Abnormal pH Study Research Articles

Prolonged acid reflux monitoring using acid exposure time and DeMeester score: two days are not enough.

Wireless pH monitoring allows for a definitive GERD diagnosis, which is essential for optimal medical or surgical management of the patient. However, there is no guideline recommendation on whether prolonged pH testing (72 or 96h) provides additional benefit when compared to the standard 48-h testing. We aimed to assess whether prolonged pH monitoring diagnoses more patients with GERD, as well as compare the DeMeester score to acid exposure time as diagnostic criteria for GERD. This was a retrospective analysis of consecutive adult patients who underwent wireless esophageal pH monitoring between August 2018 and July 2021. The primary outcome was the additional diagnoses of GERD (predominant acid exposure pattern) in patients who underwent 48-h versus 96-h pH monitoring. Secondary outcomes included comparison of the DeMeester score to acid exposure time and internal agreement between the first and second 48-h blocks of a prolonged96-hpH study. When comparing 48-h versus 96-h pH testing, the prolonged monitoring group was more likely to have a predominant reflux pattern and thus be diagnosed with definitive GERD by elevated DeMeester score (58.8% vs. 40.8%, p = 0.003) or acid exposure time > 6% (44.7% vs. 32.4%, p = 0.039). For patients who underwent prolonged testing, the results of monitoring beyond 48h led to a clinically meaningful change in study interpretation in 24.8% of patients. The study data from Days 3 to 4 yielded only a 56.6% agreement with the first 2days. In patients undergoing extended pH monitoring, almost half were found to have an abnormal pH study after a normal study on Day 1. An additional 25% of patients had a change in study interpretation by extending the study beyond 48h. Our findings suggest only 48h of pH monitoring will miss a diagnosis of GERD in a clinically important number of patients.

Preoperative esophageal testing predicts postoperative reflux status in sleeve gastrectomy patients.

Patients who undergo vertical sleeve gastrectomy (VSG) are at risk of postoperative GERD. The reasons are multifactorial, but half of conversions to Roux-en Y gastric bypass are for intractable GERD. Our institution routinely performs preoperative pH and high-resolution manometry studies to aid in operative decision making. We hypothesize that abnormal pH studies in concert with ineffective esophageal motility would lead to higher rates of postoperative reflux after VSG. A single institution retrospective review was conducted of adult patients who underwent preoperative pH and manometry testing and VSG between 2015 and 2021. Patients filled out a symptom questionnaire at the time of testing. Postoperative reflux was defined by patient-reported symptoms at 1-year follow-up. Univariate logistic regression was used to examine the relationship between esophageal tests and postoperative reflux. The Lui method was used to determine the cutpoint for pH and manometric variables maximizing sensitivity and specificity for postoperative reflux. Of 291 patients who underwent VSG, 66 (22.7%) had a named motility disorder and 67 (23%) had an abnormal DeMeester score. Preoperatively, reflux was reported by 122 patients (41.9%), of those, 69 (56.6%) had resolution. Preoperative pH and manometric abnormalities, and BMI reduction did not predict postoperative reflux status (p = ns). In a subgroup analysis of patients with an abnormal preoperative pH study, the Lui cutpoint to predict postoperative reflux was a DeMeester greater than 24.8. Postoperative reflux symptoms rates above and below this point were 41.9% versus 17.1%, respectively (p = 0.03). While manometry abnormalities did not predict postoperative reflux symptoms, GERD burden did. Patients with a mildly elevated DeMeester score had a low risk of postoperative reflux compared to patients with a more abnormal DeMeester score. A preoperative pH study may help guide operative decision-making and lead to better counseling of patients of their risk for reflux after VSG.

Evaluation of Gastroesophageal Reflux Disease in Children on the Autism Spectrum: A Study Evaluating the Tolerance and Utility of the BRAVO Wireless pH Monitoring.

Children on the autism spectrum disorder (ASD) may express pain or discomfort through stereotypic or self-injurious behaviors. Gastroesophageal reflux disease (GERD) may be challenging to diagnose in a child who is non-verbal or has impaired communication skills, diagnostic testing for GERD may be the only way to establish the diagnosis. We report our experience using the BRAVO wireless pH monitoring device for the evaluation of GERD in this patient population. Tolerance and feasibility as well as pH parameters and symptom correlation of the BRAVO pH were evaluated retrospectively in ASD children and compared it to a large cohort of non-ASD children. Only patients with studies lasting >24 hours were included. A total of 172 patients were included, 27 of those were diagnosed with autism (median age 11 years, 17 male). We found no difference in age and weight between both groups but there was a male predominance in the autism group ( P = 0.007). We found no difference in the ability to complete at least 24 hours of study duration between both groups (24/27 or 89% in ASD vs 133/145 or 92% non-ASD patients, P = 0.632). We also found no difference in the median reflux index on the worst day ( P = 0.27) or the average of both days ( P = 0.75), BRAVO pH parameters and the proportion of abnormal studies between ASD and non-ASD children. When evaluating the overall symptom correlation with GER episodes, we did not find a difference between both groups, but we did find a higher symptom correlation for GER symptom during supine position in ASD children. Study was performed for behavioral indication in 11 ASD children, all had normal esophageal mucosa but 4 of those had an abnormal BRAVO pH study. No significant side effects were reported during the study, only 2 patients (1 non-ASD and 1 ASD) complained of self-limited chest pain. BRAVO wireless pH is well tolerated and feasible in evaluating GER and behavioral symptoms in ASD children and provides a reasonable alternative to standard trans-nasal pH monitoring.

Characterization of Crural Repair in Antireflux Surgery: Preliminary Experience with a Standardized Technique

Purpose: To define and optimize cruroplasty in laparoscopic repair of hiatal hernia (LRHH). Background: Crural closure and crural repair in LRHH are used interchangeably. While crural closure entails obliteration of the diaphragmatic defect, cruroplasty involves restoring the anatomy and producing a “functional closure.” Methods: This is an IRB-approved retrospective study. Inclusion criteria were sliding hiatal hernia ≤6 cm in axial length, abnormal pH study or erosive esophagitis, use of the endostitch device to standardize surgical bite, and endoscopic fundoplication to standardize the wrap. Exclusion criteria were a history of antireflux surgery, gastroparesis, or preexisting esophageal stricture. Results: A total of 68 patients, 21 males, and 47 females met the inclusion criteria. The median age and BMI were 59 and 28, respectively. The average follow-up was 26.3 (12–62) months. There were three anatomical recurrences 3/68 (4.4%) and two of them had symptomatic recurrence. All but eight patients discontinued antisecretory therapy 60/68 (88.2%). Five of these eight patients used these medications at lesser dose or frequency rendering the overall improvement of patients to 65/68 (95.5%). There was no postoperative dysphagia. Conclusions: Laparoscopic hiatal hernia repair should focus on crural repair, not merely closure. Optimizing cruroplasty can be achieved by understanding the functional anatomy, recreating the crural sling, and adjusting the crural suture tension. This results in a low recurrence rate of hiatal hernias, a high discontinuation rate of proton pump inhibitors, significant objective clinical improvement of GERD symptoms, and no postoperative dysphagia.

Narrow-band imaging for the diagnosis of nonerosive reflux disease: an international, multicenter, randomized controlled trial

We examined the accuracy of narrow-band imaging (NBI) findings in nonerosive reflux disease (NERD) patients compared with control subjects and the impact of proton pump inhibitor (PPI) therapy on these mucosal changes in a multicenter, double-blind, randomized controlled trial. NERD patients (typical symptoms using a validated GERD questionnaire, absence of erosive esophagitis, and abnormal 48-hour pH study) and control subjects underwent high-definition white-light endoscopy followed by NBI and biopsy sampling of the distal esophagus. Then, NERD patients were randomized to esomeprazole 40 mg/day or placebo for 8 weeks, followed by repeat endoscopy. The presence of distal esophageal mucosal changes on NBI were recorded at baseline and after treatment: intrapapillary capillary loops (IPCLs; number, dilation, and tortuosity), microerosions, increased vascularity, columnar islands, and ridge/villous pattern (RVP) above the squamocolumnar junction. Of 122 screened, 21 NERD and 21 control subjects were identified (mean age, 49.5 ± 14.6 years; 62% men; and 85% white). The combination of IPCL tortuosity, RVP, and microerosions (62% vs 19%, P< .05) had a high specificity (86%) and moderate sensitivity (60%) for NERD with an area under the curve of .74. In 10 NERD patients treated with PPIs, resolution of microerosions was most significant (P= .047) compared with placebo (n= 11). RVP resolved in all NERD patients after therapy (P= .02) and correlated with acid exposure time (P= .004). Papillary length (P= .02) and basal cell thickness (P= .02) significantly correlated with a combination of IPCL tortuosity, RVP, and microerosions. In this randomized controlled trial, RVP on NBI demonstrated a high specificity, correlated with acid exposure time, and improved with PPI therapy, suggesting that it could be used as a surrogate marker for diagnosis of NERD. (Clinical trial registration number: NCT02081404.).

791 RECURRENT HIATAL HERNIA A HIGH PREDICTOR OF PATHOLOGIC REFLUX AND NEED FOR REINTERVENTION

Abstract Anti-reflux surgery (ARS) has been postulated to have high failure rates, which may approach 50% depending upon hiatal hernia size. Most failures are thought to be related to wrap disruption or hiatal hernia recurrence. Recently, diaphragmatic mesh augmentation has been shown to reduce hiatal hernia recurrence. We aimed to determine factors that influence recurrence based on vigilant imaging and diagnostic pH studies, and the need for surgical reintervention. Methods A prospectively maintained database of all patients undergoing index robotic ARS (including Hill, Nissen, Toupet, and Linx procedures) with Phasix ST ® mesh was queried. Between December 2016 and July 2020, 134 patients were identified of which 92 met inclusion criteria for post-operative barium esophagram performed at routine intervals (6, 12, or 24-months) or for recurrent symptoms. Median follow-up time was 11.4 months. Clinical characteristics, manometry, pH studies, as well as surgical approach was evaluated. Radiographic recurrences were then associated with endoscopic confirmation and rates of surgical re-intervention. Results Radiographic recurrence &amp;gt;2 cm was noted in 9 (9.8%) patients, of which 44% were symptomatic, compared to 36% of those without radiographic recurrence (p = 0.620). Endoscopy confirmed recurrence in 67% of patients with radiographic recurrence versus 0% without (p = 0.001). When all radiographic recurrences, including those &amp;lt;2 cm, were evaluated, 17 (18%) were identified, of which 53% of patients were symptomatic. Endoscopic and pH studies confirmed recurrences in 75% and 71% of these patients, respectively. Overall reintervention rates were 23% in the setting of any radiographic recurrence versus 1.3% without (p = 0.001). Conclusion Recurrence rates following robotic ARS and hiatal hernia repair with mesh augmentation appear low with nearly 1-year follow-up. Prior to surgical reintervention, endoscopic and pH studies are warranted to confirm symptomatic recurrence. Recurrent hiatal hernias, including those &amp;lt;2 cm, can lead to abnormal pH studies that merit reintervention at rates higher than those without evidence of recurrence. Longer term follow-up is required to optimally delineate true recurrence patterns.

CYP2C19 genotype variability in patients with refractory gastroesophageal reflux after per-oral endoscopic myotomy (POEM).

Background and study aims Symptomatic gastroesophageal reflux is a recognized potential adverse event following peroral endoscopic myotomy (POEM). Proton pump inhibitors (PPIs) are an effective first-line therapy; although their efficacy can be affected by genotype cytochrome P450 2C19 (CYP2C19) variability leading to enhanced clearance of PPIs. The aim of our study was to evaluate the incidence of CYP2C19 genotype variability in POEM patients with refractory gastroesophageal reflux symptoms. Patients and methods This was a single-center, prospective, cohort study of consecutive POEM cases during a 7-year study period (2013–2020). Reflux symptoms were assessed with the validated gastroesophageal reflux disease questionnaire (GerdQ) and objective pH testing after POEM. CYP2C19 genotype testing was obtained in all patients with refractory gastroesophageal reflux disease (GERD) symptoms, defined as an abnormal pH study and GerdQ score ≥ 8 while on PPIs twice daily. Results POEM was performed in 325 consecutive patients (48.3 % female; mean age 57 years) during the study period. Twenty patients (6.8 %) had PPI-refractory, post-POEM gastroesophageal reflux based on their GerdQ score (median 9, range 8–11) and abnormal pH studies. CYP2C19 genotype testing identified 55 % (11/20) of these patients as being rapid metabolizers. Out of these, 9 (82 %) had improvement in clinical GERD symptoms after changing to a PPI less affected by CYP2C19 pharmacogenetics. Conclusions Post-POEM, PPI-refractory GERD is rare. As shown in this study, rapid metabolizers commonly respond by changing to a PPI less affected by CYP2C19 pharmacogenetics, thereby reducing the risk of long-term consequences from GERD and unnecessary anti-reflux surgery.

391 How Useful Is Prolonged 96 Hr versus 48 Hr Wireless pH Monitoring in PPI Refractory GERD?

INTRODUCTION: Gastroesophageal reflux disease (GERD) is a common problem. Ambulatory pH monitoring has been used to identify pathological esophageal acid exposure and reflux-symptoms association in GERD, especially when endoscopy is normal, but the utility of prolonged 96 hr monitoring and if PPI therapy during study facilitates better management is unclear. The purpose of the study is to evaluate the clinical utility of prolonged 96 hr wireless pH monitoring, before and after PPI therapy. METHODS: We conducted a retrospective study of adult patients presenting to our center between January 2015 and June 2018 with suspected diagnosis of GERD and refractory to PPI therapy. Consecutive patients who underwent 96 hr wireless pH monitoring (Bravo®, Medtronics, Minneapolis, MN) placed endoscopically, 6 cm above LES zone were enrolled. Patients were instructed to stop PPI therapy 7 days prior to the study and to resume their usual PPI therapy on day 3 and day 4 of study. The percent time of esophageal acid exposure (pH &lt; 4) for each day during supine and upright positions and GI symptoms were analyzed using (SPSS™) version 22. Patients were excluded if the entire 96 hr study was not recorded either from battery malfunction or capsule detachment. Data compared between those with normal and abnormal pH study, and between first 48 hrs and next 48 hrs. RESULTS: 64 patients met inclusion criteria (Table 1). 42 (65%) patients had elevated &gt;4.5%. Total 24 hr acid exposure time; 38% on either D1 or D2 and 62 % on both days and 22 (35 %) had normal acid reflux study (Figure 1, Table 2). Of patients with abnormal study, 23/42 (54.7%) had persistent increase in % acid exposure time on D3 and 17/42 (40.4%) patients on D4 following PPI therapy. CONCLUSION: Our study demonstrates that prolonged 96 hr pH monitoring is feasible and clinically useful. We confirmed abnormal acid reflux in 65% of patients and normal acid reflux in 35%. Also, the abnormal reflux profile normalized in 36% of patients on their usual PPI whereas 64% had persistent abnormal acid reflux, despite their usual PPI therapy. Thus 96 hr testing allows improved diagnosis of day time or supine acid reflux symptoms, and identifies patients who are either refractory or responsive to current PPI therapy. This test could improve management of patients with PPI refractory GERD.

436 Peroral Endoscopic Myotomy Is a Safe and Effective Treatment Modality for Achalasia After Prior Failed Botulinum Toxin Treatment

INTRODUCTION: Peroral endoscopic myotomy (POEM) is shown to be effective in patients with recurrent symptoms after prior treatments such as Heller myotomy (HM) or pneumatic dilatation (PD) or Botulinum toxin (Botox) injection into lower esophageal sphincter (LES). However there is lack of a systemic study analyzing POEM in patients with prior Botox treatment alone and not confounded by other treatments. Previous Botox treatment leads to submucosal fibrosis making sub-mucosal dissection and separation of tissue planes more challenging during POEM. Hence, our study aims were to determine the safety and efficacy of POEM in achalasia patients who previously received exclusively Botox treatments. METHODS: Medical records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients who underwent timed barium esophagram (TBE) and high-resolution manometry (HREM) prior to POEM along with two-month post-POEM esophageal pH study, TBE and HREM were included. Patients were categorized into two groups as: no prior Botox (treatment naïve) and prior Botox group. Patients with prior HM or PD were excluded from both groups. Baseline patient characteristics, procedural details, TBE, HREM, pH study findings and Eckardt’s scores were compared between the two groups. Post-POEM Eckhardt’s score of ≤3 was considered as successful palliation of symptoms. RESULTS: From a total of 200 patients undergoing POEM, 103 patients met the study criteria (prior Botox = 35; treatment naïve = 68). Patients with no prior Botox injections were younger, had high LES integrated relaxation pressure (LES-IRP) on HREM, wider esophagus on TBE at 1 and 5 minutes. In terms of operative details and outcomes, the total myotomy length, operative time, complications, length of stay and 30-day readmission rates were similar for both groups (Table 1). POEM was successful in 96.9% and 93.8% patients in no Botox and prior Botox groups respectively. At two months post-POEM, similar improvements were noted in Eckhardt scores (Figure 1a), LES-IRP and height of barium columns at 1 and 5 minutes, however patients without prior Botox had greater improvement in TBE width at 1 and 5 minutes (Figure 1b,c). The rates of symptomatic GERD and abnormal esophageal pH study were also not significantly different between the two groups (Table 2). CONCLUSION: In achalasia patients with prior Botox injections, POEM is feasible and safe. Prior Botox treatment does not influence the efficacy of POEM.

437 Peroral Endoscopic Myotomy Is a Safe and Effective Treatment Modality for Geriatric Patients With Achalasia

INTRODUCTION: Peroral endoscopic myotomy (POEM) is an emerging treatment modality for achalasia. It is a particularly appealing treatment option in older patients, as it is minimally invasive like an endoscopic procedure and highly effective as surgical myotomy. However, there is lack of a systematic study analyzing and comparing POEM outcomes in young (&lt; 65 years) and geriatric patients (≥65 years). Hence, our study aims were to assess and compare the safety and efficacy of POEM in young versus geriatric patients. METHODS: Medical records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients who underwent timed barium esophagram (TBE) and high-resolution manometry (HREM) prior to POEM along with two-month post-POEM esophageal pH study, TBE and HREM were included. Patients were categorized into two groups as: young (&lt;65 years) and old (≥65 years). Demographic and procedural details, TBE, HREM, pH study findings and Eckardt scores were compared between the two groups. Post-POEM Eckhardt score of ≤3 was considered as successful palliation of symptoms. RESULTS: 148 patients met the study criteria (&lt;65 years = 93; ≥65 years = 55). Younger patients were more likely to have higher BMI, but fewer comorbidities and lower TBE height at 1 minute but wider TBE width at 5 minutes. Rest of the TBE parameters, pre-operative Eckardt's score and lower esophageal sphincter-integrated relaxation pressure (LES-IRP) were similar between the two groups. Young patients were more likely to have undergone prior Heller myotomy, where as Botox injections were more common in older group. The operative time, total myotomy length, complications, length of stay and 30-day readmission rates were similar in the two groups (Table 1). POEM was successful in 94.5% young and 96% old patients. At two-month follow up, both groups showed significant improvements in Eckhardt scores (Figure 1a) and HREM parameters, however older patients showed greater improvement in TBE height at 1 and 5 minutes (Figure 1b,c). The rates of symptomatic GERD and abnormal esophageal pH study findings were not significantly different between the two groups (Table 2). CONCLUSION: POEM is a safe and effective treatment option for geriatric patients with achalasia similar to younger patients. POEM might emerge as the preferred approach for myotomy in this patient population, because of its low morbidity compared to surgical myotomy.

Impact of fundoplication for gastroesophageal reflux in the outcome of benign tracheal stenosis

ObjectiveThis study focuses on the impact of antireflux surgery in the outcome of tracheal stenosis. MethodsWe performed a retrospective study including patients with benign tracheal stenosis who underwent esophageal manometry and dual-probe 24-hour ambulatory esophageal pH study. Patients with an abnormal pH study were managed with laparoscopic modified Nissen fundoplication or medically (omeprazole 80 mg/d, orally). Patients with normal pH study results were observed. After a 24-month follow-up, the outcome was considered satisfactory if tracheal stenosis could be managed by resection and there was no need for further dilatation or definitive decannulation. The management groups were compared using propensity score matching. ResultsA total of 175 patients were included. Abnormal pH study results were found in 74 patients (42.3%), and 12.6% of patients had typical gastroesophageal reflux symptoms. Follow-up was completed in 124 patients (20 had fundoplication, 32 received omeprazole, and 72 were observed). After propensity score matching, the outcome of tracheal stenosis in the fundoplication group was similar to that of the observation group (odds ratio, 1; P = .99) and better than that of the omeprazole group (odds ratio, 5.31; P = .03). The observation (no gastroesophageal reflux) group had a better outcome of stenosis than those treated with omeprazole (odds ratio, 3.54; P = .02). ConclusionsThe outcome of the airway stenosis was superior after laparoscopic fundoplication compared with medical treatment with omeprazole and was similar to the outcome of patients without gastroesophageal reflux. A prospective randomized trial is warranted.

Issue Highlights

Issue Highlights

PS01.050: IMPACT OF FUNDOPLICATION IN THE OUTCOME OF TRACHEAL STENOSIS PATIENTS WITH GASTROESOPHAGEAL ACID REFLUX: A RETROSPECTIVE PROPENSITY SCORE-MATCHED STUDY

Abstract Background Abnormal gastroesophageal acid reflux (GEaR) is often found in laryngeal diseases and tracheal stenosis. The study focuses on the prevalence of GEaR and the impact of anti-reflux surgery in the outcome of post-intubation tracheal stenosis Methods Prospective non-randomized study of patients with post-intubation tracheal stenosis. Inclusion criteria: adult with subglottic or recurrent tracheal stenosis. Exclusion criteria: previous gastroesophageal surgery. Patients were submitted to esophageal manometry and pH study. Patients were divided in 3 groups: one with pH study negative, one with pH study positive receiving treatment with proton pump inhibitor and one with pH study positive submitted to Nissen fundoplication. Follow-up was 24 months. Outcome was considered satisfactory when airway stenosis could be successfully managed by resection, no need for dilatation or definitive decannulation. In order to match the 3 groups, it was used a propensity score match (PSM) and them they were compared. Statistical significance was assumed for P &lt; 0.05 Results Prevalence of GEaR was assessed in 175 patients. Abnormal pH study was found in 74 (42%) with a predominance of supine reflux. Typical GEaR symptoms were found in only 21%. Abnormal manometry was found in 37%, and hypotonic lower sphincter was the most frequent finding. Of the 124 patients who met the inclusion criteria, pH study was normal in 72 and abnormal in 52 (32 underwent clinical treatment and 20 nissen fundoplication). There were no peri-operative complications. After PSM, patients with abnormal pH study submitted to fundoplication had a higher chance of a satisfactory outcome of the stenosis compared to those treated with Omeprazole (OR 5.31; CI 2.41–11.07; P = 0.03) which was similar to those without GEaR (OR 1; CI 0.47–2.11; P = 0.99). Patients without GeAR had a higher chance of resolution of the tracheal stenosis compared to the patients treated with Omeprazole (OR 3.54; CI 2.02–6.19; P = 0.02). Conclusion Asymptomatic GEaR is a frequent finding in tracheal stenosis. Nissen fundoplication was safe and effective in selected patients with tracheal stenosis and GEaR. Control of the airway stenosis was superior after fundoplication if compared to medical treatment of GEaR. A larger prospective randomized multicenter trial is needed to confirm these findings Disclosure All authors have declared no conflicts of interest.

Basal lower esophageal sphincter pressure in gastroesophageal reflux disease: An ignored metric in high-resolution esophageal manometry.

Manometry and 24-h pH interpretation have seldom been studied. Our aim was to study these parameters as gold standard in reflux disease and to identify predictors of pathological acid reflux. Retrospective case record review of all patients with reflux disease evaluated using endoscopy, manometry, and 24-h pH testing from 2010 to 2016. Patients were categorized using Johnson-DeMeester score into two groups-group I (score > 14.7, normal study) and group II (< 14.7, normal study). These groups were compared for the above-mentioned parameters. Appropriate statistical tests were applied. P-value < 0.05 was considered significant. The study group includes 94 patients (median age 44 years, 63.8% males). Sixty (63.8%) and 34 patients belonged to groups I and II, respectively, 76.6% patients had normal endoscopy while the remaining had mild esophagitis. Peristalsis was normal in 66%, followed by ineffective esophageal motility (19.1%) and fragmented peristalsis (14.9%). Demography, symptoms, endoscopy findings, and peristalsis characteristics were similar between the two groups. Group II patients had significantly lower basal lower esophageal sphincter (LES) pressure (11.9 vs. 16.6; p < 0.02), lower integrated relaxation pressure (5.7 vs. 7.4; p < 0.01), and larger separation between LES and crural diaphragm (1.7 vs. 1.4 cm; p < 0.003). Basal LES pressure < 10 mmHg had the highest likelihood ratio (2.2) to predict an abnormal pH study. Basal LES pressure, integrated relaxation pressure, and hiatus size correlated with pathological acid reflux. Hypotensive basal lower esophageal sphincter pressure was the best predictor of an abnormal pH study but with negative linear correlation.

Endoscopic Treatments of GERD.

PURPOSE OF REVIEW: Endoscopic therapies for gastroesophageal reflux disease (GERD) are minimally invasive techniques which fill the gap between the medical therapy with proton pump inhibitors (PPIs) and surgical fundoplication. The main endoscopic therapies currently available in the USA are transoral incisionless fundoplication (TIF) using EsophyX device or less commonly, Medigus Ultrasonic Surgical Endostapler, and radiofrequency energy delivery to lower esophageal sphincter using Stretta device. Our aim was to examine the available evidence for these therapies. Consistent evidence for subjective improvement is available for fundoplication using EsophyX and Stretta, but improvement in objective parameters for GERD is not seen or evaluated in all the studies. There is a reduction in long-term efficacy seen with TIF and also to a lesser extent with Stretta. Endoscopic therapies do not replace surgical fundoplication and therefore are useful in patients with breakthrough symptoms on PPI such as regurgitation or those reluctant to take long-term PPI. An ideal patient is one who has symptoms and objective evidence of GERD such as abnormal pH study or erosive esophagitis without any significant anatomic distortion such as a hiatal hernia. Since these are endoluminal procedures, they do not address the hiatal hernia reduction or repair of crural defect. Adequate training in the technique and careful patient selection are essential prior to embarking on these procedures.

Long-term Outcomes and Factors Associated With Failure After Paraesophageal Hernia Repair

Introduction: Fundoplication with or without Collis gastroplasty is frequently performed for the repair of complex hiatal hernia. However, symptoms or hernia can recur in some patients requiring re-do fundoplication. Factors associated with failed fundoplication surgery remain unclear. The aim of this study was to assess the factors associated with failed fundoplication surgery. Methods: Patients who underwent PEH repairby a single thoracic surgeon (TWR) at our institution between Jan 1, 2006 and Dec 31, 2013 was performed. Patients who presented for redo fundoplication were excluded. Failed fundoplication was defined as presence of symptoms (heartburn, chest pain and/or reflux) with either post-op abnormal pH testing (based on total time pH5.5%) or recurrence of hiatal hernia on endoscopy or barium swallow. Results: A total of 339 patients (mean age 59.6±13.3 years and 242 (71.4%) female) underwent PEH repair during the study period with a median follow up of 12.8 months (25th and 75th percentile 2.6, 47.7). Sixty patients were referred for redo fundoplication and were excluded. Of the 279 patients, 18 patients met criteria for failed fundoplication during follow-up. Median time to failure was 2.4 months [2.3, 7.2]. Fifteen patients had symptoms and abnormal pH study, 2 had symptoms and recurrence of hiatal hernia and 1 had all three (symptoms, abnormal pH study and hiatal hernia). Table 1 presents the analysis of factors associated with failed fundoplication surgery. On multivariable analysis, presence of pre-fundoplication reflux symptoms (HR: 3.7, 95% CI 1.06-12.6, P-value: 0.041) and preoperative esophageal motility disorder (HR: 2.8, 95% CI 1.1-7.2, P-value 0.028) were associated with failed fundoplication. Figure 1 presents the time-to-event analysis for failed fundoplication. Nearly all of the fundoplication failures occurred within 24 months after surgery.Figure: Time-to-event analysis of failed fundoplication.Table: Table. Analysis of Factors Associated with Failed FundoplicationConclusion: In patients undergoing PEH repair, pre-fundoplication regurgitation and esophageal motility disorder were associated with increased risk for failed fundoplication. PEH repair failure beyond 24 months after surgery is rare.

Investigation and management of gastro-oesophageal reflux inUnitedKingdom neonatal intensive care units.

In 2004, wide variation in the investigation and management of gastro-oesophageal reflux (GOR) of infants on UK major neonatal units was demonstrated. Our aim was to resurvey neonatal practitioners to determine current practice and whether it was now evidence based. A questionnaire was sent to all 207 UK neonatal units. Responses were obtained from 84% of units. The most frequent 'investigation' was a trial of therapy (83% of units); pH studies were used in 38%, upper GI contrast studies in 19% and multichannel intraluminal impedance (MII)/pH studies in 5%. Only six units suggested a threshold for an abnormal pH study and two units for an abnormal MII study. Infants were commenced on antireflux medication without investigation always in 32% of units, often in 29%, occasionally in 19% and only never in 1%. Gaviscon was used as first line treatment in 60% of units, and other medications included ranitidine in 53%, thickening agents in 27%, proton pump inhibitors in 23%, domperidone in 22% and erythromycin in 6%. There remains a wide variation in diagnostic and treatment strategies for infants with suspected GOR on neonatal intensive care units, emphasising the need for randomised trials to determine appropriate GOR management.

Favorable results from a prospective evaluation of 200 patients with large hiatal hernias undergoing LINX magnetic sphincter augmentation

IntroductionMagnetic sphincter augmentation (MSA) of the lower esophageal sphincter restores the antireflux barrier in patients with hiatal hernias ≤3 cm. We performed a prospective study in patients undergoing MSA with the LINX device during repair of paraesophageal and hernias over 3 cm axial component.Methods and proceduresMulticenter, prospective study of consecutive patients treated with MSA at the time of repair of hiatal hernias >3 cm.Results200 patients (110 female) were treated between March 2014 and February 2017 via laparoscopic hernia repair and MSA. Mean age was 59.5 years, mean BMI 29.4. 40% had esophagitis, 20% intestinal metaplasia, 72 of 77 tested had abnormal pH studies. Preoperative PPI use was reported by 87%. Eighteen patients had prior hiatal hernia/fundoplication. All had normal function. 78% of patients had axial hiatal hernia ≥5 cm or large paraesophageal component. Mean operative time was 81 min (38–193), EBL was 10 cc. Non-permanent mesh reinforcement of hiatal repair was performed in 83% of the patients. There were two readmissions for dehydration; 2 patients with pulmonary embolism, and 1 patient with cardiac ischemia. Nineteen patients required dilation. 156 pts were followed at a median of 8.6 months. GERD-HRQL scores improved from 26 preoperatively to 2 postoperatively. Complete PPI independence was achieved in 94% (147/156). Videoesophagram in 51 patients at median 11 months found 3 asymptomatic hernias <3 cm. One symptomatic patient underwent successful repair of the hernia without MSA manipulation. There have been no device explants, erosions, or migrations to date.ConclusionsThis prospective study of 200 patients with >3 cm hernias undergoing MSA with hiatoplasty resulted in favorable outcomes with median of 9 months follow-up. Comparing this to published reports of MSA in patients with <3 cm hernias, the safety and clinical efficacy of MSA are independent of initial hernia size.

CLINICAL, ENDOSCOPIC AND ESOPHAGEAL PH-IMPEDENCE STUDY IN PATIENTS WITH HEARTBURN REFERRED TO KURDISTAN CENTER FOR GASTROENTEROLOGY AND HEPATOLOGY

Background&#x0D; Heartburn is characterized by a discomfort or burning sensation behind the sternum that arises from the epigastrium and may radiate toward the neck. A subset of patients with heartburn are Non-erosive reflux disease (NERD) is characterized by reflux symptoms in the absence of esophageal mucosal breaks, with objective evidence of pathological levels of gastroesophageal reflux on pH or pH-impedance monitoring.&#x0D; Objectives&#x0D; To evaluate patients with heartburn clinically, endoscopically and by combined pH-impedance study.&#x0D; Methodology&#x0D; This is a cross-sectional descriptive study, a total of 60 cases of heartburn, referred to Kurdistan center for Gastroenterology and Hepatology in Sulaimani from February 2015 to December 2015 were enrolled. Cases interviewed and a questionnaire filled; body mass index measured. OGD and pH-impedance study were done for all participants.&#x0D; Results &#x0D; Out of 60 cases of heartburn, erosive esophagitis (EE) found in 21.7% of cases and 78.7% had normal OGD. Regurgitation found in almost all cases of EE (100%) which was statistically significant (p=0.02). Patients with hiatus hernia HH are at greater risk for EE than non-erosive cases (p=0.01). By OGD and pH-study more than half of our cases (51.6%) were proved to have gastroesophageal reflux disease (GERD). There was significant different (p &lt;0.001) between those with erosive and non-erosive esophagitis in relation to number of reflux episodes and intensity of acid exposure.&#x0D; Conclusion&#x0D; Only 21.3% of heartburn cases had EE. Having HH is a risk factor for EE. Almost half of cases with EE had abnormal pH-study; this means ODG has low sensitivity in the diagnosis of GERD with greater specificity. Adding combined pH-impedance test to OGD in the evaluation of heartburn increase the diagnostic utility of GERD.

Manometric Changes to the Lower Esophageal Sphincter After Magnetic Sphincter Augmentation in Patients With Chronic Gastroesophageal Reflux Disease.

To evaluate the manometric changes, function, and impact of magnetic sphincter augmentation (MSA) on the lower esophageal sphincter (LES). Implantation of a MSA around the gastroesophageal junction has been shown to be a safe and effective therapy for gastroesophageal reflux disease, but its effect on the LES has not been elucidated. Retrospective case control study (n = 121) evaluating manometric changes after MSA. Inclusion criteria consisted of a confirmed diagnosis of gastroesophageal reflux disease by an abnormal esophageal pH study (body mass index <35 kg/m, hiatal hernia <3 cm, and absence of endoscopic Barrett disease). Manometric changes, pH testing, and proton pump inhibitor use were assessed preoperatively and 6 and 12 months after MSA. MSA was associated with an overall increase in the median LES resting pressure (18 pre-MSA vs 23 mm Hg post-MSA; P = 0.0003), residual pressure (4 vs 9 mm Hg; P < 0.0001), and distal esophageal contraction amplitude (80 vs 90 mm Hg; P = 0.02). The percent peristalsis remained unaltered (94% vs 87%; P = 0.71).Overall, patients with a manometrically defective LES were restored 67% of the time to a normal sphincter with MSA. Those with a structurally defective or severely defective LES improved to a normal LES in 77% and 56% of patients, respectively. Only 18% of patients with a normal preoperative manometric LES deteriorated to a lower category. MSA results in significant manometric improvement of the LES without apparent deleterious effects on the esophageal body. A manometrically defective LES can be restored to normal sphincter, whereas a normal LES remains stable.