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He Y, Jin Z, Wang Y, Wu C, He X, Weng W, Cai X, Cheng K. Multifunctional Double-Loaded Oral Nanoplatform for Computed Tomography Imaging-Guided and Integrated Treatment of Inflammatory Bowel Disease. ACS NANO 2025; 19:14893-14913. [PMID: 40106686 DOI: 10.1021/acsnano.4c18865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/22/2025]
Abstract
Excessive reactive oxygen species, disruption of the epithelial barrier, immune dysregulation, and gut microbiota imbalance are key factors driving the onset of inflammatory bowel disease (IBD) and complicating its treatment. Prompt diagnosis of diseases and precise delivery of therapeutic agents to inflamed intestinal sites offer promising targeted strategies for effectively treating IBD. Here, a barium sulfate-based nanoplatform (BaSO4@PDA@CeO2/DSP, BPCD) for synergistic delivery of nanozymes and drugs was developed. With enhanced colonic retention after oral drug delivery, this nanoplatform enables precise and effective targeting of inflammatory sites and CT imaging guidance to address multiple factors contributing to IBD. A comprehensive therapeutic effect was achieved through the synergistic action of cerium oxide with the optimized Ce3+/Ce4+ ratio and sustained release of dexamethasone sodium phosphate. Benefiting from superior gastrointestinal stability, the nanoplatform is highly effective in treating IBD by alleviating oxidative stress, modulating macrophage polarization balance, gut flora composition, and repairing the epithelial barrier. BPCD inhibits the development of IBD through multiple mechanisms and has superior biocompatibility, emerging as a practical alternative to traditional IBD therapies.
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Affiliation(s)
- Yaoting He
- School of Materials Science and Engineering, State Key Laboratory of Silicon Materials, Center of Rehabilitation Biomedical Materials, Cyrus Tang Center for Sensor Materials and Applications, Zhejiang University, Hangzhou 310027, China
| | - Ziyang Jin
- Department of General Surgery, Minimally Invasive Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - YiFan Wang
- Department of General Surgery, Minimally Invasive Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Chengwei Wu
- School of Materials Science and Engineering, State Key Laboratory of Silicon Materials, Center of Rehabilitation Biomedical Materials, Cyrus Tang Center for Sensor Materials and Applications, Zhejiang University, Hangzhou 310027, China
| | - Xuzhao He
- School of Materials Science and Engineering, State Key Laboratory of Silicon Materials, Center of Rehabilitation Biomedical Materials, Cyrus Tang Center for Sensor Materials and Applications, Zhejiang University, Hangzhou 310027, China
| | - Wenjian Weng
- School of Materials Science and Engineering, State Key Laboratory of Silicon Materials, Center of Rehabilitation Biomedical Materials, Cyrus Tang Center for Sensor Materials and Applications, Zhejiang University, Hangzhou 310027, China
| | - Xiujun Cai
- Department of General Surgery, Minimally Invasive Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Kui Cheng
- School of Materials Science and Engineering, State Key Laboratory of Silicon Materials, Center of Rehabilitation Biomedical Materials, Cyrus Tang Center for Sensor Materials and Applications, Zhejiang University, Hangzhou 310027, China
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Ciriza de Los Ríos C, Gil Remezal L, Molano Nogueira FJ, García Pravia L, Sánchez Pernaute A, Rey E. Clinical and functional factors influencing the outcome of laparoscopic Nissen fundoplication. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2025. [PMID: 39831620 DOI: 10.17235/reed.2025.10615/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2025]
Abstract
BACKGROUND AND AIM Laparoscopic Nissen fundoplication (LNF) is the gold standard of antireflux surgery. Up to 30% of patients experience symptoms after surgery, with insufficient information available. The main objective is to evaluate epidemiological, clinical, and functional factors associated with symptoms after LNP. METHODS a retrospective case-control study including 79 operated patients (2015-2024). We assessed the relationship between epidemiological data, functional tests, and imaging study results with the occurrence of symptoms after LNF. RESULTS 24 asymptomatic and 55 symptomatic patients were included. Functional and imaging tests were normal in the majority of asymptomatic patients. IRP-4s (95th percentile) in asymptomatic patients is 20.4 mmHg. Female gender (OR 4, 95%CI; 1.1-14), preoperative dysphagia (OR 8.2, 95%CI: 1.4-47.6), and IRP-4s (OR 1.2, 95%CI: 1-1.3) are independent factors for postoperative dysphagia. Type-III esophagogastric junction morphology on high-resolution manometry (OR 6.1, 95%CI: 2.1-18.1) is independently associated with GERD symptoms. AET showed a trend toward being an independent factor but did not reach statistical significance (OR 1.1, 95%CI:1-1.3). Hiatal hernia in the esophagogram was associated with reintervention (OR 5.5, 95%CI: 1.6-19.1). CONCLUSIONS Asymptomatic patients mostly have normal functional tests after LNF, although IRP-4s normal value (95th percentile) is higher than proposed in the Chicago Classification. Preoperative dysphagia and female gender are independent factors for postoperative dysphagia, which should be considered in the preoperative assessment. Functional and imaging tests are essential in evaluating patients with postoperative symptoms. Dysphagia is associated with higher IRP while GERD symptoms are related to type-III-EGJ on HRM. Similarly, a hiatal hernia on the esophagogram is associated with reintervention.
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Affiliation(s)
| | - Laura Gil Remezal
- Gastroenterology, Hospital Clínico San Carlos. Universidad Complutense de Madrid, España
| | | | - Laura García Pravia
- Aparato Digestivo, Hospital Clínico San Carlos. Universidad Complutense de Madrid, España
| | - Andrés Sánchez Pernaute
- Gastrointestinal Surgery, Hospital Clínico San Carlos. Universidad Complutense de Madrid, España
| | - Enrique Rey
- Gastroenterology, Hospital Clínico San Carlos. Universidad Complutense de Madrid, España
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Pagadapelli AA, Shah J, Yewale R, Pujari R, Bapaye A. Peroral endoscopic myotomy plus natural orifice transluminal endoscopic wrap release for dysphagia after laparoscopic Heller myotomy and Dor fundoplication. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2025; 10:24-27. [PMID: 39925398 PMCID: PMC11806425 DOI: 10.1016/j.vgie.2024.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/11/2025]
Affiliation(s)
- Arun Arora Pagadapelli
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Jimil Shah
- Department of Gastroenterology, Post Graduate Institute of Medical Research, Chandigarh, India
| | - Rohan Yewale
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Rajendra Pujari
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
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Diehl DL. Top tips for pneumatic dilation of the lower esophageal sphincter (with video). Gastrointest Endosc 2024; 100:1095-1099. [PMID: 38942334 DOI: 10.1016/j.gie.2024.06.028] [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: 05/12/2024] [Revised: 06/12/2024] [Accepted: 06/17/2024] [Indexed: 06/30/2024]
Affiliation(s)
- David L Diehl
- Department of Gastroenterology and Hepatology, Geisinger Commonwealth School of Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
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Kohn GP, Hassan C, Lin E, Wong YHI, Morozov S, Mittal S, Thompson SK, Lin C, Chen D, Elliott J, Jahagirdar V, Newman N, Shukla R, Siersema P, Zaninotto G, Griffiths EA, Wijnhoven BP, ISDE Collaborating Members Group. International Society for Diseases of the Esophagus consensus on management of the failed fundoplication. Dis Esophagus 2024; 37:doae090. [PMID: 39444316 PMCID: PMC11605648 DOI: 10.1093/dote/doae090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2024] [Revised: 09/21/2024] [Accepted: 10/08/2024] [Indexed: 10/25/2024]
Abstract
Fundoplication is a durable, effective, and well-accepted treatment for gastroesophageal reflux disease. Nonetheless, troublesome postoperative symptoms do occasionally occur with management varying widely among centers. In an attempt to standardize definition and management of postfundoplication symptoms, a panel of international experts convened by the Guidelines Committee of the International Society for Diseases of the Esophagus devised a list of 33 statements across 5 domains through a Delphi approach, with at least 80% agreement to establish consensus. Eight statements were endorsed for the domain of Definitions, four for the domain of Investigations, nine for Dysphagia, nine for Heartburn, and four for Revisional surgery. This consensus defined as the treatment goal of fundoplication the resolution of symptoms rather than normalization of physiology or anatomy. Required investigations of all symptomatic postfundoplication patients were outlined. Further management was standardized by patients' symptomatology. The appropriateness of revisional fundoplication and the techniques thereof were described and the role of revisional surgery for therapies other than fundoplication were assessed. Fundoplication remains a frequently-performed operation, and this is the first international consensus on the management of various postfundoplication problems.
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Affiliation(s)
- Geoffrey P Kohn
- Eastern Health Clinical School Research Unit, Monash University, Melbourne, 3128, Australia
- Melbourne Upper GI Surgical Group, Melbourne, 3144, Australia
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Milan, 20072, Italy
- IRCCS Humanitas Research Hospital, Milan, 20089, Italy
| | - Edward Lin
- Department of Surgery, Emory University School of Medicine, Atlanta, 30322, USA
| | | | - Sergey Morozov
- Federal Research Center of Nutrition and Biotechnology, Moscow, 115446, Russia
- Russian Medical Academy of Continuing Professional Education, Moscow, 115446, Russia
| | - Sumeet Mittal
- Department of Surgery, Norton Thoracic Institute, Phoenix, 85013, USA
| | - Sarah K Thompson
- Department of Surgery, Flinders University, Adelaide, 5042, Australia
| | - Chelsea Lin
- Monash University Medical School, Melbourne, 3800, Australia
| | - David Chen
- Monash University Medical School, Melbourne, 3800, Australia
| | - Jordi Elliott
- Monash University Medical School, Melbourne, 3800, Australia
| | | | - Natasha Newman
- Monash University Medical School, Melbourne, 3800, Australia
| | | | - Peter Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, 6525, The Netherlands
| | - Giovanni Zaninotto
- Department of Surgery and Cancer, Imperial College London, London, W12 0NN, UK
| | - Ewen A Griffiths
- Department of Upper GI Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B5 7UG, UK
- University of Birmingham, Institute of Immunology and Immunotherapy, Birmingham, B15 2TT, UK
| | - Bas P Wijnhoven
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, 3015, The Netherlands
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Salehi N, Cygiel G, Marshall T, Al Asadi H, Tumati A, Turaga A, Alqamish M, Finnerty BM, Fahey TJ, Zarnegar R. Clinical outcomes of endoscopic balloon dilation for dysphagia after anti-gastroesophageal reflux surgery. Surg Endosc 2024; 38:6894-6900. [PMID: 39210060 DOI: 10.1007/s00464-024-11203-0] [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] [Received: 04/22/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Dysphagia is a potential complication following anti-gastroesophageal reflux surgery (ARS), with challenging management. Endoscopic balloon dilation is recommended for patients with significant dysphagia from tight wraps or strictures. We aim to evaluate factors associated with the need for post-ARS dilation and the outcomes of balloon dilation. Additionally, we assessed the predictors of sustained clinical failure after dilation. METHODS A retrospective analysis was conducted on patients who underwent robotic or laparoscopic ARS between January 2012 and April 2023. Patients were divided based on whether they received balloon dilation using a through-the-scope wire-guided dilator. Excluded were those with pre-existing achalasia, other dilation devices, or inadequate follow-up. RESULTS Of 1002 patients, 69 underwent 94 postoperative dilations, and the remainder were controls. The dilation cohort was older (63.78 vs. 56.14 years, P = 0.032) and had more magnetic sphincter augmentations (MSA) (P = 0.004), a prior history of ARS (P = 0.039), and a higher rate of laparoscopic surgery (P = 0.009) compared to controls. Of all dilations, 54 (57.5%) patients reported immediate dysphagia improvement, and 39 (41.5%) had sustained improvement. Sixteen (23.2%) patients required reoperation, primarily for hiatal hernia recurrence or slipped wrap. Multivariable logistic regression showed that MSA (OR 0.04, 95% CI 0.01-0.46, P = 0.031) and requiring multiple dilations (OR 0.16, CI 0.03-0.68) predicted sustained dilation failure. CONCLUSIONS Factors including older age, history of prior ARS, and MSA are correlated with higher post-ARS dilation rates. Although dilation improves symptoms in approximately half of patients initially, one-fourth may eventually require reoperation, mostly due to a slipped wrap or hernia recurrence. Thus, in cases of persistent dysphagia, consideration for surgical failure is important, and further imaging and workup are warranted. Patients who undergo MSA and those who have more than one dilation are more likely to experience dilation failure.
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Affiliation(s)
- Niloufar Salehi
- Department of Surgery, Division of Endocrine and Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA.
| | - Gala Cygiel
- Department of Surgery, Division of Endocrine and Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Teagan Marshall
- Department of Surgery, Division of Endocrine and Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Hala Al Asadi
- Department of Surgery, Division of Endocrine and Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Abhinay Tumati
- Department of Surgery, Division of Endocrine and Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Anjani Turaga
- Department of Surgery, Division of Endocrine and Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Maria Alqamish
- Department of Surgery, Division of Endocrine and Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Brendan M Finnerty
- Department of Surgery, Division of Endocrine and Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Thomas J Fahey
- Department of Surgery, Division of Endocrine and Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Rasa Zarnegar
- Department of Surgery, Division of Endocrine and Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
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Al Asadi H, Najah H, Li Y, Marshall T, Salehi N, Turaga A, Finnerty BM, Fahey TJ, Zarnegar R. Determination of causes of post-operative dysphagia after anti-reflux surgery based on intra-operative planimetry. Surg Endosc 2024; 38:5623-5633. [PMID: 39101988 DOI: 10.1007/s00464-024-11101-5] [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] [Received: 04/21/2024] [Accepted: 07/16/2024] [Indexed: 08/06/2024]
Abstract
INTRODUCTION Dysphagia after anti-reflux surgery (ARS) is one of the most common indications for re-operative anti-reflux surgery and a leading cause of patient dissatisfaction. Unfortunately, the factors affecting its development are poorly understood. We investigated the correlation between pre-operative manometric and the intra-operative impedance planimetry (EndoFLIP™) measurements and development of post-operative dysphagia. METHODS A review of patients who underwent index robotic ARS in our institution. Patients who underwent pre-operative manometry and intra-operative EndoFLIP™ were included in our study. Dysphagia was assessed pre-operatively and at 3-month after surgery. RESULTS Fifty-five patients (26.9%) reported post-operative dysphagia, and 34 (16.6%) reported new or worsening dysphagia. On pre-operative manometry, patients with post-operative dysphagia had a lower distal contractile integral [868.7 (IQR 402.2-1447) mmHg s cm vs 1207 (IQR 612.1-2111) mmHg s cm, p = 0.006) and lower esophageal sphincter (LES) pressure [14.7 IQR (8.9-23.6) mmHg vs 20.7 IQR (10.2-32.6) mmHg, p = 0.01] compared to those without post-operative dysphagia. They were also found to have higher pre-operative cross-sectional surface area (CSA) [83 IQR (44.5-112) mm2 vs 66 IQR (42-93) mm2, p = 0.02], and distensibility index (DI) [4.2 IQR (2.2-5.5) mm2/mmHg vs 2.9 IQR (1.6-4.6) mm2/mmHg, p = 0.003] compared to patients without post-operative dysphagia. Additionally, the decrease in CSA [- 34 (- 18.5, - 74.5) mm2 vs - 26.5 (- 10.5, - 53.7) mm2, p = 0.03] and DI [- 2.3 (- 1.2, - 3.7) mm2/mmHg vs - 1.6 (- 0.7, - 3.3) mm2/mmHg, p = 0.03] measurements were greater in patients with post-operative dysphagia. CONCLUSION Patients who developed dysphagia post-operatively had poorer pre-operative motility and a greater change in LES characteristics intra-operatively. This finding suggests the utility of pre-operative manometry and intra-operative EndoFLIP in identifying patients at risk of developing dysphagia post-operatively.
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Affiliation(s)
- Hala Al Asadi
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Haythem Najah
- Department of Digestive and Endocrine Surgery, Orleans University Hospital Center, 14 Avenue de L'hopital, 45067, Orleans, France
| | - Ying Li
- Department of Population and Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Teagan Marshall
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Niloufar Salehi
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Anjani Turaga
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Brendan M Finnerty
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Thomas J Fahey
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA
| | - Rasa Zarnegar
- Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA.
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Shah RH, Amin S. Emerging indications for third space endoscopy. Best Pract Res Clin Gastroenterol 2024; 71:101911. [PMID: 39209414 DOI: 10.1016/j.bpg.2024.101911] [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: 02/03/2024] [Accepted: 04/03/2024] [Indexed: 09/04/2024]
Abstract
This chapter will explore the recent advancements and innovations in the field of third space endoscopy. The traditional principles of per-oral endoscopic myotomy and endoscopic submucosal dissection have been applied to offer solutions to traditionally difficult to manage problems including esophageal diverticula, post-fundoplication dysphagia, post-sleeve gastrectomy stricture, bariatric procedure and Hirschsprung disease. Typically, these problems were managed surgically with potentially high rates of morbidity and mortality; however, the principles of third space endoscopy offer a safer and less invasive option for management. All of these applications of third space endoscopy are less than a decade old with some emerging in the last 1-2 years. In this chapter, we will explore the pathophysiology of these diseases and how third space endoscopy can offer a solution. We will also review the relevant literature along with the safety and effectiveness of the proposed innovations.
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Affiliation(s)
- Rahil H Shah
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami, Miami, FL, USA
| | - Sunil Amin
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami, Miami, FL, USA.
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Sanagapalli S, Plumb A, Lord RV, Sweis R. How to effectively use and interpret the barium swallow: Current role in esophageal dysphagia. Neurogastroenterol Motil 2023; 35:e14605. [PMID: 37103465 DOI: 10.1111/nmo.14605] [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: 01/26/2023] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND The barium swallow is a commonly performed investigation, though recent decades have seen major advances in other esophageal diagnostic modalities. PURPOSE The purpose of this review is to clarify the rationale for components of the barium swallow protocol, provide guidance on interpretation of findings, and describe the current role of the barium swallow in the diagnostic paradigm for esophageal dysphagia in relation to other esophageal investigations. The barium swallow protocol, interpretation, and reporting terminology are subjective and non-standardized. Common reporting terminology and an approach to their interpretation are provided. A timed barium swallow (TBS) protocol provides more standardized assessment of esophageal emptying but does not evaluate peristalsis. Barium swallow may have higher sensitivity than endoscopy for detecting subtle strictures. Barium swallow has lower overall accuracy than high-resolution manometry for diagnosing achalasia but can help secure the diagnosis in cases of equivocal manometry. TBS has an established role in objective assessment of therapeutic response in achalasia and helps identify the cause of symptom relapse. Barium swallow has a role in the evaluating manometric esophagogastric junction outflow obstruction, in some cases helping to identify where it represents an achalasia-like syndrome. Barium swallow should be performed in dysphagia following bariatric or anti-reflux surgery, to assess for both structural and functional postsurgical abnormality. Barium swallow remains a useful investigation in esophageal dysphagia, though its role has evolved due to advancements in other diagnostics. Current evidence-based guidance regarding its strengths, weaknesses, and current role are described in this review.
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Affiliation(s)
- Santosh Sanagapalli
- Department of Gastroenterology and Hepatology, St. Vincent's Hospital Sydney, Darlinghurst, Australia
- School of Clinical Medicine, St. Vincent's Healthcare Campus, University of New South Wales, Sydney, Australia
| | - Andrew Plumb
- Centre for Medical Imaging, University College London Hospital, London, UK
| | - Reginald V Lord
- Department of Surgery, University of Notre Dame School of Medicine, Sydney, Australia
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
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Sarici IS, Eriksson SE, Zheng P, Hoppo T, Jobe BA, Ayazi S. Need for frequent dilations after magnetic sphincter augmentation: an assessment of associated factors and outcomes. Surg Endosc 2023; 37:7159-7169. [PMID: 37336846 DOI: 10.1007/s00464-023-10197-5] [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] [Received: 04/01/2023] [Accepted: 06/02/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Dysphagia is the most common complaint after magnetic sphincter augmentation (MSA), with nearly one-third of patients requiring at least one dilation following MSA. A subset of patients require frequent dilations, but there is a paucity of data on the characteristics of this population. This study aimed to identify predictors of the need for frequent dilations within the first year after implant and to assess these patients' outcomes. METHODS This is a retrospective review of prospectively collected data of patients who underwent MSA over an 8-year period. Frequent dilations were defined as 2 or more dilations within 1 year of surgery. Patients completed baseline and 1-year postoperative GERD-HRQL questionnaires and objective physiology testing. Baseline demographic, clinical characteristics, and objective testing data were compared between patients who did and did not require frequent dilations. RESULTS A total of 697 (62.7% female) patients underwent MSA, with 62 (8.9%) patients requiring frequent dilation. At a mean (SD) of 12.3 (3.4) months follow-up, the frequent dilation group had higher median GERD-HRQL total scores (21.0 vs. 5.0, p < 0.001), PPI use (20.8% vs.10.1%, p = 0.023), dissatisfaction (46.7% vs. 11.6%, p < 0.001), and device removal (25.8% vs. 2.2%, p < 0.001) rates. Acid normalization was comparable (p = 0.997). Independent predictors of frequent dilation included preoperative odynophagia (OR 2.85; p = 0.001), IRP > 15 mmHg (OR 2.88; p = 0.006), and > 30% incomplete bolus clearance (OR 1.94; p = 0.004). At a mean (SD) of 15.7 (10.7) months, 28 (45.1%) patients underwent device removal after frequent dilation. Independent predictors of device removal after frequent dilation within 5 years of surgery were preoperative odynophagia (OR 7.18; p = 0.042), LES resting pressure > 45 mmHg (OR 28.5; p = 0.005), and ≥ 10% failed swallows (OR 23.5; p < 0.001). CONCLUSIONS The need for frequent dilations after MSA is a marker for poor symptom control, dissatisfaction, and device removal. Patients with preoperative odynophagia, high LES pressures, and poor esophageal motility should be counseled of their risk for these poor outcomes.
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Affiliation(s)
- Inanc S Sarici
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Sven E Eriksson
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Ping Zheng
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Toshitaka Hoppo
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
- Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Blair A Jobe
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
- Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Shahin Ayazi
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA.
- Department of Surgery, Drexel University, Philadelphia, PA, USA.
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Desai N, Kline M, Duncan D, Godiers M, Patel V, Keilin S, Jain AS. Expanding the role of pneumatic dilation for nonachalasia patients: a comparative study. Gastrointest Endosc 2023; 97:251-259. [PMID: 36228696 PMCID: PMC11273289 DOI: 10.1016/j.gie.2022.09.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/14/2022] [Accepted: 09/27/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Treatment options for nonachalasia obstructive disorders of the esophagogastric junction (EGJ) are limited. The aim of this study was to assess the treatment efficacy of pneumatic dilation (PD) for the disorders of EGJ outflow obstruction (EGJOO) and postfundoplication EGJ obstruction (PF-EGJO) and to assess attitudes regarding training in PD. METHODS This was a 2-part study. The main study was a prospective, single-center study comparing treatment outcomes after PD in patients with EGJOO and PF-EGJO, defined using manometry criteria, versus achalasia. Treatment success was defined as a post-PD Eckardt score (ES) of ≤2 at the longest duration of follow-up available. In a substudy, a 2-question survey was sent to 78 advanced endoscopy fellowship sites in the United States regarding training in PD. RESULTS Of the 58% of respondents to the advanced endoscopy program director survey, two-thirds reported no training in PD at their program. The primary rationale cited was lack of a clinical need for PD. Sixty-one patients (15 achalasia, 32 EGJOO, and 14 PF-EGJO) were included in the main study with outcomes available at a mean follow-up of 8.8 months. Overall, mean ES decreased from 6.30 to 2.89 (P < .0001), and a mean percentage of improvement in symptoms reported by patients was 55.3%. ES ≤2 was achieved by 33 of 61 patients (54.1%). CONCLUSIONS PD is an effective treatment for the nonachalasia obstructive disorders of the EGJ. There may be a current gap in training and technical expertise in PD.
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Affiliation(s)
- Nikita Desai
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Meredith Kline
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Debra Duncan
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marie Godiers
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vaishali Patel
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Steven Keilin
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anand S Jain
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
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How provocative tests in addition to wet swallows during high-resolution manometry can direct clinical management. Curr Opin Gastroenterol 2022; 38:402-410. [PMID: 35762700 DOI: 10.1097/mog.0000000000000848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Provocative tests have been advocated to address limitations of high-resolution manometry (HRM) with wet swallows. We describe the commonly used provocative manometric manoeuvres [rapid drink challenge (RDC), multiple rapid swallows (MRS), solid swallows and the solid test meal (STM)], compare their diagnostic yield and accuracy to wet swallows, and outline their role in directing clinical management. RECENT FINDINGS Provocative testing with RDC and STM identifies a proportion of achalasia cases missed by standard testing, and RDC can play a similar role to radiology in the evaluation of treatment response. In EGJOO, provocative testing with RDC and STM not only increase the diagnostic yield, but can also help differentiate between spurious cases and those representing true outflow obstruction likely to respond to achalasia-type therapies. MRS and STM can help determine the clinical relevance (or otherwise) of ineffective oesophageal motility, and in this setting, MRS may predict the likelihood of postfundoplication dysphagia. RDC and STM can help identify cases of postfundoplication dysphagia more likely to respond to dilatation. SUMMARY Provocative testing has been shown to increase diagnostic yield of HRM, clarify inconclusive diagnoses, allows corroboration of dysmotility with patient symptoms and helps direct clinical management.
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Pneumatische Dilatation ist zur Behandlung einer Dysphagie nicht zielführend. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022. [DOI: 10.1055/a-1781-8070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Patel DA, Yadlapati R, Vaezi MF. Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics. Gastroenterology 2022; 162:1617-1634. [PMID: 35227779 PMCID: PMC9405585 DOI: 10.1053/j.gastro.2021.12.289] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/03/2021] [Accepted: 12/12/2021] [Indexed: 12/13/2022]
Abstract
Dysphagia is a common symptom with significant impact on quality of life. Our diagnostic armamentarium was primarily limited to endoscopy and barium esophagram until the advent of manometric techniques in the 1970s, which provided the first reliable tool for assessment of esophageal motor function. Since that time, significant advances have been made over the last 3 decades in our understanding of various esophageal motility disorders due to improvement in diagnostics with high-resolution esophageal manometry. High-resolution esophageal manometry has improved the sensitivity for detecting achalasia and has also enhanced our understanding of spastic and hypomotility disorders of the esophageal body. In this review, we discuss the current approach to diagnosis and therapeutics of various esophageal motility disorders.
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Affiliation(s)
- Dhyanesh A. Patel
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Diego
| | - Rena Yadlapati
- Vanderbilt University Medical Center and Division of Gastroenterology, University of California San Diego
| | - Michael F. Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Diego
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Gkolfakis P, Lorenzo D, Blero D, Louis H, Lemmers A, Arvanitakis M, Eisendrath P, Devière J. Pneumatic dilation for the treatment of persistent post-laparoscopic fundoplication dysphagia: long-term efficacy and safety. Expert Rev Gastroenterol Hepatol 2022; 16:289-296. [PMID: 35235494 DOI: 10.1080/17474124.2022.2049241] [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
BACKGROUND Post-laparoscopic fundoplication (LF) dysphagia occurs in 5%-17% of patients and optimal management remains a topic of expert discussion. We assessed the efficacy and safety of pneumatic dilation (PD) in patients with persistent post-lLF dysphagia. METHODS Medical files of patients treated with PD for persistent post-fundoplication-associated dysphagia were reviewed. The primary outcome was long-term clinical success. Secondary endpoints were initial clinical success, dysphagia recurrence rate, and PD-related complication incidence. RESULTS Overall, 46 patients (74% women, 57.9±11.9 years) underwent 74 PD (mean: 1.6±0.8). A 30 mm, 35 mm, and 40 mm balloon was used in 45.9%, 43.2%, and 10.8%, respectively, of dilations. Among 45 patients with available follow-up, the overall long-term success rate of PD was 31/45 (68.9% [55.4-82.4]). Initial clinical success was 36/45 (80% [68.3-91.7]). Dysphagia recurred in 9 patients (25%; 95%CI 10.9-39.1) and 4 of these were effectively treated with a new dilation. Among 14 non-responders to PD, 11 underwent surgery. Four complications (2 perforations, 1 muscularis dilaceration, and 1 peri-procedural bleeding) occurred in 4 patients (incidence: 5.4% [95%CI; 0.3-10.6]) and were treated with partially covered self-expandable esophageal stents andhemostatic clips. CONCLUSIONS Pneumatic balloon dilation for post-fundoplication-associated symptoms is associated with a satisfactory long-term success rate and acceptable safety profile.
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Affiliation(s)
- Paraskevas Gkolfakis
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Diane Lorenzo
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel Blero
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Hubert Louis
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arnaud Lemmers
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Marianna Arvanitakis
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre Eisendrath
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Devière
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Debourdeau A, Vitton V, Barthet MA, Gonzalez JM. If pneumatic dilation is not enough efficient for post fundoplication dysphagia, is Per Oral Endoscopic Myotomy a good answer to manage it? Gut 2022; 71:221-222. [PMID: 33785553 DOI: 10.1136/gutjnl-2021-324238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 01/19/2023]
Affiliation(s)
- Antoine Debourdeau
- Endoscopy Unit, CHU Montpellier, Montpellier Univ, Montpellier, France .,Medicine Faculty, Montpellier Univ, Montpellier, France
| | - Véronique Vitton
- Gastroenterology Department, Assistance Publique Hopitaux de Marseille, Marseille, France
| | - Marc A Barthet
- Gastroenterology, Assistance Publique Hopitaux de Marseille, Marseille, France
| | - Jean-Michel Gonzalez
- Gastroenterology, Hopital Nord, Assistance Publique - Hôpitaux de Marseille, Marseille, France
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Rodríguez de Santiago E, Sanchez-Vegazo CT, Peñas B, Shimamura Y, Tanabe M, Álvarez-Díaz N, Parejo S, Kazuya S, Marcos-Carrasco N, Vazquez-Sequeiros E, Inoue H, Albillos A. Antireflux mucosectomy (ARMS) and antireflux mucosal ablation (ARMA) for gastroesophageal reflux disease: a systematic review and meta-analysis. Endosc Int Open 2021; 9:E1740-E1751. [PMID: 34790538 PMCID: PMC8589565 DOI: 10.1055/a-1552-3239] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 07/09/2021] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Antireflux mucosectomy (ARMS) and antireflux mucosal ablation (ARMA) are new endoscopic procedures for patients with gastroesophageal reflux disease (GERD). We conducted a meta-analysis to systematically assess the feasibility, clinical success, and safety of these procedures. Patients and methods We searched Embase, PubMed, and Cochrane Central from inception to October 2020. Overlapping reports, animal studies, and case reports were excluded. Our primary outcomes were clinical success and adverse events (AEs). Secondary outcomes included technical success, endoscopic esophagitis, 24-hour pH monitoring, and proton pump inhibitor (PPI) use. A random effects model was used to pool data. Results In total, 15 nonrandomized studies (12 ARMS, n = 331; 3 ARMA, n = 130) were included; 10 were conducted in patients with refractory GERD. The technical success rate was 100 %. The pooled short-term (first assessment within the first 6 months), 1-year, and 3-year clinical success rates were 78 % (95 % confidence interval [95 %CI] 70 %-85 %), 72% (95 %CI 47 %-92 %), and 73 % (95 %CI 65 %-81 %), respectively. ARMS and ARMA yielded similar clinical success. The proportion of patients off PPIs at 1 year was 64 % (95 %CI 52 %-75 %). There were significant drops ( P < 0.01) in validated clinical questionnaires scores, presence of esophagitis, and acid exposure time. The most common AE (11 %, 95 %CI 8 %-15 %) was dysphagia requiring dilation (7%, 95 %CI 5 %-11 %). Four cases of perforation were recorded, all in patients undergoing ARMS. Conclusions Our meta-analysis of nonrandomized studies suggests that ARMS and ARMA are safe and effective for patients with GERD.
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Affiliation(s)
- Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD, Universidad de Alcalá, Madrid, Spain
| | - Carlos Teruel Sanchez-Vegazo
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD, Universidad de Alcalá, Madrid, Spain
| | - Beatriz Peñas
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD, Universidad de Alcalá, Madrid, Spain
| | - Yuto Shimamura
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Mayo Tanabe
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | | | - Sofía Parejo
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD, Universidad de Alcalá, Madrid, Spain
| | - Sumi Kazuya
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Natalia Marcos-Carrasco
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD, Universidad de Alcalá, Madrid, Spain
| | - Enrique Vazquez-Sequeiros
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD, Universidad de Alcalá, Madrid, Spain
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD, Universidad de Alcalá, Madrid, Spain
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18
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Rodríguez de Santiago E, Albéniz E, Estremera-Arevalo F, Teruel Sanchez-Vegazo C, Lorenzo-Zúñiga V. Endoscopic anti-reflux therapy for gastroesophageal reflux disease. World J Gastroenterol 2021; 27:6601-6614. [PMID: 34754155 PMCID: PMC8554403 DOI: 10.3748/wjg.v27.i39.6601] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/01/2021] [Accepted: 08/31/2021] [Indexed: 02/06/2023] Open
Abstract
Gastroesophageal reflux disease has an increasing incidence and prevalence worldwide. A significant proportion of patients have a suboptimal response to proton pump inhibitors or are unwilling to take lifelong medication due to concerns about long-term adverse effects. Endoscopic anti-reflux therapies offer a minimally invasive option for patients unwilling to undergo surgical treatment or take lifelong medication. The best candidates are those with a good response to proton pump inhibitors and without a significant sliding hiatal hernia. Transoral incisionless fundoplication and nonablative radiofrequency are the techniques with the largest body of evidence and that have been tested in several randomized clinical trials. Band-assisted ligation techniques, anti-reflux mucosectomy, anti-reflux mucosal ablation, and new plication devices have yielded promising results in recent noncontrolled studies. Nonetheless, the role of endoscopic procedures remains controversial due to limited long-term and comparative data, and no consensus exists in current clinical guidelines. This review provides an updated summary focused on the patient selection, technical details, clinical success, and safety of current and future endoscopic anti-reflux techniques.
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Affiliation(s)
- Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid 28034, Spain
| | - Eduardo Albéniz
- Endoscopy Unit, Gastroenterology Department, Hospital Universitario de Navarra. Gastrointestinal Endoscopy Research Unit, Navarrabiomed Biomedical Research Center. Pamplona, Spain
| | - Fermin Estremera-Arevalo
- Endoscopy Unit, Gastroenterology Department, Hospital Universitario de Navarra. Gastrointestinal Endoscopy Research Unit, Navarrabiomed Biomedical Research Center. Pamplona, Spain
| | - Carlos Teruel Sanchez-Vegazo
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid 28034, Spain
| | - Vicente Lorenzo-Zúñiga
- Endoscopy Unit, Gastroenterology Department, Hospital Universitari i Politècnic La Fe, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia 46026, Spain
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Bredenoord AJ, Babaei A, Carlson D, Omari T, Akiyama J, Yadlapati R, Pandolfino JE, Richter J, Fass R. Esophagogastric junction outflow obstruction. Neurogastroenterol Motil 2021; 33:e14193. [PMID: 34120375 DOI: 10.1111/nmo.14193] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 12/13/2022]
Abstract
In the Chicago Classification version 4.0 (CCv4), esophagogastric junction outflow obstruction (EGJOO) is manometrically defined as an elevated median integrated relaxation pressure (IRP) and elevated intrabolus pressure (IBP) during supine wet swallows, and persistently elevated median IRP in the upright position. A clinically relevant conclusive diagnosis of EGJOO requires a manometric diagnosis of EGJOO and associated symptoms such as dysphagia and/or chest pain with at least one of the following supportive investigations (pharmacologic provocation, timed barium esophagogram, and/or endoflip). The Chicago Classification is intended for diagnosis of primary esophageal motor disorders, and thus history and endoscopic evaluation are important to exclude conditions (eg, previous surgery, strictures, or masses) that can secondarily generate the EGJOO pattern on HRM. While a manometric finding of EGJOO is often made and can be an early sign of achalasia, more often it is a manometric finding without clinical implications. The proposed changes in CC4.0 have attempted to make the diagnosis more specific, in order to reduce the number of clinically irrelevant diagnoses and avoid confusion by patients and physicians alike.
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Affiliation(s)
- Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Arash Babaei
- Division of Gastroenterology, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Dustin Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Taher Omari
- College or Medicine & Public Health, Flinders University, Adelaide, SA, Australia
| | - Jun Akiyama
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Rena Yadlapati
- Division of Gastroenterology & Hepatology, Center for Esophageal Diseases, University of California San Diego, La Jolla, CA, USA
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Joel Richter
- Joy McCann Culverhouse Center for Esophageal Diseases, University of South Florida College of Medicine, Tampa, FL, USA
| | - Ronnie Fass
- Esophageal and Swallowing Center, Division of Gastroenterology and Hepatology, Metrohealth Medical System, Case Western Reserve University, Cleveland, OH, USA
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