24-h pH Research Articles

Gastroesophageal reflux symptoms do not correlate with objective pH testing after peroral endoscopic myotomy.

Peroral endoscopic myotomy (POEM) is an emerging treatment for esophageal achalasia. Postoperative reflux has been found in a significant number of patients, but it is unknown whether subjective reports of reflux correlate with objective pH testing. The purpose of this study was to compare the objective rate of reflux with standardized reflux symptom scales after POEM. Our hypothesis was that subjective symptoms would not correlate with objective measurement of reflux. Data on all patients undergoing POEM were collected prospectively between August 2012 and June 2014 and included demographics, objective testing (48-h pH probe, manometry, endoscopy), as well as gastroesophageal reflux disease health-related quality of life (GERD-HRQL), GERD symptom scale (GERSS), and antacid use. Forty-three patients underwent POEM during the study period. The mean age was 53.5 ± 17.4 years with a BMI of 29.6 ± 8.4 kg/m(2), and 27 (63%) were male. Forty-two patients (98%) completed at least 6 months of follow-up, and 26 (60%) underwent repeat pH measurement. Dysphagia scores improved from 4 (0-5) at baseline to 0 (0-3) (p < 0.001). On follow-up pH testing, 11 (42%) were normal and 15 (58%) had elevated DeMeester scores. Postoperative GERSS or GERD-HRQL scores did not correlate with DeMeester scores on Spearman's rank-order tests (r = 0.02, p = 0.93 and r = 0.04, p = 0.50, respectively). Postoperative PPI use was not significantly associated with normal or abnormal pH testing: 5 of 7 (71%) patients who were taking PPIs postoperatively had abnormal DeMeester scores compared to 9 of 18 (50%) of patients who were not taking PPIs (p = 0.332). Peroral endoscopic myotomy provides excellent dysphagia relief for patients with achalasia, but is associated with a high rate of reflux on pH testing postoperatively. Subjective symptoms are not a reliable indicator of postoperative reflux. Routine pH testing should be considered in all patients following POEM.

PH Impedance vs. traditional pH monitoring in clinical practice: an outcome study.

The addition of impedance to 24-h pH monitoring has allowed detection of weakly acidic reflux, but the extent to which pH-impedance (pH-MII) monitoring improves outcomes is unknown. This was a prospective observational study. Patients referred for pH or pH-MII monitoring completed a standardized questionnaire on improvement in the dominant symptom, their satisfaction, and treatment at 3 and 12months after the test during a telephone interview. A total of 184 patients (mean age, 52years, range, 19-82years; 35% with typical symptoms; and 89% tested off therapy) completed pH (n=92) or pH-MII monitoring (n=92) over a period of 15months. The two arms were similar in terms of demographic, clinical, and endoscopic variables. Ten patients in the pH-MII arm showed evidence of weakly acidic reflux disease. There was no difference in the percentage of patients in the pH and pH-MII monitoring arms who experienced improvement in their dominant symptom after 3 (58 vs. 63%; p=0.621) or 12months (66 vs. 70%; p=0.234), and the same was true for patient satisfaction. There were also no between-group difference in the use of proton pump inhibitors (PPIs) after 3 (63 vs. 68.5%; p=0.437) or 12months (47 vs. 60.5%; p=0.051). PPIs were prescribed more frequently after a positive test (p<0.001) although they were used by 45.6% of the negative patients. Only one patient underwent fundoplication. Two-thirds of patients undergoing pH-MII monitoring experience a positive outcome, similarly to what occurs after traditional pH monitoring. Physicians often pay little attention to the test results, especially if they are negative.

Safety, Tolerability, Pharmacokinetics, and Pharmacodynamics of Single Rising TAK-438 (Vonoprazan) Doses in Healthy Male Japanese/non-Japanese Subjects.

OBJECTIVES:To evaluate safety, tolerability, pharmacokinetics, and pharmacodynamics of TAK-438 (vonoprazan, a potassium-competitive acid blocker) in healthy male subjects.METHODS:In two phase I, randomized, double-blind, placebo-controlled, single rising-dose studies, healthy male subjects (Japan N=84; UK N=63) received a single TAK-438 dose (1–120 mg in Japan and 1–40 mg in the UK). Assessments included safety, tolerability, pharmacokinetics, and pharmacodynamics (intragastric pH).RESULTS:Plasma concentration–time profiles of TAK-438 at all dose levels showed rapid absorption (median Tmax up to 2 h). Estimated mean elimination half-life was up to 9 h. Exposure was slightly greater than dose proportional. No clear difference in TAK-438 pharmacokinetics was observed between Japanese and non-Japanese subjects. Acid suppression was dose dependent and similar in both studies. The 24-h intragastric pH ≥4 holding time ratio with 40 mg TAK-438 was 92% in Japan and 87% in the UK. TAK-438 was well tolerated, with no adverse events reported in Japanese subjects; 10 of 63 UK subjects experienced 12 treatment-emergent adverse events (non-serious). Increases in serum gastrin and pepsinogen I and II concentrations were observed at doses ≥10 mg, but there were no changes in alanine aminotransferase concentrations.CONCLUSIONS:Single oral doses of TAK-438 20–120 mg caused rapid, profound, and 24-h suppression of gastric acid secretion in healthy male subjects, regardless of geographical region, and TAK-438 was well tolerated at all doses studied, making it a potential alternative to proton pump inhibitors for the treatment of acid-related disorders.

Gastro-oesophageal reflux symptoms and coeliac disease: no role for routine duodenal biopsy.

Coeliac disease (CD) has been linked to gastro-oesophageal reflux disease (GORD). Previous studies have demonstrated an increased prevalence of reflux in patients with CD. However data on the risk for CD in patients presenting with reflux are conflicting. The aim of this study was to establish the prevalence of CD in patients with GORD and to elucidate the mechanisms for reflux symptoms in newly diagnosed CD patients. Group A: patients who had undergone routine duodenal biopsy were prospectively recruited between 2004 and 2014. Diagnostic yield was compared with that of a screening cohort. Group B: 32 patients with newly diagnosed CD who had undergone oesophageal manometry and 24-h pH studies were prospectively recruited. Group A: 3368 patients (58.7% female, mean age 53.4 years) underwent routine duodenal biopsy. Of these patients, 850 (25.2%) presented with GORD. The prevalence of CD among GORD patients was 1.3% (0.7-2.4%), which was not significantly higher than that in the general population (P=0.53). Within the context of routine duodenal biopsy at endoscopy (when corrected for concurrent symptoms, age and sex), reflux was found to be negatively associated with CD [adjusted odds ratio 0.12 (0.07-0.23), P<0.0001]. In group B, 34% of patients complained of reflux. On manometry, 9% had a hypotensive lower oesophageal sphincter and 40.6% had oesophageal motor abnormalities, with 25% significantly hypocontractile. On pH studies, 33% demonstrated reflux episodes. The prevalence of undiagnosed CD among GORD patients is similar to that in the general population, and routine duodenal biopsy cannot be recommended. A significant number of patients with newly diagnosed CD were found to have reflux and/or oesophageal dysmotility on pH/manometry studies; this may explain the high prevalence of reflux symptoms in CD.

PWE-172 Does salivary pepsin measurement change diagnostic outcome in patients investigated by 24h ph monitoring?

Introduction Pepsin, a gastric enzyme, has been proposed as a marker of gastro-oesophageal reflux disease (GORD) when present in saliva.1 In contrast to routine diagnostic methods, quantification of salivary pepsin is rapid and non-invasive. Furthermore, 24h pH-monitoring has limited sensitivity.2We aimed to evaluate the impact of salivary pepsin measurement on diagnosis of GORD in patients undergoing 24h pH-monitoring. Method Patients referred for 24h pH-monitoring (off medication) were invited to take part in the study. Eligible participants complained of heartburn, regurgitation, chest pain or acid in the mouth and were referred for testing by a gastroenterologist, upper gastrointestinal surgeon or respiratory consultant. Presence of additional atypical symptoms was assessed by questionnaire (Reflux Symptom Index). Patients underwent high resolution oesophageal manometry and catheter-based 24h pH-monitoring. During the monitoring period, participants collected up to three saliva samples at the time of experiencing their predominant symptom (s). Pepsin concentration of samples was quantified using a lateral flow device (Peptest) where at least one sample containing >25ng/ml pepsin was indicative of reflux disease. Diagnostic outcome by pepsin measurement and 24h pH-monitoring (>4.2% of time pH Results 100 participants recruited; 80 participants included in final analysis (exclusions: corrupt pH study (n = 1), no pepsin samples collected (n = 19)). 81% of participants returned at least one positive pepsin sample. 39/80 (49%) patients were classified as having reflux disease based on 24h-pH monitoring (mean%time pH Conclusion A higher proportion of the total population was found to have GORD based on pepsin measurement (81% vs 49% using pH), which may reflect the poor sensitivity of 24h pH-monitoring. Measurement of salivary pepsin changed the diagnostic outcome when compared to 24h pH-monitoring in 44% of symptomatic reflux patients. Further studies should explore the relationships between pepsin concentration and symptoms of reflux. This study may support the use of salivary pepsin measurement to prevent false-negative diagnosis based on 24h pH-monitoring alone. Disclosure of interest A. Rasijeff: None Declared, W. Jackson: None Declared, J. Burke: None Declared, P. Dettmar Shareholder of: RD Biomed Limited. References Hayat JO, et al. Gut 2015;64:373–380 Dent J, et al. Gut 2010;59:714–721

Pepsin and bile acids in saliva in patients with laryngopharyngeal reflux – a prospective comparative study

Laryngopharyngeal reflux (LPR) and biliary duodenogastric reflux can cause damage to the laryngeal mucosa and voice disorders. The aim of this study was to find out whether levels of pepsin and bile acids in the saliva can serve as diagnostic markers of LPR. A prospective comparative study. Twenty-eight patients with LPR proven via high-resolution manometry and combined multichannel intraluminal impedance and 24-h pH monitoring and 48 healthy controls without symptoms of LPR were included in the study. In the patients with LPR symptoms, oesophagogastroscopy with oesophageal biopsy was performed. The levels of total pepsin, active pepsin, bile acids and the pH of the saliva were determined in all participants and compared between the groups. Reflux symptom index (RSI) and reflux finding score (RFS) were also obtained and compared. The groups differed significantly in RSI (P = 0.00), RFS (P = 0.00), the levels of bile acids (P = 0.005) and total pepsin in saliva (P = 0.023). The levels of total pepsin and bile acids were about three times higher in the patients with LPR than in the healthy controls. There was a significant correlation between the RSI and RFS score and the level of total pepsin and bile acids in the saliva. Histopathological examination of the oesophageal biopsy taken 5 cm above the lower oesophageal sphincter confirmed reflux in almost 93% of patients with symptoms. The study results show that the levels of total pepsin and bile acids in saliva are significantly higher in patients with LPR than in the controls, thus suggesting this as a useful tool in the diagnosis of LPR and particularly biliary LPR.

Effects of Graded Levels of Chromium Methionine on Performance, Carcass Traits, Meat Quality, Fatty Acid Profiles of Fat, Tissue Chromium Concentrations, and Antioxidant Status in Growing-Finishing Pigs.

A 97-day feeding trial was conducted to investigate the effects of dietary chromium methionine (CrMet) on performance, carcass traits, meat quality, fatty acid profiles of fat, tissue chromium concentrations, and antioxidant status in growing-finishing pigs. A total of 180 crossbred pigs with a mean initial body weight (BW) 30.18 ± 0.28kg were allotted to 5 treatments with 6 replicates per treatment and 6 pigs per pen in a randomized complete block design based on BW and sex. Treatments were added with 0 (control), 100, 200, 400, and 800μg/kg chromium as CrMet. Blood samples were obtained from the anterior vena cava on days 97. Carcass characteristics, pork quality, and tissue chromium concentration data were collected from one pig per pen. The results indicated that supplemental CrMet did not significantly affect growth performance, carcass traits, or meat amino acid profiles. Chromium at 100, 400, and 800μg/kg decreased drip loss but increased shear force (P < 0.05). Pigs fed 100 or 400μg/kg had a higher 24-h pH than the control (P < 0.05). While meat color, muscle moisture, crude protein, or crude fat were not affected by CrMet. Supplemental 800μg/kg chromium reduced C18:0 levels in belly fat (P < 0.05), and chromium supplementation increased cis-9, trans 11-conjugated linoleic acid levels linearly (P < 0.05). Dietary CrMet supplementation increased serum, kidney, and muscle chromium contents (P < 0.05) but did not affect liver chromium contents. Besides, tissue chromium concentrations were increased linearly with increased chromium dosage (P < 0.05). Chromium at 400μg/kg increased serum glutathione peroxidase activities (P < 0.05), and chromium at 800μg/kg decreased serum total antioxidant capacity levels (P < 0.05). Nevertheless, liver and kidney antioxidant status were not significantly affected by CrMet. These results indicated that dietary supplementation CrMet did not significantly influence growth and carcass traits, but improved meat quality at the expense of tenderness. Therefore, the long-term exposure to 800μg/kg chromium affected fatty acid compositions and reduced serum antioxidant capacity.

One- and ten-year outcome of laparoscopic anterior 120° versus total fundoplication: a double-blind, randomized multicenter study.

Nissen fundoplication is an effective treatment for gastroesophageal reflux disease (GERD) but can cause adverse effects like flatulence and dysphagia. The aim was to compare laparoscopic anterior 120° fundoplication (APF) to total fundoplication (Nissen) concerning flatulence and other adverse effects, in a randomized blinded study. Seventy-two patients were randomized to APF (n = 36) or Nissen (n = 36). Gastroscopy, 24-h pH monitoring and evaluation for symptoms and quality of life using questionnaires (GSRS, PGWB and 7-graded Likert scales) were performed preoperatively, at 1 and 10 years postoperatively. Patients and the researchers were blinded to operative method. When entering the study, most patients had mild-moderate reflux disease according to the symptom score, the 24-h pH measurements, and frequency and grade of esophagitis. At 1-year (n = 68) flatulence, dysphagia, heartburn and acid regurgitation did not differ between groups. More patients could belch (p = 0.005), and pH monitoring showed a higher time with pH < 4 in the APF group (p = 0.006). At 10 years (n = 61), the APF group reported less dysphagia (p < 0.001), more heartburn (p = 0.019) and more patients could belch (p = 0.012) and vomit (p < 0.001) compared to the Nissen. No difference remained at 10 years in pH monitoring (n = 23) between groups. Symptoms of heartburn and acid regurgitation were less than preoperatively in both groups (p < 0.001). No revisional operations were performed. Both procedures offer good long-term control of reflux symptom, with modest post-fundoplication symptoms. Anterior 120° fundoplication results in less dysphagia, better ability to belch and vomit than total fundoplication at 10-year follow-up. The results suggest that APF could be an alternative to Nissen fundoplication in the surgical treatment of mild-moderate GERD.

Sa1048 Comparison of Gastric Acid Inhibition With 4-Times-Daily Dosing of Esomeprazole and Rabeprazole in Healthy Japanese Individuals

Background: Potent neutralization of intragastric pH is important in the treatment of acidrelated diseases such as peptic ulcers and gastroesophageal reflux disease (GERD). However, once (o.i.d.)or twice (b.i.d.)-daily dosing of a standard dose of proton pump inhibitors (PPIs) does not always provide sufficient acid inhibition over a 24-h period, particularly for rapid metabolizers (RMs) of CYP2C19. We previously reported that esomeprazole (b.i.d.) exerts [check] potent acid inhibition in CYP2C19 RMs compared to omeprazole, lansoprazole, and rabeprazole, and that complete inhibition of gastric acid secretion in all patients is difficult. Although rabeprazole (10 mg, q.i.d.) and lansoprazole (30 mg, q.i.d.) reportedly induce sufficient acid inhibition in CYP2C19 RMs, whether or not esomeprazole (20 mg, q.i.d.) can induce sufficient inhibition over a 24-h period in RMs remains unclear. We therefore examined the efficacy of esomeprazole q.i.d. in achieving sufficient acid inhibition. Methods: In a randomized cross-over study, 30 healthy, Helicobacter pylori-negative, young Japanese volunteers (10 RMs, 10 intermediate metabolizers [IMs], and 10 poor metabolizers [PMs] of CYP2C19) received esomeprazole 20 mg b.i.d. or q.i.d. for 1 week. Intragastric pH monitoring was performed on Day 7. Intragastric pHs were also compared to esomeprazole 20 mg q.i.d. and rabeprazole 10 mg q.i.d. (13 RMs, 15 IMs and 7 PMs). Data from 24-h pH monitoring from our previous study of the efficacy of rabeprazole 10 mg q.i.d was used for comparison. Results: Median pH attained with esomeprazole 20 mg b.i.d. differed

Aetiology of bronchiectasis in Guangzhou, southern China.

Aetiologies of bronchiectasis in mainland China and their comparisons with those in western countries are unknown. We aimed to investigate bronchiectasis aetiologies in Guangzhou, southern China, and to determine ethnic or geographic differences with reports from western countries. Consecutive patients with steady-state bronchiectasis were randomly recruited. Past history was meticulously extracted. Patients underwent physical examination, saccharine test, humoral immunity assays, gastroesophageal reflux scoring and sputum culture. Fiberoptic bronchoscopy, total immunoglobin E (IgE) and Aspergillus fumigatus-specific IgE measurement, 24-h gastroesophageal pH monitoring and miscellaneous screening tests were performed, if indicated. This entailed comparisons on aetiologies with literature reports. We enrolled 148 patients (44.6 ± 13.8 years, 92 females), most of whom had mild to moderate bronchiectasis. Idiopathic (46.0%), post-infectious (27.0%) and immunodeficiency (8.8%) were the most common aetiologies. Miscellaneous aetiologies consisted of asthma (5.4%), gastroesophageal reflux (4.1%), aspergillosis (2.7%), congenital lung malformation (2.0%), Kartagener syndrome (1.4%), rheumatoid arthritis (1.4%), chronic obstructive pulmonary disease (0.7%), Young's syndrome (0.7%), yellow nail's syndrome (0.7%), eosinophilic bronchiolitis (0.7%) and foreign bodies (0.7%). No notable differences in clinical characteristics between idiopathic and known aetiologies were found. Ethnic or geographic variations of aetiologies were overall unremarkable. Idiopathic, post-infectious and immunodeficiency constitute major bronchiectasis aetiologies in Guangzhou. Clinical characteristics of patients between known aetiologies and idiopathic bronchiectasis were similar. Ethnicity and geography only account for limited differences in aetiologic spectra. These findings will offer rationales for early diagnosis and management of bronchiectasis in future studies and clinical practice in China.

Weak peristalsis with large breaks in chronic cough: association with poor esophageal clearance.

Gastroesophageal reflux plays an important role in chronic cough (CC). Whether disturbed esophageal motility contributes to increased esophageal reflux exposure or interferes with swallowed bolus clearance is unclear. This study used high resolution esophageal manometry and impedance (HRIM) together with Chicago Classification, and 24-h impedance pH (MII/pH) to address these questions in patients with CC compared with heartburn (HB). A retrospective review of 32 patients with CC (mean age 57 [95% CI: 52-62] years) and 32 patients with symptoms of HB (55 [52-62] years) referred for HRIM and MII/pH between September 2012 and September 2013 was undertaken. Weak peristalsis with large breaks (WPLBs) was observed in 34% of CC patients compared with only 12% of HB patients (p = 0.027). Pathological acid exposure time (AET) was identified in 81% of CC patients with WPLBs compared with 29% without (p = 0.011). Increased AET was associated with prolonged clearance time of refluxed events (p = 0.006) rather than increased number of events. AET correlated with the percentage of peristaltic events with large breaks in CC (ρ = 0.467, p = 0.007). Similar data were obtained for total bolus (acid and non-acid) exposure time. Only one of the CC patients with WPLBs exhibited complete bolus transit (CBT) on swallowing compared with 81% without WPLBs (p < 0.001). Moreover, the percentage of peristaltic events associated with CBT negatively correlated with the percentage of peristaltic events with large breaks (r = -0.653, p < 0.001) in CC. One-third of CC patients exhibit WPLBs, which directly impacts on clearance of refluxed events and bolus's swallowed. These observations may have important implications for esophageal-bronchial interaction in CC.

Gastroesophageal reflux in asymptomatic obese subjects: An esophageal impedance-pH study.

To investigate the relationship between reflux and body mass index (BMI) in the asymptomatic obese population using the impedance-pH technique. Gastroesophageal reflux is frequent in the obese population. However, the relationship between acid reflux and BMI in asymptomatic obese people is unclear. Forty-six obese (BMI > 25 kg/m(2)) people were enrolled in this prospective study. We evaluated the demographic findings and 24-h impedance pH values of the whole group. Gas, acid (pH < 4), weak acid (pH = 4-7) and weak alkaline (pH ≥ 7) reflux parameters were analyzed. The mean age of patients was 49.47 ± 12.24 years, and half of them were men. The mean BMI was 30.64 ± 3.95 kg/m(2) (25.14-45.58 kg/m(2)). BMI of 23 was over 30 kg/m(2). Seventeen patients had a comorbidity (hypertension, diabetes mellitus, or ischemic heart disease). Endoscopic examination revealed esophagitis in 13 of the 28 subjects (10 Grade A, 3 Grade B). The subjects were divided into two groups according to BMI (< 30 and > 30 kg/m(2)). Demographic and endoscopic findings, and impedance results were similar in these two groups. However, there was a positive correlation between BMI and total and supine pH < 4 episodes (P = 0.002, r = 0.414; P = 0.000, r = 0.542), pH < 4 reflux time (P = 0.015, r = 0.319; P = 0.003, r = 0.403), and DeMeester score (P = 0.012, r = 0.333). Acid reflux is correlated with BMI in asymptomatic obese individuals.

A prospective cross-sectional study of laparoscopic subtotal Lind fundoplication for gastro-oesophageal reflux disease – A durable and effective anti-reflux procedure

Introduction: Laparoscopic partial fundoplication for gastro-oesophageal reflux disease (GORD) is reported to have fewer side effects when compared to Nissen fundoplication, but doubts remain over its long term durability in controlling reflux. The aim of this study was to assess outcome of symptoms for all patients presenting with GORD undergoing routine laparoscopic subtotal Lind fundoplication. Materials & Methods: All patients undergoing laparoscopic fundoplication between August, 1999 and November, 2007 performed by a single surgeon were included in the study. The anti-reflux procedure studied was laparoscopic Lind (300°) fundoplication with crural repair in all cases. Patients completed pre and post-operative questionnaires containing validated scoring systems for heartburn, gas bloat, dysphagia and overall patient satisfaction. Results: Over the 100-month period, 320 consecutive patients underwent laparoscopic subtotal Lind fundoplication. Of these, 256 (80%) replied to the questionnaire at a mean of 31 months (range 3–96 months) following surgery. 91.4% of respondents had an improvement in heartburn symptom score with a significant reduction in score from 7.74 preoperatively to 1.25 postoperatively (p < 0.001). There was also a significant reduction of mean modified Visick score for reflux control (heartburn and regurgitation) from 3.49 preoperatively to 1.48 after surgery (p < 0.001). In total, 22 patients developed recurrent reflux symptoms with half of these reporting their recurrence within two years following surgery. Because of this all were tested with post-operative pH testing, yet only one had a 24-h pH time outside the normal range. Overall patient satisfaction was high with a visual analogue score of 9 and 88% of the patients claimed they would have the operation again. Conclusion: Laparoscopic Lind fundoplication demonstrates excellent reflux control when performed routinely for all patients presenting with GORD. This technique is both durable and efficacious in controlling reflux symptoms.

Laparoscopic anterior versus posterior fundoplication for gastro-esophageal reflux disease: a meta-analysis and systematic review.

Although laparoscopic posterior fundoplication (LPF) i.e., Nissen or Toupet have the proven efficacy for controlling gastro-esophageal reflux surgically, there remain problems with postoperative dysphagia and gas bloat syndrome. To decrease some of these postoperative complications, laparoscopic anterior fundoplication (LAF) was introduced. The aim of this study was to conduct a meta-analysis and systematic review of randomized controlled trials (RCTs) to investigate the merits and drawbacks of LPF versus LAF for the treatment of gastro-esophageal reflux disease (GERD). A search of Medline, Embase, Science Citation Index, Current Contents, PubMed, ISI Web of Science, and the Cochrane Database identified all RCTs comparing different types of LPF and LAF published in the English Language between 1990 and 2013. The meta-analysis was prepared in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement. Data was extracted and analyzed on ten variables which include dysphagia score, heartburn rate, redo operative rate, operative time, overall complications, rate of conversion to open, Visick grading of satisfaction, overall satisfaction, length of hospital stay, and postoperative 24-h pH scores. Nine trials totaling 840 patients (anterior = 425, posterior = 415) were analyzed. There was a significant reduction in the odds ratio for dysphagia in the LAF group compared to the LPF group. Conversely, significant reduction in the odds ratio for heartburn was observed for LPF compared to LAF. Comparable effects were noted for both groups for other variables which include redo surgery, operating time, overall complications, conversion rate, Visick's grading, patients' satisfaction, length of hospital stay, and postoperative 24-h pH scores. Based on this meta-analysis, LPF compared to LAF is associated with significant reduction in heartburn at the expense of higher dysphagia rate on a short- and medium-term basis. We therefore conclude that LPF is a better alternative to LAF for controlling GERD symptoms.

A novel endoscopic submucosal dissection technique for proton pump inhibitor-refractory gastroesophageal reflux disease

Objectives: Although drug treatment is the usual first-line therapy for gastroesophageal reflux disease (GERD), not all patients receive satisfactory relief from drug therapy, alone. We developed an endoscopic fundoplication technique using endoscopic submucosal dissection (ESD); the technique is referred to as ESD for GERD (ESD-G). This study investigated the safety and efficacy of this novel technique in patients with drug-refractory GERD. Patients and methods: ESD-G narrows the hiatal opening through ESD of the esophagogastric junction (EGJ) mucosa. For safety reasons, the range of mucosal resection was limited to half (1/2 or 1/4 +1/4) of the circumference of the EGJ lumen. ESD-G was performed on 13 patients with proton pump inhibitor (PPI)-refractory GERD. GERD symptoms, PPI dose, and 24-h esophageal pH monitoring results were compared before and 6 months after the procedure. Results. In 12 cases, symptoms significantly improved after ESD-G. Five patients demonstrated improved esophagitis, three were able to discontinue PPI therapy, and three were able to reduce their PPI dosage following surgery. The esophageal pH <4 holding time ratio was also decreased after ESD-G. Conclusions. ESD-G may be useful for PPI-refractory GERD patients.

Supplementing antioxidants to pigs fed diets high in oxidants: II. Effects on carcass characteristics, meat quality, and fatty acid profile.

The study was conducted to determine effects of dietary supplementation with a blend of antioxidants (ethoxyquin and propyl gallate) on carcass characteristics, meat quality, and fatty acid profile in finishing pigs fed a diet high in oxidants. A total of 100 crossbred barrows (10.9±1.4 kg BW, 36±2 d of age) were randomly allotted to 5 diet treatments (5 replicate pens per treatment, 4 pigs per pen). Treatments included: 1) HO: high oxidant diet containing 5% oxidized soy oil and 10% PUFA source which contributed 5.56% crude fat and 2.05% docosahexanoic acid (DHA) to the diet; 2) VE: the HO diet with 11 IU/kg of added vitamin E; 3) AOX: the HO diet with antioxidant blend (135 mg/kg); 4) VE+AOX: the HO diet with both vitamin E and antioxidant blend; and 5) SC: a standard corn-soy control diet with nonoxidized oil and no PUFA source. The trial lasted for 118 d; on d 83, the HO diet pigs were switched to the SC diet due to very poor health. From that point, the VE pigs displayed the poorest performance. On d 118, 2 pigs from each pen were harvested for sampling. Compared to pigs fed SC diet, the HO and VE pigs (P<0.05) showed lighter carcass weight, less back fat, less lean body mass, and smaller loin eye area. In addition, the VE pigs had decreased dressing percentage than the AOX and VE+AOX pigs (65.7 vs. 75.3 and 74.2%). Compared to the SC pigs, greater moisture percentage (74.7 vs. 77.4%) and less extractable lipid content (2.43 vs. 0.95%) were found in VE fed pigs (P<0.05). Drip loss of loin muscle in VE pigs was less than SC pigs (0.46 vs. 3.98%, P=0.02), which was associated with a trend for a greater 24-h muscle pH (5.74 vs. 5.54, P=0.07). The antioxidant blend addition in the high oxidant diet attenuated all of these effects to levels similar to SC (P>0.05), except a* value (redness) and belly firmness. Visible yellow coloration of backfat and lipofuscin in HO and VE pigs was observed at harvest at d 118. The high oxidant diet resulted in greater concentration of DHA in backfat (P<0.001); switching the diet on d 83 resulted in HO pigs having a similar fatty acid profile to SC at d 118 pigs. Vitamin E concentration in plasma and muscle was greater in HO and SC than VE, AOX, and VE+AOX on d 118. Feeding the high oxidant diet caused a series of changes in carcass characteristics and meat quality. Addition of antioxidant blend attenuated many of these, whereas the protective effects of supplemental vitamin E at 11 IU/kg were minimal during the finisher phase of the study.

Exhaled Breath Condensate Pepsin: Potential Noninvasive Test for Gastroesophageal Reflux in COPD and Bronchiectasis.

Acid gastroesophageal reflux is a common problem in non-cystic fibrosis bronchiectasis and COPD. Invasive methods are used to diagnose gastroesophageal reflux, but the ability to detect pulmonary microaspiration of gastric contents using this method is unclear. A noninvasive option to detect pulmonary microaspiration is to measure pepsin in exhaled breath condensate (EBC), but this has not been related to esophageal pH monitoring in these lung conditions. This study aimed to measure pepsin concentrations and pH in EBC and to determine the relationship to gastroesophageal reflux in bronchiectasis or COPD. Subjects with bronchiectasis (n=10) or COPD (n=10) and control subjects (n=10) completed 24-h esophageal pH monitoring for detection of acid gastroesophageal reflux, measuring the percentage of reflux time in the proximal esophagus and the DeMeester score (DMS). Concurrently, 3 samples of EBC were collected from each subject, and pH was measured and pepsin concentrations were analyzed by enzyme-linked immunosorbent assay. EBC pepsin was detected in subjects with bronchiectasis (44%) or COPD (56%) and in control subjects (10%). A diagnosis of gastroesophageal reflux was not associated with a higher concentration of EBC pepsin in bronchiectasis (P=.21) or COPD (P=.11). EBC pepsin concentration did not correlate with DMS (rs=0.36) or proximal reflux index (rs=0.25) in subjects with bronchiectasis or with DMS (rs=0.28) or proximal reflux index (rs=0.21) in patients with COPD. EBC and sputum pepsin concentrations were moderately correlated in bronchiectasis (rs=0.56) and in COPD (rs=0.43). Pepsin is detectable in EBC samples in bronchiectasis and COPD. Although no association was found between pepsin concentrations and a diagnosis of gastroesophageal reflux, a moderate relationship between sputum and EBC pepsin concentrations suggests that EBC pepsin may be a useful noninvasive marker of pulmonary microaspiration.

Efficacy and adverse events of laparoscopic gastrostomy placement in children: results of a large cohort study.

A gastrostomy placement is frequently performed in pediatric patients who require long-term enteral tube feeding. However, data on efficacy, perioperative complications and postoperative gastroesophageal reflux (GER) after laparoscopic gastrostomy (LAG) placement is limited. The aim of this study is to evaluate long-term efficacy and adverse events after LAG in a large cohort and determine whether routine preoperative 24-h pH monitoring should be used to predict postoperative GER. A retrospective observational cohort study was performed including 300 patients (75 % neurologically impaired) that underwent LAG. After a median follow-up of 2.63 years, feeding was successful in 95.9 % of patients. Weight-for-length z-scores significantly increased (p < 0.0005). Major complications were seen in only 6 patients (2.0 %), but minor complications occurred frequently (73.6 %). Overall incidence of GER remained unchanged after LAG. Sensitivity and specificity of preoperative pH monitoring were 17.5 and 76.9 %, respectively. LAG placement in pediatric patients leads to successful feeding in 96 % of patients and serious adverse events are rare. However, the minor complication rate is high. Overall incidence of GER does not increase after LAG. Preoperative 24-h pH monitoring is not a reliable tool to predict postoperative GER. This invasive investigation technique should therefore not be routinely performed.

Effectiveness of antireflux surgery for the cure of chronic cough associated with gastroesophageal reflux disease.

The effectiveness of surgical therapy for chronic cough secondary to gastroesophageal reflux disease remains controversial. The purpose of this study was to assess the efficacy of surgery and to identify the preoperative clinical profile that could predict the positive effects of treatment on chronic cough. Of 299 patients who underwent antireflux surgery between 1995 and 2010, 67 patients were affected by chronic cough and typical symptoms. In addition, 83 patients with typical symptoms were selected to form the control group, according to the parameters of age, sex, and the period of surgical activity. Preoperatively, all patients underwent a workup, including symptom assessment, barium swallow, upper gastrointestinal endoscopy, esophageal manometry, and 24-h pH recording or intraluminal impedance/pH monitoring in the absence of esophagitis. Patients with chronic cough also were administered a high-resolution computed tomography scan of the chest, a methacholine challenge test, and spirometry. Surgery was performed on patients positive for gastroesophageal reflux disease and negative for pulmonary diseases. The patients were followed up for a median of 84 months after surgery. No significant differences in preoperative reflux symptoms or esophagitis were found between the two groups. After surgery, chronic cough was absent in 57 (85 %) patients. Of the ten patients who still reported chronic cough, reflux symptoms relapsed in five, two of whom developed esophagitis. In the other five patients, typical symptoms were absent, and their chronic cough had improved but had not disappeared. Surgery is effective for the treatment of chronic cough secondary to gastroesophageal reflux disease, particularly if associated with severe and long-standing typical symptoms.

Peroral Endoscopic Myotomy (POEM) for Esophageal Primary Motility Disorders: Analysis of 100 Consecutive Patients

IntroductionPeroral endoscopic myotomy (POEM) is a flexible endoscopic approach to the lower esophageal sphincter (LES) providing access for a myotomy to relieve dysphagia. The technique has been adopted worldwide due to reports of excellent short-term clinical outcomes. We report on a consecutive patient cohort with clinical and objective outcomes representing the establishment of a POEM program within a busy esophageal surgical practice. MethodsComprehensive data was collected prospectively on all patients undergoing POEM from October 2010 to November 2013 at a single institution. Patients were classified based on high-resolution manometry (HRM). Operative data and immediate outcomes were reviewed. Symptom scores, HRM, and timed barium swallow (TBS) were performed prior to the procedure. Patients were asked to undergo routine postoperative testing 6–12 months after surgery with the addition of standard 24-h pH to the preoperative protocol. Morbidity was defined as requiring additional procedures or prolonged hospital stay >2 days. ResultsOne hundred POEM patients were included in the final analysis. The mean age was 58 years (18–83 years). Primary presenting symptoms included dysphagia 81, chest pain 10, and regurgitation 9. The mean follow-up was 16 months. HRM diagnoses were 75 achalasia (30 type I, 43 type II, 2 type III), 12 nutcracker esophagus, 5 diffuse esophageal spasm (DES), and 8 isolated hypertensive non-relaxing LES.The mean operative time was 128 min. The median hospital length of stay (LOS) was 1 day. The overall morbidity was 6 %; all were treated endoscopically or with conservative management without further sequelae (three had intra-tunnel leak diagnosed on routine esophagram and one developed a postoperative intra-tunnel hemorrhage, one developed Ogilvie’s, and one required prolonged intubation for CO2 retention).The average LES resting/residual pressure significantly decreased (44.3/22.2 to 19.6/11.7 in millimeters of mercury). Esophageal emptying improved from 40 to 90 % on TBS with 93 % patients demonstrating >90 % emptying at 1 min. Of the achalasia patients, 36 % (17/47) showed some return of normal peristalsis (≥70 % peristalsis) on post-op HRM.Abnormal acid exposure was present on postoperative testing in 38 % (26/68). Of these, 14 were asymptomatic. No reflux patient required additional antireflux procedure.Eckardt scores decreased from 6 to 1. Dysphagia was improved or eradicated in 97 % with a complete resolution accomplished in 89 %. Complete dysphagia relief was better for achalasia patients (46/47 patients; 97.8 %) vs. non-achalasia patients (17/24; 70.8 %). Of those with preoperative chest pain, 91.5 % reported complete relief.Four patients have refractory dysphagia. Two non-achalasia patients underwent subsequent laparoscopic Heller myotomy and two are improved following serial endoscopic dilatations. ConclusionThis study represents the largest POEM series to date that includes objective data. Despite reflux in one/three of patients, POEM provides excellent relief of dysphagia (97 %) and chest pain (91.5 %) for patients with esophageal spastic disorders with acceptable procedural morbidity.