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Nimma IR, Al Jawish M, Koop A, Kumbhari V, Elli F, Badurdeen D. Breakthrough Contractions During Multiple Rapid Swallows on High-Resolution Esophageal Manometry: A Marker of Esophageal Dysmotility in Post-Bariatric Surgery Patients. Obes Surg 2025; 35:154-160. [PMID: 39658687 DOI: 10.1007/s11695-024-07604-8] [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: 10/11/2024] [Revised: 11/14/2024] [Accepted: 11/22/2024] [Indexed: 12/12/2024]
Abstract
BACKGROUND This study investigates multiple rapid swallows during high-resolution esophageal manometry (HREM) as an indicator of esophageal dysmotility following bariatric surgery. Gastrointestinal complications, including esophageal dysfunction, are common after bariatric surgery, and predictive markers are lacking. METHODS Retrospective analysis of adult patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2013 and 2023 and were subsequently evaluated by HREM. Contractile reserve (CR) and breakthrough contractions were assessed during MRS and HREM studies assessed by the Chicago Classification version 4.0. RESULTS Breakthrough contractions were found in 52.2% of patients undergoing HREM during multiple rapid swallows (MRS), including 70% of patients classified as normal manometry. Presence of breakthrough contractions correlated with greater DCI (1039 vs. 446 mmhg-s-cm, p = 0.05), and was more common after SG compared to RYGB (58.3% vs. 41.7%, p = 0.089) and in proton pump inhibitor users (100% vs. 72.7%, p = 0.093). Contractile reserve was observed in 56.5% of patients, similar to non-bariatric cohorts. CONCLUSIONS Breakthrough contractions are frequent in post-bariatric patients, even with normal manometry, suggesting early esophageal dysfunction. Sleeve gastrectomy patients showed a higher trend of these contractions, potentially due to increased intragastric pressure. Further studies are needed to understand long-term implications.
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Difante LDS, Trindade EN, Lopes ADB, Martins EF, Remus IB, Trindade MRM. CLINICAL RELEVANCE OF ESOPHAGEAL MOTILITY DISORDERS AFTER BARIATRIC SURGERY: A PROSPECTIVE STUDY BASED ON HIGH-RESOLUTION IMPEDANCE MANOMETRY. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2024; 37:e1842. [PMID: 39630843 DOI: 10.1590/0102-6720202400048e1842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2024] [Accepted: 10/09/2024] [Indexed: 12/07/2024]
Abstract
BACKGROUND There is recent evidence showing that obesity is associated with gastroesophageal reflux disease and esophageal dysmotility, although symptoms are not always present. AIMS This is a prospective study based on high-resolution manometry findings in bariatric surgery candidates and their correlation with postoperative dysphagia. METHODS Manometric evaluation was performed on candidates for bariatric surgery from 2022 to 2024. The examination was conducted according to the protocol of the fourth version of the Chicago Classification, including different positions and provocative maneuvers to confirm the diagnosis of dysmotility. Patients were followed for 90 days after surgery to verify the occurrence of dysphagia or difficulty adapting to the diet. RESULTS High-resolution manometry was performed on 46 candidates for bariatric surgery with a mean body mass index of 46.5 kg/m2. Esophagogastric junction outflow obstruction was diagnosed in 16 (34.8%) patients, and ineffective esophageal motility was diagnosed in 8 (17.4%) patients. None of the subjects reported symptoms during the preoperative period. Out of the 46 individuals initially included, 44 underwent bariatric surgery, 23 (52.3%) underwent Roux-en-Y gastric bypass, and 21 (47.7%) underwent sleeve gastrectomy. One patient with esophagogastric junction outflow obstruction reported dysphagia after Roux-en-Y bypass, but symptoms spontaneously resolved during the 90-day follow-up period. CONCLUSIONS Although patients with severe obesity have a high prevalence of esophageal motility disorders, no clinical repercussions were observed after bariatric surgery during the study period.
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Affiliation(s)
- Lucas Dos Santos Difante
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Department of Digestive Surgery - Porto Alegre (RS), Brazil
| | - Eduardo Neubarth Trindade
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Department of Digestive Surgery - Porto Alegre (RS), Brazil
| | - Antonio de Barros Lopes
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Department of Gastroenterology - Porto Alegre (RS), Brazil
| | - Eduardo Ferreira Martins
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Department of Digestive Surgery - Porto Alegre (RS), Brazil
| | - Isadora Bosini Remus
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Department of Digestive Surgery - Porto Alegre (RS), Brazil
| | - Manoel Roberto Maciel Trindade
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Department of Digestive Surgery - Porto Alegre (RS), Brazil
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He T, Wang P, Wang LX, Tong MH, Duan ZJ. Relationship of different metabolic obesity phenotypes with reflux esophagitis: a propensity score matching analysis. BMC Endocr Disord 2024; 24:239. [PMID: 39506726 PMCID: PMC11542364 DOI: 10.1186/s12902-024-01771-6] [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: 10/24/2023] [Accepted: 10/30/2024] [Indexed: 11/08/2024] Open
Abstract
BACKGROUND Obesity is associated with an increased risk of reflux esophagitis (RE). Metabolic abnormalities have been implicated in the pathogenesis of RE. However, the role of metabolic status in the risk of RE among individuals with varying degrees of obesity remains unclear. Therefore, our study aimed to assess the association between metabolic obesity phenotypes and the risk of RE. METHODS This study included a cohort of 24,368 participants aged 18 years and older who underwent upper gastrointestinal endoscopy at the First Affiliated Hospital of Dalian Medical University during health checkups between January 1, 2008, and December 31, 2021. Among these participants, a total of 9,947 individuals were classified into four groups based on their obesity phenotype: metabolically healthy normal weight (MHNW), metabolically healthy obesity (MHO), metabolically unhealthy normal weight (MUNW), and metabolically unhealthy obesity (MUO). To account for potential confounding factors, multivariate logistic regression analysis was applied to examine the association between metabolic obesity phenotypes and the risk of RE, with stratification by sex and age. RESULTS Among all participants, the MUNW, MHO, and MUO groups demonstrated a higher risk of RE when compared to the MHNW group. After controlling for all confounding factors, the MUO group exhibited the highest risk, with an odds ratio (OR) of 3.723 (95% CI: 2.751-5.040) in males and 5.482 (95% CI: 4.080-7.367) in females. The prevalence of RE increased in proportion to the number of metabolic risk factors. Subgroup analyses, which accounted for all confounders, revealed that the MHO, MUNW, and MUO phenotypes were associated with an elevated risk of RE in individuals under 60 years old as well as those over 60 years old. Interestingly, a more comprehensive analysis indicated that obesity may have a greater effect on the risk of RE than metabolic disorders. CONCLUSIONS Both metabolic disorders and obesity were associated with an increased risk of RE. The effect of obesity on RE prevalence may be stronger than that of metabolic disorders, emphasizing the significance of obesity regardless of metabolic health status. Clinical interventions should address not only obesity but also metabolic disorders in order to reduce the risk of RE.
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Affiliation(s)
- Tao He
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116011, China
- Dalian Central Laboratory of Integrative Neuro-gastrointestinal Dynamics and Metabolism Related Diseases Prevention and Treatment, Dalian, 116011, China
| | - Peng Wang
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116011, China
- Dalian Central Laboratory of Integrative Neuro-gastrointestinal Dynamics and Metabolism Related Diseases Prevention and Treatment, Dalian, 116011, China
| | - Li-Xia Wang
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116011, China
- Dalian Central Laboratory of Integrative Neuro-gastrointestinal Dynamics and Metabolism Related Diseases Prevention and Treatment, Dalian, 116011, China
| | - Meng-Han Tong
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116011, China
- Dalian Central Laboratory of Integrative Neuro-gastrointestinal Dynamics and Metabolism Related Diseases Prevention and Treatment, Dalian, 116011, China
| | - Zhi-Jun Duan
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116011, China.
- Dalian Central Laboratory of Integrative Neuro-gastrointestinal Dynamics and Metabolism Related Diseases Prevention and Treatment, Dalian, 116011, China.
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He T, Sun XY, Tong MH, Zhang MJ, Duan ZJ. Association Between Different Metabolic Obesity Phenotypes and Erosive Esophagitis: A Retrospective Study. Diabetes Metab Syndr Obes 2024; 17:3029-3041. [PMID: 39166154 PMCID: PMC11334917 DOI: 10.2147/dmso.s471499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 08/10/2024] [Indexed: 08/22/2024] Open
Abstract
Background and Aim Obesity is association with elevated risks of erosive esophagitis (EE), and metabolic abnormalities play crucial roles in its development. The aim of the study was to assess the association between metabolic obesity phenotypes and the risk of EE. Methods This retrospective study enrolled 11,599 subjects who had undergone upper gastrointestinal endoscopy at the First Affiliated Hospital of Dalian Medical University from January 1, 2008, to December 31, 2023. The enrolled individuals were grouped into four cohorts based on their metabolic health and obesity profiles, namely, metabolically healthy non-obesity (MHNO; n=2134, 18.4%), metabolically healthy obesity (MHO; n=1736, 15.0%), metabolically unhealthy non-obesity (MUNO; n=4290, 37.0%), and metabolically unhealthy obesity (MUO; n=3439, 29.6%). The relationships of the different phenotypes of metabolic obesity with the risks of developing EE in the different sexes and age groups were investigated by multivariate logistic regression analysis. Results The MUNO, MHO, and MUO cohorts exhibited elevated risks of developing EE than the MHNO cohort. The confounding factors were adjusted for, and the findings revealed that the MUO cohort exhibited the greatest risk of EE, with odds ratios (ORs) of 5.473 (95% CI: 4.181-7.165) and 7.566 (95% CI: 5.718-10.010) for males and females, respectively. The frequency of occurrence of EE increased following an increase in proportion of metabolic risk factors. Subgroup analyses showed that the individuals under and over 60 years of age in the MHO, MUNO, and MUO cohorts exhibited elevated risks of developing EE. Further analysis suggested that obesity has a stronger influence on the risks of developing EE compared to metabolic disorders. Conclusion Metabolic disorders and obesity are both related with an elevated risk of EE, in which obesity has a potentially stronger influence. Clinical interventions should target both obesity and metabolic disorders to reduce EE risk.
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Affiliation(s)
- Tao He
- Department of Gastroenterology, the First Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China
- Dalian Central Laboratory of Integrative Neuro-Gastrointestinal Dynamics and Metabolism Related Diseases Prevention and Treatment, Dalian, People’s Republic of China
| | - Xiao-Yu Sun
- Department of Gastroenterology, the First Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China
- Dalian Central Laboratory of Integrative Neuro-Gastrointestinal Dynamics and Metabolism Related Diseases Prevention and Treatment, Dalian, People’s Republic of China
| | - Meng-Han Tong
- Department of Gastroenterology, the First Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China
- Dalian Central Laboratory of Integrative Neuro-Gastrointestinal Dynamics and Metabolism Related Diseases Prevention and Treatment, Dalian, People’s Republic of China
| | - Ming-Jie Zhang
- Department of Gastroenterology, the First Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China
- Dalian Central Laboratory of Integrative Neuro-Gastrointestinal Dynamics and Metabolism Related Diseases Prevention and Treatment, Dalian, People’s Republic of China
| | - Zhi-Jun Duan
- Department of Gastroenterology, the First Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China
- Dalian Central Laboratory of Integrative Neuro-Gastrointestinal Dynamics and Metabolism Related Diseases Prevention and Treatment, Dalian, People’s Republic of China
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Ottoboni Brunaldi V, Ghanem OM, Abu Dayyeh BK. Physiological Archetypes of de novo Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy. FOREGUT: THE JOURNAL OF THE AMERICAN FOREGUT SOCIETY 2024; 4:140-149. [DOI: 10.1177/26345161231218918] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
Abstract
Laparoscopic Sleeve Gastrectomy (LSG) is the most common bariatric surgery in the world. While clinically effective, recent studies have shown increasingly higher rates of gastroesophageal reflux disease (GERD) and esophageal motility disorders. We reviewed all the literature and unraveled the underlying mechanism of post-LSG GERD. Finally, we propose a new classification to help us understand the disease and guide work-up, treatment, and future refinements in the surgical technique.
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Visaggi P, Ghisa M, Barberio B, Chiu PW, Ishihara R, Kohn GP, Morozov S, Thompson SK, Wong I, Hassan C, Savarino EV. Gastro-esophageal diagnostic workup before bariatric surgery or endoscopic treatment for obesity: position statement of the International Society of Diseases of the Esophagus. Dis Esophagus 2024; 37:doae006. [PMID: 38281990 PMCID: PMC11919618 DOI: 10.1093/dote/doae006] [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: 11/17/2023] [Accepted: 01/03/2024] [Indexed: 01/30/2024]
Abstract
Obesity is a chronic and multifactorial condition characterized by abnormal weight gain due to excessive adipose tissue accumulation that represents a growing worldwide challenge for public health. In addition, obese patients have an increased risk of hiatal hernia, esophageal, and gastric dysfunction, as well as gastroesophageal reflux disease, which has a prevalence over 40% in those seeking endoscopic or surgical intervention. Surgery has been demonstrated to be the most effective treatment for severe obesity in terms of long-term weight loss, comorbidities, and quality of life improvements and overall mortality decrease. The recent emergence of bariatric endoscopic techniques promises less invasive, more cost-effective, and reproducible approaches to the treatment of obesity. With the endorsement of the International Society for Diseases of the Esophagus, we started a Delphi process to develop consensus statements on the most appropriate diagnostic workup to preoperatively assess gastroesophageal function before bariatric surgical or endoscopic interventions. The Consensus Working Group comprised 11 international experts from five countries. The group consisted of gastroenterologists and surgeons with a large expertise with regard to gastroesophageal reflux disease, bariatric surgery and endoscopy, and physiology. Ten statements were selected, on the basis of the agreement level and clinical relevance, which represent an evidence and experience-based consensus of the International Society for Diseases of the Esophagus.
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Affiliation(s)
- Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- Digestive Endoscopy Unit, Pisa University Hospital, Pisa, Italy
| | - Matteo Ghisa
- Digestive Endoscopy Unit, Department of Gastroenterology, Padua University Hospital, Padua, Italy
| | - Brigida Barberio
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Philip W Chiu
- Department of Surgery, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Geoffrey P Kohn
- Department of Surgery, Monash University Eastern Health Clinical School, Melbourne, Australia
- Melbourne Upper GI Surgical Group, c/o Cabrini Hospital, Malvern, Australia
| | - Sergey Morozov
- Department of Gastroenterology, Hepatology and Nutrition, Federal Research Center of Nutrition, Biotechnology and Food Safety, Moscow, Russia
| | - Sarah K Thompson
- College of Medicine & Public Health, Flinders University, Bedford Park, Australia
| | - Ian Wong
- Department of Surgery, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Biomedical Sciences, Endoscopy Unit, IRCCS Humanitas Clinical and Research Center, Milan, Italy
| | - Edoardo Vincenzo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- Gastroenterology Unit, Azienda Ospedale Università of Padua, Padua, Italy
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Xie M, Deng L, Fass R, Song G. Obesity is associated with higher prevalence of gastroesophageal reflux disease and reflux related complications: A global healthcare database study. Neurogastroenterol Motil 2024; 36:e14750. [PMID: 38297487 DOI: 10.1111/nmo.14750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 01/08/2024] [Accepted: 01/16/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Prior studies have demonstrated that obesity may be associated with the development of gastroesophageal reflux disease (GERD) and GERD-related complications. However, such association has never been assessed in a global-wide real-world patient population. METHODS The TriNetX electronic health records network, which involves 92 healthcare organizations in 12 countries, was utilized for this multicenter global health research network study. The cohort with obesity comprised adult patients with body mass index (BMI) of more than 30 kg/m2. We performed 1:1 propensity score matching to decrease confounders effects. The prevalence of GERD and GERD-related complications including erosive esophagitis, Barrett's esophagus (BE), BE with dysplasia, and esophageal adenocarcinoma were assessed. RESULTS A total of 2,356,548 patients were included in the obesity and non-obesity groups after propensity score matching. In the group with obesity, patients had a significantly higher prevalence of GERD (30% vs. 24%, OR 1.35, 95% CI 1.34-1.36) compared to the group without obesity. Further analysis showed a higher prevalence of GERD-related complications in the group with obesity with statistical significance: Erosive esophagitis (OR 1.07, 95% CI 1.05-1.08), Barrett's esophagus (1.08, 1.05-1.10), BE with dysplasia (1.11, 1.04-1.18), esophageal cancer (1.32, 1.15-1.51). CONCLUSION Globally, obesity was associated with a higher prevalence of GERD and GERD-related complications.
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Affiliation(s)
- Mengdan Xie
- Division of Gastroenterology and Hepatology Department of Medicine MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Lifu Deng
- Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ronnie Fass
- Division of Gastroenterology and Hepatology Department of Medicine MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Gengqing Song
- Division of Gastroenterology and Hepatology Department of Medicine MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
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Maselli R, Fiacca M, Pellegatta G, de Sire R, De Blasio F, Capogreco A, Galtieri PA, Massimi D, Trotta M, Hassan C, Repici A. Peroral Endoscopic Myotomy for Achalasia after Bariatric Surgery: A Case Report and Review of the Literature. Diagnostics (Basel) 2023; 13:3311. [PMID: 37958207 PMCID: PMC10647658 DOI: 10.3390/diagnostics13213311] [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: 09/14/2023] [Revised: 10/07/2023] [Accepted: 10/18/2023] [Indexed: 11/15/2023] Open
Abstract
INTRODUCTION Achalasia following bariatric surgery is a rare phenomenon with diverse potential physiopathological origins. AIMS This article aims to explore the hypothetical physiopathological connection between bariatric surgery and the subsequent onset of achalasia. MATERIAL AND METHODS A review was conducted to identify studies reporting cases of peroral endoscopic myotomy (POEM) after bariatric procedures and detailing the outcomes in terms of the technical and clinical success. Additionally, a case of a successful POEM performed on a patient two years after undergoing laparoscopic sleeve gastrectomy (LSG) is presented. RESULTS The selection criteria yielded eight studies encompassing 40 patients treated with POEM for achalasia after bariatric surgery: 34 after Roux-en-Y gastric bypass (RYGB) and 6 after LSG. The studies reported an overall technical success rate of 97.5%, with clinical success achieved in 85% of cases. Adverse events were minimal, with only one case of esophageal leak treated endoscopically. However, a postprocedural symptomatic evaluation was notably lacking in most of the included studies. CONCLUSIONS Achalasia poses a considerable challenge within the bariatric surgery population. POEM has emerged as a technically viable and safe intervention for this patient demographic, providing an effective treatment option where surgical alternatives for achalasia are limited. Our findings highlight the promising outcomes of POEM in these patients, but the existing data remain limited. Hence, prospective studies are needed to elucidate the optimal pre-surgical assessment and timing of endoscopic procedures for optimizing outcomes.
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Affiliation(s)
- Roberta Maselli
- Humanitas Clinical and Research Center—IRCCS, 20089 Milan, Italy (C.H.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
| | - Matteo Fiacca
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
- Department of Surgery, Oncology and Gastroenterology, University of Padua, 35128 Padua, Italy
| | - Gaia Pellegatta
- Humanitas Clinical and Research Center—IRCCS, 20089 Milan, Italy (C.H.); (A.R.)
| | - Roberto de Sire
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
- Gastroenterology, Department of Clinical Medicine and Surgery, University Federico II, 80138 Naples, Italy
| | - Federico De Blasio
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
- Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, University Politecnica delle Marche, 60126 Ancona, Italy
| | - Antonio Capogreco
- Humanitas Clinical and Research Center—IRCCS, 20089 Milan, Italy (C.H.); (A.R.)
| | | | - Davide Massimi
- Humanitas Clinical and Research Center—IRCCS, 20089 Milan, Italy (C.H.); (A.R.)
| | - Manuela Trotta
- Humanitas Clinical and Research Center—IRCCS, 20089 Milan, Italy (C.H.); (A.R.)
| | - Cesare Hassan
- Humanitas Clinical and Research Center—IRCCS, 20089 Milan, Italy (C.H.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
| | - Alessandro Repici
- Humanitas Clinical and Research Center—IRCCS, 20089 Milan, Italy (C.H.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
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Barba Orozco E, Ezquerra Duran A. Study of gastroesophageal reflux. Interpretation of functional tests in the obese patient. Cir Esp 2023; 101 Suppl 4:S8-S18. [PMID: 37979941 DOI: 10.1016/j.cireng.2023.01.015] [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: 10/21/2022] [Accepted: 01/09/2023] [Indexed: 11/20/2023]
Abstract
Overweight and obesity are a public health problem and in 1997 obesity was recognized as a global epidemic by the World Health Organization (WHO). Overweight and obesity affect almost 60% of adults and one in three children in Europe according to the most recent WHO report. Objectively, gastroesophageal reflux disease (GERD) is defined as the presence of characteristic esophageal mucosal damage assessed by endoscopy and/or the demonstra-tion of pathological acid exposure by reflux monitoring studies. The prevalence of GERD is increased in obese patients In overweight and obese patients, the clinical symptoms of GERD are especially present in the supine position and this correlates with more frequent episodes of nocturnal reflux in the 24-h pH monitoring, there is also an increase in the number of refluxes with content acid. In the population with symptoms, digestive endoscopy detects data of erosive esophagitis in 50% of patients, while 24-h pH-impedanciometry diagnoses 92% of patients with non-erosive reflux disease (NERD) The presence of persistent GERD in the mucosa affects esophageal motility and patients may develop ineffective esophageal motility-type disorders, so we will review the interpre-tation of the functional tests that determine motility, which is esophageal manometry, and those that determine reflux gastroesophageal, acid and non-acid, which is the pH measure-ment with or without 24-h impedanciometry.
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Affiliation(s)
- Elizabeth Barba Orozco
- Gastroenterology Department, Neurogastroenterology and Motility Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain.
| | - Alberto Ezquerra Duran
- Gastroenterology Department, Neurogastroenterology and Motility Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
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Maev IV, Andreev DN, Ovsepyan MA, Barkalova EV. Gastroesophageal reflux disease: risk factors, current possibilities of diagnosis and treatment optimisation. MEDITSINSKIY SOVET = MEDICAL COUNCIL 2022:16-26. [DOI: 10.21518/2079-701x-2022-16-7-16-26] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
Gastroesophageal reflux disease (GERD) is one of the most common causes of health care seeking at the primary care level in many countries. At an epidemiological level, GERD has been shown to be associated with a number of risk factors: obesity, tobacco smoking, alcohol abuse, certain patterns of eating behaviour, and the use of several medications. GERD is now regarded as a heterogeneous disease and includes different phenotypes (erosive reflux disease, non-erosive reflux disease, hypersensitive oesophagus, functional heartburn), the proper diagnosis of which improves the effectiveness of therapy in patients with heartburn symptoms. Daily impedance–pH monitoring is known to be an integral part of the diagnostic algorithm for GERD and is a functional diagnostic method to record all types of refluxes entering the oesophagus regardless of pH, to assess their association with symptoms, and to determine whether patients with heartburn symptoms belong to a particular phenotype. Esophageal manometry plays a key role in the evaluation of patients with heartburn symptoms, as it helps to rule out other conditions that may mimic GERD: achalasia cardia and scleroderma esophagus. This technique is used to assess thoracic esophageal motility and sphincter function and in the assessment of patients prior to antireflux surgery or in the refractory course of GERD. The article describes in detail GERD risk factors (triggers of heartburn), as well as diagnostic aspects, taking into account a differentiated approach to patients with heartburn based on daily impedance–pH monitoring data in accordance with the current guidelines and recommendations.
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Affiliation(s)
- I. V. Maev
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - D. N. Andreev
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - M. A. Ovsepyan
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - E. V. Barkalova
- Yevdokimov Moscow State University of Medicine and Dentistry
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Role of Obesity, Physical Exercise, Adipose Tissue-Skeletal Muscle Crosstalk and Molecular Advances in Barrett's Esophagus and Esophageal Adenocarcinoma. Int J Mol Sci 2022; 23:ijms23073942. [PMID: 35409299 PMCID: PMC8999972 DOI: 10.3390/ijms23073942] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 02/07/2023] Open
Abstract
Both obesity and esophageal adenocarcinoma (EAC) rates have increased sharply in the United States and Western Europe in recent years. EAC is a classic example of obesity-related cancer where the risk of EAC increases with increasing body mass index. Pathologically altered visceral fat in obesity appears to play a key role in this process. Visceral obesity may promote EAC by directly affecting gastroesophageal reflux disease and Barrett’s esophagus (BE), as well as a less reflux-dependent effect, including the release of pro-inflammatory adipokines and insulin resistance. Deregulation of adipokine production, such as the shift to an increased amount of leptin relative to “protective” adiponectin, has been implicated in the pathogenesis of BE and EAC. This review discusses not only the epidemiology and pathophysiology of obesity in BE and EAC, but also molecular alterations at the level of mRNA and proteins associated with these esophageal pathologies and the potential role of adipokines and myokines in these disorders. Particular attention is given to discussing the possible crosstalk of adipokines and myokines during exercise. It is concluded that lifestyle interventions to increase regular physical activity could be helpful as a promising strategy for preventing the development of BE and EAC.
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Shah K, Raffa F, Naik RD. Obesity and esophageal dysmotility. OBESITY AND ESOPHAGEAL DISORDERS 2022:61-76. [DOI: 10.1016/b978-0-323-98365-5.00004-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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13
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Tesic-Rajkovic S, Radovanovic-Dinic B. Lesions in the oral cavity and esophagus caused by prescribed drugs: A review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2021; 166:21-27. [PMID: 34747416 DOI: 10.5507/bp.2021.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 10/18/2021] [Indexed: 11/23/2022] Open
Abstract
Almost all drugs, including some plant-based compounds, can have adverse effects, about 10% of which are expressed at the level of the digestive tract and in some cases resemble gastrointestinal diseases. Most commonly manifest as difficult and/or painful swallowing, nausea, vomiting, diarrhea and constipation. In rare cases, lesions caused by medications may be complicated by bleeding, strictures and perforations and can manifest in all segments of the gastrointestinal tract (GIT). The diagnosis is made from a detailed medical history and clinical examination inter alia. and best confirmed by proximal or distal endoscopy.
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Affiliation(s)
- Snezana Tesic-Rajkovic
- Faculty of Medicine, University of Nis, Serbia.,Clinic for Gastroenterology and Hepatology, University Clinical Center, Nis, Serbia
| | - Biljana Radovanovic-Dinic
- Faculty of Medicine, University of Nis, Serbia.,Clinic for Gastroenterology and Hepatology, University Clinical Center, Nis, Serbia
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Takahashi S, Matsumura T, Kaneko T, Tokunaga M, Oura H, Ishikawa T, Nagashima A, Shiratori W, Akizue N, Ohta Y, Kikuchi A, Fujie M, Saito K, Okimoto K, Maruoka D, Nakagawa T, Arai M, Kato J, Kato N. Clinical Characteristics of Esophageal Motility Disorders in Patients With Heartburn. J Neurogastroenterol Motil 2021; 27:545-554. [PMID: 34642275 PMCID: PMC8521463 DOI: 10.5056/jnm20131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/30/2020] [Accepted: 10/16/2020] [Indexed: 12/12/2022] Open
Abstract
Background/Aims Esophageal motility disorders (EMDs) contribute to the pathophysiology of gastroesophageal reflux disease. However, the causes of EMDs and their impact on gastroesophageal reflux disease-associated symptoms remain unknown. This study aims to elucidate clinical features associated with various types of EMDs in patients with heartburn symptoms. Methods Of the 511 patients who underwent high-resolution manometry, 394 who were evaluated for heartburn symptoms were examined. Patients subjected to high-resolution manometry were classified into 4 groups outflow obstruction group, hypermotility group, hypomotility group, and normal motility group. Symptoms were evaluated using 3 questionnaires. Patient characteristics and symptoms for each EMD type were compared with those of the normal motility group. Results Of the 394 patients, 193 (48.9%) were diagnosed with EMDs, including 71 with outflow obstruction, 15 with hypermotility, and 107 with hypomotility. The mean dysphagia score was significantly higher in each of the 3 EMD groups compared with those with normal motility. The mean acid reflux and dyspepsia scores were significantly lower in the outflow obstruction group (P < 0.05). The mean body mass index and median Brinkman index were significantly higher in the hypermotility group (P = 0.001 and P = 0.018, respectively), whereas the mean diarrhea and constipation scores were significantly lower in the hypomotility group (P < 0.05). Conclusions The results of our study indicate that different EMDs have distinct characteristics. Cigarette smoking and high body mass index were associated with esophageal hypermotility. Assessment of the dysphagia symptom scores may help identify patients with EMDs.
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Affiliation(s)
- Satsuki Takahashi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomoaki Matsumura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tatsuya Kaneko
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Mamoru Tokunaga
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hirotaka Oura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tsubasa Ishikawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ariki Nagashima
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Wataru Shiratori
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoki Akizue
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuki Ohta
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Atsuko Kikuchi
- Department of Clinical Engineering Center, Chiba University Hospital, Chiba, Japan
| | - Mai Fujie
- Department of Clinical Engineering Center, Chiba University Hospital, Chiba, Japan
| | - Keiko Saito
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kenichiro Okimoto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Daisuke Maruoka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomoo Nakagawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Makoto Arai
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Jun Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Herbella FAM, Patti MG. The Impact of Bariatric Procedures on Esophageal Motility. FOREGUT: THE JOURNAL OF THE AMERICAN FOREGUT SOCIETY 2021; 1:268-276. [DOI: 10.1177/26345161211043462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
Abstract
Bariatric operations may cause or cure gastroesophageal reflux disease (GERD). The comprehension of esophageal motility following different types of bariatric procedures may help understand the relationship between GERD and bariatric surgery. This review focused on the impact of bariatric procedures on esophageal motility. We found that lower esophageal sphincter resting pressure is increased after adjustable gastric banding; is unaltered or decreased after Roux-en-Y gastric bypass; and is decreased after sleeve gastrectomy. Lower esophageal sphincter relaxation may be abnormal after all these procedures. Esophageal body contractility is worsened after sleeve gastrectomy.
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Andreev DN, Kucheryavyy YA. Obesity as a risk factor for diseases of the digestive system. TERAPEVT ARKH 2021; 93:954-962. [PMID: 36286892 DOI: 10.26442/00403660.2021.08.200983] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 09/04/2021] [Indexed: 12/12/2022]
Abstract
Currently, the global prevalence of obesity among the worlds adult population is about 650 million people, which makes it possible to consider this chronic metabolic disease as a non-infectious pandemic of the 21st century. It has been proven that obesity is associated with several gastroenterological diseases, while the mechanisms of these associations are extremely heterogeneous and multifactorial. Hypertrophy and hyperplasia of adipocytes in obesity lead to a change in the profile of adipokine production (a decrease in adiponectin, an increase in leptin), an increase in the production of pro-inflammatory cytokines (interleukin-1, 6, 8, tumor necrosis factor ), C-reactive protein, free fatty acids, as well as active forms of oxygen (superoxide radicals, H2O2). All the above induces the development of chronic slowly progressive inflammation, oxidative stress, and insulin resistance. In addition, peptides secreted by adipocytes (adiponectin, leptin, nesfatin-1 and apelin) can modulate gastrointestinal motility, acting both centrally and peripherally. The qualitative and quantitative changes in the intestinal microbiota observed in obese patients (increased Firmicutes and decreased Bacteroidetes) lead to a decrease in the production of short-chain fatty acids and an increase in the intestinal permeability due to disruption of intercellular tight junctions, which leads to increased translocation of bacteria and endotoxins into the systemic circulation. Numerous studies have demonstrated the association of obesity with diseases of the esophagus (gastroesophageal reflux disease, Barretts esophagus, esophageal adenocarcinoma, esophageal motility disorders), stomach (functional dyspepsia, stomach cancer), gallbladder (cholelithiasis, gallbladder cancer), pancreas (acute pancreatitis, pancreatic cancer), liver (non-alcoholic fatty liver disease, hepatocellular carcinoma), intestine (diverticular disease, irritable bowel syndrome, colorectal cancer).
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Lemme EMDO, Alvariz AC, Pereira GLC. ESOPHAGEAL FUNCTIONAL DISORDERS IN THE PRE-OPERATORY EVALUATION OF BARIATRIC SURGERY. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:190-194. [PMID: 34190780 DOI: 10.1590/s0004-2803.202100000-34] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/11/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Obesity is an independent risk factor for esophageal symptoms, gastroesophageal reflux disease (GERD), and motor abnormalities. When contemplating bariatric surgery, patients with obesity type III undergo esophagogastroduodenoscopy (EGD) and also esophageal manometry (EMN), and prolonged pHmetry (PHM) as part of their pre-operative evaluation. OBJECTIVE Description of endoscopy, manometry and pHmetry findings in patients with obesity type III preparing for bariatric surgery, and correlation of these findings with the presence of typical GERD symptoms. METHODS Retrospective study in which clinical symptoms of GERD were assessed, focusing on the presence of heartburn and regurgitation. All patients underwent EMN, PHM and most of them EGD. RESULTS 114 patients (93 females-81%), average age 36 years old, average BMI of 45.3, were studied. Typical GERD symptoms were referred by 43 (38%) patients while 71 (62%) were asymptomatic. Eighty two patients (72% of total) underwent EGD and 36 (42%) evidenced esophageal abnormalities. Among the abnormal findings, hiatal hernia was seen in 36%, erosive esophagitis (EE) in 36%, and HH+EE in 28%. An abnormal EMN was recorded in 51/114 patients (45%). The main abnormality was a hypotensive lower esophageal sphincter (LES) in 32%, followed by ineffective esophageal motility in 25%, nutcracker esophagus in 19%, IEM + hypotensive LES in 10%, intra-thoracic LES (6%), hypertensive LES (4%), aperistalsis (2%) and achalasia (2%). Among the 43 symptomatic patients, 23 (53%) had abnormal EMN and 31/71 asymptomatic cases (44%) also presented this finding (P=0.30). PHM showed abnormal reflux in 60/114 patients (53%), with a predominance of bi-positional reflux (42%), followed by supine reflux (33%) and upright reflux (25%). Abnormal PHM was found in 26/43 symptomatic cases (60%) and also among 34/71 asymptomatic cases (48%) (P=0.19). CONCLUSION Manometric abnormalities were common in obesity type III patients, the most frequent being hypotensive LES, followed by IEM. Most patients were asymptomatic. There was no correlation between the finding of motor abnormalities and the presence of symptoms. More than half the patients had abnormal reflux at PHM. We found no significant correlation between abnormal reflux and the presence of symptoms.
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Affiliation(s)
| | - Angela Cerqueira Alvariz
- Universidade Federal do Rio de Janeiro, Departamento de Gastroenterologia, Rio de Janeiro, RJ, Brasil
| | - Guilherme Lemos Cotta Pereira
- Membro Titular do Colégio Brasileiro de Cirurgia Digestiva; Membro Titular da Sociedade Brasileira de Cirurgia Laparoscópica, Brasil
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Tian P, Fu J, Liu Y, Bian S, Li M, Zhang M, Liu J, Jin L, Zhang Z, Zhang P. Current status of gastroesophageal reflux disease after sleeve gastrectomy: Still a long way to go. Biosci Trends 2021; 15:305-312. [PMID: 34373428 DOI: 10.5582/bst.2021.01288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Obesity is a public health concern that is becoming increasingly more serious around the world. Bariatric surgery has become more prevalent due to the obesity epidemic worldwide. Sleeve gastrectomy (SG) is one of the most popular procedures which is safe and efficient. Despite all its favorable features, however, there is an increasing evidence from the literature that the long-term incidence of gastroesophageal reflux disease (GERD) is likely to represent the Achilles' heel of this procedure. Management of severe reflux after SG usually requires revisional surgery. The relationship between SG and GERD needs to be better ascertained in order to prevent related complications, such as esophageal adenocarcinoma. This review attempts to elucidate the effect of SG on GERD and the postoperative management of reflux disease according to recent literature in the hope of drawing the attention of clinicians to postoperative gastroesophageal reflux and guiding the optimal management strategy associated with this "troublesome complication".
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Affiliation(s)
- Peirong Tian
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Jing Fu
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yang Liu
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Shibo Bian
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Mengyi Li
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Meng Zhang
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Jia Liu
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Lan Jin
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Zhongtao Zhang
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
| | - Peng Zhang
- Division of Metabolic and Bariatric Surgery, Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
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Abstract
PURPOSE OF REVIEW Obesity is a major health epidemic, with the prevalence reaching ∼40% in the United States in recent years. It is associated with increased risk of hypertension, diabetes, heart disease, stroke, obstructive sleep apnea (OSA), and gynecologic conditions requiring surgery. Those comorbidities, in addition to the physiologic changes associated with obesity, lead to increased risk of perioperative complications. The purpose of this review is to highlight the anesthetic considerations for robotic assisted hysterectomy in obese patients. RECENT FINDINGS In the general gynecologic population, minimally invasive surgery is associated with less postoperative fever, pain, hospital length of stay, total cost of care and an earlier return to normal function. This also applies to robotic surgery in obese patients, which is on the rise. The physiologic changes of obesity bring different anesthetic challenges, including airway management and intraoperative ventilation. Vascular access and intraoperative blood pressure monitoring can also be challenging and require modifications. Optimizing analgesia with a focus on opioid-sparing strategies is crucial due to the increased prevalence of OSA in this patient population. SUMMARY Anesthesia for obese patients undergoing robotic hysterectomy is challenging and must take into consideration the anatomic and physiologic changes associated with obesity.
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Donatelli G, Cereatti F, Soprani A. Per Oral Endoscopic Myotomy for the Management of Achalasia in a Patient with Prior Lap Band, Sleeve Gastrectomy, and Roux-en-Y Gastric Bypass. Obes Surg 2021; 31:2843-2844. [PMID: 33856637 DOI: 10.1007/s11695-021-05370-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/06/2021] [Accepted: 03/22/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Achalasia after bariatric surgery is a rare pathological entity. Nonetheless, several cases have been described in literature. Per oral endoscopic myotomy has recently emerged as the preferred approach for the management of esophageal motility disorders. MATERIAL AND METHODS We report a video case of POEM performed in a female patient with prior multiple bariatric surgical procedures. In her past medical history, she underwent to laparoscopic lap band, sleeve gastrectomy, and Roux-Y-gastric bypass. RESULTS POEM was carried out without complication. Myotomy was performed only for 1 cm below the cardias due to the presence of the gastro-jejunal anastomosis. Post-operative course was uneventful and oral diet was restarted after one day. At 2 months follow-up, the patient is asymptomatic with no weight regain. CONCLUSION We report the first case of POEM after three different bariatric surgical procedure. Fibrosis due to prior interventions did not hampered POEM procedure, and the shorter myotomy due to the presence of small gastric pouch did not reduced its efficacy.
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Affiliation(s)
- Gianfranco Donatelli
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, 8 Place de l'Abbé G. Hénocque 75013 Ramsay Santé, Paris, France.
| | - Fabrizio Cereatti
- Unité d'Endoscopie Interventionnelle, Hôpital Privé des Peupliers, 8 Place de l'Abbé G. Hénocque 75013 Ramsay Santé, Paris, France
| | - Antoine Soprani
- Service de Chirurgie Digestive, Clinique Geoffroy Saint Hilaire, Ramsay Santé, Paris, France
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de Mello Del Grande L, Herbella FAM, Katayama RC, Lima WG, Patti MG. Transdiaphragmatic Pressure Gradient (TPG) Has a Central Role in the Pathophysiology of Gastroesophageal Reflux Disease (GERD) in the Obese and it Correlates with Abdominal Circumference but Not with Body Mass Index (BMI). Obes Surg 2021; 30:1424-1428. [PMID: 31858395 DOI: 10.1007/s11695-019-04345-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Pathophysiology of gastroesophageal reflux disease (GERD) is multifactorial. An increased transdiaphragmatic pressure gradient (TPG) may be a main element for GERD in the obese patient. This study aims to evaluate the role of TPG in the physiopathology of GERD in obese individuals. METHODS We studied 47 unselected consecutive candidates for bariatric operations (body mass index (BMI) > 35). All patients underwent high-resolution manometry and esophageal pH monitoring. Individuals were grouped as GERD + or GERD - based on DeMeester score. Abdominal pressure (AP) and thoracic pressure (TP), transdiaphragmatic pressure gradient (AP-TP), and lower esophageal sphincter (LES) retention pressure (LES basal pressure-TPG) were determined. Manometric variables were compared with a group of 20 lean healthy individuals (BMI < 25). RESULTS There were 27 (57%) GERD + patients and 20 (43%) GERD - patients. TPG, waist circumference, LES retention pressure, and AP were higher in GERD + group as compared with GERD - individuals. GERD - group had manometric parameters similar to controls except for AP. GERD + patients had higher AP and TPG and lower LES retention pressure compared with controls. TPG and LES retention pressure correlated with waist circumference and DeMeester score. BMI correlated with AP but not with waist circumference or DeMeester score. CONCLUSION In the obese, GERD presence and severity were associated to a high TPG due to increase AP that correlates with waist circumference.
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Affiliation(s)
- Leonardo de Mello Del Grande
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil
| | - Fernando Augusto Mardiros Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil.
| | - Rafael Caue Katayama
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil
| | - William Guidini Lima
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil
| | - Marco G Patti
- Department of Medicine and Surgery, University of North Carolina, Chapel Hill, NC, USA
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Kolb JM, Jonas D, Funari MP, Hammad H, Menard-Katcher P, Wagh MS. Efficacy and safety of peroral endoscopic myotomy after prior sleeve gastrectomy and gastric bypass surgery. World J Gastrointest Endosc 2020; 12:532-541. [PMID: 33362906 PMCID: PMC7739145 DOI: 10.4253/wjge.v12.i12.532] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/10/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Per-oral endoscopic myotomy (POEM) is safe and effective for the treatment of achalasia. There is limited data on performance of POEM in patients with altered upper gastrointestinal anatomy, especially after bariatric surgery. Outcomes in patients with prior sleeve gastrectomy have not been reported. AIM To assess the efficacy and safety of POEM in patients with prior bariatric surgery. METHODS A prospective POEM database was reviewed from 3/2017-5/2020 to identify patients who underwent POEM after prior bariatric surgery. Efficacy was assessed by technical success (defined as the ability to successfully complete the procedure) and clinical success [decrease in Eckardt score (ES) to ≤ 3 post procedure]. Safety was evaluated by recording adverse events. RESULTS Six patients (50% male, mean age 48 years) with a history of prior bariatric surgery who underwent POEM were included. Three had prior sleeve gastrectomy (SG) and three prior Roux-en-Y gastric bypass (RYGB). Four patients had achalasia subtype II and 2 had type I. Most (4) patients had undergone previous achalasia therapy. Technical success was 100%. Clinical success was achieved in 4 (67%) patients at mean follow-up of 21 mo. In one of the clinical failures, EndoFLIP evaluation demonstrated adequate treatment and candida esophagitis was noted as the likely cause of dysphagia. There were no major adverse events. CONCLUSION POEM is technically feasible after both RYGB and SG and offers an effective treatment for this rare group of patients where surgical options for achalasia are limited.
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Affiliation(s)
- Jennifer M Kolb
- Division of Gastroenterology, University of Colorado-Denver, Aurora, CO 80045, United States
| | - Daniel Jonas
- Department of Internal Medicine, University of Colorado Hospital, Aurora, CO 80045, United States
| | - Mateus Pereira Funari
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São paulo 05403000, São paulo, Brazil
| | - Hazem Hammad
- Division of Gastroenterology, University of Colorado-Denver, Aurora, CO 80045, United States
| | - Paul Menard-Katcher
- Division of Gastroenterology, University of Colorado-Denver, Aurora, CO 80045, United States
| | - Mihir S Wagh
- Interventional Endoscopy, Division of Gastroenterology, University of Colorado-Denver, Aurora, CO 80045, United States
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Postobesity Surgery Esophageal Dysfunction: A Combined Cross-Sectional Prevalence Study and Retrospective Analysis. Am J Gastroenterol 2020; 115:1669-1680. [PMID: 32558689 DOI: 10.14309/ajg.0000000000000733] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Esophageal dysmotility including features of achalasia may develop because of bariatric surgery. However, the prevalence of these complications is unknown. We sought to define the prevalence of dysphagia and major esophageal motility disorders including achalasia after bariatric surgery through a large retrospective database review. METHODS Patients with a history of laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass who underwent a diagnostic high-resolution impedance manometry (HRIM) either before or after bariatric surgery across 3 large tertiary referral sites from June 2012 through February 2019 were identified from a procedural database. HRIM studies were interpreted per the Chicago classification v3.0 by a blinded investigator (K.R.). Demographic/clinical features were collected. In addition, patients who underwent bariatric surgery from January 2014 to April 2015 were contacted and administered a validated symptom assessment survey to gauge the overall prevalence of dysphagia in a postbariatric population. RESULTS A total of 137 patients were identified, including 97 who underwent HRIM after bariatric surgery (laparoscopic sleeve gastrectomy [n = 39, 40.1%]; Roux-en-Y gastric bypass [n = 58, 59.8%]) at a median of 5.84 years (interquartile range 2.1-12.5) postoperatively and 40 preoperative bariatric surgery candidates with medically complicated obesity. A manometric pattern consistent with achalasia was identified in 7 (7.2%) postsurgical patients compared with none in the preoperative group (P = 0.08). We further identified a separate achalasia-like pattern defined by aperistalsis and increased intragastric pressure (postobesity surgery esophageal dysfunction [POSED]) in 5 (5.2%) postsurgical patients vs none found preoperatively (P = 0.14). Achalasia or POSED was associated with postbariatric surgery (12.4% vs 0%, P = 0.02). Increasing time since surgery was independently associated with the development of achalasia (median 12.5 vs 5.8 years, P = 0.02), POSED (median 15.0 vs 5.8 years, P = 0.02) and major motility disorders (6.6 vs 4.9 years, P = 0.01). Furthermore, among 271 postbariatric surgery patients contacted for symptom assessment via survey, the prevalence of dysphagia was 13.7% at a mean 3.9 years after surgery. DISCUSSION Postoperative dysphagia is a common long-term complication of bariatric surgery. This is potentially the consequence of a time-dependent association with the development of postoperative esophageal dysmotility, particularly achalasia and POSED. Consequently, esophageal dysmotility may be an important under-recognized complication of bariatric surgery.
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Mechanical Ventilation Guided by Uncalibrated Esophageal Pressure May Be Potentially Harmful. Anesthesiology 2020; 133:145-153. [PMID: 32349074 DOI: 10.1097/aln.0000000000003327] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Esophageal balloon calibration was proposed in acute respiratory failure patients to improve esophageal pressure assessment. In a clinical setting characterized by a high variability of abdominal load and intrathoracic pressure (i.e., pelvic robotic surgery), the authors hypothesized that esophageal balloon calibration could improve esophageal pressure measurements. Accordingly, the authors assessed the impact of esophageal balloon calibration compared to conventional uncalibrated approach during pelvic robotic surgery. METHODS In 30 adult patients, scheduled for elective pelvic robotic surgery, calibrated end-expiratory and end-inspiratory esophageal pressure, and the associated respiratory variations were obtained at baseline, after pneumoperitoneum-Trendelenburg application, and with positive end-expiratory pressure (PEEP) administration and compared to uncalibrated values measured at 4-ml filling volume, as per manufacturer recommendation. Data are expressed as median and [25th, 75th percentile]. RESULTS Ninety calibrations were successfully performed. Chest wall elastance worsened with pneumoperitoneum-Trendelenburg and PEEP (19.0 [15.5, 24.6] and 16.7 [11.4, 21.7] cm H2O/l) compared to baseline (8.8 [6.3, 9.8] cm H2O/l; P < 0.0001 for both comparisons). End-expiratory and end-inspiratory calibrated esophageal pressure progressively increased from baseline (3.7 [2.2, 6.0] and 7.7 [5.9, 10.2] cm H2O) to pneumoperitoneum-Trendelenburg (6.2 [3.8, 10.2] and 16.1 [13.1, 20.6] cm H2O; P = 0.014 and P < 0.001) and PEEP (8.8 [7.7, 15.6] and 18.9 [16.3, 22.0] cm H2O; P < 0.0001 vs. baseline for both comparison; P < 0.001 and P = 0.002 vs. pneumoperitoneum-Trendelenburg) and, at each study step, they were persistently lower than uncalibrated esophageal pressure (P < 0.0001 for all comparisons). Overall, difference among uncalibrated and calibrated esophageal pressure was 5.1 [3.8, 8.4] cm H2O at end-expiration and 3.8 [3.0, 6.3] cm H2O at end-inspiration. Uncalibrated esophageal pressure swing was always lower than calibrated one (P < 0.0001 for all comparisons) with a difference of -1.0 [-1.8, -0.4] cm H2O. CONCLUSIONS In a clinical setting with variable chest wall mechanics, uncalibrated measurements substantially overestimated absolute values and underestimated respiratory variations of esophageal pressure. Calibration could substantially improve mechanical ventilation guided by esophageal pressure.
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Tajima H, Narasaka T, Akutsu D, Suzuki H, Matsui H, Maruo K, Yamasaki H, Mizokami Y. The Risks of Exfoliative Esophagitis in Patients with Atrial Fibrillation: A retrospective observational study. Medicine (Baltimore) 2020; 99:e21681. [PMID: 32872038 PMCID: PMC7437837 DOI: 10.1097/md.0000000000021681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The aging of the population has resulted in atrial fibrillation (AF) becoming increasingly prevalent. Treatment focuses on the prevention of thromboembolism through the use of catheter ablation or drug therapy with anticoagulants, such as warfarin or direct oral anticoagulants (DOACs). Dabigatran-induced exfoliative esophagitis has been reported as a rare side effect of DOACs. Although most cases are mild, some result in severe outcomes. However, the etiology of exfoliative esophagitis remains incompletely understood. The aim of this study is to investigate the etiology of exfoliative esophagitis and identify its risk factors by observational study.The participants were 524 patients using anticoagulants who received catheter ablation for AF and subsequently underwent upper gastrointestinal endoscopy at University of Tsukuba Hospital. Exfoliative esophagitis was noted in 21 (4.0%) patients. Potential risk factors for exfoliative esophagitis were examined retrospectively by comparing patients with and without this condition across the following parameters that were extracted retrospectively from the electronic medical records: physical characteristics, comorbidities, blood-based cardiac markers, echocardiographic and endoscopic findings, and current medications.Regarding physical characteristics, patients with exfoliative esophagitis had significantly higher body weight and BMI. No association was observed between exfoliative esophagitis and comorbidities. Associations were also not found for cardiac markers, echocardiographic findings, or endoscopic findings. In terms of current medications, patients receiving oral dabigatran showed the highest prevalence of exfoliative esophagitis at 8.8% (13/148). The adjusted odds ratio of dabigatran for exfoliative esophagitis was 10.3 by multivariable logistic regression analysis.Obesity and oral dabigatran were found to be significant risk factors for exfoliative esophagitis.
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Affiliation(s)
| | | | | | | | | | | | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Schlottmann F, Dreifuss NH, Patti MG. Obesity and esophageal cancer: GERD, Barrett´s esophagus, and molecular carcinogenic pathways. Expert Rev Gastroenterol Hepatol 2020; 14:425-433. [PMID: 32441160 DOI: 10.1080/17474124.2020.1764348] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Increases in the rates of esophageal adenocarcinoma (EAC) have paralleled rises in the prevalence of overweight and obesity. Despite not being fully understood, obesity-related EAC seems to have different carcinogenic pathways. AREAS COVERED This comprehensive review will thoroughly evaluate the current literature, describing the underlying mechanisms that help understanding the strong association between obesity and esophageal cancer. EXPERT COMMENTARY The risk of esophageal cancer among obese individuals could be partially explained by several factors: high prevalence of GERD; linear association between central adiposity and Barrett´s esophagus development; low levels of adiponectin and high levels of leptin that alter cell proliferation processes; insulin-resistant state that creates a tumorigenesis environment; and changes in the esophageal microbiota due to unhealthy dietary habits that promote carcinogenesis. In addition, a large proportion of obese patients are undergoing sleeve gastrectomy which can worsen GERD or cause de novo reflux, esophagitis, and Barrett´s metaplasia.
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Affiliation(s)
| | - Nicolás H Dreifuss
- Department of Surgery, Hospital Alemán of Buenos Aires , Buenos Aires, Argentina
| | - Marco G Patti
- Department of Medicine and Surgery, University of North Carolina , Chapel Hill, NC, USA
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27
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Singendonk M, Kritas S, Omari T, Feinle-Bisset C, Page AJ, Frisby CL, Kentish SJ, Ferris L, McCall L, Kow L, Chisholm J, Khurana S. Upper Gastrointestinal Function in Morbidly Obese Adolescents Before and 6 Months After Gastric Banding. Obes Surg 2019; 28:1277-1288. [PMID: 29103072 DOI: 10.1007/s11695-017-3000-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The effects of laparoscopic adjustable gastric band (LAGB) placement on upper gastrointestinal tract function in obese adolescents are unknown. Therefore, our aim was to determine the short-term effects of LAGB on esophageal motility, gastroesophageal reflux, gastric emptying, appetite-regulatory hormones, and perceptions of post-prandial hunger and fullness. METHODS This study was part of a prospective cohort study (March 2009-December 2015) in one tertiary referral hospital. The study included obese adolescents (14-18 years) with a body mass index (BMI) > 40 (or ≥ 35 with comorbidities). Gastric emptying was assessed by 13C-octanoic acid breath test, pharyngeal, and esophageal motor function by high-resolution manometry with impedance (HRIM), and appetite and other perceptions using 100-mm visual analogue scales. Dysphagia symptoms were scored using a Dakkak questionnaire. Data were compared pre- and post-LAGB placement and at a 6-month follow-up. RESULTS Based upon analysis of 15 adolescents, at the 6-month follow-up, LAGB placement: (i) led to a significant reduction in weight and BMI; (ii) increased fullness and decreased hunger post-meal; (iii) increased symptoms of dysphagia after solid food; and, despite these effects, (iv) caused little or no changes to appetite hormones, while (v) effects on gastric emptying, esophageal motility, esophageal bolus transport, and esophageal emptying were not significant. CONCLUSION In adolescents, LAGB improved BMI and altered the sensitivity to nutrients without significant effects on upper gastrointestinal tract physiology at the 6-month follow-up.
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Affiliation(s)
- M Singendonk
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/AMC, Amsterdam, The Netherlands
| | - S Kritas
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia
| | - T Omari
- Human Physiology, Medical Science and Technology, School of Medicine, Flinders University, Adelaide, South Australia, Australia.
| | - C Feinle-Bisset
- Centre for Nutrition and Gastrointestinal Diseases, Adelaide Medical School, University of Adelaide, Adelaide, Australia.,NHMRC Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, Australia
| | - A J Page
- South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia
| | - C L Frisby
- Centre for Nutrition and Gastrointestinal Diseases, Adelaide Medical School, University of Adelaide, Adelaide, Australia.,South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia
| | - S J Kentish
- Centre for Nutrition and Gastrointestinal Diseases, Adelaide Medical School, University of Adelaide, Adelaide, Australia.,South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia
| | - L Ferris
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia.,Human Physiology, Medical Science and Technology, School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - L McCall
- Gastroenterology Unit, Women's & Children's Hospital, Adelaide, Australia
| | - L Kow
- Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - J Chisholm
- Department of Surgery, Flinders Medical Centre, Adelaide, Australia
| | - S Khurana
- Paediatric Surgery & Urology, Women's & Children's Hospital, Adelaide, Australia.,Department of Surgery, Flinders Medical Centre, Adelaide, Australia
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Friedman DT, Duffy AJ. Outcomes of routine upper gastrointestinal series screening and surveillance after laparoscopic adjustable gastric banding. Surg Endosc 2019; 34:2178-2183. [PMID: 31346752 DOI: 10.1007/s00464-019-07005-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/19/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Esophageal dilatation and dysmotility are known complications of the laparoscopic adjustable gastric band (LAGB), but their incidence varies widely in the literature. There are no formal recommendations guiding surveillance for these potentially underdiagnosed pathologies. This study demonstrates the utility and outcomes of a yearly upper gastrointestinal series screening protocol to detect and manage esophageal dysfunction after LAGB. METHODS We reviewed charts for all patients presenting for an outpatient surgical encounter related to LAGB between January 1, 2015 and December 31, 2017. Exclusion criteria included failure to undergo UGIS 6 months or more after band placement, or having undergone band placement in combination with another bariatric procedure. Descriptive statistics were used to characterize demographics, imaging findings and surgical outcomes. All imaging classifications were based on final radiologist report. Means were compared using a Student's t test. RESULTS A total of 322 records were reviewed with 39 patients excluded; 31 without UGIS and 8 with concomitant gastric bypass. 85% were female with an average age of 50 years. 66.8% identified as white or Caucasian with 24.7% black/African-American. Greater than 75% of the cohort had at least 5-year follow-up interval. UGIS was performed for symptoms in 66.1% and for routine screening in 33.9%. Of asymptomatic patients, 47.9% demonstrated esophageal dilatation or dysmotility on UGIS, similar to 51.3% of symptomatic patients. 96.8% of all patients went on to band removal. Sixty-four patients had repeat UGIS an average of 8 months following band removal, of which 40.6% were persistently abnormal. CONCLUSIONS The incidence of esophageal pathology was significantly higher than most reported series, as was the number of patients with persistently abnormal UGIS despite band removal. The data supports our policy of yearly UGIS for all post-LAGB patients, with strong recommendation for band removal if esophageal dilatation or dysmotility is found.
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Affiliation(s)
- Danielle T Friedman
- Department of Surgery, Gastrointestinal Section, Yale University, New Haven, CT, USA.
- Department of Surgery, Jacobi Medical Center, 1400 Pelham Parkway South, Building 1, 2N25, Bronx, NY, 10461, USA.
| | - Andrew J Duffy
- Department of Surgery, Gastrointestinal Section, Yale University, New Haven, CT, USA
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Challenges of Robotic Gynecologic Surgery in Morbidly Obese Patients and How to Optimize Success. Curr Pain Headache Rep 2019; 23:51. [DOI: 10.1007/s11916-019-0788-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Schlottmann F, Nayyar A, Herbella FAM, Patti MG. Preoperative Evaluation in Bariatric Surgery. J Laparoendosc Adv Surg Tech A 2018; 28:925-929. [PMID: 30004270 DOI: 10.1089/lap.2018.0391] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
An adequate preoperative workup is critical for the success of bariatric surgery. A key component of the preoperative evaluation involves a comprehensive patient education about surgical outcomes and the postoperative behavioral regimen required. A complete medical evaluation should include the study of the cardiovascular, pulmonary, and gastrointestinal systems as well as a metabolic status assessment. The nutrition professional should be in charge of the nutritional assessment, preoperative weight loss efforts, and diet education regarding postoperative eating behaviors. A psychological evaluation is also needed because psychosocial factors have a significant impact on the long-term outcomes of bariatric surgery, including adherence to recommended postoperative lifestyle regimen, emotional adjustment, and weight loss outcomes. We recommend preoperative abdominal ultrasound to assess for biliary tract pathology, steatosis, fibrosis, and presence of nonalcoholic steatohepatitis. A routine preoperative esophagogastroduodenoscopy is also recommended to evaluate common gastrointestinal disorders associated with obesity. Preoperative weight loss should be strongly encouraged.
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Affiliation(s)
- Francisco Schlottmann
- 1 Department of Surgery, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina.,2 Department of Surgery, Hospital Alemán of Buenos Aires , Buenos Aires, Argentina
| | - Apoorve Nayyar
- 1 Department of Surgery, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - Fernando A M Herbella
- 3 Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo , Sao Paulo, Brazil
| | - Marco G Patti
- 1 Department of Surgery, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina.,4 Department of Medicine, University of North Carolina , Chapel Hill, North Carolina
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Valezi AC, Herbella FAM, Schlottmann F, Patti MG. Gastroesophageal Reflux Disease in Obese Patients. J Laparoendosc Adv Surg Tech A 2018; 28:949-952. [PMID: 30004267 DOI: 10.1089/lap.2018.0395] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) and obesity coexist in many patients in the Western population. The association is not coincidental, since GERD pathophysiology is, in part, linked to obesity. Visceral adipose tissue secretes hormones, which increase the risk of GERD. Obesity increases esophageal motor disorders and higher number of transient lower esophageal sphincter relaxations. Central obesity increases abdominal-thoracic pressure gradient and disrupts the gastroesophageal junction by inducing hiatal hernia formation. Obese patients benefit from weight loss by diet to decrease GERD symptoms; however, Roux-en-Y gastric bypass surgery is associated with a higher weight loss and a decrease in GERD symptoms, and is considered the best way to treat both diseases at the same time.
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Affiliation(s)
- Antono C Valezi
- 1 Department of Surgery, State University of Londrina , Londrina, Brazil
| | | | - Francisco Schlottmann
- 3 Department of Surgery, University of North Carolina , Chapel Hill, North Carolina.,4 Department of Surgery, Hospital Alemán of Buenos Aires , Buenos Aires, Argentina
| | - Marco G Patti
- 3 Department of Surgery, University of North Carolina , Chapel Hill, North Carolina
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Tseng PH, Wong RKM, Wu JF, Chen CC, Tu CH, Lee YC, Lee HC, Wang HP, Wu MS. Normative values and factors affecting water-perfused esophageal high-resolution impedance manometry for a Chinese population. Neurogastroenterol Motil 2018; 30:e13265. [PMID: 29230939 DOI: 10.1111/nmo.13265] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 11/20/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Combined esophageal high-resolution impedance manometry (HRIM) measures multiple pressures and bolus transit simultaneously, facilitating detailed assessment of esophageal motility. Currently, normative values for water-perfused HRIM systems for Chinese populations are lacking. METHODS Healthy volunteers were enrolled for comprehensive anthropometric measures, blood biochemistry tests, and an HRIM study using 22 water-perfused pressure sensors and 12 impedance channels. Ten 5-mL liquid swallows of saline at 30-second intervals were conducted. The following parameters were calculated: distal contractile integral (DCI), distal latency (DL), lower esophageal sphincter (LES) basal pressure, 4-second integrated relaxation pressure (IRP-4s), and complete bolus transit percentage. Normal values were established based on the 5th and 95th percentiles. KEY RESULTS All 66 participants (34 male, 32 female, aged 21-64 years) completed the study and tolerated the HRIM procedure well. The upper normal limit (95th percentile) of IRP-4 second was 20 mmHg. The 5th-95th percentile range for DCI, DL, and complete bolus transit was 99-2186 mmHg●s●cm, 6.2-11.3 second, and 50%-100%, respectively. Age was negatively correlated with DL. Females had significantly higher upper limits for IRP-4s and median DCI than males. Multivariate analyses confirmed that IRP-4s was higher in females, and that higher body mass index and waist circumference were associated with reduced DL and better bolus transit, respectively. CONCLUSIONS AND INFERENCES We established normative values for the water-perfused HRIM system for a Chinese population. Gender and anthropometric factors may affect various major HRIM parameters and should be taken into account when interpreting HRIM results in clinical practice.
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Affiliation(s)
- P-H Tseng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - R K M Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Medicine, University Medical Cluster, National University Health System, Singapore
| | - J-F Wu
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - C-C Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - C-H Tu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Y-C Lee
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - H-C Lee
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - H-P Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - M-S Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Yang D, Draganov PV. Expanding Role of Third Space Endoscopy in the Management of Esophageal Diseases. ACTA ACUST UNITED AC 2018; 16:41-57. [PMID: 29435819 DOI: 10.1007/s11938-018-0169-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OPINION STATEMENT: "Third space" endoscopy, also commonly referred as submucosal endoscopy, is founded on the principle that the deeper layers of the gastrointestinal (GI) tract can be accessed by tunneling in the submucosal space without compromising the integrity of the overlying mucosa. Peroral endoscopic myotomy (POEM), endoscopic submucosal dissection (ESD), and submucosal tunneling endoscopic resection (STER) are innovative techniques within the field of third space endoscopy in the management of esophageal disorders. POEM has become an accepted minimally invasive therapy for achalasia and related motility disorders with excellent short-term results, with early studies yielding similar efficacy to surgical myotomy and increased durability when compared to pneumatic balloon dilation (PBD). Data are needed to establish long-term outcomes with POEM, with particular interest on the incidence of gastroesophageal reflux, which appears to be higher than initially anticipated. ESD, a mature endoscopic resection technique in Asia, has recently gained traction in the West as a viable option for the management of early Barrett's esophagus (BE) neoplasia. Compared to standard endoscopic mucosal resection (EMR), ESD allows the en bloc resection of lesions irrespective of size, which may facilitate histological interpretation and reduce recurrence rates. Large prospective randomized controlled trials are needed to validate the efficacy and safety of this technique and to further define its role in the endoscopic armamentarium in early BE neoplasia. STER is an attractive technique that theoretically permits the resection of subepithelial esophageal tumors (SETs) arising from the deeper GI layers. Initial studies from highly experienced endoscopic centers support its technical feasibility and safety, although these results should be interpreted with caution due to variability arising from small numbers and heterogeneity among studies. Overall, third space endoscopy is an expanding field within endoscopic therapeutics for the treatment of esophageal diseases. While initial results have been very promising, large prospective studies, long-term data, and structured training programs with the establishment of competency parameters are needed before third space endoscopy can be advocated outside of highly specialized centers.
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16th Street Suite 5262, Gainesville, FL, 32608, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16th Street Suite 5262, Gainesville, FL, 32608, USA.
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Camilleri M, Malhi H, Acosta A. Gastrointestinal Complications of Obesity. Gastroenterology 2017; 152:1656-1670. [PMID: 28192107 PMCID: PMC5609829 DOI: 10.1053/j.gastro.2016.12.052] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/08/2016] [Accepted: 12/12/2016] [Indexed: 12/19/2022]
Abstract
Obesity usually is associated with morbidity related to diabetes mellitus and cardiovascular diseases. However, there are many gastrointestinal and hepatic diseases for which obesity is the direct cause (eg, nonalcoholic fatty liver disease) or is a significant risk factor, such as reflux esophagitis and gallstones. When obesity is a risk factor, it may interact with other mechanisms and result in earlier presentation or complicated diseases. There are increased odds ratios or relative risks of several gastrointestinal complications of obesity: gastroesophageal reflux disease, erosive esophagitis, Barrett's esophagus, esophageal adenocarcinoma, erosive gastritis, gastric cancer, diarrhea, colonic diverticular disease, polyps, cancer, liver disease including nonalcoholic fatty liver disease, cirrhosis, hepatocellular carcinoma, gallstones, acute pancreatitis, and pancreatic cancer. Gastroenterologists are uniquely poised to participate in the multidisciplinary management of obesity as physicians caring for people with obesity-related diseases, in addition to their expertise in nutrition and endoscopic interventions.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
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Carabotti M, Severi C. Upper Gastrointestinal Diseases Before and After Bariatric Surgery. METABOLISM AND PATHOPHYSIOLOGY OF BARIATRIC SURGERY 2017:343-349. [DOI: 10.1016/b978-0-12-804011-9.00045-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Gross RD, Gisser R, Cherpes G, Hartman K, Maheshwary R. Subclinical dysphagia in persons with Prader-Willi syndrome. Am J Med Genet A 2016; 173:384-394. [PMID: 27759943 DOI: 10.1002/ajmg.a.38015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/18/2016] [Indexed: 12/17/2022]
Abstract
Prader-Willi Syndrome (PWS) is caused by a genetic imprinting abnormality resulting from the lack of expression of the paternal genes at 15q11-q13. Intellectual disability, low muscle tone, and life-threatening hyperphagia are hallmarks of the phenotype. The need for the Heimlich maneuver, death from choking, and pulmonary infection occur in a disproportionally high number of persons with PWS. The widely held belief is that eating behaviors are responsible for choking and aspiration; yet, no investigation had sought to determine if swallowing impairments were present in persons with PWS. To address this research and clinical gap, simultaneous videofluoroscopy and nasal respiratory signals were used to record swallowing function and breathing/swallowing coordination in 30 participants with PWS. Subjects consumed thin liquid and barium cookies under two randomized conditions as follows: (i) controlled (cues to swallow and standardized bolus sizes); (ii) spontaneous (no cues or bolus size control). Under videofluoroscopy, the cohort showed disordered pharyngeal and esophageal swallowing in both conditions with disturbances in timing, clearance, and coordination of swallowing with the respiratory cycle. No participant showed a sensory response such as attempting to clear residue or coughing; thereby supporting the lack of overt symptoms. We conclude that the high death rate from choking and pulmonary infection in children and adults with PWS may be related, in part, to underlying, asymptomatic dysphagia. The combination of rapid eating and dysphagia would increase the risk of aspiration-related morbidity and mortality. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Roxann Diez Gross
- Department of Medical Research, The Children's Institute of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ronit Gisser
- Department of Medical Research, The Children's Institute of Pittsburgh, Pittsburgh, Pennsylvania
| | - Gregory Cherpes
- Department of Medical Research, The Children's Institute of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katie Hartman
- Department of Medical Research, The Children's Institute of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rishi Maheshwary
- Department of Radiology, West Penn Allegheny Health System, Pittsburgh, Pennsylvania
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Luo RB, Montalvo D, Horgan S. Peroral endoscopic myotomy after gastric bypass: An effective solution for de novo achalasia. Surg Obes Relat Dis 2016; 13:e1-e3. [PMID: 27916564 DOI: 10.1016/j.soard.2016.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 10/04/2016] [Accepted: 10/04/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Ran B Luo
- Department of Surgery, Center for the Future of Surgery, University of California, San Diego, San Diego, CA.
| | - Domingo Montalvo
- Department of Surgery, Center for the Future of Surgery, University of California, San Diego, San Diego, CA
| | - Santiago Horgan
- Department of Surgery, Center for the Future of Surgery, University of California, San Diego, San Diego, CA
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Tanaka Y, Ihara E, Nakamura K, Muta K, Fukaura K, Mukai K, Bai X, Takayanagi R. Clinical characteristics associated with esophageal motility function. J Gastroenterol Hepatol 2016; 31:1133-40. [PMID: 26670865 DOI: 10.1111/jgh.13262] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 11/20/2015] [Accepted: 12/07/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Esophageal motility disorders (EMDs) affect coordinated esophageal contractility. Recent developments in high-resolution manometry have improved diagnosis of EMDs; however, the etiology of EMDs remains to be determined. This study aimed to determine which clinical characteristics are associated with esophageal motility. METHODS From May 2013 to July 2014, 97 patients (54 women, 43 men; age, 16-89 years) with suspected EMDs were assessed by high-resolution manometry in Kyushu University Hospital. Esophageal motility was evaluated by measuring the distal contractile integral (DCI), basal lower esophageal sphincter pressure, and integrated relaxation pressure (IRP). Data on age, gender, body mass index (BMI), Brinkman Index, and blood tests were retrospectively collected and analyzed. RESULTS Fifty patients were diagnosed as normal, nine with achalasia, twelve with esophagogastric junction outflow obstruction, four with distal esophageal spasm, one with jackhammer esophagus, six with absent peristalsis, ten with frequent failed peristalsis, and five with weak peristalsis. The median DCI was 1229.0 mmHg-s-cm, the median basal lower esophageal sphincter pressure was 25.3 mmHg, and the median IRP was 9.6 mmHg. Patients with major motility disorders were excluded from analysis. By multivariate regression analysis, BMI (P = 0.029) and total cholesterol (P = 0.023) were negatively associated with DCI, while BMI (P = 0.007) was negatively associated with IRP and glucose (P = 0.044) was positively associated with IRP. CONCLUSIONS Both BMI and total cholesterol could be highly predictive factors for esophageal body contractility, while BMI and glucose could be predictive factors for lower esophageal sphincter contractile function.
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Affiliation(s)
- Yoshimasa Tanaka
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Kazuhiko Nakamura
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Kazumasa Muta
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Keita Fukaura
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Koji Mukai
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Xiaopeng Bai
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Ryoichi Takayanagi
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
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Carabotti M, Avallone M, Cereatti F, Paganini A, Greco F, Scirocco A, Severi C, Silecchia G. Usefulness of Upper Gastrointestinal Symptoms as a Driver to Prescribe Gastroscopy in Obese Patients Candidate to Bariatric Surgery. A Prospective Study. Obes Surg 2016; 26:1075-1080. [PMID: 26328530 DOI: 10.1007/s11695-015-1861-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Before bariatric surgery, the necessity of routine upper gastrointestinal endoscopy is controversial, and guidelines recommend endoscopy in symptomatic cases. However, impaired visceral sensation occurring in obese patients may be misleading. The purpose of the study is to evaluate prospectively the prevalence of gastrointestinal symptoms, endoscopic findings, and the relation between symptoms and endoscopic findings in obese patients before surgery. MATERIALS AND METHODS One hundred forty-two consecutive patients candidate to primary bariatric surgery filled out the validated Rome III symptomatic questionnaire and performed endoscopy. RESULTS With a median age of 41 years and BMI of 44 Kg/m(2), 83% were females. Symptoms were referred by 43% of patients: gastroesophageal reflux disease (GERD) (27.9%) and dyspepsia (24.6%), subdivided in postprandial distress (PDS) (66.7%) and epigastric pain (33.3%) syndromes. Of GERD patients, 19.7% presented concomitantly PDS. Belching was present in 8.2% and nausea and/or vomiting in 1.6% of patients. At endoscopy, one or more lesions were present in 47.1% of the patients: erosive esophagitis (5.6%), hiatal hernia (23.2%), gastroduodenal erosions (6.3%), and peptic ulcers (3.5%). At histology, 24% of patients have Helicobacter pylori infection, and its prevalence in gastroduodenal erosions and ulcers was 22.2 and 60%, respectively. Surprisingly, in patients with peptic lesions H. pylori-negative, no chronic use of NSAIDs was reported. Analyzing the coexistence of symptoms and lesions, these resulted equally distributed beyond the presence of symptoms, being present in 44.2 and 49.4% of symptomatic and asymptomatic patients, respectively. CONCLUSIONS The presence of symptoms cannot be considered as a valuable guide to indicate endoscopy since the majority of endoscopic lesions were asymptomatic and not H. pylori-related.
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Affiliation(s)
- Marilia Carabotti
- Department of Internal Medicine and Medical Specialties, University of Rome "Sapienza", viale del Policlinico 155, 00161, Rome, Italy.
| | - Marcello Avallone
- Department of Medical Surgical Sciences and Biotechnology, University of Rome "Sapienza", Polo Pontino, Corso della Repubblica 79, 04100, Latina, Italy
| | - Fabrizio Cereatti
- Department of Medical Surgical Sciences and Biotechnology, University of Rome "Sapienza", Polo Pontino, Corso della Repubblica 79, 04100, Latina, Italy
| | - Alessandro Paganini
- Department P. Stefanini, University of Rome "Sapienza", viale del Policlinico 155, 00161, Rome, Italy
| | - Francesco Greco
- AUSL Viterbo Ospedale Andosilla, via Ferretti 169, 01033, Civita Castellana, VT, Italy
| | - Annunziata Scirocco
- Department of Internal Medicine and Medical Specialties, University of Rome "Sapienza", viale del Policlinico 155, 00161, Rome, Italy
| | - Carola Severi
- Department of Internal Medicine and Medical Specialties, University of Rome "Sapienza", viale del Policlinico 155, 00161, Rome, Italy
| | - Gianfranco Silecchia
- Department of Medical Surgical Sciences and Biotechnology, University of Rome "Sapienza", Polo Pontino, Corso della Repubblica 79, 04100, Latina, Italy
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Mojoli F, Iotti GA, Torriglia F, Pozzi M, Volta CA, Bianzina S, Braschi A, Brochard L. In vivo calibration of esophageal pressure in the mechanically ventilated patient makes measurements reliable. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:98. [PMID: 27063290 PMCID: PMC4827205 DOI: 10.1186/s13054-016-1278-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 03/31/2016] [Indexed: 01/22/2023]
Abstract
Background Esophageal pressure (Pes) can provide information to guide mechanical ventilation in acute respiratory failure. However, both relative changes and absolute values of Pes can be affected by inappropriate filling of the esophageal balloon and by the elastance of the esophagus wall. We evaluated the feasibility and effectiveness of a calibration procedure consisting in optimization of balloon filling and subtraction of the pressure generated by the esophagus wall (Pew). Methods An esophageal balloon was progressively filled in 36 patients under controlled mechanical ventilation. VBEST was the filling volume associated with the largest tidal increase of Pes. Esophageal wall elastance was quantified and Pew was computed at each filling volume. Different filling strategies were compared by performing a validation occlusion test. Results Fifty series of measurements were performed. VBEST was 3.5 ± 1.9 ml (range 0.5–6.0). Esophagus elastance was 1.1 ± 0.5 cmH2O/ml (0.3–3.1). Both Pew and the result of the occlusion test differed among filling strategies. At filling volumes of 0.5, VBEST and 4.0 ml respectively, Pew was 0.0 ± 0.1, 2.0 ± 1.9, and 3.0 ± 1.7 cmH2O (p < 0.0001), whereas the occlusion test was satisfactory in 22 %, 98 %, and 88 % of cases (p < 0.0001). Conclusions Under mechanical ventilation, an increase of balloon filling above the conventionally recommended low volumes warrants complete transmission of Pes swings, but is associated with significant elevation of baseline. A simple calibration procedure allows finding the filling volume associated with the best transmission of tidal Pes change and subtracting the associated baseline artifact, thus making measurement of absolute values of Pes reliable. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1278-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Francesco Mojoli
- Anesthesia and Intensive Care, Emergency Department, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy. .,Anesthesia, Intensive Care and Pain Therapy, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Giorgio Antonio Iotti
- Anesthesia and Intensive Care, Emergency Department, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Francesca Torriglia
- Anesthesia, Intensive Care and Pain Therapy, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Marco Pozzi
- Anesthesia and Intensive Care, Emergency Department, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Carlo Alberto Volta
- Anesthesia and Intensive Care, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Arcispedale Sant'Anna, Ferrara, Italy
| | - Stefania Bianzina
- Anesthesia, Intensive Care and Pain Therapy, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Antonio Braschi
- Anesthesia and Intensive Care, Emergency Department, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy.,Anesthesia, Intensive Care and Pain Therapy, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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Nadaleto BF, Herbella FAM, Patti MG. Gastroesophageal reflux disease in the obese: Pathophysiology and treatment. Surgery 2015; 159:475-86. [PMID: 26054318 DOI: 10.1016/j.surg.2015.04.034] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Revised: 04/07/2015] [Accepted: 04/28/2015] [Indexed: 12/12/2022]
Abstract
Obesity is a condition that has increased all over the world in the last 3 decades. Overweight and gastroesophageal reflux disease (GERD) are related. GERD may have different causative factors in the obese compared with lean individuals. This review focuses on the proper treatment for GERD in the obese based on its pathophysiology. Increased abdominal pressure may play a more significant role in obese subjects with GERD than the defective esophagogastric barrier usually found in nonobese individuals. A fundoplication may be used to treat GERD in these individuals; however, outcomes may be not as good as in nonobese patients and it does not act on the pathophysiology of the disease. All bariatric techniques may ameliorate GERD symptoms owing to a decrease in abdominal pressure secondary to weight loss. However, some operations may lead to a disruption of natural anatomic antireflux mechanisms or even lead to slow gastric emptying and/or esophageal clearance and thus be a refluxogenic procedure. Roux-en-Y gastric bypass decreases both acid and bile reflux from the stomach into the esophagus. On the other hand, gastric banding is a refluxogenic operation, and sleeve gastrectomy may show different outcomes based on the anatomy of the gastric tube.
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Affiliation(s)
- Barbara F Nadaleto
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil.
| | - Marco G Patti
- Department of Surgery, Pritzker School of Medicine, University of Chicago, Chicago, IL
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Abstract
BACKGROUND Although esophageal hypomotility is prevalent in obese patients, its cause remains unknown. Leptin, a hormone derived from adipose tissue, may be involved in this phenomenon because it has been shown to decrease gastric and intestinal motility in animals. It has been hypothesized that elevated plasma leptin concentration is a risk factor for esophageal dysmotility in obese patients. OBJECTIVE To determine whether plasma leptin concentrations are higher in obese patients with esophageal hypomotility than in obese patients with a normal motility profile. METHOD Fasting plasma leptin concentration (assessed by radioimmuoassay) was measured in all patients who were included in a study protocol investigating esophageal manometry before bariatric surgery. The patients completed standardized surveys regarding epidemiological data, upper gastrointestinal symptoms, medical history and medication(s). Basal levels of leptin, as well as corrected leptin scores adjusted for sex and body mass index, were compared in patients with and without esophageal dysmotility. RESULTS Nine patients without dysmotility and eight with dysmotility were included. Both groups were comparable with regard to age (42±9 versus 38±9 years), sex (78% versus 75% women) and body mass index (49±10 kg⁄m2 versus 42±7 kg⁄m2). There were no significant differences regarding medication(s) and comorbidities between the two groups. When compared with normal predicted values, the corrected leptin scores were 30% higher in patients with dysmotility than in the control group with normal motility (P≤0.05). CONLCUSION Obese patients with esophageal dysmotility exhibited elevated plasma leptin concentrations, suggesting a role for leptin in promoting esophageal hypomotility.
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