 0.001). However, when the efficacy of three treatments were compared to each other in terms of improvement in TBE or HREM parameters at 2 mo, there was no significant difference (P > 0.05).

CONCLUSION: POEM, PD and LHM were all effective in improving esophageal function in achalasia at short-term. There was no difference in efficacy between the three treatments.

[Patient's Risk Factors for Perioperative Aspiration Pneumonia]

This article reviews patient's own risk factors for perioperative aspiration pneumonia. Maintaining the function of the lower esophageal sphincter (LES), the airway protective reflex, and the oral hygiene are the most important to prevent the pneumonia. The LES is adversely affected by excessive stomach distention, some medication given in perioperative periods, and habitual smoking, as well as pathological status such as esophageal hiatus hernia and achalasia. Postapoplectic patients may have insufficient airway protective reflex including swallowing and laryngeal reflex. It is emphasized that the perioperative oral care is increasing in its importance for the prevention of aspiration pneumonia.

[Analysis of the characteristic of pharyngeal paraesthesia patients by high resolution manometry]

OBJECTIVE

To discuss the pressure changing characteristics of upper esophageal sphincter (UES), lower esophageal sphincter (LES) and the esophagus kinetic characteristics of pharyngeal paraesthesia patients.

METHOD

To take high resolution manometry in 44 cases of pharyngeal paraesthesia patients and 23 normal subjects separately. According to the RSI score,the 44 patients were divided into group A (the group without reflux, RSI < 13, n = 25) and group B (the group with reflux, RSI ≥ 13, n = 19).

RESULT

The UES average resting pressure and average residual pressure of patients group were higher than the control group (P < 0.05); The UES average resting pressure and average residual pressure of group B were higher than group A (P < 0.05); The LES average resting pressure and average residual pressure of group B were lower than group A and the control group (P < 0.05); The comparison of LES average resting pressure and average residual pressure between group A and the control group was not statistically significant (P > 0.05). The esophagus DCI of group B was lower than that of group A and control group (P < 0.05). The esophagus DCI comparison between group A and control group was not statistically significant (P > 0.05).

CONCLUSION

The pharyngeal paresthesia symptoms of'patients was associated with the increasing of UES pressure. The pharyngeal paresthesia symptoms of group with reflux was related to low pressure of LES and high pressure of UES. The last part of esophagus of group with reflux had obstacles in powers, which weaken the peristalsis and declined the ability to clear the bolus and gastric reflux material.

Peroral endoscopic myotomy for achalasia in patients aged ≥ 65 years

AIM: To investigate the safety and efficacy of peroral endoscopic myotomy (POEM) for achalasia in patients aged ≥ 65 years.

METHODS: From November 2011 to August 2014, 15 consecutive patients (aged ≥ 65 years) diagnosed with achalasia were prospectively recruited and all underwent POEM at our institution. Eckardt score, lower esophageal sphincter (LES) pressure, esophageal diameter, SF-36 questionnaire, and procedure-related complications were used to evaluate the outcomes.

RESULTS: All 15 patients were treated successfully by POEM, with a median operation time of 55 min. Median myotomy length was 10 cm. Three patients underwent circular myotomy and 12 full-thickness myotomies. Symptoms remitted in all cases during post-POEM follow-up of 6-39 mo. Eckardt score reduced significantly (pre-operation vs post-operation: 8.0 vs 1.0, P < 0.05). Median LES pressure decreased from 27.4 to 9.6 mmHg (P < 0.05). Median diameter of the esophagus was significantly decreased (pre-operation vs post-operation: 51.0 mm vs 30.0 mm, P < 0.05). Only one patient had reflux, which was resolved with oral proton pump inhibitors. No serious complications related to POEM were found. The quality of life of the 15 patients improved significantly after POEM.

CONCLUSION: POEM is a safe and effective technique for treatment of achalasia in patients aged ≥ 65 years, with improvement in symptoms and quality of life.

Duodenocutaneous fistula in rats as a model for "wound healing-therapy" in ulcer healing: the effect of pentadecapeptide BPC 157, L-nitro-arginine methyl ester and L-arginine

While very rarely reported, duodenocutanenous fistula research might alter the duodenal ulcer disease background and therapy. Our research focused on rat duodenocutaneous fistulas, therapy, stable gastric pentadecapeptide BPC 157, an anti-ulcer peptide that healed other fistulas, nitric oxide synthase-substrate L-arginine, and nitric oxide synthase-inhibitor L-nitro-arginine methyl ester (L-NAME). The hypothesis was, duodenal ulcer-healing, like the skin ulcer, using the successful BPC 157, with nitric oxide-system involvement, the "wound healing-therapy", to heal the duodenal ulcer, the fistula-model that recently highlighted gastric and skin ulcer healing. Pressure in the lower esophageal and pyloric sphincters was simultaneously assessed. Duodenocutaneous fistula-rats received BPC 157 (10 μg/kg or 10 ng/kg, intraperitoneally or perorally (in drinking water)), L-NAME (5 mg/kg intraperitoneally), L-arginine (100 mg/kg intraperitoneally) alone and/or together, throughout 21 days. Duodenocutaneous fistula-rats maintained persistent defects, continuous fistula leakage, sphincter failure, mortality rate at 40% until the 4(th) day, all fully counteracted in all BPC 157-rats. The BPC 157-rats experienced rapidly improved complete presentation (maximal volume instilled already at 7(th) day). L-NAME further aggravated the duodenocutaneous fistula-course (mortality at 70% until the 4(th) day); L-arginine was beneficial (no mortality; however, maximal volume instilled not before 21(st) day). L-NAME-worsening was counteracted to the control level with the L-arginine effect, and vice versa, while BPC 157 annulled the L-NAME effects (L-NAME + L-arginine; L-NAME + BPC 157; L-NAME + L-arginine + BPC 157 brought below the level of the control). It is likely that duodenocutaneous fistulas, duodenal/skin defect simultaneous healing, reinstated sphincter function, are a new nitric oxide-system related phenomenon. In conclusion, resolving the duodenocutanenous fistulashealing, nitric oxide-system involvement, should illustrate further wound healing therapy to heal duodenal ulcers.

[Analyses of the characteristics of esophageal motility in patients with pharyngeal paraesthesia who visit the Department of gastroenterology]

OBJECTIVE

To investigate the influence of the local sensory abnormality in throat while the change of motility in the upper esophageal sphincter (UES) and lower esophageal sphincter (LES), as well as the change of esophageal body in pharyngeal paraesthesia.

METHODS

From January 2014 to January 2015 there were sixty-four patients who had pharyngeal susceptible syndrome (PSS) but without confirmed organic disease were enrolled as the PSS group, forty healthy volunteers as the control group. High resolution manometry (HRM) was utilized to distinguish esophageal motility patterns of PSS, including the muscular tension of LES and UES, the integrity, adaptability, amplitude, speed and duration of esophageal peristalsis at 10 swallows.

RESULTS

The resting LES and UES pressures and the distal contractile integral (DCI) of esophagus in PSS group were lower than that in control group (P < 0.05). The esophageal peristalsis was decelerated and shortened in duration, and amplitude of contraction notably lower in PSS group compared with its counterpart (P < 0.05). The integrity of esophageal peristalsis was impaired in PSS with remarkable changes in motility patterns, involving ratio of major and minor interrupts, and synchronous contraction rate (P < 0.05). As for the time course from relaxation to the lowest pressure point of UES and time for restoration, no definite difference was noticed between the two groups (P > 0.05). The average peak pressure was similar in two groups (P > 0.05).

CONCLUSIONS

Muscle tension around the UES has no obvious change when pharyngeal paraesthesia occurred, but the reduction of esophageal motor function, clearance ability, anti-reflux gastroesophageal junction, causing the abnormal reflux which hurt the pharyngeal surface mucosa maybe one of the most important reasons leading to pharyngeal paresthesia.

A Meta-Analysis of Randomized Controlled Trials to Compare Long-Term Outcomes of Nissen and Toupet Fundoplication for Gastroesophageal Reflux Disease

Aim

In recent years, several studies with large sample sizes and recent follow-up data have been published comparing outcomes between laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication. It is now timely to be re-evaluated and synthesized long-term efficacy and adverse events of both total and partial posterior fundoplication.

Materials and Methods

Electronic searches for RCTs comparing the outcome after laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication were performed in the databases of MEDLINE, EMBASE, and the Cochrane Center Register of Controlled Trials. The data of evaluation in positive and adverse results of laparoscopic Nissen fundoplication and laparoscopic Nissen fundoplication were extracted and compared using meta-analysis.

Results

13 RCTs were ultimately identified involving 814 (52.05%) and 750 (47.95%) patients who underwent laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication, respectively. The operative time, perioperative complications, postoperative satisfaction, recurrence, and the rates of medication adoption or re-operation due to recurrence were not significantly different between two groups. The two types of fundoplication both reinforced the anti-reflux barrier and elevated the lower esophageal sphincter pressure. However, rates of adverse results involving dysphasia, gas-bloat syndrome, inability to belch and re-operation due to severe dysphasia were significantly higher after LNF. In the subgroup analysis of wrap length≤2cm, laparoscopic Nissen fundoplication was associated with a significantly higher incidence of postoperative dysphagia. However, in the subgroup wrap length>2cm, the difference was not statistically significant.

Conclusion

Laparoscopic Toupet fundoplication might be the better surgery approach for gastroesophageal reflux disease with a lower rate of postoperative adverse results and equal effectiveness as Laparoscopic Nissen fundoplication.

[Paradoxical sphincters in the abdomen]

Nitric oxide molecules serve as neurotransmitters to relax smooth muscle tension in many parts of the body. In humans and other mammals they play an important role for correct smooth muscle function in unusual locations. We previously described this mechanism (Stelzner, Chirurg. doi:10.1007/s00104-014-2777-z, 2014) using the occlusive mechanism of the upper and lower esophageal sphincters as an example. Cells producing nitric oxide can be found in the gastric fundus, the anorectal continence organ, vesicourethraltract and also in the uterine cervix in the final trimester of pregnancy. In all these locations they serve as elements of anatomical sphincter structures that have a paradoxical function. These observations confirm the points made in the introduction of this article on the stretch sphincter mechanism of the lower esophageal sphincter and the treatment of gastroesophageal reflux disease by retensioning of the esophagus in the diaphragmatic hiatus. In particular, high-resolution esophageal manometry of the lower esophageal sphincter can easily detect every functional disturbance caused by gastric plication and such changes were to be expected based on what we described in articles I and II.

The disappointing performance of the new "Magnetic Sphincters": a wrong idea or a wrong realization?

.

Peroral endoscopic myotomy can improve esophageal motility in patients with achalasia from a large sample self-control research (66 patients)

Background

Peroral endoscopic myotomy (POEM) as a new approach to achalasia attracts broad attention. The primary objective of this study was to evaluate the results with esophageal motility after POEM through the first large sample clinical research.

Patients and Methods

We have a self-control research with all patients (205 in total) who underwent POEM from 2010 to 2014 at our Digestive Endoscopic Center, 66 patients of which underwent high resolution manometry (HRM) before and after POEM in our motility laboratory. Follow-ups last for 5.6 months on average. Outcome variables analyzed included upper esophageal sphincter pressure (UESP), upper esophageal sphincter residual pressure (UESRP), lower esophageal sphincter pressure (LESP), lower esophageal sphincter residual pressure (LESRP) and esophageal body peristalsis. We have a statistical analysis to illustrate how POEM impacts on the change of esophageal motility.

Results

The symptoms related to dysphagia were relieved in 95% of patients in recent term after POEM. While HRM showed a statistically significant reduction of URSRP, LESP and LESRP (P<0.01), however, peristalsis was not consistently affected. There were 11 patients who had undergone other prior endoscopic treatment (endoscopic dilation or botulinum toxin injection) and 55 patients had not. The statistical difference (P>0.05) did not occur for these two groups on LESP and LESRP reduction.

Conclusions

POEM clearly relieved the symptoms related to dysphagia by lowering the pressure of upper esophageal sphincter (UES) and lower esophageal sphincter (LES),and other endoscopic treatment before POEM did not affect the improvement of LES pressure. These results are concluded from our short-term follow-up study, while the long-term efficacy remains to be further illustrated.

Trial Registration

Chinese Clinical Trial Register ChiCTR-TRC-12002204)

Achalasia: a systematic review

IMPORTANCE

Achalasia significantly affects patients' quality of life and can be difficult to diagnose and treat.

OBJECTIVE

To review the diagnosis and management of achalasia, with a focus on phenotypic classification pertinent to therapeutic outcomes.

EVIDENCE REVIEW

Literature review and MEDLINE search of articles from January 2004 to February 2015. A total of 93 articles were included in the final literature review addressing facets of achalasia epidemiology, pathophysiology, diagnosis, treatment, and outcomes. Nine randomized controlled trials focusing on endoscopic or surgical therapy for achalasia were included (734 total patients).

FINDINGS

A diagnosis of achalasia should be considered when patients present with dysphagia, chest pain, and refractory reflux symptoms after an endoscopy does not reveal a mechanical obstruction or an inflammatory cause of esophageal symptoms. Manometry should be performed if achalasia is suspected. Randomized controlled trials support treatments focused on disrupting the lower esophageal sphincter with pneumatic dilation (70%-90% effective) or laparoscopic myotomy (88%-95% effective). Patients with achalasia have a variable prognosis after endoscopic or surgical myotomy based on subtypes, with type II (absent peristalsis with abnormal pan-esophageal high-pressure patterns) having a very favorable outcome (96%) and type I (absent peristalsis without abnormal pressure) having an intermediate prognosis (81%) that is inversely associated with the degree of esophageal dilatation. In contrast, type III (absent peristalsis with distal esophageal spastic contractions) is a spastic variant with less favorable outcomes (66%) after treatment of the lower esophageal sphincter.

CONCLUSIONS AND RELEVANCE

Achalasia should be considered when dysphagia is present and not explained by an obstruction or inflammatory process. Responses to treatment vary based on which achalasia subtype is present.

High-resolution manometry findings in patients with an intrathoracic stomach

Intrathoracic stomach is a rare finding. The real value of the high-resolution manometry (HRM) in the preoperative evaluation of these patients has not yet being fully tested. This study aims to evaluate: 1) the HRM pattern of patients with an intrathoracic stomach; and 2) HRM findings as predictors for prosthetic reinforcement of the hiatus. We reviewed 33 patients (27 women, mean age 66 years) with an intrathoracic stomach who underwent HRM. Fifteen patients did the HRM as part of preoperative workup and were operated on in our institution. All patients were submitted to a laparoscopic Nissen fundoplication. HRM results show that the lower esophageal sphincter (LES) was transposed in all patients. Hiatal hernia was diagnosed in 21 (63%) patients. The length of the hernia was 4 ± 2 cm (range, 1 to 9 cm). LES oscillation was observed in 23 (69%) patients with a mean of 1 ± 0.4 cm (range, 0.4 to 2 cm). Hiatal mesh reinforcement was necessary in five (33%) of the operated patients. HRM findings did not predict hiatal mesh reinforcement. Our results show that: 1) HRM has a poor sensibility for hiatal hernia diagnosis; 2) half of the patients with an intrathoracic stomach have a normal HRM; and 3) HRM does not predict mesh hiatal hernia repair.

Multiple good options are available for achalasia management

BACKGROUND

The aim of achalasia management is relieving functional obstruction at the esophagogastric junction. Pneumatic dilation (PD), Heller myotomy (HM), and Botox (BT) are available for this purpose. Many studies have compared efficacy of one treatment regimen to another however, many patients with achalasia undergo combinations of different procedures.

AIM

: The aim of this study was to follow-up achalasia patients treated at a tertiary referral center over a 10-year period and to compare patient satisfaction and symptoms in patients who were treated with either a single treatment (ST) versus multiple treatments (MT).

METHODS

A cohort of achalasia patients treated at the Medical University of South Carolina between 2002 and 2012 were identified, contacted by telephone, and completed a questionnaire about their treatments and symptoms. Symptomatic response was classified using the Eckardt score, and overall patient satisfaction was determined on a scale from 1 to 10. Data were analyzed using a paired Student t test.

RESULTS

Data were collected from 57 patients and 3 patients were excluded from the study because they had no prior interventions for achalasia. Demographic analysis of the patients revealed a mean age of 62.7 years (range, 24 to 89 y) with 45% males and 55% females. The average elapsed time since the last definitive treatment was 2.82 years. Twenty-eight patients had an ST performed and 26 patients underwent MT. The average number of different interventions in the MT group was 3 procedures/patient. There were no significant differences in overall patient satisfaction (ST, 7.5 vs. MT, 8; P=0.66) and the Eckardt scores between the 2 groups (ST, 3.39 vs. MT, 3.3; P=0.77).

CONCLUSIONS

MT options are available for management of achalasia. Improvement of clinical symptoms and overall patient satisfaction does not differ if the patient underwent an ST modality or a combination of different treatments.

Increased inspiratory esophagogastric junction pressure in systemic sclerosis: An add-on to antireflux barrier

AIM: To investigate crural diaphragm (CD) function in systemic sclerosis (SSc) using high-resolution manometry and standardized inspiratory maneuvers.

METHODS: Eight SSc volunteers (average age, 40.1 years; one male) and 13 controls (average age, 32.2 years; six males) participated in the study. A high-resolution manometry/impedance system measured the esophagus and esophagogastric junction (EGJ) pressure profile during swallows and two respiratory maneuvers: sinus arrhythmia maneuver (SAM; the average of six EGJ peak pressures during 5-s deep inhalations) and threshold maneuver (TM; the EGJ peak pressures during forced inhalation under 12 and 24 cmH₂O loads). Inspiratory diaphragm lowering (IDL) was taken as the displacement of the EGJ high-pressure zone during the SAM.

RESULTS: SSc patients had lower mean lower esophageal sphincter pressure than controls during normal breathing (19.7 ± 2.8 mmHg vs 32.2 ± 2.7 mmHg, P = 0.007). Sinus arrhythmia maneuver pressure was higher in SSc patients than in controls (142.6 ± 9.4 mmHg vs 104.6 ± 13.8 mmHg, P = 0.019). Sinus arrhythmia maneuver pressure normalized to IDL was also higher in SSc patients than in controls (83.8 ± 13.4 mmHg vs 37.5 ± 6.9 mmHg, P = 0.005). Threshold maneuver pressures normalized to IDL were also greater in SSc patients than in controls (TM 12 cmH₂O: 85.1 ± 16.4 mmHg vs 43.9 ± 6.3 mmHg, P = 0.039; TM 24 cmH₂O: 85.2 ± 16.4 mmHg vs 46.2 ± 6.6 mmHg, P = 0.065). Inspiratory diaphragm lowering in SSc patients was less than in controls (2.1 ± 0.3 cm vs 3 ± 0.2 cm, P = 0.011).

CONCLUSION: SSc patients had increased inspiratory EGJ pressure. This is an add-on to EGJ pressure and indicates that the antireflux barrier can be trained.

Gastroesophageal reflux disease-related symptom assessment in subjects with malignant dysphagia receiving esophageal stents

Concerns remain over the ability to stent across of the lower esophageal sphincter (LES) for esophageal adenocarcinoma and the effects of gastroesophageal (GE) reflux. Thus, the aim of this study was to demonstrate minimal quality-of-life (QOL) side effects in patients undergoing esophageal stenting across the LES. An Institutional Review Board-approved prospective clinical trial evaluated the results of the Gastrointestinal Symptom questionnaire that includes a validated GE reflux disease (GERD) assessment (GERD-HRQL) and a dysphagia assessment. Consecutive patients were enrolled in this clinical trial, with 81 per cent male, 19 per cent female, median age of 62 years, with adenocarcinoma of the GE junction as their diagnosis. The median dysphagia score was 3 (only liquids can be tolerated) prestent and was improved to a median score of 0 (ability to eat all foods) poststent (P = 0.01). The median GERD score was 0 (none) prestent and did not change with a median score of 0 (none) poststent (P = 0.2). All GERD-related questions were unchanged prestent and poststent in all categories, specifically: frequency of GERD, time of day of reflux, pain behind breastbone, and pain medications. There was also no difference in regurgitation frequency (median prestent 1 vs poststent 0, P = 0.08), texture (prestent 2 [semisolid] vs poststent 1 [liquid]). There was only a statistical change in the ability to belch (prestent 0 [no ability] to poststent 1 [ability]), P = 0.02) and the ability to vomit. Esophageal stenting across the GE junction for dysphagia relief in esophageal malignancies does not adversely effect a patient's QOL in regard to reflux-related symptoms.

[Reflux and hiatus hernia in the controversy between conservative and operative therapy]

Approximately 20 % of the population are affected by gastroesophageal reflux disease (GERD). The subjective clinical and objective pathological extent of the disease is highly variable and the underlying pathophysiological mechanisms extraordinarily diverse. The importance of hiatus hernia for GERD has been intensively debated for decades. Hiatus hernia was initially considered to be at the center of the pathophysiology but later the function of the lower esophageal sphincter was increasingly considered to be of importance. Currently, additional relevant pathophysiological cofactors are being detected with the continuous improvement in diagnostic methods and used for therapeutic decision-making. Despite standardization of the operative technique and increasing criticism on long-term proton pump inhibitor (PPI) therapy, antireflux surgery still requires a very critical assessment of indications based on a comprehensive diagnostic evaluation.

Diagnosis and treatment of achalasia patients: a ten-year review of the clinical features

BACKGROUND/AIMS

To study the clinical features, the diagnosis and treatment efficacy with pneumatic balloon dilatation in patients with achalasia in a teaching hospital in Eastern Saudi Arabia.

METHODOLOGY

Clinical records of patients with the diagnosis of achalasia during the period from 2001 to 2012 were reviewed. Their presentation, radiologic, monometric and endoscopic findings as well as treatment outcome with pneumatic dilatation were reviewed. RESULTS Results: Thirty-one new patients were diagnosed with achalasia during the study period. The mean age at the diagnosis was 36 years, ranging from 14 to 85 years of age. Male to female ratio was 1.4: 1.7. Five patients while waiting received 20mg of long acting calcium channel blockers (Nifedipine) for four months without any impressive result and asked for pneumatic dilation. Pneumatic dilation in one-year follow-up revealed 91% satisfaction and long term follow-up of 5 to 10 years showed 83% satisfaction of patients. During procedure and follow-up, no significant complication was noted. CONCLUSIONSAchalasia effects all ages in both sexes. Graded Pneumatic Balloon Dilation (PBD) is a safe and effective form of symptomatic treatment of achalasia without significant complication in the hands of experts.

Stretta: A valuable endoscopic treatment modality for gastroesophageal reflux disease

One potential option for the management of refractory gastro-esophageal reflux disease (GERD) is the delivery of radiofrequency energy to the gastro-esophageal junction (Stretta). This endoscopic therapy is safe, effective, durable, and repeatable if necessary and serves an unmet need for many GERD sufferers. Stretta could be effective in decreasing esophageal sensitivity to acid and in decreasing the gastro-esophageal junction compliance, which in turn contributes to symptomatic benefit by decreasing refluxate volume. Therefore, Stretta may serve as an endoscopic pain modulator and should be considered in patients with refractory symptoms despite proton pump inhibitors, as well as in patients with functional heartburn.

Impedance-high resolution manometry analysis of patients with nonerosive reflux disease

BACKGROUND & AIMS

Transient lower esophageal sphincter relaxations (TLESRs) contribute to episodes of reflux. Few studies have assessed the frequencies or compositions of TLESRs and reflux episodes in patients with reflux disease. We used combined high-resolution manometry and impedance monitoring to analyze reflux episodes and esophageal motility in these patients, compared with those of healthy individuals.

METHODS

We evaluated the frequency of TLESRs and the relationship between the reflux pattern and esophageal pressures during TLESRs in 14 patients with nonerosive reflux disease (NERD) and 11 controls. Study participants underwent combined high-resolution manometry and impedance monitoring before and 60 minutes after a solid and liquid meal. The diagnosis of NERD was confirmed by a 24-hour pH impedance test.

RESULTS

The frequency of TLESRs did not differ between patients with NERD and controls. In patients with NERD, TLESRs were associated more often with reflux episodes than in controls (93% ± 6% vs 66% ± 19%; P < .05). Patients with NERD had a higher percentage of pure liquid reflux episodes (33% ± 15% vs 10% ± 2%; P < .05), whereas controls had a higher percentage of mixed reflux episodes (45% ± 16% vs 67% ± 17% in patients with NERD; P < .05). Patients with NERD also had a higher percentage of reflux (liquid and mixed) associated with common cavities (74% ± 18% vs 50% ± 20% in controls; P < .05).

CONCLUSIONS

In contrast to previous studies, we found that TLESRs are associated more often with reflux in patients with NERD than control subjects; this association increases when only liquid and mixed refluxes are considered. These findings indicate that factors involved in the occurrence of reflux in patients with NERD during TLESRs are different from those in healthy subjects.

[Gastroesophageal reflux disease and connective tissue dysplasia in aspect of premorbid and comorbid disorders]

AIM

To investigate the phenotypic and visceral signs of connective tissue dysplasia (CTD) and comorbid diseases of the digestive system in gastroesophageal reflux disease (GERD) patients with different types of esophageal reflux as the predictors of its variants.

MATERIAL AND METHODS

In 124 patients with GERD the clinical features, phenotypic and visceral signs of undifferentiated CTD were studied in details.

RESULTS

In 82.0% of patients with GERD associated with gastroesophageal type of reflux (GER) phenotypic and especially visceral signs of STD were detected, mainly in the form of cardiochalasia and hiatal hernia. In patients with duodenogastroesophageal reflux symptoms (DGER) the signs of STD were marked in 42.0% of cases, mostly in the form of biliary tract structure abnormalities. The risk of GERD associated with prevalence of GER, was 11.9 times higher in the presence of diagnostically meaningful combination of 6 or more signs of STD than in patients with DGER. Realization of predictor options in GER occurs in the preference of sharp, acidic foods, spices, taking medications that reduce lower esophageal sphincter tone. GERD, associated with DGER, is formed in patients with family history of diseases of the biliary tract and in the preference of food rich of calories.

CONCLUSION

Study of STD symptoms as predictors of structural development of GERD and its variants is prospective to predict disease, choice of profession and eating behavior, primarily in young adults.