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Hugova K, Mares J, Hakanson B, Repici A, von Rahden BHA, Bredenoord AJ, Bisschops R, Messmann H, Ruppenthal T, Mann O, Izbicki J, Harustiak T, Fumagalli Romario U, Rosati R, Germer CT, Schijven M, Emmermann A, von Renteln D, Dautel S, Fockens P, Boeckxstaens G, Rösch T, Martinek J, Werner YB. Per-oral endoscopic myotomy versus laparoscopic Heller's myotomy plus Dor fundoplication in patients with idiopathic achalasia: 5-year follow-up of a multicentre, randomised, open-label, non-inferiority trial. Lancet Gastroenterol Hepatol 2025:S2468-1253(25)00012-3. [PMID: 40112837 DOI: 10.1016/s2468-1253(25)00012-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2024] [Revised: 01/15/2025] [Accepted: 01/16/2025] [Indexed: 03/22/2025]
Abstract
BACKGROUND In this trial, we previously showed per-oral endoscopic myotomy (POEM) to be non-inferior to laparoscopic Heller's myotomy (LHM) plus Dor fundoplication in managing symptoms in patients with idiopathic achalasia 2 years post-procedure. However, post-procedural gastro-oesophageal reflux was more common after POEM at 2 years. Here we report 5-year follow-up data. METHODS This study is a multicentre, randomised, open-label, non-inferiority trial performed at eight centres in six European countries (Germany, Italy, Czech Republic, Sweden, the Netherlands, and Belgium). Patients with symptomatic primary achalasia were eligible for inclusion if they were older than 18 years and had an Eckardt symptom score higher than 3. Patients were randomly assigned (1:1; randomly permuted blocks of sizes 4, 8, or 12) to undergo either POEM or LHM plus Dor fundoplication. The primary endpoint was clinical success, defined by an Eckardt symptom score of 3 or less without the use of additional treatments, at 2 years, and was reported previously. Prespecified secondary endpoints at 5 years were clinical success; Eckardt symptom score; Gastrointestinal Quality of Life Index score; lower oesophageal sphincter function by high-resolution manometry; and parameters of post-procedural reflux (reflux oesophagitis according to the Los Angeles classification; pH-metry, and DeMeester clinical score). We hypothesised that POEM would be non-inferior (with a non-inferiority margin of -12·5 percentage points) to LHM plus Dor fundoplication with regards to clinical success. All analyses were performed on a modified intention-to-treat (mITT) population, which included all patients who underwent the assigned procedure. This study is registered with ClinicalTrials.gov (NCT01601678) and is complete. FINDINGS Between Dec 7, 2012, and Oct 9, 2015, 241 patients were randomly assigned (120 to POEM and 121 to LHM) and 221 had the assigned treatment (112 POEM and 109 LHM; mITT). 5-year follow up data were available for 90 (80%) patients in the POEM group and 87 (80%) patients in the LHM group. Clinical success rate at 5 years was 75·0% (95% CI 66·2 to 82·1) after POEM and 70·8% (61·7 to 78·5) after LHM (difference 4·2 percentage points [95% CI -7·4 to 15·7]). The mean Eckardt symptom score decreased from baseline to 5 years in both groups and the overall difference in mean scores was -0·29 (95% CI -0·62 to 0·05). Change in Gastrointestinal Quality of Life Index scores, as well as in integrated relaxation pressure on manometry, from baseline to 5 years, did not differ significantly between the groups. At 5 years, 26 (41%) of 63 patients after POEM and 18 (31%) of 58 patients after LHM had reflux oesophagitis (difference 10·2 percentage points [95% CI -7·0 to 26·8]). Significant oesophagitis (Los Angeles classification grade B, C, or D) was observed in nine (14%) of 63 patients after POEM and in four (7%) of 58 patients after LHM. pH-metry was performed in 81 (37%) of 221 patients, with higher mean acid exposure time for POEM (10·2% [95% CI 7·6 to 14·2]) than for LHM (5·5% [3·1 to 11·8]). Significantly more patients in the POEM than in the LHM group had abnormal acid exposure time at 5 years (>4·5%; 28 [62%] of 45 vs 11 [31%] of 36; difference 31·7 percentage points [95% CI 9·8 to 50·5]). The presence of reflux symptoms at 5 years was similar in both groups, with a mean DeMeester clinical score of 1·3 (95% CI 1·0 to 1·6) after POEM and 1·1 (0·9 to 1·4) after LHM. The complications of peptic stricture, Barrett's oesophagus, and oesophageal adenocarcinoma were not reported. INTERPRETATION Our long-term results support the role of POEM as a less invasive myotomy approach that is non-inferior to LHM in controlling symptoms of achalasia. Gastro-oesophageal reflux was common in both groups, but with a tendency towards higher rates in the POEM group. Thus, patients should be provided with the advantages and disadvantages of each approach in decision making. FUNDING European Clinical Research Infrastructure Network, Hamburgische Stiftung für Wissenschaften, Entwicklung und Kultur Helmut und Hannelore Greve, Dr med Carl-August Skröder Stiftung, Dr Gerhard Büchtemann Stiftung, Agnes-Graefe Stiftung, Georg und Jürgen Rickertsen Stiftung, Reinhard Frank Stiftung, Johann Max Böttcher Stiftung, Richard und Annemarie Wolf Stiftung, Olympus Europa, German Society for Gastroenterology and Metabolism and Olympus Europe Foundation, United European Gastroenterology Week, Olympus EuroNOTES Research Fund Program, Harvard Catalyst, the Harvard Clinical and Translational Science Center, and Harvard University and its affiliated academic health-care centres.
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Affiliation(s)
- Kristina Hugova
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Institute of Physiology First Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Jan Mares
- Department of Data Science, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Bengt Hakanson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - Alessandro Repici
- Department of Gastroenterology, Istituto Clinico Humanitas Rozzano, Milan, Italy
| | | | - Albert J Bredenoord
- Department of Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium; Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Tania Ruppenthal
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver Mann
- Department of General, Visceral, and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob Izbicki
- Department of General, Visceral, and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tomas Harustiak
- Third Department of Surgery First Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | | | - Riccardo Rosati
- Department of Digestive Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Marlies Schijven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Department of Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Public Health, Digital Health, Amsterdam, Netherlands
| | - Alice Emmermann
- Department of Surgery, Israelitic Hospital Hamburg, Hamburg, Germany
| | - Daniel von Renteln
- Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal, QC, Canada
| | - Sarah Dautel
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Paul Fockens
- Department of Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Guy Boeckxstaens
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium; Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Martinek
- Institute of Physiology First Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Gastroenterology and Hepatology, St Anne's University Hospital Brno, Brno, Czech Republic
| | - Yuki B Werner
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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Lande L, Whealon S, Singer E, Greenspon LW, Rains E, Kwait R, Buckley M, Peng W, Sawicki J, Falkinham JO, Williams MD, Peterson DD. Bronchoscopic detection of aspiration in patients with bronchiectasis and Mycobacterium avium complex pulmonary infection. Respir Med Res 2025; 87:101166. [PMID: 40121826 DOI: 10.1016/j.resmer.2025.101166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 02/05/2025] [Accepted: 03/07/2025] [Indexed: 03/25/2025]
Abstract
RATIONALE To investigate whether gastroesophageal reflux with laryngopharyngeal reflux and aspiration play a role in the pathogenesis of bronchiectasis and Mycobacterium avium complex (MAC) pulmonary infection. METHODS In this prospective case-control study, subjects included 31 patients with bronchiectasis undergoing bronchoscopy to investigate suspected MAC infection and 9 control subjects undergoing bronchoscopy for alternative reasons. Patients drank 45 mL of FD&C Blue #1 mixed with 200 mL of tap water the night prior to bronchoscopy. During bronchoscopy, the bronchial mucosa was inspected for the presence of blue dye staining. Bronchoalveolar lavage (BAL) samples were obtained from the most affected segments on CT scan and were cultured for mycobacteria and assayed for pepsin and bile acids. Gastric aspirate samples were obtained for mycobacterial culture. RESULTS 93.8% of patients with confirmed pulmonary MAC infection and 91.7% of patients with evidence of bronchiectasis by CT scan, but negative mycobacterial cultures, had blue dye staining of the bronchial mucosa vs. 11.3% of control patients (p < 0.001). Areas of abnormality on CT correlated with airways demonstrating blue staining by bronchoscopy in 100% of MAC patients and 90.9% of patients with bronchiectasis and negative mycobacterial cultures. MAC patients had higher median BAL pepsin levels compared to combined MAC negative patients (subjects with bronchiectasis and negative mycobacterial cultures and true controls), 5.4 ng/mL vs. 3.4 ng/mL (p = 0.019). 78.6% of MAC patients vs. 26.3% of combined MAC negative patients had BAL bile acid concentrations of >/= 0.493 uM (p = 0.005). There was no significant difference in age, supraglottic index, reflux symptoms, gastric pH, or proton pump inhibitor use between the MAC positive vs. MAC negative patients. 42.8% of patients with growth of MAC on BAL also had growth of MAC in the gastric aspirate. CONCLUSIONS Reflux and aspiration of gastric contents into the airways show a strong association with bronchiectasis and may be associated with MAC pulmonary disease. The novel method introduced in this study of drinking blue dye the evening prior to bronchoscopy should be utilized in the evaluation of infectious and inflammatory lung diseases in which aspiration may play a role.
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Affiliation(s)
- Leah Lande
- Division of Pulmonary and Critical Care Medicine, Lankenau Medical Center, Wynnewood, USA.; Lankenau Institute for Medical Research, Wynnewood, USA..
| | - Spencer Whealon
- Division of Pulmonary and Critical Care Medicine, Lankenau Medical Center, Wynnewood, USA
| | - Eden Singer
- Division of Pulmonary and Critical Care Medicine, Lankenau Medical Center, Wynnewood, USA
| | - Lee W Greenspon
- Division of Pulmonary and Critical Care Medicine, Lankenau Medical Center, Wynnewood, USA
| | - Erin Rains
- Division of Pulmonary and Critical Care Medicine, Lankenau Medical Center, Wynnewood, USA
| | - Rebecca Kwait
- Division of Pulmonary and Critical Care Medicine, Lankenau Medical Center, Wynnewood, USA
| | | | - Weidan Peng
- Lankenau Institute for Medical Research, Wynnewood, USA
| | - Janet Sawicki
- Lankenau Institute for Medical Research, Wynnewood, USA
| | | | - Myra D Williams
- Department of Biological Sciences, Virginia Tech, Blacksburg, USA
| | - Donald D Peterson
- Division of Pulmonary and Critical Care Medicine, Lankenau Medical Center, Wynnewood, USA
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He Z, Wu J, He Z, Chen J, Fang W, Zhang Y, Shen X, Ren Y, Chen Y, He J, Yan D, Chen P, Zhou M. A Paper-Based Sensor for the Detection of Gastroesophageal Reflux Disease Utilizing a Cleavable Fluorescent Polymer. Adv Healthc Mater 2025; 14:e2402919. [PMID: 39823160 DOI: 10.1002/adhm.202402919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Revised: 11/27/2024] [Indexed: 01/19/2025]
Abstract
Nowadays, gastroesophageal reflux disease (GERD) has emerged as one of the major hazards to the health of the upper gastrointestinal tract, and there is an urgent need for a low-cost, user-friendly, and non-invasive detection method. Herein, a paper-based sensor (CP sensor) for the non-invasive screening of GERD is proposed. The sensor is structured as a specially shaped cellulose paper strip embedded with fluorescent colloids, which are self-assembled from a cleavable synthetic fluorescent polymer (P4). Benefiting from the introduction of amide bonds and the unique assembled structure of the nanocolloids, the pepsin in the sample solution will hydrolyze the water-soluble branches in the micellar shell during detection, resulting in a corresponding output of the fluorescent signal. This responsiveness, which can be observed by the naked eye, is so sensitive with a minimum detectable concentration for pepsin as low as 0.3 ng·mL-1. Clinical trials have further demonstrates that the designed paper sensor is capable of providing improved accuracy in the early diagnosis of GERD.
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Affiliation(s)
- Zejian He
- College of Materials Science and Engineering, Zhejiang University of Technology, Hangzhou, 310014, P. R. China
- Stoddart Institute of Molecular Science, Department of Chemistry, Zhejiang University, Hangzhou, 310058, P. R. China
- Zhejiang-Israel Joint Laboratory of Self-Assembling Functional Materials, ZJU-Hangzhou Global Scientific and Technological Innovation Center, Zhejiang University, Hangzhou, 311215, P. R. China
| | - Jun Wu
- Department of Otolaryngology, The Fourth Affiliated Hospital Zhejiang University School of Medicine, Yiwu, 322000, P. R. China
| | - Zhen He
- College of Materials Science and Engineering, Zhejiang University of Technology, Hangzhou, 310014, P. R. China
| | - Jia Chen
- Otolaryngology Department, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, 310009, P. R. China
| | - Weipin Fang
- Department of Gastroenterology, The First People's Hospital of Jiande, Hangzhou, 311600, P. R. China
| | - Yifan Zhang
- College of Materials Science and Engineering, Zhejiang University of Technology, Hangzhou, 310014, P. R. China
| | - Xinyi Shen
- College of Materials Science and Engineering, Zhejiang University of Technology, Hangzhou, 310014, P. R. China
| | - Yangjing Ren
- College of Materials Science and Engineering, Zhejiang University of Technology, Hangzhou, 310014, P. R. China
| | - Yulong Chen
- College of Materials Science and Engineering, Zhejiang University of Technology, Hangzhou, 310014, P. R. China
| | - Jianguo He
- Otolaryngology Department, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, 310009, P. R. China
| | - Donghai Yan
- Department of Gastroenterology, The First People's Hospital of Jiande, Hangzhou, 311600, P. R. China
| | - Pin Chen
- Department of Clinical Laboratory, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, 310006, P. R. China
| | - Mi Zhou
- College of Materials Science and Engineering, Zhejiang University of Technology, Hangzhou, 310014, P. R. China
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Gyawali CP, Marchetti L, Rogers BD, Chan WW, Wong MW, Visaggi P, Rengarajan A, Carlson DA, Savarino E, de Bortoli N, Chen CL, Pandolfino J. The Lyon Score: A Novel Reflux Scoring System Based on the Lyon Consensus 2.0 That Associates With Treatment Outcome From Antireflux Therapy. Am J Gastroenterol 2024:00000434-990000000-01332. [PMID: 39297514 PMCID: PMC11919791 DOI: 10.14309/ajg.0000000000003083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 09/13/2024] [Indexed: 10/25/2024]
Abstract
INTRODUCTION We explored if a score derived from parameters from esophageal testing could increase confidence in diagnosing conclusive gastroesophageal reflux disease and in predicting outcome. METHODS A prediction score was developed using metrics based on Lyon Consensus 2.0 thresholds extracted from endoscopy and pH-impedance monitoring. The Lyon score was the sum of weighted scores derived from a logistic regression model. The outcome was response to antireflux therapy, defined as 50% reduction in global symptoms on validated questionnaires. An existing database of endoscopy-negative patients with typical reflux symptoms undergoing esophageal testing from 2 centers (Europe and the United States) constituted the developmental cohort, while 2 separate cohorts (Europe and Asia) served as validation cohorts. Receiver operating characteristics analysis determined performance of the Lyon score in predicting treatment response. RESULTS In 281 developmental cohort patients (median age 53 years, 57.7% female), the Lyon score demonstrated an area under the curve (AUC) of 0.819 in predicting 50% symptom improvement ( P < 0.001) on receiver operating characteristics, with an optimal threshold of 6.25 (sensitivity 81.2%, specificity 73.4%). Of the individual components, only acid exposure time (AUC 0.799, P < 0.001), mean nocturnal baseline impedance (AUC 0.785, P < 0.001), and reflux episodes (AUC 0.764, P < 0.001) approached the Lyon score performance. The Lyon score segregated treatment response in both the European (AUC 0.908, P < 0.001) and Asian validation cohorts (AUC 0.637, P < 0.001) and outperformed the DeMeester score in sensitivity for predicting outcome in the developmental and Asian validation cohorts. DISCUSSION The novel Lyon score segregates reflux phenotypes and identifies likelihood of symptom response from antireflux therapy.
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Affiliation(s)
- C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lorenzo Marchetti
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Digestive Diseases, Campus Bio Medico University of Rome, Rome, Italy
| | - Benjamin D Rogers
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ming-Wun Wong
- Department of Medicine, Division of Gastroenterology and Hepatology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Pierfrancesco Visaggi
- Department of Translational Research and New Technologies in Medicine and Surgery, Division of Gastroenterology, University of Pisa, Pisa, Italy
| | - Arvind Rengarajan
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Dustin A Carlson
- Kenneth C. Griffin Esophageal Center, Northwestern Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Nicola de Bortoli
- Department of Translational Research and New Technologies in Medicine and Surgery, Division of Gastroenterology, University of Pisa, Pisa, Italy
| | - Chien-Lin Chen
- Department of Medicine, Division of Gastroenterology and Hepatology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - John Pandolfino
- Kenneth C. Griffin Esophageal Center, Northwestern Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Fuchs KH, Kafetzis I, Hann A, Meining A. Hiatal Hernias Revisited-A Systematic Review of Definitions, Classifications, and Applications. Life (Basel) 2024; 14:1145. [PMID: 39337928 PMCID: PMC11433396 DOI: 10.3390/life14091145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 08/15/2024] [Accepted: 08/19/2024] [Indexed: 09/30/2024] Open
Abstract
INTRODUCTION A hiatal hernia (HH) can be defined as a condition in which elements from the abdominal cavity herniate through the oesophageal hiatus in the mediastinum and, in the majority of cases, parts of the proximal stomach. Today, the role of HHs within the complex entity of gastroesophageal reflux disease (GERD) is very important with regard to its pathophysiology, severity, and therapeutic and prognostic options. Despite this, the application and stringent use of the worldwide accepted classification (Skinner and Belsey: Types I-IV) are lacking. The aim of this study was to carry out a systematic review of the clinical applications of HH classifications and scientific documentation over time, considering their value in diagnosis and treatment. METHODS Following the PRISMA concept, all abstracts published on pubmed.gov until 12/2023 (hiatal hernia) were reviewed, and those with a focus and clear description of the application of the current HH classification in the full-text version were analysed to determine the level of classification and its use within the therapeutic context. RESULTS In total, 9342 abstracts were screened. In 9199 of the abstracts, the reports had a different focus than HH, or the HH classification was not used or was incompletely applied. After further investigation, 60 papers were used for a detailed analysis, which included more than 12,000 patient datapoints. Among the 8904 patients, 83% had a Type I HH; 4% had Type II; 11% had Type III; and 1% had Type IV. Further subgroup analyses were performed. Overall, the precise application of the HH classification has been insufficient, considering that only 1% of all papers and only 54% of those with a special focus on HH have documented its use. CONCLUSIONS The application and documentation of a precise HH classification in clinical practice and scientific reports are decreasing, which should be rectified for the purpose of scientific comparability.
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Affiliation(s)
- Karl Hermann Fuchs
- Laboratory for Interventional and Experimental Endoscopy (InExEn), University of Würzburg, Grombühlstr. 12, 97080 Würzburg, Germany
| | - Ioannis Kafetzis
- Laboratory for Interventional and Experimental Endoscopy (InExEn), University of Würzburg, Grombühlstr. 12, 97080 Würzburg, Germany
| | - Alexander Hann
- Laboratory for Interventional and Experimental Endoscopy (InExEn), University of Würzburg, Grombühlstr. 12, 97080 Würzburg, Germany
- Head of Gastroenterology, Zentrum Innere Medizin, University of Würzburg, 97080 Würzburg, Germany
| | - Alexander Meining
- Laboratory for Interventional and Experimental Endoscopy (InExEn), University of Würzburg, Grombühlstr. 12, 97080 Würzburg, Germany
- Head of Gastroenterology, Zentrum Innere Medizin, University of Würzburg, 97080 Würzburg, Germany
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Singh AP, Singla N, Budhwani E, Januszewicz W, Memon SF, Inavolu P, Nabi Z, Jagtap N, Kalapala R, Lakhtakia S, Darisetty S, Reddy DN, Ramchandani M. Defining "true acid reflux" after peroral endoscopic myotomy for achalasia: a prospective cohort study. Gastrointest Endosc 2024; 99:166-173.e3. [PMID: 37598862 DOI: 10.1016/j.gie.2023.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND AND AIMS The symptoms of reflux in achalasia patients undergoing peroral endoscopic myotomy (POEM) are believed to result from gastroesophageal reflux, and the current treatment primarily focuses on acid suppression. Nevertheless, other factors such as nonreflux acidification caused by fermentation or stasis might play a role. This study aimed to identify patients with "true acid reflux" who actually require acid suppression and fundoplication. METHODS In this prospective large cohort study, the primary objective was to assess the incidence and risk factors for true acid reflux in achalasia patients undergoing POEM. Acid reflux with normal and delayed clearance defined true acid reflux, whereas other patterns were labeled as nonreflux acidification patterns on manual analysis of pH tracings. These findings were corroborated with a symptom questionnaire, esophagogastroscopy, esophageal manometry, and timed barium esophagogram at 3 months after the POEM procedure. RESULTS Fifty-four achalasia patients aged 18 to 80 years (mean age, 41.1 ± 12.8 years; 59.3% men; 90.7% with type II achalasia) underwent POEM, which resulted in a significant mean Eckardt score improvement (6.7 to 1.6, P < .05). True acid reflux was noted in 29.6% of patients as compared with 64.8% on automated analysis. Acid fermentation was the predominant acidification pattern seen in 42.7% of patients. On multivariable logistic regression analysis, increasing age (odds ratio, 1.12; 95% confidence interval, 1.02-1.27; P = .04) and preprocedural integrated relaxation pressure (IRP; odds ratio, 1.13; 95% confidence interval, 1.04-1.30; P = .02) were significantly associated with true acid reflux in patients after undergoing POEM. CONCLUSIONS A manual review of pH tracings helps to identify true acid reflux in patients with achalasia after undergoing POEM. Preprocedural IRP can be a predictive factor in determining patients at risk for this outcome. (Clinical trial registration number: NCT04951739.).
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Affiliation(s)
| | - Neeraj Singla
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Ekant Budhwani
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Wladyslaw Januszewicz
- Department of Gastroenterology, Hepatology and Clinical Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Sana Fatima Memon
- Department of Medical Gastroenterology AIG Hospitals, Hyderabad, India
| | - Pradev Inavolu
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Zaheer Nabi
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Nitin Jagtap
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Rakesh Kalapala
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | - Sundeep Lakhtakia
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
| | | | | | - Mohan Ramchandani
- Department of Medical Gastroenterology, AIG Hospitals, Hyderabad, India
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Brand D, Pomenti S, Katzka DA. Roles of swallowing and belching in different phenotypes of gastroesophageal reflux disease. Neurogastroenterol Motil 2024; 36:e14703. [PMID: 37942686 DOI: 10.1111/nmo.14703] [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: 07/18/2023] [Revised: 10/14/2023] [Accepted: 10/24/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND The contributions of swallowing and belching to specific gastroesophageal reflux disease (GERD) phenotypes are unclear. METHODS This study retrospectively analyzed esophageal pH/impedance studies, comparing reflux events preceded by gastric belching (GB), supragastric belching (SGB), air swallowing, and liquid/solid swallowing based on reflux position, lower esophageal sphincter (LES) pressure, and acid exposure time (AET). KEY RESULTS 20 GERD patients and 10 controls were studied. Upright GERD patients and controls had a higher proportion of reflux events with a preceding swallow or belch (0.64, 0.64) than the supine group (0.38, p = 0.043). The upright group and controls trended toward a higher proportion of reflux events preceded by overall swallowing (0.61, 0.50) and air swallowing (0.55, 0.48) than the supine group (0.32, 0.31 p = 0.064, p = 0.11), but the three groups had similar rates of liquid/solid swallowing (0.032, 0.024, 0.017, p = 0.69). LES pressure did not correlate with reflux events preceded by swallowing (R2 = 0.021, p = 0.44). There was a higher rate of events preceded by gastric belching in the control group (0.14) than in the upright (0.032) and supine groups (0.066, p = 0.049). LES pressure did not correlate with the rate of events preceded by belching (R2 = 0.000093, p = 0.96). Normal AET patients had a higher rate of events preceded by GB (0.12) than those with increased acid exposure (0.030, p = 0.0083), but the two groups had similar rates of preceding air (0.43, 0.47, p = 0.68), liquid/solid (0.018, 0.032, p = 0.30), and overall swallowing (0.44, 0.53, p = 0.38). CONCLUSIONS AND INFERENCES Swallowing more than belching is a dominant mechanism for reflux irrespective of GERD position, LES pressure, and AET.
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Affiliation(s)
- David Brand
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | - Sydney Pomenti
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | - David A Katzka
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
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8
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Menon R, Vasani SS, Widdicombe NJ, Lipman J. Laryngeal injury following endotracheal intubation: Have you considered reflux? Anaesth Intensive Care 2023; 51:14-19. [PMID: 36168788 DOI: 10.1177/0310057x221102472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Laryngotracheal injury is an increasingly common complication of intubation and mechanical ventilation, with an estimated 87% of intubated and ventilated patients developing a laryngotracheal injury often preventing their rehabilitation from acute illness. Laryngotracheal injuries encompass a diverse set of pathologies including inflammation and oedema in addition to vocal cord ulceration and paralysis, granuloma, stenosis, and scarring. The existing literature has identified several factors including intubation duration, endotracheal tube size, type and cuff pressures, and technical factors including the skill and experience of the endoscopist. Despite these associations, a key aspect in the sequelae of laryngotracheal injuries is due to reflux and is not clearly related to iatrogenic and mechanical factors.Laryngopharyngeal reflux is a type of reflux that contaminates the upper aerodigestive tract. The combination of patient positioning and continuous nasogastric tube feeding act to affect the upper aerodigestive tract with acidic and non-acidic refluxate that causes direct and indirect mucosal injury impeding healing.Despite laryngopharyngeal reflux being an established and recognised causative factor of upper aerodigestive tract inflammatory pathology and laryngotracheal injury, it is very understudied in critical care. Further, there is yet to be an agreed pathway to assess, manage and prevent laryngotracheal injury in intubated and ventilated patients. The incidence of laryngopharyngeal reflux in the intubated and mechanically ventilated patient in the intensive care unit is currently unknown. Prospective studies may allow us to understand further potential mechanisms of upper aerodigestive tract injury due to laryngopharyngeal reflux and herald the development of preventative and management strategies of laryngopharyngeal reflux-mediated upper aerodigestive tract injury in critically ill patients.
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Affiliation(s)
- Rahul Menon
- Department of Otorhinolaryngology, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Sarju S Vasani
- Department of Otorhinolaryngology, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Neil J Widdicombe
- Department of Intensive Care, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Jeffrey Lipman
- Department of Intensive Care, Royal Brisbane and Women's Hospital, Herston, Australia
- The University of Queensland Centre for Clinical Research, The University of Queensland, Herston, Australia
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nimes University Hospital, Nimes, France
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9
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Sleep Positional Therapy for Nocturnal Gastroesophageal Reflux: A Double-Blind, Randomized, Sham-Controlled Trial. Clin Gastroenterol Hepatol 2022; 20:2753-2762.e2. [PMID: 35301135 DOI: 10.1016/j.cgh.2022.02.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/23/2022] [Accepted: 02/23/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Experimental studies have suggested that sleep position plays a role in the occurrence of nocturnal gastroesophageal reflux and the left lateral decubitus position is most favorable. The aim of this study was to evaluate the effect of a novel electronic sleep positional therapy wearable device on sleep position and nocturnal reflux symptoms. METHODS We performed a double-blind, randomized, sham-controlled trial in patients with nocturnal symptoms of gastroesophageal reflux. Patients were advised to sleep in the left lateral decubitus position and were assigned randomly (1:1) to an electronic sleep positional therapy wearable device, programmed to either produce a vibration when in the right lateral position (intervention) or only during the first 20 minutes (sham). The primary outcome was treatment success, defined as a 50% or more reduction in the nocturnal reflux score. Secondary outcomes included change in sleep position and reflux symptoms. RESULTS One hundred patients were randomized. In the intention-to-treat analysis, the rate of treatment success was 44% in the intervention group (22 of 50) vs 24% in the sham group (12 of 50) (risk difference, 20%; 95% CI, 1.8%-38.2%; P = .03). Treatment led to a significant avoidance of sleeping in the right lateral decubitus position (intervention 2.2% vs sham 23.5%; P = .000) and increased time sleeping in the left lateral decubitus position (intervention 60.9% vs sham 38.5%; P = .000). More reflux-free nights were observed in the intervention group (intervention 9 nights [interquartile range, 6-11 nights] vs sham 6 nights [interquartile range, 3-9 nights]; P = .01). CONCLUSIONS Sleep positional therapy using an electronic wearable device promotes sleeping in the left lateral decubitus position and effectively alleviates nocturnal reflux symptoms compared with sham treatment (https://www.trialregister.nl, NL8655).
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10
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The Lyon Consensus Criteria for GERD Diagnosis in a Greek Population: The Clinical Impact and Changes in GERD Diagnosis in a Real-World, Retrospective Study. J Clin Med 2022; 11:jcm11185383. [PMID: 36143030 PMCID: PMC9503370 DOI: 10.3390/jcm11185383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 12/02/2022] Open
Abstract
(1) Introduction/aim: Gastroesophageal reflux disease (GERD) affects 8−33% globally. The gold standard examination technique in diagnosing GERD is 24 h pHmetry ± impedance. Recently, new diagnostic criteria were introduced by the Lyon Consensus for GERD diagnosis. Our aim was to investigate the diagnostic yield of pHmetry + impedance using the Lyon Consensus criteria in a real-world study. (2) Patients and methods: Our study included 249 consecutive patients (M/F: 120/129, mean age 50 ± 15 years) who underwent 24 h pH+ impedance monitoring in our department, during a 5-year period. Epidemiological, endoscopic, clinical, and 24 h pH+ impedance data were retrospectively collected. (3) Results: Typical GERD symptoms were reported by 140/249 (56.2%) patients, whereas 99/249 (39.6%) patients reported various extraesophageal symptoms. Endoscopic findings supportive of GERD based on the Lyon Consensus were present in 42/185 (22.7%). An AET value of >6% was observed in 60/249 (24.1%). GERD diagnosis according to the Lyon Consensus criteria was set in 63/249 (25.3%) patients; a rate significantly lower than that observed by implementing the older criteria (32.1%), p < 0.001. In the multivariate analysis, the existence of endoscopic findings supportive of GERD diagnosis as defined by the Lyon Consensus (p = 0.036), a De Meester score of over 14.7, and the presence of typical GERD symptoms were correlated to GERD diagnosis (p < 0.001, respectively) using the criteria defined for pH−impedance monitoring. (4) Conclusions: Changes in the diagnostic criteria concerning the 24 h pH−impedance monitoring of GERD based on the Lyon Consensus led to a conclusive GERD diagnosis in approximately 25% of the patients. This rate of GERD diagnosis is reduced in comparison to the one confirmed with the use of previously established criteria.
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11
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Levin MD. About the Diagnosis of GERD in the Article by Sharma et al. "Esophageal Pathology in Asymptomatic and Symptomatic Patients with Obesity Undergoing Evaluation for Bariatric Surgery". J Gastrointest Surg 2022; 26:2029-2030. [PMID: 35882760 DOI: 10.1007/s11605-022-05397-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 05/27/2022] [Indexed: 01/31/2023]
Affiliation(s)
- M D Levin
- State Medical Center for Rehabilitation and Geriatrics, Amnon VeTamar, 1/2, 42202, Netanya, Israel.
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12
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Sozzi M, Siboni S, Bonavina L. Sleeping on the Right Side After Esophagectomy. Clin Gastroenterol Hepatol 2022; 21:1377-1378. [PMID: 35552013 DOI: 10.1016/j.cgh.2022.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 04/26/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Marco Sozzi
- Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milano, Italy
| | - Stefano Siboni
- Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milano, Italy
| | - Luigi Bonavina
- Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milano, Italy
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13
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Parsa N, Friedel D, Stavropoulos SN. POEM, GPOEM, and ZPOEM. Dig Dis Sci 2022; 67:1500-1520. [PMID: 35366120 DOI: 10.1007/s10620-022-07398-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 12/09/2022]
Abstract
Our tripartite narrative review discusses Peroral Endoscopic Myotomy (POEM), gastric POEM (GPOEM) and POEM for Zenker's diverticula (ZPOEM). POEM is the prototypical procedure that launched the novel "3rd space endoscopy" field of advanced endoscopy. It revolutionized achalasia therapy by offering a much less invasive version of the prior gold standard, the laparoscopic Heller myotomy (HM). We review in detail indications, outcomes, technique variations and comparative data between POEM and HM particularly with regard to the hotly debated issue of GERD. We then proceed to discuss two less illustrious but nevertheless important offshoots of the iconic POEM procedure: GPOEM for gastroparesis and ZPOEM for the treatment of hypopharyngeal diverticula. For GPOEM, we discuss the rationale of pylorus-directed therapies, briefly touch on GPOEM technique variations and then focus on the importance of proper patient selection and emerging data in this area. On the third and final part of our review, we discuss ZPOEM and expound on technique variations including our "ultra-short tunnel technique". Our review emphasizes that, despite the superiority of endoscopy over surgery for the treatment of hypopharyngeal diverticula, there is no clear evidence yet of the superiority of the newfangled ZPOEM technique compared to the conventional endoscopic myotomy technique practiced for over two decades prior to the advent of ZPOEM.
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Affiliation(s)
- Nasim Parsa
- Division of Gastroenterology and Hepatology, University of Missouri Health System, Columbia, MO, USA
| | - David Friedel
- Division of Gastroenterology, Hepatology and Nutrition, NYU-Winthrop Hospital, 222 Station Plaza N Suite 429, Mineola, NY, 11501, USA
| | - Stavros N Stavropoulos
- Division of Gastroenterology, Hepatology and Nutrition, NYU-Winthrop Hospital, 222 Station Plaza N Suite 429, Mineola, NY, 11501, USA.
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14
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Al-Marhabi A, Hashem A, Zuberi BF, Onyekwere C, Lodhi I, Mounir M, Alkhowaiter S, Al Awadhi S, Naidoo VG, Hamada Y. The views of African and Middle Eastern Gastroenterologists on the management of mild-to-moderate, non-erosive gastro-esophageal reflux disease (GERD). Expert Rev Gastroenterol Hepatol 2022; 16:217-233. [PMID: 35184616 DOI: 10.1080/17474124.2022.2043744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Gastro-esophageal reflux disease (GERD) is a common gastrointestinal disorder that occurs when backflow of the gastric contents into the esophagus results in troublesome symptoms. Though GERD has been extensively studied in Western populations, literature on the management of GERD in patients in Africa and Middle East (AME) is scarce. AREAS COVERED In this review, we provide an overview of the management of mild-to-moderate GERD in AME. Here we focus on the efficacy and safety of currently available treatments for GERD to help physicians and community pharmacists appropriately manage patients with mild-to-moderate GERD in the primary healthcare setting, detailing specific situations and patient scenarios that are relevant to the region, including management of GERD during Ramadan and post-bariatric surgery. EXPERT OPINION Under-appreciation of the burden of GERD in the region has resulted in a lack of consensus on management. Barriers that currently prevent the adoption of treatment guidelines in the primary healthcare setting may include lack of availability of local guidelines and referral systems, a paucity of region-specific research, and dogmatic adherence to traditional practice. By increasing awareness, strengthening knowledge, and by more effective utilization of resources, physicians and pharmacists could optimize GERD management strategies to better support patients.
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Affiliation(s)
- Ahmed Al-Marhabi
- Department of Internal Medicine, College of Medicine, Imam AbdulRahman Bin Faisal University, Khobar, Kingdom of Saudi Arabia
| | - Ahmed Hashem
- Endemic Medicine Department, Cairo University, Egypt.,Department of Medicine & Gastroenterology, Saudi German Hospital Jeddah, Jeddah, Kingdom of Saudi Arabia
| | - Bader Faiyaz Zuberi
- Department of Medicine & Gastroenterology, Dow University of Health Sciences, Karachi, Pakistan
| | - Charles Onyekwere
- Department of Medicine, Lagos State University College of Medicine, Lagos, Nigeria
| | - Imran Lodhi
- Global Medical Sciences, Reckitt Healthcare, London, UK
| | - Mohamed Mounir
- Regional Medical Affairs, Reckitt Benckiser (Arabia) FZE, Dubai, United Arab Emirates
| | - Saad Alkhowaiter
- Gastroenterology, King Saud University, King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Sameer Al Awadhi
- Digestive Diseases Unit, Rashid Hospital, Dubai, United Arab Emirates
| | - Vasudevan G Naidoo
- Department of Gastroenterology, Inkosi Albert Luthuli Central Hospital, Durban, South Africa.,Department of Gastroenterology, University of KwaZulu-Natal, Durban, South Africa
| | - Yasser Hamada
- Endemic Medicine Department, Cairo University, Egypt
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15
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Rusu RI, Fox MR, Tucker E, Zeki S, Dunn JM, Jafari J, Warburton F, Wong T. Validation of the Lyon classification for GORD diagnosis: acid exposure time assessed by prolonged wireless pH monitoring in healthy controls and patients with erosive oesophagitis. Gut 2021; 70:2230-2237. [PMID: 33579789 DOI: 10.1136/gutjnl-2020-323798] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/11/2021] [Accepted: 01/26/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Acid exposure time (AET) from ambulatory pH studies and reflux oesophagitis are independent measurements used by the Lyon classification to diagnose GORD. This study aimed to validate AET reference ranges and diagnostic thresholds by analysis of 96-hour wireless pH studies from healthy, asymptomatic controls (HCs) and patients with and without oesophagitis. DESIGN HC and consecutive patients referred for wireless pH studies (off acid suppressants for >7 days) underwent 96-hour pH studies at two tertiary referral centres. Erosive oesophagitis was categorised by the Los Angeles (LA) classification. Linear regression and receiver operating curve (ROC) analysis were performed to define optimal diagnostic cut-offs. RESULTS Prolonged, 96-hour pH studies were completed in 39 HCs (age 28 (18-53) years, 72% female) and 944 patients (age 46 (16-85) years, 65% female), of whom 136 (14.5%) had reflux oesophagitis. Median AET in HC was 1.3% (upper 95th percentile 4.6%) for any study day and 2.6% (upper 95th percentile 6.9%) for the worst day (24-hour period) during the study. ROC analysis for average AET differentiated HC from patients with moderate-to-severe oesophagitis (LA BCD; sensitivity 87%, specificity 95%, positive predictive value (PPV) 59%, negative predictive value 99% for a cut-off AET of 4.3%; area under the receiver operating curve 0.95). Specificity was higher, but PPV was substantially lower for severe oesophagitis (LA CD). 'Worst-day' analysis provided similar results; however, day-to-day variability was high. CONCLUSION Diagnostic thresholds for average AET were identified that accurately discriminate between HCs and patients with erosive oesophagitis. The findings provide conditional support for diagnostic criteria for GORD proposed by the Lyon Consensus.
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Affiliation(s)
- Radu-Ionut Rusu
- Oesophageal Physiology Laboratory, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mark R Fox
- Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Digestive Diseases, Center for Integrative Gastroenterology, Klinik Arlesheim, Arlesheim, Switzerland.,NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Emily Tucker
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Sebastian Zeki
- Oesophageal Physiology Laboratory, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jason M Dunn
- Oesophageal Physiology Laboratory, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jafar Jafari
- Oesophageal Physiology Laboratory, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fiona Warburton
- Oral Clinical Research Unit, Faculty of Dentistry, Oral and Craniofacial Sciences, King's College London, London, UK
| | - Terry Wong
- Oesophageal Physiology Laboratory, Guy's and St Thomas' NHS Foundation Trust, London, UK
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16
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Modayil RJ, Zhang X, Rothberg B, Kollarus M, Galibov I, Peller H, Taylor S, Brathwaite CE, Halwan B, Grendell JH, Stavropoulos SN. Peroral endoscopic myotomy: 10-year outcomes from a large, single-center U.S. series with high follow-up completion and comprehensive analysis of long-term efficacy, safety, objective GERD, and endoscopic functional luminal assessment. Gastrointest Endosc 2021; 94:930-942. [PMID: 33989646 DOI: 10.1016/j.gie.2021.05.014] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/03/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) is becoming the treatment of choice for achalasia. Data beyond 3 years are emerging but are limited. We herein report our 10-year experience, focusing on long-term efficacy and safety including the prevalence, management, and sequelae of postoperative reflux. METHODS This was a single-center prospective cohort study. RESULTS Six hundred ten consecutive patients received POEM from October 2009 to October 2019, 160 for type 1 achalasia (26.2%), 307 for type II (50.3%), 93 for type III (15.6%), 25 for untyped achalasia (4.1%), and 23 for nonachalasia disorders (3.8%). Two hundred ninety-two patients (47.9%) had prior treatment(s). There was no aborted POEM. Median operation time was 54 minutes. Accidental mucosotomies occurred in 64 patients (10.5%) and clinically significant adverse events in 21 patients (3.4%). No adverse events led to death, surgery, interventional radiology interventions/drains, or altered functional status. At a median follow-up of 30 months, 29 failures occurred, defined as postoperative Eckardt score >3 or need for additional treatment. The Kaplan-Meier clinical success estimates at years 1, 2, 3, 4, 5, 6, and 7 were 98%, 96%, 96%, 94%, 92%, 91%, and 91%, respectively. These are highly accurate estimates because only 13 patients (2%) were missing follow-up assessments. One hundred twenty-five patients (20.5%) had reflux symptoms more than once per week. At a median of 4 months, the pH study was completed in 406 patients (66.6%) and was positive in 232 (57.1%), and endoscopy was completed in 438 patients (71.8%) and showed reflux esophagitis in 218 (49.8%), mostly mild. CONCLUSIONS POEM is exceptionally safe and highly effective on long-term follow-up, with >90% clinical success at ≥5 years.
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Affiliation(s)
- Rani J Modayil
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Xiaocen Zhang
- Department of Medicine, Mt Sinai St Luke's-West Hospital Center, New York, New York, USA
| | - Brooke Rothberg
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Maria Kollarus
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Iosif Galibov
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Hallie Peller
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Sharon Taylor
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Collin E Brathwaite
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Bhawna Halwan
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - James H Grendell
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Stavros N Stavropoulos
- Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA
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Effects of Diaphragmatic Breathing on the Pathophysiology and Treatment of Upright Gastroesophageal Reflux: A Randomized Controlled Trial. Am J Gastroenterol 2021; 116:86-94. [PMID: 33009052 DOI: 10.14309/ajg.0000000000000913] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/17/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Uncontrolled results suggest that diaphragmatic breathing (DB) is effective in gastroesophageal reflux disease (GERD) but the mechanism of action and rigor of proof is lacking. This study aimed to determine the effects of DB on reflux, lower esophageal sphincter (LES), and gastric pressures in patients with upright GERD and controls. METHODS Adult patients with pH proven upright GERD were studied. During a high-resolution impedance manometry, study patients received a standardized pH neutral refluxogenic meal followed by LES challenge maneuvers (Valsalva and abdominal hollowing) while randomized to DB or sham. After that, patients underwent 48 hours of pH-impedance monitoring, with 50% randomization to postprandial DB during the second day. RESULTS On examining 23 patients and 10 controls, postprandial gastric pressure was found to be significantly higher in patients compared with that in controls (12 vs 7 mm Hg, P = 0.018). Valsalva maneuver produced reflux in 65.2% of patients compared with 44.4% of controls (P = 0.035). LES increased during the inspiratory portion of DB (42.2 vs 23.1 mm Hg, P < 0.001) in patients and healthy persons. Postprandial DB reduced the number of postprandial reflux events in patients (0.36 vs 2.60, P < 0.001) and healthy subjects (0.00 vs 1.75, P < 0.001) compared with observation. During 48-hour ambulatory study, DB reduced the reflux episodes on day 2 compared with observation on day 1 in both the patient and control groups (P = 0.049). In patients, comparing DB with sham, total acid exposure on day 2 was not different (10.2 ± 7.9 vs 9.4 ± 6.2, P = 0.804). In patients randomized to DB, esophageal acid exposure in a 2-hour window after the standardized meal on day 1 vs day 2 reduced from 11.8% ±6.4 to 5.2% ± 5.1, P = 0.015. DISCUSSION In patients with upright GERD, DB reduces the number of postprandial reflux events pressure by increasing the difference between LES and gastric pressure. These data further encourage studying DB as therapy for GERD.
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18
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Burton L, Falk GL, Beattie J, Novakovic D, Simpson S, Van der Wall H. Findings from a novel scintigraphic gastroesophageal reflux study in asymptomatic volunteers. AMERICAN JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING 2020; 10:342-348. [PMID: 33329936 PMCID: PMC7724283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/06/2020] [Indexed: 06/12/2023]
Abstract
Gastroesophageal reflux disease (GERD) is a common and growing problem in most western countries. It may present with the typical symptoms of heartburn and regurgitation or with the effects of extra-esophageal disease. We have developed and validated a scintigraphic test that evaluates reflux at both sites in patients at high risk of laryngopharyngeal reflux and lung aspiration. We hypothesized that the test may be able to separate physiologic reflux from pathological reflux and examined this possibility in normal asymptomatic volunteers. Asymptomatic volunteers were screened with the Belafsky reflux symptom index (RSI) and entered into the trial if scores were less than 13. 99mTc Phytate was ingested orally and dynamic studies from the pharynx to the stomach were obtained while upright and supine. A delayed study of the thorax was also obtained for lung aspiration of refluxate. Studies were semi-quantitated graphically as time-activity curves. A total of 25 volunteers were studied (13 M, 12 F) with a mean age of 57.5 yr (Range 40-85 yr). None gave a history of heartburn or regurgitation. Mean RSI was 4.1 (range 0-10). Testing showed upright gastroesophageal reflux to the mid-upper esophagus without pharyngeal contamination in 32%. None of the subjects showed supine reflux or lung aspiration. This result corresponds well with intraluminal impedance/pH monitoring in normal volunteers. The scintigraphic reflux test gives similar results to standard intraluminal impedance/pH studies in normal volunteers. A significant proportion of asymptomatic volunteers demonstrate upright reflux only.
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Affiliation(s)
- Leticia Burton
- CNI Molecular Imaging & University of Notre DameSydney, Australia
| | | | | | - Daniel Novakovic
- Department of ENT Surgery, Canterbury Hospital, Faculty of Medicine and Health, University of SydneyAustralia
| | - Scott Simpson
- Section of Gastroenterology, Sydney Adventist HospitalSydney, Australia
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Burton L, Joffe D, Mackey DW, Van der Wall H, Falk GL. A transformational change in scintigraphic gastroesophageal reflux studies: A comparison with historic techniques. Clin Physiol Funct Imaging 2020; 41:136-145. [PMID: 33155748 DOI: 10.1111/cpf.12677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/05/2020] [Accepted: 11/04/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND The inclusion of scintigraphy in the diagnostic algorithm for gastroesophageal reflux is controversial due to variability in methodology and reporting. A novel scintigraphic reflux study has been developed and validated against the current standards for the diagnosis of gastroesophageal reflux disease (GORD). OBJECTIVE To compare a new scintigraphic reflux test against historic techniques and standardised diagnostic reference tests for gastroesophageal reflux disease. METHODS Paired scintigraphic studies were conducted in seventeen patients. All patients underwent at least one other standardised diagnostic reflux test such as 24- hour oesophageal impedance/ pH, and oesophageal manometry, barium swallow, gastroscopy or the Peptest. Patients inadvertently presented at sites B for scintigraphic reflux testing rather than at Site A which was part of an approved study. The findings from sites B did not correlate with clinical symptoms and other diagnostic reference tests from GORD. These studies were then repeated at Site A with approval from the patients. A second reflux study was performed at site A, utilising a novel technique with the capability of assessing oesophageal and extra-oesophageal disease. RESULTS The Site A technique shows good concordance with the reference diagnostic tests with an accuracy of 82.4% and kappa of 0.64 (SE: 0.16, p = 0.00). Site B had an overall accuracy of 47.1% and kappa of 0.066 (SE: 0.068, p = 0.45). CONCLUSION The Site A technique shows higher accuracy than either site B or the historic reflux techniques. It has characteristics that make it an effective screening tool for assessment of local oesophageal disease and its extraoesophageal manifestations.
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Affiliation(s)
- Leticia Burton
- CNI Molecular Imaging & University of Notre Dame, Sydney, NSW, Australia
| | - David Joffe
- Department of Respiratory Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Douglas W Mackey
- CNI Molecular Imaging & University of Notre Dame, Sydney, NSW, Australia
| | - Hans Van der Wall
- CNI Molecular Imaging & University of Notre Dame, Sydney, NSW, Australia
| | - Gregory L Falk
- Sydney Heartburn Clinic, Concord Hospital & University of Sydney, Sydney, NSW, Australia
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20
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When did gastro-esophageal reflux become a disease? A historical perspective on GER(D) nomenclature. Int J Pediatr Otorhinolaryngol 2020; 137:110214. [PMID: 32658809 DOI: 10.1016/j.ijporl.2020.110214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/07/2020] [Accepted: 06/17/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Within the span of a few decades, gastro-esophageal reflux (GER) evolved from a rare entity to the most commonly diagnosed upper gastro-intestinal disease, i.e. gastro-esophageal reflux disease (GERD). The boundaries of GERD remain matter of controversy and appear to be ever expanding in both children and adults. Our aim is to answer the questions: when did GER become a disease? And when did it become specifically a pediatric disease? METHODS We performed a comprehensive historical review of the original medical literature using Medline and Google, along with a compilation of original and secondary texts in English, French and German. RESULTS Our finding is that those actively involved in treating the reflux, first surgeons in the 1960s and then gastroenterologists in the 1970s, initiated naming it a disease. In pediatrics, the possible correlation between reflux events and sudden infant death syndrome accelerated the management of reflux associated with respiratory symptoms with surgery in the 1970s. Surgeons were also the first specialists to formulate the term pediatric GERD in 1982. CONCLUSION Understanding the genesis of GERD may shed light upon its expansion as a disease category and its persistent controversial nature in pediatrics.
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21
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Nocturnal Gastroesophageal Reflux Disease (GERD) and Sleep: An Important Relationship That Is Commonly Overlooked. J Clin Gastroenterol 2020; 54:663-674. [PMID: 32657961 DOI: 10.1097/mcg.0000000000001382] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gastroesophageal reflux disease (GERD) is a prevalent, chronic medical condition that affects 13% of the adult population globally at least once a week. Sleep disturbances are frequently encountered in up to 25% of the GERD patients, likely due to nocturnal gastroesophageal reflux (GER). With advance in diagnostic techniques allowing for an improved understanding of involved physiological mechanisms of nocturnal reflux, there is growing evidence of a bidirectional relationship between GERD and sleep disturbances. Furthermore, nocturnal GER is associated with more complicated GERD. Obstructive sleep apnea (OSA) and GERD also have been linked, but to what degree remains controversial. Treatment of nocturnal GER has been shown to improve both subjective and objective sleep measures. The therapeutic approach includes lifestyle modifications and medication individualization and optimization with proton-pump inhibitors serving as the mainstay of treatment. Antireflux surgery and newer endoscopic procedures have been demonstrated to control nocturnal GER.
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Gualdoni J, Ritzenthaler J, Burlen J, Stocker A, Abell T, Roman J, Nunley DR. Gastroesophageal Reflux and Microaspiration in Lung Transplant Recipients: The Utility of a Single Esophageal Manometry and pH Probe Monitoring Study. Transplant Proc 2020; 52:977-981. [PMID: 32151388 DOI: 10.1016/j.transproceed.2020.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/23/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Gastroesophageal reflux (GER) in recipients of lung transplant (LTX) is associated with chronic allograft rejection, presumably via microaspiration that damages airway epithelium. Most LTX programs perform a single post-LTX esophageal study to evaluate for GER; the efficacy of this test is unclear. METHODS Patients with 1 year of post-LTX follow-up, including routine bronchoscopies with bronchoalveolar lavage fluid (BALF) samples as well as high-resolution esophageal manometry and pH probe monitoring (HREMpH), were evaluated. BALF samples were analyzed with competitive enzyme-linked immunosorbent assay to detect bile salts, which are indicative of aspiration. These results were compared to results of HREMpH studies post LTX. RESULTS Ninety BALF samples were analyzed for bile salts and acted as disease positive for this evaluation. Of the 13 HREMpH cases, 8 were positive for GER, but only 3 were positive for bile salts via assay. Of the 5 HREMpH-negative cases, 2 experienced aspiration. A solitary HREMpH study had 60.0% sensitivity and 37.5% specificity with positive and negative likelihood ratios: 0.96 and 1.07, respectively. CONCLUSION Microaspiration appears to be an intermittent phenomenon, and HREMpH screening poorly correlates with BALF evidence of aspiration; which may not be adequate. As aspiration detection is crucial in this population, further analysis is warranted.
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Affiliation(s)
- J Gualdoni
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States.
| | - J Ritzenthaler
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - J Burlen
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - A Stocker
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - T Abell
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - J Roman
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States; Robley Rex VA Medical Center, Louisville, Kentucky, United States
| | - D R Nunley
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
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23
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Werner YB, Hakanson B, Martinek J, Repici A, von Rahden BHA, Bredenoord AJ, Bisschops R, Messmann H, Vollberg MC, Noder T, Kersten JF, Mann O, Izbicki J, Pazdro A, Fumagalli U, Rosati R, Germer CT, Schijven MP, Emmermann A, von Renteln D, Fockens P, Boeckxstaens G, Rösch T. Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia. N Engl J Med 2019; 381:2219-2229. [PMID: 31800987 DOI: 10.1056/nejmoa1905380] [Citation(s) in RCA: 325] [Impact Index Per Article: 54.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pneumatic dilation and laparoscopic Heller's myotomy (LHM) are established treatments for idiopathic achalasia. Peroral endoscopic myotomy (POEM) is a less invasive therapy with promising early study results. METHODS In a multicenter, randomized trial, we compared POEM with LHM plus Dor's fundoplication in patients with symptomatic achalasia. The primary end point was clinical success, defined as an Eckardt symptom score of 3 or less (range, 0 to 12, with higher scores indicating more severe symptoms of achalasia) without the use of additional treatments, at the 2-year follow-up; a noninferiority margin of -12.5 percentage points was used in the primary analysis. Secondary end points included adverse events, esophageal function, Gastrointestinal Quality of Life Index score (range, 0 to 144, with higher scores indicating better function), and gastroesophageal reflux. RESULTS A total of 221 patients were randomly assigned to undergo either POEM (112 patients) or LHM plus Dor's fundoplication (109 patients). Clinical success at the 2-year follow-up was observed in 83.0% of patients in the POEM group and 81.7% of patients in the LHM group (difference, 1.4 percentage points; 95% confidence interval [CI], -8.7 to 11.4; P = 0.007 for noninferiority). Serious adverse events occurred in 2.7% of patients in the POEM group and 7.3% of patients in the LHM group. Improvement in esophageal function from baseline to 24 months, as assessed by measurement of the integrated relaxation pressure of the lower esophageal sphincter, did not differ significantly between the treatment groups (difference, -0.75 mm Hg; 95% CI, -2.26 to 0.76), nor did improvement in the score on the Gastrointestinal Quality of Life Index (difference, 0.14 points; 95% CI, -4.01 to 4.28). At 3 months, 57% of patients in the POEM group and 20% of patients in the LHM group had reflux esophagitis, as assessed by endoscopy; at 24 months, the corresponding percentages were 44% and 29%. CONCLUSIONS In this randomized trial, POEM was noninferior to LHM plus Dor's fundoplication in controlling symptoms of achalasia at 2 years. Gastroesophageal reflux was more common among patients who underwent POEM than among those who underwent LHM. (Funded by the European Clinical Research Infrastructure Network and others; ClinicalTrials.gov number, NCT01601678.).
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Affiliation(s)
- Yuki B Werner
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Bengt Hakanson
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Jan Martinek
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Alessandro Repici
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Burkhard H A von Rahden
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Albert J Bredenoord
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Raf Bisschops
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Helmut Messmann
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Marius C Vollberg
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Tania Noder
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Jan F Kersten
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Oliver Mann
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Jakob Izbicki
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Alexander Pazdro
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Uberto Fumagalli
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Riccardo Rosati
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Christoph-Thomas Germer
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Marlies P Schijven
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Alice Emmermann
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Daniel von Renteln
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Paul Fockens
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Guy Boeckxstaens
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
| | - Thomas Rösch
- From the Departments of Interdisciplinary Endoscopy (Y.B.W., T.N., T.R.), Epidemiology and Statistics (J.F.K.), and General, Visceral, and Thoracic Surgery (O.M., J.I.), University Hospital Hamburg-Eppendorf, and the Department of Surgery, Israelitic Hospital (A.E.), Hamburg, the Department of Surgery, University Hospital Würzburg, Würzburg (B.H.A.R., C.-T.G.), and the Department of Gastroenterology, University Hospital Augsburg, Augsburg (H.M.) - all in Germany; the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, and the Department of Surgery, Ersta Hospital, Stockholm (B.H.); the Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine (J.M.), and the 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and University Hospital Motol (A.P.) - all in Prague, Czech Republic; the Departments of Gastroenterology (A.R.) and Digestive Surgery (U.F.), Istituto Clinico Humanitas Rozzano, and the Department of Digestive Surgery, IRCCS Ospedale San Raffaele (R.R.) - both in Milan; Amsterdam University Medical Centers location AMC, Amsterdam Gastroenterology and Metabolism (A.J.B., P.F.) and Surgery (M.P.S.), University of Amsterdam, Amsterdam; the Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Translational Research Center for Gastrointestinal Disorders, Katholieke Universiteit Leuven, Leuven, Belgium (R.B., G.B.); the Department of Psychology, Harvard University, Cambridge, MA (M.C.V.); and the Division of Gastroenterology, Montreal University Hospital and Research Center, Montreal (D.R.)
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Dutta P, Funston W, Mossop H, Ryan V, Jones R, Forbes R, Sen S, Pearson J, Griffin SM, Smith JA, Ward C, Forrest IA, Simpson AJ. Randomised, double-blind, placebo-controlled pilot trial of omeprazole in idiopathic pulmonary fibrosis. Thorax 2019; 74:346-353. [PMID: 30610155 PMCID: PMC6484692 DOI: 10.1136/thoraxjnl-2018-212102] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 10/25/2018] [Accepted: 11/12/2018] [Indexed: 12/13/2022]
Abstract
Background Cough is a common, disabling symptom of idiopathic pulmonary fibrosis (IPF), which may be exacerbated by acid reflux. Inhibiting gastric acid secretion could potentially reduce cough. This study aimed to determine the feasibility of a larger, multicentre trial of omeprazole for cough in IPF, to assess safety and to quantify cough. Methods Single-centre, double-blind, randomised, placebo-controlled pilot trial of the proton pump inhibitor (PPI) omeprazole (20 mg twice daily for 3 months) in patients with IPF. Primary objectives were to assess feasibility and acceptability of trial procedures. The primary clinical outcome was cough frequency. Results Forty-five participants were randomised (23 to omeprazole, 22 to placebo), with 40 (20 in each group) having cough monitoring before and after treatment. 280 patients were screened to yield these numbers, with barriers to discontinuing antacids the single biggest reason for non-recruitment. Recruitment averaged 1.5 participants per month. Geometric mean cough frequency at the end of treatment, adjusted for baseline, was 39.1% lower (95% CI 66.0% lower to 9.3% higher) in the omeprazole group compared with placebo. Omeprazole was well tolerated and adverse event profiles were similar in both groups, although there was a small excess of lower respiratory tract infection and a small fall in forced expiratory volume and forced vital capacity associated with omeprazole. Conclusions A large randomised controlled trial of PPIs for cough in IPF appears feasible and justified but should address barriers to randomisation and incorporate safety assessments in relation to respiratory infection and changes in lung function.
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Affiliation(s)
- Prosenjit Dutta
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Wendy Funston
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Mossop
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Vicky Ryan
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Rhys Jones
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Rebecca Forbes
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Shilpi Sen
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Jeffrey Pearson
- Institute for Cell and Molecular Biosciences, Newcastle University, Newcastle upon Tyne, UK
| | - S Michael Griffin
- Northern Oesophago-Gastric Cancer Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jaclyn A Smith
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester, UK
| | - Christopher Ward
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Ian A Forrest
- Department of Respiratory Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - A John Simpson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Department of Respiratory Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Long-term outcomes following surgical repair of giant paraoesophageal hiatus hernia. Surg Endosc 2018; 33:1846-1853. [DOI: 10.1007/s00464-018-6463-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 09/18/2018] [Indexed: 10/27/2022]
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Angle of His Accentuation Is a Viable Alternative to Dor Fundoplication as an Adjunct to Laparoscopic Heller Cardiomyotomy: Results of a Randomized Clinical Study. Dig Dis Sci 2018; 63:2395-2404. [PMID: 29796913 DOI: 10.1007/s10620-018-5130-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 05/18/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND There is no consensus regarding the type of anti-reflux procedure to be used as an adjunct to laparoscopic Heller cardiomyotomy (LHCM). The aim of this study was to compare Angle of His accentuation (AOH) with Dor Fundoplication (Dor) as an adjunct to LHCM. METHODS A total of 110 patients with achalasia cardia presenting for LHCM from March 2010 to July 2015 were randomized to Dor and AOH. Symptom severity, achalasia-specific quality of life (ASQOL), new onset heartburn, and patient satisfaction were assessed using standardized scores preoperatively, at 3, 6 months, and then yearly. The primary outcome was relief of esophageal symptoms while secondary outcomes were new onset heartburn and ASQOL. RESULTS Both groups were comparable with respect to the baseline demographic characteristics. There was no conversion to open and no mortality in either group. Median operative time was 128 min in AOH and 144 min in Dor group (p < 0.01). Mean follow-up was 36 months and was available in 98% patients. There was significant improvement in esophageal symptoms in both groups with no statistically significant difference between the two groups (p > 0.05). There was no difference in cumulative symptom scores between the two groups over the period of follow-up. New onset heartburn was seen in 11% in AOH and 9% in Dor group. Mean ASQOL score improved in both groups with no difference between the two groups (p = 0.83). Patient satisfaction was similar in both groups. CONCLUSION AOH is similar to Dor as an adjunct to LHCM in safety and efficacy and can be performed in shorter time. CLINICAL REGISTRATION NUMBER CTRI: REF/2014/06/007146.
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Scandiffio P, Mantilla T, Amaral F, França F, Basting R, Turssi C. Anti-erosive effect of calcium carbonate suspensions. J Clin Exp Dent 2018; 10:e776-e780. [PMID: 30305876 PMCID: PMC6174013 DOI: 10.4317/jced.54994] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/05/2018] [Indexed: 11/05/2022] Open
Abstract
Background This study aimed to investigate the ability of different concentrations of calcium carbonate (CaCO3) suspensions to control enamel surface loss. Material and Methods Seventy-five enamel slabs were embedded, ground and polished in a pneumatic grinder-polisher machine. Reference areas were created with UPVC tape and the specimens were randomly allocated into five groups (n = 15) for exposure to hydrochloric acid solution to simulate gastric juice (0.01 M, pH 2) for 2 minutes. The samples were then exposed to suspensions containing 0.0001, 0.001, 0.01 or 0.1 mmol/L CaCO3 for 1 minute. Artificial saliva was used as control. The samples were subjected to a total of five erosive cycles followed by treatment with CaCO3 suspension. Surface loss was measured (in µm) using optical profilometry. Results One-way ANOVA (p = 0.009) and Tukey's test showed a significant reduction in surface loss when compared to the group not exposed to CaCO3 (0.74, +/- 0.23 µm), and the 0.01 mmol/L (0.40; +/- 0.23 µm) and 0.1 mmol/L suspensions (0.37; +/- 0.26 µm). Conclusions The lower concentrated suspensions were incapable of significantly reducing enamel surface loss. Rinsing with 0.01 and 0.1 mmol/L calcium carbonate suspensions was revealed as a potentially promising strategy to prevent enamel erosion. Key words:Tooth erosion, gastric acid, calcium carbonate, prevention and control.
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Affiliation(s)
- Priscila Scandiffio
- DDS, São Leopoldo Mandic Institute and Dental Research Center, Rua José Rocha Junqueira, 13, Campinas, SP, Brazil
| | - Tais Mantilla
- DDS, MSc, PhD student, School of Dentistry, University of São Paulo, Av. Professor Lineu Prestes 2227, São Paulo, SP, Brazil
| | - Flávia Amaral
- DDS, MSc, PhD, Assistant Professor, São Leopoldo Mandic Institute and Dental Research Center, Rua José Rocha Junqueira, 13, Campinas, SP, Brazil
| | - Fabiana França
- DDS, MSc, PhD, Assistant Professor, São Leopoldo Mandic Institute and Dental Research Center, Rua José Rocha Junqueira, 13, Campinas, SP, Brazil
| | - Roberta Basting
- DDS, MSc, PhD, Assistant Professor, São Leopoldo Mandic Institute and Dental Research Center, Rua José Rocha Junqueira, 13, Campinas, SP, Brazil
| | - Cecilia Turssi
- DDS, MSc, PhD, Assistant Professor, São Leopoldo Mandic Institute and Dental Research Center, Rua José Rocha Junqueira, 13, Campinas, SP, Brazil
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Gyawali CP, Kahrilas PJ, Savarino E, Zerbib F, Mion F, Smout AJPM, Vaezi M, Sifrim D, Fox MR, Vela MF, Tutuian R, Tack J, Bredenoord AJ, Pandolfino J, Roman S. Modern diagnosis of GERD: the Lyon Consensus. Gut 2018; 67:1351-1362. [PMID: 29437910 PMCID: PMC6031267 DOI: 10.1136/gutjnl-2017-314722] [Citation(s) in RCA: 903] [Impact Index Per Article: 129.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 01/11/2018] [Accepted: 01/14/2018] [Indexed: 12/12/2022]
Abstract
Clinical history, questionnaire data and response to antisecretory therapy are insufficient to make a conclusive diagnosis of GERD in isolation, but are of value in determining need for further investigation. Conclusive evidence for reflux on oesophageal testing include advanced grade erosive oesophagitis (LA grades C and D), long-segment Barrett's mucosa or peptic strictures on endoscopy or distal oesophageal acid exposure time (AET) >6% on ambulatory pH or pH-impedance monitoring. A normal endoscopy does not exclude GERD, but provides supportive evidence refuting GERD in conjunction with distal AET <4% and <40 reflux episodes on pH-impedance monitoring off proton pump inhibitors. Reflux-symptom association on ambulatory reflux monitoring provides supportive evidence for reflux triggered symptoms, and may predict a better treatment outcome when present. When endoscopy and pH or pH-impedance monitoring are inconclusive, adjunctive evidence from biopsy findings (histopathology scores, dilated intercellular spaces), motor evaluation (hypotensive lower oesophageal sphincter, hiatus hernia and oesophageal body hypomotility on high-resolution manometry) and novel impedance metrics (baseline impedance, postreflux swallow-induced peristaltic wave index) can add confidence for a GERD diagnosis; however, diagnosis cannot be based on these findings alone. An assessment of anatomy, motor function, reflux burden and symptomatic phenotype will therefore help direct management. Future GERD management strategies should focus on defining individual patient phenotypes based on the level of refluxate exposure, mechanism of reflux, efficacy of clearance, underlying anatomy of the oesophagogastric junction and psychometrics defining symptomatic presentations.
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Affiliation(s)
- C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Peter J Kahrilas
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Frank Zerbib
- Department of Gastroenterology, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - Francois Mion
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France,Digestive Physiology, Université de Lyon, Lyon I University, Lyon, France,Université de Lyon, Inserm U1032, Lyon, France
| | - André J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Michael Vaezi
- Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark R Fox
- Gastroenterology, St. Claraspital, Kleinriehenstrasse 30, Basel, Switzerland,Zürich Neurogastroenterology and Motility Research Group, Clinic for Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Radu Tutuian
- Division of Gastroenterology, University Clinics for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - Jan Tack
- Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - John Pandolfino
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sabine Roman
- Digestive Physiology, Hopital E Herriot, Hospices Civils de Lyon, Université de Lyon, Lyon, France,Digestive Physiology, Université de Lyon, Lyon I University, Lyon, France,Université de Lyon, Inserm U1032, Lyon, France
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30
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Neuvonen P, Sand J, Matikainen M, Rantanen T. Does Nissen Fundoplication Provide Lifelong Reflux Control? Symptomatic Outcome After 31-33 Years. World J Surg 2018; 41:2046-2052. [PMID: 28258450 DOI: 10.1007/s00268-017-3924-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND A substantial number of people are suffering from gastroesophageal reflux disease (GERD). The indication for surgical treatment is the failure of medical treatment in patients with objectively verified GERD. The use of PPIs has been noted to increase with the length of follow-up after fundoplication, raising questions concerning the durability of surgical results. The aim of the study was to investigate the results of open Nissen fundoplication (ONF) over a follow-up of more than 31 years. METHODS ONF was performed for 38 consecutive patients. Questionnaires concerning long-term outcome were sent on December 14, 2015, to the 24 patients still living. Long-term symptom evaluation was carried out using the Gastrointestinal Symptom Rating Scale (GSRS), Visick grading, a Visual Analog Scale (VAS), the DeMeester-Johnson reflux scale, and the 15D tool. RESULTS Seventeen (70.8%) of the 24 patients still living participated in the study. The typical symptoms of GERD had resolved significantly. Dysphagia was graded as none or minimal by 13 (81.3%) patients. The mean 15D score of the patient group was clinically and statistically the same (0.896 vs. 0.899) as that of the age- and sex-standardized general population (p = 0.912). Six (15.8%) patients had used antireflux medication after the operation and 4 of them (10.6%) continuously. CONCLUSIONS Patients in the present study used PPIs less frequently than what has been reported in previous long-term follow-up studies. Our results indicate that successful surgery may provide lifelong relief of GERD symptoms and normalize the health-related quality of life in GERD patients.
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Affiliation(s)
- P Neuvonen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - J Sand
- Päijät-Häme Central Hospital, Lahti, Finland
| | - M Matikainen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - T Rantanen
- Department of Surgery, Kuopio University Hospital, Box 100, 70029, Kuopio, KYS, Finland.
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Is the Routine Use of Impedance Analysis for the Diagnosis of Gastro-Esophageal Reflux Disease More Expensive than Conventional pH Monitoring? Cost Analysis of Two Procedures. Indian J Surg 2017; 79:192-195. [PMID: 28659670 DOI: 10.1007/s12262-016-1444-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 01/13/2016] [Indexed: 10/22/2022] Open
Abstract
Conventional 24-h pH monitoring is the gold standard for the diagnosis of non-erosive, non-acidic gastro-esophageal reflux disease. Multichannel Intraluminal Impedance (MII) analysis markedly improves diagnostic accuracy of non-erosive, non-acidic gastro-esophageal reflux disease. However, MII catheters are more expensive than standard catheters. This study aimed to determine the rates of acid or non-acid reflux and by making a retrospective projection, to predict the costs of two algorithms. We retrospectively reviewed the medical data of 102 patients who presented to our hospital with suspected non-erosive GERD and underwent 24 h impedance/pH-monitoring. Demographic characteristics, Demeester scores, number of reflux episodes, and results of impedance analysis were recorded. According to these data, cost was calculated either for the scenario in which impedance measurement was performed solely or following a negative conventional pH monitoring. Thirty-seven of all 102 patients (36.3 %) had a Demeester score greater than 14.7. These patients were assigned as group 1 (acid reflux). The impedance analysis of the remaining 65 patients detected 34 patients (33.3 %) to have more than 50 reflux episodes over a period of 24 h and assigned as Group 2, and 31 patients (30.4 %) had no reflux (group 3). The cost of the single- step algorithm using MII catheter was calculated as $15,300, while the total cost of two-step scenario would have been predicted as $16,890. Our study showed that an initial conventional pH monitoring can make the diagnosis of GERD in only one third of the patients with suspected non-erosive GERD. In nearly two-thirds of patients, however, repeated procedures and use of impedance catheters are needed. It is clear that this algorithm has certain drawbacks with regard to cost, patient comfort, and workforce loss.
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Butterfield KJ. Outpatient Anesthetic Safety Considerations for Obstructive Sleep Apnea. Oral Maxillofac Surg Clin North Am 2017; 29:189-196. [PMID: 28417891 DOI: 10.1016/j.coms.2016.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Most patients with obstructive sleep apnea (OSA) are not diagnosed preoperatively. The STOP-Bang questionnaire may identify patients at risk of OSA, especially those with severe OSA. Patients with mild to moderate OSA, with optimized comorbidities, can usually safely undergo outpatient surgery. Patients with severe OSA, who are not optimized medically, should avoid outpatient surgery.
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Affiliation(s)
- Kevin J Butterfield
- Division of Dentistry/Oral and Maxillofacial Surgery, Department of Otolaryngology, Ottawa Hospital, University of Ottawa School of Medicine, Ottawa, Ontario, Canada.
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Ribeiro MCB, Araújo ABD, Terra-Júnior JA, Crema E, Andreollo NA. LATE EVALUATION OF PATIENTS OPERATED FOR GASTROESOPHAGEAL REFLUX DISEASE BY NISSEN FUNDOPLICATION. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2017; 29:131-134. [PMID: 27759771 PMCID: PMC5074659 DOI: 10.1590/0102-6720201600030001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/07/2016] [Indexed: 12/13/2022]
Abstract
Background: Surgical treatment of GERD by Nissen fundoplication is effective and safe,
providing good results in the control of the disease. However, some authors have
questioned the efficacy of this procedure and few studies on the long-term
outcomes are available in the literature, especially in Brazil. Aim: To evaluate patients operated for gastro-esophageal reflux disease, for at least
10 years, by Nissen fundoplication. Methods: Thirty-two patients were interviewed and underwent upper digestive endoscopy,
esophageal manometry, 24 h pH monitoring and barium esophagogram, before and after
Nissen fundoplication. Results: Most patients were asymptomatic, satisfied with the result of surgery (87.5%) 10
years after operation, due to better symptom control compared with preoperative
and, would do it again (84.38%). However, 62.5% were in use of some type of
anti-reflux drugs. The manometry revealed lower esophageal sphincter with a mean
pressure of 11.7 cm H2O and an average length of 2.85 cm. The average
DeMeester index in pH monitoring was 11.47. The endoscopy revealed that most
patients had a normal result (58.06%) or mild esophagitis (35.48%). Barium swallow
revealed mild esophageal dilatation in 25,80% and hiatal hernia in 12.9% of cases.
Conclusion: After at least a decade, most patients were satisfied with the operation,
asymptomatic or had milder symptoms of GERD, being better and with easier control,
compared to the preoperative period. Nevertheless, a considerable percentage still
employed anti-reflux medications.
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Affiliation(s)
- Maxwel Capsy Boga Ribeiro
- Clinics Hospital and Department of Surgery, Faculty of Medicine, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | - Amanda Bueno de Araújo
- Clinics Hospital and Department of Surgery, Faculty of Medicine, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | - Juverson Alves Terra-Júnior
- Clinics Hospital and Department of Surgery, Faculty of Medicine, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | - Eduardo Crema
- Clinics Hospital and Department of Surgery, Faculty of Medicine, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | - Nelson Adami Andreollo
- Program in Sciences of Surgery, State University of Campinas, Unicamp, Campinas, SP, Brazil
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Jones JW, Sykes KJ, Pavelonis A, Pappu H, Nguyen AM, Garnett JD. Analyzing the Area Under the Curve of Pharyngeal pH Probes in the Diagnosis of Reflux Disease. Ann Otol Rhinol Laryngol 2017; 126:274-278. [PMID: 28056532 DOI: 10.1177/0003489416687308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To analyze the area under the curve (AUC) from 24-hour pharyngeal pH probes and evaluate this parameter as a predictor of disease severity for laryngopharyngeal reflux. METHODS Eighty patients met inclusion criteria of a completed 24-hour pharyngeal pH probe and Reflux Symptom Index (RSI) questionnaire. The AUC was calculated below a pH threshold of 5.5 using the trapezoidal rule. The RSI and RYAN scores were correlated with AUC values, and nonparametric tests were used for comparisons. RESULTS The median AUC value was 18 007 pH-seconds with an interquartile range (IQR) of 63 156, the median RSI score was 21 (IQR = 16), and the median RYAN score was 15.3 (IQR = 78). There was a Spearman's correlation of .36 between the RSI scores and AUC values ( P = .001) and a moderate correlation between AUC values and RYAN scores (0.58, P < .001). An insignificant correlation of .19 between RYAN scores and RSI scores was observed ( P = .09). CONCLUSIONS The AUC may be a useful objective value in establishing the diagnosis of laryngopharyngeal reflux. Prospective studies with larger patient populations are necessary to validate these findings and determine standardized thresholds for symptomatic patients.
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Affiliation(s)
- Joel W Jones
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Kevin J Sykes
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Anna Pavelonis
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Hema Pappu
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Amy M Nguyen
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, KS, USA
| | - James D Garnett
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine, Kansas City, KS, USA
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Ida T, Inamori M, Inoh Y, Fujita K, Hamanaka J, Chiba H, Kusakabe A, Morohashi T, Goto T, Maeda S. Clinical Characteristics of Severe Erosive Esophagitis among Patients with Erosive Esophagitis: A Case-control Study. Intern Med 2017; 56:1293-1300. [PMID: 28566589 PMCID: PMC5498190 DOI: 10.2169/internalmedicine.56.8058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective The risk factors associated with severe erosive esophagitis are not well defined in Japan. We aimed to evaluate the risk factors associated with the endoscopic severity of esophageal mucosal injury. Methods Eighty consecutive Japanese patients with severe erosive esophagitis [Los Angeles (LA) classification grade C or D] who had undergone upper endoscopies in the Gastroenterology Division of Omori Red Cross Hospital between June 2010 and March 2013 were retrospectively analyzed. For each case, a control with mild erosive esophagitis (LA classification grade A or B) who was matched by sex and age was randomly selected during the same period. Among the endoscopic findings, the condition of the gastroesophageal flap valve (GEFV) was graded according to Hill's classification. We identified the risk factors for severe erosive esophagitis using a multivariable logistic regression model. Results A poor performance status (PS) (odds ratio [OR]=17.1201, 95% confidence interval [CI]=3.0268-140.3121, p=0.0008) and an abnormal GEFV (OR=3.0176, 95% CI=1.0589-9.4939, p=0.0385) were risk factors for severe erosive esophagitis, while the presence of open-type gastric mucosal atrophy (GMA) was inversely associated with severe erosive esophagitis (OR=0.2772, 95% CI=0.1087-0.6675, p=0.0040). Conclusion Among patients with erosive esophagitis, a poor PS and an abnormal GEFV were associated while GMA was inversely associated with severe erosive esophagitis. Drug therapy alone or in combination with physical therapy may improve the therapeutic effect on severe erosive esophagitis in patients with a poor PS.
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Affiliation(s)
- Tomonori Ida
- Department of Gastroenterology, Omori Red Cross Hospital, Japan
| | - Masahiko Inamori
- Department of Medical Education, Yokohama City University School of Medicine, Japan
| | - Yumi Inoh
- Office of Postgraduate Medical Education, Yokohama City University Hospital, Japan
| | - Koji Fujita
- Office of Postgraduate Medical Education, Yokohama City University Hospital, Japan
| | - Jun Hamanaka
- Department of Gastroenterology, Omori Red Cross Hospital, Japan
| | - Hideyuki Chiba
- Department of Gastroenterology, Omori Red Cross Hospital, Japan
| | - Akihiko Kusakabe
- Department of General Medicine, Yokohama City University Hospital, Japan
| | - Taiki Morohashi
- Department of Gastroenterology, Omori Red Cross Hospital, Japan
| | - Toru Goto
- Department of Gastroenterology, Omori Red Cross Hospital, Japan
| | - Shin Maeda
- Department of Gastroenterology, Yokohama City University Hospital, Japan
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Fransson SG, Sökjer H, Johansson KE, Tibbling L. Radiologic Diagnosis of Gastro-Oesophageal Reflux. Acta Radiol 2016. [DOI: 10.1177/028418518702800313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
It has been proposed that the high density of ordinary barium suspensions may complicate the radiologic diagnosis of gastro-oesophageal reflux. For this reason P-contrast was developed (Ferring AB); a contrast medium with the same density as water (1 g/cm3). A comparison of P-contrast and barium (Mixobar Ventrikel 400 mg/ml) was performed in 82 patients. All patients were examined with both contrast media and the findings were compared with those at reflux test at manometry, endoscopy and 24-hour pH monitoring. Another 40 patients and 15 symptom-free controls were examined with two different amounts of barium, 100 ml and 200 ml, to study if the radiologic diagnosis of reflux varied with the volume of contrast medium administered. P-contrast was found to have no advantages over barium for the diagnosis of gastro-oesophageal reflux. The outcome of the radiologic examination was not influenced by the different volumes of barium used.
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Fransson SG, Sökjer H, Johansson KE, Tibbling L. Radiologic Diagnosis of Gastro-Oesophageal Reflux by Means of Graded Abdominal Compression. Acta Radiol 2016. [DOI: 10.1177/028418518802900109] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of the study was to ascertain whether abdominal compression by a standardized technique increases the reliability of the radiologic diagnosis of gastro-oesophageal reflux. Eightyeight patients were examined by means of a manometric reflux test, 24-hour measurements of pH and endoscopy. The radiologic examination was performed with and without graded abdominal compression, the patient at the same time turning from side to side. When abdominal compression was included the result of the radiologic examination was positive in 31 patients. In the absence of abdominal compression reflux was detected in 11 of these patients. In one patient reflux was detected only without compression. All these 31 patients had one more test positive and in 27 at least 2 more tests were positive. Another 21 patients had reflux disease as indicated by at least 2 of the 3 other tests. The compression technique seems to yield no false positive responses, and proved to be significantly more reliable than examinations without compression.
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Abstract
Gastroesophageal reflux disease is one of the commonest chronic conditions in the western world and its prevalence is increasing worldwide. The discovery of the acid pocket explained the paradox of acid reflux occurring more frequently in the postprandial period despite intragastric acidity being low due to the buffering effect of the meal. The acid pocket was first described in 2001 when it was detected as an area of low pH immediately distal to the cardia using dual pH electrode pull-through studies 15 minutes after a meal. It was hypothesized that there was a local pocket of acid close to the gastroesophageal junction that escapes the buffering effect of the meal, and that this is the source of postprandial acidic reflux. The presence of the acid pocket has been confirmed in other studies using different techniques including high-resolution pHmetry, Bravo capsule, magnetic resonance imaging, and scintigraphy. This review aims to describe what we know about the acid pocket including its length, volume, fluid constituents, and its relationship to the lower esophageal sphincter and squamocolumnar junction. We will discuss the possible mechanisms that lead to the formation of the acid pocket and examine what differences exist in patients who suffer from acid reflux. Treatments for reflux disease that affect the acid pocket will also be discussed.
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Patel A, Gyawali CP. Definitions of Gastroesophageal Reflux Disease (GERD). DIAGNOSIS AND TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE 2016:1-17. [DOI: 10.1007/978-3-319-19524-7_1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Grossi L, Ciccaglione AF, Marzio L. Typical and atypical symptoms of gastro esophageal reflux disease: Does Helicobacter pylori infection matter? World J Gastrointest Pharmacol Ther 2015; 6:238-243. [PMID: 26558157 PMCID: PMC4635163 DOI: 10.4292/wjgpt.v6.i4.238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 07/15/2015] [Accepted: 09/08/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze whether the presence of Helicobacter pylori (H. pylori) infection could affect the quality of symptoms in gastro-esophageal reflux disease (GERD) patients.
METHODS: one hundred and forty-four consecutive patients referred to our Unit for suspected GERD were recruited for the study. All patients underwent esophageal pH-metric recording. For those with a positive test, C13 urea breath test was then performed to assess the H. pylori status. GERD patients were stratified according to the quality of their symptoms and classified as typical, if affected by heartburn and regurgitation, and atypical if complaining of chest pain, respiratory and ears, nose, and throat features. H. pylori-negative patients were also asked whether they had a previous diagnosis of H. pylori infection. If a positive response was given, on the basis of the time period after successful eradication, patients were considered as “eradicated” (E) if H. pylori eradication occurred more than six months earlier or “recently eradicated” if the therapy had been administered within the last six months. Patients without history of infection were identified as “negative” (N). χ2 test was performed by combining the clinical aspects with the H. pylori status.
RESULTS: one hundred and twenty-nine of the 144 patients, including 44 H. pylori-positive and 85 H. pylori-negative (41 negative, 21 recently eradicated, 23 eradicated more than 6 mo before), were eligible for the analysis. No difference has been found between H. pylori status and either the number of reflux episodes (138 ± 23 vs 146 ± 36, respectively, P = 0.2, not significant) or the percentage of time with pH values < 4 (6.8 ± 1.2 vs 7.4 ± 2.1, respectively, P = 0.3, not significant). The distribution of symptoms was as follows: 13 typical (30%) and 31 atypical (70%) among the 44 H. pylori-positive cases; 44 typical (52%) and 41 atypical (48%) among the 85 H. pylori-negative cases, (P = 0.017 vs H. pylori+; OR = 2.55, 95%CI: 1.17-5.55). Furthermore, clinical signs in patients with recent H. pylori eradication were similar to those of H. pylori-positive (P = 0.49; OR = 1.46, 95%CI: 0.49-4.37); on the other hand, patients with ancient H. pylori eradication showed a clinical behavior similar to that of H. pylori-negative subjects (P = 0.13; OR = 0.89, 95%CI: 0.77-6.51) but different as compared to the H. pylori-positive group (P < 0.05; OR = 3.71, 95%CI: 0.83-16.47).
CONCLUSION: Atypical symptoms of GERD occur more frequently in H. pylori-positive patients than in H. pylori-negative subjects. In addition, atypical symptoms tend to decrease after H. pylori eradication.
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Yasuda A, Yasuda T, Imamoto H, Kato H, Nishiki K, Iwama M, Makino T, Shiraishi O, Shinkai M, Imano M, Furukawa H, Okuno K, Shiozaki H. A newly modified esophagogastrostomy with a reliable angle of His by placing a gastric tube in the lower mediastinum in laparoscopy-assisted proximal gastrectomy. Gastric Cancer 2015; 18:850-8. [PMID: 25318978 DOI: 10.1007/s10120-014-0431-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 09/27/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND An optimal reconstruction method for proximal gastrectomy (PG) remains elusive. Esophagogastrostomy (EG) is technically simple but suffers from the disadvantage of gastroesophageal reflux. Jejunal interposition (JI) has a low rate of gastroesophageal reflux, but the procedure is more complicated, and delayed gastric emptying is a problem. METHODS We created a modified EG and have used the modified technique for PG since 2006. The procedure involves shaping the remnant stomach into a gastric conduit. The EG is performed high on the anterior wall, and the conduit is kept straight by applying a circular stapler inserted from the anterior wall of the antrum. The tip of the gastric conduit is then inserted into the lower mediastinum, creating a sharp angle of His. In this retrospective cohort study, the clinical and physiological outcomes were compared between 25 patients who underwent this procedure and 21 patients who underwent JI from 2001 to 2005. RESULTS Laparoscopic procedures were performed more frequently, and residual food and bile reflux were less common in the EG group than in the JI group. No significant differences in remnant gastritis or reflux esophagitis were observed between the two groups. However, the late complication of intestinal obstruction occurred only in the JI group. CONCLUSIONS The modified EG technique has advantages over the JI technique because of its simplicity and low incidence of residual food and bile reflux. The next step would be to explore this technique further by a prospective multi-institutional study to confirm the reproducibility of its benefits. Miniabstract: The modified EG technique has advantages over the JI technique because of its simplicity, high rate of laparoscopy use, and low incidence of gastroesophageal reflux.
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Affiliation(s)
- Atsushi Yasuda
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan.
| | - Takushi Yasuda
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Haruhiko Imamoto
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Hiroaki Kato
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Kohei Nishiki
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Mitsuru Iwama
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Tomoki Makino
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Osamu Shiraishi
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Masayuki Shinkai
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Motohiro Imano
- Cancer Center, Kinki University Hospital, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Hiroshi Furukawa
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Kiyokata Okuno
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Hitoshi Shiozaki
- Department of Surgery, Faculty of Medicine, Kinki University, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-8511, Japan
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A prospective analysis of GERD after POEM on anterior myotomy. Surg Endosc 2015; 30:2496-504. [PMID: 26416381 PMCID: PMC4887532 DOI: 10.1007/s00464-015-4507-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 08/01/2015] [Indexed: 01/21/2023]
Abstract
Background Peroral endoscopic myotomy (POEM) is an emerging, minimally invasive procedure capable of overcoming limitations of achalasia treatments, but gastroesophageal reflux disease (GERD) after POEM is of concern and its risk factors have not been evaluated. This prospective study examined GERD and the association of POEM with reflux esophagitis. Methods Achalasia patients were recruited from a single center. The pre- and postoperative assessments included Eckardt scores, manometry, endoscopy, and pH monitoring. Results Between September 2011 and November 2014, 105 patients underwent POEM; 70 patients were followed up 3 months after POEM. Postoperatively, significant reductions were observed in lower esophageal sphincter (LES) pressure [from 40.0 ± 22.8 to 20.7 ± 14.0 mmHg (P < 0.05)], LES residual pressure [from 22.1 ± 13.3 to 11.4 ± 6.6 mmHg (P < 0.05)], and Eckardt scores [from 5.7 ± 2.5 to 0.7 ± 0.8 (P < 0.05)]. Symptomatic GERD and moderate reflux esophagitis developed in 5 and 11 patients (grade B, n = 8; grade C, n = 3), respectively, and were well controlled with proton pump inhibitors. Univariate logistic regression analysis revealed integrated relaxation pressure was a predictor of ≥grade B reflux esophagitis. No POEM factors were found to be associated with reflux esophagitis. Conclusion POEM is effective and safe in treating achalasia, with no occurrence of clinically significant refractory GERD. Myotomy during POEM, especially of the gastric side, was not associated with ≥grade B (requiring medical intervention) reflux esophagitis. Extended gastric myotomy (2–3 cm) during POEM is recommended to improve outcomes.
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Dynamics of quality of life improvement after floppy Nissen fundoplication for gastroesophageal reflux disease. Wideochir Inne Tech Maloinwazyjne 2015; 10:389-97. [PMID: 26649085 PMCID: PMC4653267 DOI: 10.5114/wiitm.2015.54187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 01/29/2015] [Accepted: 03/09/2015] [Indexed: 11/29/2022] Open
Abstract
Introduction Gastroesophageal reflux disease (GERD) has a negative impact on global quality of life (QOL) of patients. In patients affected by GERD, laparoscopic Nissen fundoplication is one of the most commonly performed laparoscopic procedures worldwide. Aim To prospectively analyze the dynamics of QOL as well as severity of pain in patients with GERD, before and after laparoscopic floppy Nissen fundoplication. Material and methods The study involved 104 consecutive patients operated on for GERD in whom laparoscopic floppy Nissen fundoplication was performed. QOL was assessed before surgery and 1, 3, 6, 12 and 24 months after. The following instruments were used: FACIT-G, FACIT-TS-G, GIQLI, GERD symptom scale. Results It was found that symptom relief and quality of life improvement presented different dynamics in the postoperative course. Observations revealed relief of symptoms 1 month after surgery and improvement in QOL related to the gastrointestinal tract and pain 3 months after surgery. Global QOL increased significantly as late as 12 months after surgery. Conclusions Gastroesophageal reflux disease is a chronic disease of long duration, leading to impairment of quality of life. Patients, apart from typical symptoms of GERD, suffer from pain of significant severity. QOL improves significantly after surgery. Surgical treatment results in relief of GERD symptoms, which leads to gradual improvement of QOL.
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Lee AL, Goldstein RS. Gastroesophageal reflux disease in COPD: links and risks. Int J Chron Obstruct Pulmon Dis 2015; 10:1935-49. [PMID: 26392769 PMCID: PMC4574848 DOI: 10.2147/copd.s77562] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
COPD is a long-term condition associated with considerable disability with a clinical course characterized by episodes of worsening respiratory signs and symptoms associated with exacerbations. Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal conditions in the general population and has emerged as a comorbidity of COPD. GERD may be diagnosed by both symptomatic approaches (including both typical and atypical symptoms) and objective measurements. Based on a mix of diagnostic approaches, the prevalence of GERD in COPD ranges from 17% to 78%. Although GERD is usually confined to the lower esophagus in some individuals, it may be associated with pulmonary microaspiration of gastric contents. Possible mechanisms that may contribute to GERD in COPD originate from gastroesophageal dysfunction, including altered pressure in the lower esophageal sphincter (which normally protect against GERD) and changes in esophageal motility. Proposed respiratory contributions to the development of GERD include respiratory medications that may alter esophageal sphincter tone and changes in respiratory mechanics, with increased lung hyperinflation compromising the antireflux barrier. Although the specific cause and effect relationship between GERD and COPD has not been fully elucidated, GERD may influence lung disease severity and has been identified as a significant predictor of acute exacerbations of COPD. Further clinical effects could include a poorer health-related quality of life and an increased cost in health care, although these factors require further clarification. There are both medical and surgical options available for the treatment of GERD in COPD and while extensive studies in this population have not been undertaken, this comorbidity may be amenable to treatment.
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Affiliation(s)
- Annemarie L Lee
- West Park Healthcare Centre, University of Toronto, Toronto, ON, Canada ; Department of Physical Therapy, University of Toronto, Toronto, ON, Canada ; Institute for Breathing and Sleep, Austin Hospital, Melbourne, VIC, Australia
| | - Roger S Goldstein
- West Park Healthcare Centre, University of Toronto, Toronto, ON, Canada ; Department of Physical Therapy, University of Toronto, Toronto, ON, Canada ; Department of Medicine, University of Toronto, Toronto, ON, Canada
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Wang B, Zhang W, Liu S, Du Z, Shan C, Qiu M. A Chinese randomized prospective trial of floppy Nissen and Toupet fundoplication for gastroesophageal disease. Int J Surg 2015; 23:35-40. [PMID: 26360740 DOI: 10.1016/j.ijsu.2015.08.074] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 07/28/2015] [Accepted: 08/14/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION To evaluate the clinical outcomes of laparoscopic floppy Nissen fundoplication (LNF) and laparoscopic Toupet fundoplication (LTF) for the treatment of gastroesophageal disease (GERD). METHODS A total of 84 patients with GERD were randomized to either LNF (n = 43) or LTF (n = 41) between January 2010 and January 2013. The primary endpoint measures were the DeMeester score, distal esophageal amplitude (DEA), peristaltic frequency, lower esophageal sphincter pressure (LESP), short-term and long-term postoperative dysphagia and recurrence rate. The secondary endpoints were improvements in symptom scores and quality of life (QoL), and perioperative complications. RESULTS LNF group had a lower DeMeester score and a higher LESP compared to LTF group after surgery (DeMeester score: P = 0.007; LESP: P = 0.027). The mean DEA and peristaltic frequency both improved significantly after surgery in 2 groups. There was no difference in the incidence of short-term adverse events (including dysphagia, heartburn, regurgitation et al.) between the two groups (P = 0.157). At the time of the latest follow-up, there was no difference in the incidence of symptomatic reflux symptom (heartburn and regurgitation) between the two groups (heartburn: P = 0.363; regurgitation: P = 1.000). A higher frequency of dysphagia was present in the LNF group compared with the LTF group (P = 0.023). DISCUSSION LNF is associated with an excessive elevation of LESP which may lead to further persistent dysphagia. Partial fundoplication may provide adequate reflux control, improve esophageal body motility and minimize complications associated with an 'over-tight' fundal wrap. CONCLUSION LTF seems to be as safe and effective on the long-term as LNF, but with a lower incidence of postoperative dysphagia (ChiCTR-TRC-13003945).
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Affiliation(s)
- Bin Wang
- Department of General Surgery, The Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai 200003, China
| | - Wei Zhang
- Department of General Surgery, The Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai 200003, China
| | - Sheng Liu
- Department of General Surgery, The Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai 200003, China
| | - Zhipeng Du
- Department of General Surgery, The Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai 200003, China
| | - Chengxiang Shan
- Department of General Surgery, The Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai 200003, China.
| | - Ming Qiu
- Department of General Surgery, The Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai 200003, China.
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Abstract
Background: It has been previously demonstrated that patients with reflux esophagitis exhibit a significant impairment in the secretion of salivary protective components versus controls. However, the secretion of salivary protective factors in patients with nonerosive reflux disease (NERD) is not explored. The authors therefore studied the secretion of salivary volume, pH, bicarbonate, nonbicarbonate glycoconjugate, protein, epidermal growth factor (EGF), transforming growth factor alpha (TGF-α) and prostaglandin E2 in patients with NERD and compared with the corresponding values in controls (CTRL). Methods: Salivary secretion was collected during basal condition, mastication and intraesophageal mechanical (tubing, balloon) and chemical (initial saline, acid, acid/pepsin, final saline) stimulations, respectively, mimicking the natural gastroesophageal reflux. Results: Salivary volume, protein and TGF-α outputs in patients with NERD were significantly higher than CTRL during intraesophageal mechanical (P < 0.05) and chemical stimulations (P < 0.05). Salivary bicarbonate was significantly higher in NERD than CTRL group during intraesophageal stimulation with both acid/pepsin (P < 0.05) and saline (P < 0.01). Salivary glycoconjugate secretion was significantly higher in the NERD group than the CTRL group during chewing (P < 0.05), mechanical (P < 0.05) and chemical stimulation (P < 0.01). Salivary EGF secretion was higher in patients with NERD during mechanical stimulation (P < 0.05). Conclusions: Patients with NERD demonstrated a significantly stronger salivary secretory response in terms of volume, bicarbonate, glycoconjugate, protein, EGF and TGF-α than asymptomatic controls. This enhanced salivary esophagoprotection is potentially mediating resistance to the development of endoscopic mucosal changes by gastroesophageal reflux.
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Staehelin A, Zingg U, Devitt PG, Esterman AJ, Smith L, Jamieson GG, Watson DI. Preoperative factors predicting clinical outcome following laparoscopic fundoplication. World J Surg 2015; 38:1431-43. [PMID: 24366275 DOI: 10.1007/s00268-013-2415-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Antireflux surgery is effective for the treatment of gastroesophageal reflux, but not all patients benefit equally from it. The challenge is to identify the patients who will ultimately benefit from antireflux surgery. The aim of this study was to identify preoperative factors that predict clinical outcome after antireflux surgery, with special interest in the influence of socioeconomic factors. METHODS Preoperative clinical and socioeconomic data from 1,650 patients who were to undergo laparoscopic fundoplication were collected prospectively. Clinical outcome measures (persistent heartburn, dysphagia, satisfaction) were assessed at short-term (1 year) and longer-term (≥ 3 years) follow-up. RESULTS At early follow-up, male gender (relative risk [RR] 1.091, p < 0.001) and the presence of a hiatus hernia (RR 1.065, p = 0.002) were independently associated with less heartburn. Male gender was also associated with higher overall satisfaction (RR 1.046, p = 0.034). An association was found between postoperative dysphagia and age (RR 0.988, p = 0.007) and the absence of a hiatus hernia (RR 0.767, p = 0.001). At longer-term follow-up, only male gender (RR 1.125, p < 0.001) was an independent prognostic factor for heartburn control. Male gender (RR 0.761, p = 0.001), the presence of a hiatus hernia (RR 0.823, p = 0.014), and cerebrovascular comorbidities (RR 1.306, p = 0.019) were independent prognosticators for dysphagia at longer-term follow-up. A hiatus hernia was the only factor associated with better overall satisfaction. Socioeconomic factors did not influence any clinical outcomes at short- and longer-term follow-up. CONCLUSION Male gender and hiatus hernia are associated with a better clinical outcome following laparoscopic fundoplication, whereas socioeconomic status does not influence outcome.
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Affiliation(s)
- Annina Staehelin
- Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia
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The Gut and Sleep. Sleep Med 2015. [DOI: 10.1007/978-1-4939-2089-1_51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Symptomatic outcome following laparoscopic Heller’s cardiomyotomy with Dor fundoplication versus laparoscopic Heller’s cardiomyotomy with angle of His accentuation: results of a randomized controlled trial. Surg Endosc 2014; 29:2344-51. [PMID: 25427411 DOI: 10.1007/s00464-014-3958-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 11/03/2014] [Indexed: 02/03/2023]
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Zsolt S, Paszt A, Géczi T, Abrahám S, Tóth I, Horváth Z, Pieler J, Tajti J, Varga A, Tiszlavicz L, Németh I, Izbéki F, Rosztóczy A, Wittmann T, Lázár G. [Comparison of surgical patients with gastroesophageal reflux disease and Barrett's esophagus]. Magy Seb 2014; 67:287-96. [PMID: 25327403 DOI: 10.1556/maseb.67.2014.5.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Barrett's esophagus (BE) is the only known precursor of adenocarcinoma occuring in the lower third of the esophagus. According to statistics, severity and elapsed time of gastroesophageal reflux disease (GERD) are major pathogenetic factors in the development of Barrett's esophagus. PATIENTS AND METHODS In a retrospective study between 2001 and 2008, we compared the preoperative results (signs and sympthoms, 24 hour pH manometry, esophageal manometry, Bilitec) and treatment efficacy of 176 GERD patients and 78 BE patients, who have undergone laparoscopic Nissen procedure for reflux disease. RESULTS The two groups of patients had similar demographic features, and elapsed time of reflux sympthoms were also equal. Both groups were admitted for surgery after a median time of 1.5 years (19.87 vs. 19.20 months) of ineffective medical (proton pump inhibitors) treatment. Preoperative functional tests showed a more severe presence of acid reflux in the BE group (DeMeester score 18.9 versus 41.9, p < 0.001). On the other hand, mano-metry - despite confirming lower esophageal sphincter (LES) damage - did not show difference between the two groups (12.10 vs. 12.57 mmHg, p = 0.892). We did not experience any mortality cases with laparoscopic antireflux procedures, although in two cases we had to convert during the operation (1 due to extensive adhesions, and 1 due to injury to the spleen). 3 months after the procedure - according to Visick score - both groups experienced a significant decrease, or lapse in reflux complaints (group I: 73%, group II: 81% of patients), LES functions improved (17.58 vs.18.70 mmHg), and the frequency and exposition of acid reflux decreased (DeMeester score 7.73 vs. 12.72). CONCLUSION The severity of abnormal acid reflux occuring parallel with the incompetent function of the damaged LES triggers not only inflammation in the gastroesophageal junction (GEJ), but also metaplastic process, and the development of Barrett's esophagus. Laparoscopic Nissen procedure for reflux disease can further improve outcome among patients with GERD not responding to conservative therapy.
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Affiliation(s)
- Simonka Zsolt
- Szegedi Tudományegyetem Sebészeti Klinika 6725 Szeged Pf. 427
| | - Attila Paszt
- Szegedi Tudományegyetem Sebészeti Klinika 6725 Szeged Pf. 427
| | - Tibor Géczi
- Szegedi Tudományegyetem Sebészeti Klinika 6725 Szeged Pf. 427
| | | | - Illés Tóth
- Szegedi Tudományegyetem Sebészeti Klinika 6725 Szeged Pf. 427
| | - Zoltán Horváth
- Szegedi Tudományegyetem Sebészeti Klinika 6725 Szeged Pf. 427
| | - József Pieler
- Szegedi Tudományegyetem Sebészeti Klinika 6725 Szeged Pf. 427
| | - János Tajti
- Szegedi Tudományegyetem Sebészeti Klinika 6725 Szeged Pf. 427
| | - Akos Varga
- Szegedi Tudományegyetem Sebészeti Klinika 6725 Szeged Pf. 427
| | | | | | - Ferenc Izbéki
- Szegedi Tudományegyetem I. Sz. Belgyógyászati Klinika Szeged
| | | | - Tibor Wittmann
- Szegedi Tudományegyetem I. Sz. Belgyógyászati Klinika Szeged
| | - György Lázár
- Szegedi Tudományegyetem Sebészeti Klinika 6725 Szeged Pf. 427
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