Development Of Gastroesophageal Reflux Research Articles

Gastroesophageal Reflux after Peroral Endoscopic Myotomy: Myth or Reality?

AbstractPeroral endoscopic myotomy (POEM) is an accepted treatment for achalasia cardia (AC), and results are comparable to those of laparoscopic Heller myotomy (LHM). In recent years, several reports have confirmed higher incidence of gastroesophageal reflux (GER) following POEM. This review evaluates the current evidence regarding post-POEM GER, critically examines the potential contributing factors responsible for GER, limitations of the current available functional testing, and precautions and preventive measures, and provides future directions for research. Factors conclusively contributing to increased post-POEM GER include injury to the sling fibers of the lower esophageal sphincter, length of gastric myotomy > 2 cm, and others. Historically, these same factors have been implicated for development of GER after surgical (laparoscopic) myotomy. Although less invasive, optimal technique of POEM may be important to control post-POEM GER. Most post-POEM GER occurs during the immediate post-POEM period, is mild, and is easily treatable using proton-pump inhibitors. GER incidence plateaus at 2 years and is comparable to that after LHM. Patients should therefore be prescribed proton-pump inhibitors for at least 2 years. Antireflux procedures (ARPs) are infrequently required in these patients as the incidence of refractory GER is low. Novel ARPs have been recently described and are currently under evaluation. Conclusive diagnosis of GER is a clinical challenge. Most patients are asymptomatic, and GER is diagnosed only on abnormal esophageal acid exposure (EAE). Studies have demonstrated that current measures to diagnose GER are inadequate, inaccurate, and cannot differentiate between true GER and abnormal EAE due to food fermentation in the distal esophagus. The Lyon Consensus criteria should be implemented for confirmation of diagnosis of GER. Finally, the review recommends an evidence-based clinical algorithm for evaluation and management of post-POEM GER and provides guidelines for future research in this field.

Evaluation of gastroesophageal reflux in pediatric laparoscopic appendectomy procedures.

The increased intra-abdominal pressure during laparoscopic surgical procedures was reported to be a factor in the development of gastroesophageal reflux. This study evaluated the presence of gastroesophageal reflux and associated factors using 24-h pH monitoring in children undergoing laparoscopic appendectomy. Children who underwent laparoscopic surgery for presumed acute appendicitis between June 2017 and June 2018 were included in the study. After pre-operative endotracheal intubation, pH catheters were placed for 24-h esophageal pH monitoring. Relationships between gastroesophageal reflux and procedure time, pre-operative fasting time, age, weight, and body mass index (BMI) were evaluated. A total of 60 pediatric patients were included in the study. Their mean (SD) age was 11.82 (3.71) years (range, 4-17 years). The mean (SD) body weight was 41.27 (16.72) kg (range, 15-90 kg) and the mean (SD) BMI were 17.96 (4.37). The mean pre-operative fasting time was 15.52 (12.1) h, while the mean operative time was 38.42 (17.96) min. Lower age and weight were significantly associated with the presence of post-operative gastroesophageal reflux (p<0.05). Mean procedure time, mean pre-operative fasting time, and BMI were not significantly associated with intra- or post-operative gastroesophageal reflux (p>0.05). The lack of a significant relationship between mean procedure time and gastroesophageal reflux suggests that the mean duration of the laparoscopic procedures performed in this study is safe in terms of gastroesophageal reflux. The results also indicate that young age and low weight should be considered risk factors for gastroesophageal reflux in pediatric patients undergoing laparoscopic appendectomy.

КАШЕЛЬ И ГАСТРОЭЗОФАГЕАЛЬНЫЙ РЕФЛЮКС: НЕПРОСТЫЕ ВЗАИМОДЕЙСТВИЯ (ЧАСТЬ 2)

For many decades, researchers have been interested in the problem of the relationship between cough and gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD). The question has not only theoretical, but also practical significance, since it determines the diagnostic and therapeutic, both for coughing and for GER, while uniting under their «banners» specialists of various profiles: physicians, pediatricians, gastroenterologists, pulmonologists and others. This article presents and discusses the data of domestic and international publications on this issue and, based on current knowledge, the concept of the relationship between GER, GERD and cough, including bronchoobstructive syndrome in bronchial asthma, is proposed, as well as recommendations for practical work of doctors in this clinical situation. Based on the available data, it can be argued that the relationship between GER (GERD) and cough is obvious, but many details of this interaction remain poorly understood. It should be noted the important role played by a hiatal hernia (HH) both in the development of GER and the cough associated with it. Children with chronic cough that do not respond to basic therapy are shown to be examined in order to identify the possible effect of GER on its formation. In this regard, it is important to identify HH in order to determine the tactics of patient management and resolve the issue of its surgical correction. On the other hand, patients with GERD are shown at least a minimal examination to clarify the state of the respiratory system, even in the absence of obvious respiratory symptoms.

Efficacy of surgical or endoscopic treatment of idiopathic achalasia: a systematic review and network meta-analysis

Treatment of achalasia has changed substantially over the past 20 years. Therapeutic options offered to patients vary, depending on access to both resources and expertise, and include pneumatic dilation (PD), laparoscopic Heller's myotomy (LHM), or per-oral endoscopic myotomy (POEM). Although there are head-to-head trials of these interventions, many of these are small and underpowered, so relative efficacy is unknown. We did a systematic review and network meta-analysis to try to resolve this uncertainty. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and Embase Classic from database inception up to June 11, 2020, for randomised controlled trials (RCTs) assessing the efficacy of POEM, LHM, or PD, compared with each other in adults with idiopathic achalasia. We extracted all data as dichotomous outcomes (treatment success or failure) after completion of therapy. We also extracted country of origin, number of centres, duration of follow-up, and primary outcome measure used to define treatment success or failure. Data were extracted for intention-to-treat analyses, with all dropouts assumed to be treatment failures (ie, symptomatic at final point of follow-up), wherever trial reporting allowed this. We pooled data using a random effects model, and assessed heterogeneity between studies using the I2 statistic. Risk of bias was examined for all studies. The primary outcome was efficacy, in terms of a dichotomous measure of treatment success or failure, after a minimum of 1 year of follow-up. Secondary outcomes were occurrence of perforation, adverse events, serious adverse events (including death), need for reintervention, need for surgery as a result of complications, development of gastro-oesophageal reflux, or erosive oesophagitis. Efficacy was reported as a pooled relative risk (RR) of treatment failure, with a 95% CI, for each comparison tested, and ranked by therapy according to P-score. Of 1044 studies initially assessed, nine were eligible RCTs, which comprised 911 participants in total. None of the nine studies were at low risk of bias. Of the 911 participants 372 (41%) participants were randomly assigned to LHM, 317 (35%) participants to PD, and 222 (24%) participants to POEM. Of the three strategies, POEM was ranked first (RR of failure of treatment 0·33, 95% CI 0·15-0·71; P-score 0·89), then LHM (RR 0·45, 0·26-0·78, P-score 0·61). There was moderate heterogeneity between studies (I2=61·5%). Both POEM and LHM were superior to PD on direct and indirect comparison, but neither was significantly more effective than the other. There were no significant differences in perforation rates, need for re-intervention or surgery, gastro-oesophageal reflux, erosive oesophagitis, or serious adverse events, but PD was less likely to lead to adverse events than POEM. POEM and LHM should be the preferred treatments for idiopathic achalasia. PD performed worst in terms of treatment success, and therefore its role in the management of patients with achalasia is less certain. None.

Semi-Solid Nutrients for Prevention of Enteral Tube Feeding-Related Complications in Japanese Population: A Systematic Review and Meta-Analysis.

The aim of this systematic review was to assess the best available evidence on semi-solid nutrients for prevention of complications associated with enteral tube feeding (ETF). PubMed (MEDLINE), EMBASE, Cochrane Central Register of Controlled Trial, Ichushi-web, and World Health Organization International Clinical Trials Registry Platform databases were searched for relevant articles. Randomized controlled trials (RCTs), cluster RCTs, and crossover trials comparing the effects of semi-solid nutrients with those of control interventions in patients on ETF were included in the review. The primary outcome was development of gastroesophageal reflux (GER). Eight RCTs and five crossover trials involving 889 study participants in total were examined via meta-analysis. The meta-analysis showed that semi-solid nutrients significantly decreased the risk of GER (risk ratio 0.39; 95% confidence interval (CI) 0.21 to 0.73) and the GER index (mean difference −2.93; 95% CI −5.18 to −0.68). Dwell time in the stomach was significantly shortened (standardized mean difference (SMD) −0.50; 95% CI −0.99 to −0.02), as was care time defined as the time needed to prepare and administer the nutrient solution (SMD −8.02; 95% CI −10.94 to −5.10). Semi-solid nutrients significantly decrease the risk of GER and the dwell time in the stomach in adult patients.

Principles of surgical treatment of recurrent hiatal hernias (review of literature)

Recurrent hiatal hernia is the re-displacement of the abdominal organs into the chest after surgical treatment. Indications for repeated surgical interventions for this pathology are resistant to medical correction gastroesophageal reflux or anatomical disorders, bearing the risk of developing life-threatening conditions. The key task of revision interventions is to identify and address the causes of the failure of the primary operation. The main factors of the recurrence of hernias of this localization are the large size of the hiatal opening, the mechanical weakness of the legs of the diaphragm and the shortening of the esophagus. To increase the reliability of the esophageal aperture plasty in the surgical treatment of recurrent hiatal hernias, prosthetic materials are widely used. When the esophagus is shortened, it is possible to increase its length by creating a gastric stalk (gastroplasty) or fixing the stomach to the anterior abdominal wall (gastropexy). The disadvantage of both methods is the occurring functional impairment. An alternative approach is the formation of a fundoplication wrap in the chest with the closure of the esophageal opening only with its own tissues. To eliminate or prevent the development of gastroesophageal reflux, antireflux reconstruction is an essential component of operations for recurrent hiatal hernias. The option of fundoplication is selected in accordance with the contractility of the esophagus. With normokinesia, circular fundoplication was preferred, with impaired motor skills – free reconstructions.

Prestenotic dilation of proximal parts of stomach as a predictor for development of gastro-esophageal reflux in late period after laparoscopic gastroplication

Objective. Estimation of immediate and late results of laparoscopic gastroplication (LGP) and analysis of predictors of unfavorable outcomes of bariatric operation.&#x0D; Маterials and methods. The investigation was conducted on background of results of examination and surgical treatment on 79 patients, suffering obesity and metabolic syndrome, to whom LGP was accomplished on the cathedral bases of the Shupyk NMAPE Department of Surgery and Vascular Surgery in 2015 - 2018 yrs.&#x0D; Results. In accordance to secondary investigations, done in one year after the operative intervention, the body mass index lowering/ improvement of the glycemia and lipidogram indices, as well as the arterial pressure normalization and reduction of the apnoe rate while sleeping were registered. In accordance to data of secondary roentgenoscopy with contrasting of the foregut, conducted in 6 mo after LGP, in 20 (25.3%) patients irregular narrowing of a gastric tube higher than gastric angle was registered. In 12 mo roentgenological signs of significant widening of the gastric tube, formatted of fundus and cardia were seen, as well as the angle of His enhancement, presence of gastro-esophageal reflux of the contrast, аnd 2 patients have had the signs of axial cardial hiatal hernia. Simultaneously in 20.2% patients the symptoms of gastro-esophageal reflux disease with essential lowering of the patients’ quality of life were observed.&#x0D; Conclusion. LGP constitutes a potentially secure and effective bariatric operation, after which the body mass reduces significantly and constantly. But in 20.2% patients the morbidity occur: through 12 mo after the operation GERD and reflux-esophagitis evolves. The origin of this late complications is a partial stenosis in the gastric angle region, what causes the development of prestenotic dilation of proximal gastric parts.

Surgical repair of long-gap esophageal atresia: A retrospective study comparing the management of long-gap esophageal atresia in the Nordic countries

BackgroundSeveral surgical procedures have been described in the reconstruction of long-gap esophageal atresia (LGEA). We reviewed the surgical methods used in children with LGEA in the Nordic countries over a 15-year period and the postoperative complications within the first postoperative year. MethodsRetrospective multicenter medical record review of all children born with Gross type A or B esophageal atresia between 01/01/2000 and 12/31/2014 reconstructed within their first year of life. ResultsWe included 71 children; 56 had Gross type A and 15 type B LGEA. Delayed primary anastomosis (DPA) was performed in 52.1% and an esophageal replacement procedure in 47.9%. Gastric pull-up (GPU) was the most frequent procedure (25.4%). The frequency of chromosomal abnormalities, congenital heart defects and other anomalies was significantly higher in patients who had a replacement procedure. The frequency of gastroesophageal reflux (GER) was significantly higher after DPA compared to esophageal replacement (p = 0.013). At 1-year follow-up the mean body weight was higher after DPA than after organ interposition (p = 0.043). ConclusionDPA and esophageal replacement procedures were equally applied. Postoperative complications and follow-up were similar except for the development of GER and the body weight at 1-year follow-up. Long-term results should be investigated. Type of studyTreatment study. Level of evidenceLevel III.

Gastroesophageal reflux in mechanically ventilated children: Not a risk factor for Ventilator Associated Pneumonia (VAP)?

Background : Gastroesophageal reflux (GER) is fairly common in children and mechanically ventilated children are at increased risk for the development of GER. Information on GER and development of ventilator associated pneumonia (VAP) is limited. Methods : A prospective observational cohort study was performed in mechanically ventilated children aged 1 year to 15 years within first 24 hrs of (initiation of mechanical ventilation) in Pediatric Intensive Care Unit (PICU), AIIMS using 24 hr esophageal pH metry and were followed up for 7 days for development of VAP using CDC criteria. Presence of GER was defined as fall in esophageal pH < 4 for more than 4% of total time . Results : A total of 61 patients (mean age (median): 73 (30-132), boys: 44 (72.1%), girls: 17 (27.9%)) were enrolled in the study. Total number of reflux episodes were 1855 and at least 1 episode of reflux was seen in 32 (52.46%) patients. As per definition of GER, 12 (19.7%) children had GER. Of the enrolled children, 17 (27.87%) patients developed VAP; 7 patients had VAP and at least 1 episode of acidic reflux however, no patient had both GER (as per definition) and VAP. Of 44 patients who did not develop VAP, at least 1 episode of reflux was seen in 25 patients while 12 patients (27.27%) had GER positive and 32 patients (72.72%) did not have GER. There was no correlation of age, sex, weight, mode of ventilation and PRISM score with GER. Conclusion : Acid reflux was common in ventilated patients but GER was less common and presence of acid reflux or GER did not increase the risk of development of ventilator associated pneumonia.

Cornelia de Lange syndrome and esophageal stricture in a 9-year-old child

Children with rare diseases may be found to have various malformations, including those of the gastrointestinal tract. The authors followed up a 9‑year-old child with Cornelia de Lange syndrome, who was found to have esophageal stricture with the development of gastroesophageal reflux and esophagitis.

The role of factors of the hemostasis system and fibrinolysis in the development of gastroesophageal reflux in patients with chronic obstructive pulmonary disease

Gastroesophageal reflux disease (GERD) and chronic obstructive pulmonary disease (COPD) belong to common pathological conditions comorbid in 25–60 % of cases.Objective: to find probable mechanisms of GERD progressing against the ground of COPD by means of learning various links of the blood clotting system, anticoagulative blood activity and fibrinolysis for further improvement of the ways to correct the disorders found.Methods. 124 patients with COPD were examined including 90 with comorbid GERD. The control group included 24 practically healthy individuals of an appropriate age and sex. Clinical, biochemical, instrumental and statistical methods of examination were applied.Results. The patients were divided into the following groups: the 1st group – 34 patients with COPD, the 2nd group – 30 patients with COPD with endoscopically negative GERD, the 3rd group – 30 patients with COPD and endoscopically positive non-erosive GERD, the 4th group – 30 patients with COPD and endoscopically positive erosive GERD. The following results were found: while examining coagulation hemostasis – decrease of prothrombin time, fibrinogen content; while examining anticoagulation blood potential – decrease of thrombin time, activity of antithrombin III; while examining fibrinolytic blood activity – inhibition of the total fibrinolytic activity (at the expense of enzymatic activity decrease) and compensatory increase of non-enzymatic fibrinolytic activity, decrease of Hageman-dependent fibrinolysis activity.Conclusions. Disorders of coagulation hemostasis, anti-coagulation potential and fibrinolytic blood activity are intensified with the increase of severity of bronchial obstructive syndrome and promote the development of endoscopically positive erosive GERD

Development of gastro-esophageal reflux during laparoscopic surgery in lateral jack-knife position: a comparison with reverse Trendelenburg/Trendelenburg position in patients lying supine

Objective To evaluate development of gastro-esophageal reflux (GER) during laparoscopic surgery in lateral jack-knife position under general anesthesia through comparing with reverse Trendelenburg/ Trendelenburg position in the patients lying supine.Methods Ninety patients of both sexes,aged 18-64 yr,of ASA physical status Ⅰ or Ⅱ,with body mass index of 18-30 kg/m2,scheduled for elective laparoscopic surgery under general anesthesia,were randomly divided into 3 groups (n =30 each):lateral jack-knife position group (group L),Trendelenburg position group (group T) and reverse Trendelenburg position group (group Tre).Anesthesia was induced with midazolam,sufentanil,propofol and cisatracurium besylate and maintained with propofol and remifentanil given by target-controlled infusion.A pH-sensitive probe was inserted through nose into the lower esophagus and pH value was continuously recorded until 1 min after extubation.GER was defined as pH value ≤ 4 lasting for ≥ 1 min in the lower esophagus during surgery.The development of GER during surgery and the lowest pH value in the lower esophagus when GER developed were recorded.Results Compared with group Tre,the incidence of GER (27％) and total number of times GER had occurred were significantly increased in group L,and no significant changes were found in the indices mentioned above in L and T groups.When GER developed,the lowest pH value in the lower esophagus was 2.1 ± 1.3,2.6 ± 1.2 and 3.5 in L,T and Tre groups,respectively.Conclusion The incidence of GER is 27 ％ during laparoscopic surgery when the patients are in lateral jack-knife position and it is higher than that obtained with reverse Trendelenburg position in the patients lying supine. Key words: Posture ; Laparoscopy ; Gastroesophageal reflux

Prevalence of gastroesophageal reflux in cystic fibrosis and implications for lung disease.

Gastroesophageal reflux (GER) is common in patients with cystic fibrosis (CF) and is often regarded as playing a role in the pathogenesis of CF lung disease. Individuals with CF have many predisposing factors to the development of GER, with a reported prevalence ranging from 35 to 81%. Several studies have suggested that patients with CF who have coexisting GER have more severe lung disease with lower pulmonary function and increased numbers of respiratory exacerbations. Furthermore, GER may alter the respiratory microbiology in CF. Both the acid and nonacid components of GER may have an effect on lung disease. More than 50% of U.S. patients with CF were being treated with proton pump inhibitors in 2012; however, data regarding safety and efficacy of these agents in CF are lacking. Pharmacologic and surgical treatment of GER may improve respiratory morbidity, although prospective controlled studies have not been performed. Given the lack of evidence-based guidelines for evaluation, diagnosis, and treatment of GER in CF, initiation of treatment for symptomatic GER should be based on standard guidelines for the general population. Because there is no clear evidence that GER leads to worse respiratory outcomes in CF or that treatment of GER improves pulmonary outcomes, invasive testing for GER in patients without reflux symptoms is not warranted. Further studies to determine the role of GER in CF lung disease and the risks and benefits of surgical and pharmacologic therapy for GER are warranted.

Gastroesophageal Reflux Is Not Associated With Dental Erosion in Children

Dental erosion is a complication of gastroesophageal reflux (GER) in adults; in children, it is not clear if GER has a role in dental pathologic conditions. Dietary intake, oral hygiene, high bacterial load, and decreased salivary flow might contribute independently to GER development or dental erosion, but their potential involvement in dental erosion from GER is not understood. We investigated the prevalence of dental erosion among children with and without GER symptoms, and whether salivary flow rate or bacterial load contribute to location-specific dental erosion. We performed a cross-sectional study of 59 children (ages, 9-17 y) with symptoms of GER and 20 asymptomatic children (controls); all completed a questionnaire on dietary exposure. Permanent teeth were examined for erosion into dentin, erosion locations, and affected surfaces. The dentist was not aware of GER status, and the gastroenterologist was not aware of dental status. Stimulated salivary flow was measured and salivary bacterial load was calculated for total bacteria, Streptococcus mutans, and Lactobacilli. Controlling for age, dietary intake, and oral hygiene, there was no association between GER symptoms and dental erosion by tooth location or affected surface. Salivary flow did not correlate with GER symptoms or erosion. Erosion location and surface were independent of total bacteria and levels of Streptococcus mutans and Lactobacilli. Location-specific dental erosion is not associated with GER, salivary flow, or bacterial load. Prospective studies are required to determine the pathogenesis of GER-associated dental erosion and the relationship between dental caries to GER and dental erosion.

Impact of Minimally Invasive Surgery in the Spectrum of Current Achalasia Treatment Options

Minimally invasive Heller myotomy has evolved the "gold standard" procedure for achalasia in the spectrum of current treatment options. The laparoscopic technique has proved superior to the thoracoscopic approach due to improved visualization of the esophagogastric junction. Operative controversies most recently include the length of the myotomy, especially of its fun-dic part, with respect to the balance between postoperative persistent dysphagia and development of gastroesophageal reflux, as well as the type of the added antireflux procedure. Peri-operative mortality should approach 0%, and favorable long-term results can be achieved in > 90%.

Acute development of gastroesophageal reflux after radiofrequency catheter ablation of atrial fibrillation

Acute development of gastroesophageal reflux after radiofrequency catheter ablation of atrial fibrillation

Acute development of gastroesophageal reflux after radiofrequency catheter ablation of atrial fibrillation

Acute development of gastroesophageal reflux after radiofrequency catheter ablation of atrial fibrillation

Minimally Invasive Surgery as First-Line Therapy for Achalasia

To the Editor, The optimal choice of treatment in patients with achalasia has been the subject of an ongoing discussion. Wang et al. [1] have provided an important meta-analysis of randomized and controlled treatment trials for achalasia. Laparoscopic myotomy proved to be the preferred method for patients with achalasia. The advantage of myotomy over other techniques had not been clearly demonstrated before. We would like to point out in the context of this recent analysis that minimally invasive myotomy should be regarded as the first-line therapy for achalasia. Surgical myotomy has been used to successfully treat achalasia since the early 1900s [2]. Relief of dysphagia is achieved in 90–95% of patients, and symptoms are alleviated in the long term. Young age was—among other baseline factors investigated by our group—associated with increased need for surgery in patients with achalasia [3]. Minimally invasive surgery has influenced the management of achalasia more than any other gastrointestinal disorder. Laparoscopic Heller myotomy has become the most frequently performed procedure for this disorder. Also, in another recently published meta-analysis, laparoscopic myotomy with partial fundoplication was the most effective surgical technique compared with all endoscopic and other surgical approaches, with a low complication rate and minimal development of gastroesophageal reflux [4]. Thus, the application of minimally invasive surgery to the therapy of esophageal achalasia has determined an unexpected change in the treatment algorithm of the disease. The minimally invasive approach offers several more inherent advantages, such as superior visualization of the gastroesophageal junction and a magnified view of both layers of the esophageal muscularis propria as well as of the oblique gastric fibres. Furthermore, the technical innovation introduced in the laparoscopic era is the use of intraoperative endoscopy to identify precisely the gastroesophageal junction and to examine the completeness of the myotomy, as well as to discover occult perforations by transillumination and air insufflation. An extended myotomy of 3 cm below the gastroesophageal junction more effectively disrupts the lower esophageal sphincter, thus improving the results of surgical therapy for dysphagia without an increased rate of abnormal gastroesophageal reflux [5]. A matter of debate has been the direction of the myotomy over the stomach, which may be closer to the lesser or to the greater curvature, and can divide the semicircular (clasp) fibres and the oblique (sling) fibres in distinct proportions [6]. The muscle edges are to be separated to expose the mucosa for about 30–40% of the circumferential diameter. The major cause of failures after Heller myotomy is incomplete distal myotomy on account of the danger of mucosal perforation. However, recurrent or persistent achalasia in most cases derives from undissected distal muscle layers and will require revisional surgery. Also, in patients previously treated with injection of botulinum toxin developing fibrosis and inflammation at the level of the gastroesophageal junction with loss of the anatomic planes, the dissection may be difficult and risky due to occult mucosal leakages. These margins, the most distal dissection of the myotomy, and patients with previous Botox therapy render the most dangerous and challenging components of the surgical myotomy. I. Gockel (&) H. Lang Department of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Mainz, Germany e-mail: gockel@ach.klinik.uni-mainz.de

Lack of distal esophageal contractions is a key determinant of gastroesophageal reflux disease after repair of esophageal atresia

The objective of this study is to investigate the characteristics of esophageal motor activity responsible for the development of gastroesophageal reflux (GER) in patients with esophageal atresia (EA). The subjects consisted of 29 patients with EA (1 month to 19 years). Computerized esophageal manometry was conducted to investigate esophageal contractions at swallow. A topographic esophageal manometric analysis was conducted in each subject, providing 3-dimensional displays to reveal the pressure continuum representing esophageal contractions. Significant contractions in the middle esophagus just below the anastomosis were absent in all subjects. Contractions in the distal esophagus were conspicuously absent in 17 subjects. Of these 17, 6 had already undergone fundoplication, and 9 had symptomatic GER requiring fundoplication subsequent to this study. The remaining 12 patients had contractions in the distal esophagus and did not require medical/surgical intervention. A lack of distal esophageal contractions was significantly correlated with the development of GER (P < .001). There was a significant difference in esophageal acid exposure between the 2 groups (median, 38% vs 4%, P < .001). Lack of distal esophageal contractions indicating an impaired clearing capacity is considered a potential key determinant of GER in patients with EA.

Influence of halothane, isoflurane, and sevoflurane on gastroesophageal reflux during anesthesia in dogs

To determine whether maintenance of anesthesia with halothane or sevoflurane is associated with a lower incidence of gastroesophageal reflux (GER) than the use of isoflurane in dogs undergoing orthopedic surgery. 90 dogs. Dogs were evaluated during elective orthopedic surgery. Dogs with a history of vomiting or that had received any drugs that would alter gastrointestinal tract function were excluded from the study. The anesthetic protocol used was standardized to include administration of acepromazine maleate and morphine prior to induction of anesthesia with thiopental. Dogs were allocated to receive halothane, isoflurane, or sevoflurane to maintain anesthesia. A sensor-tipped catheter was placed to measure esophageal pH during anesthesia. Gastroesophageal reflux was defined as an esophageal pH < 4 or > 7.5. 51 dogs had 1 or more episodes of acidic GER during anesthesia. Reflux was detected in 14 dogs receiving isoflurane, 19 dogs receiving halothane, and 18 dogs receiving sevoflurane. In dogs with GER, mean +/- SD time from probe placement to onset of GER was 36 +/- 65 minutes and esophageal pH remained < 4 for a mean of 64% of the measurement period. There was no significant association between GER and start of surgery or moving a dog on or off the surgery table. Dogs that developed GER soon after induction of anesthesia were more likely to regurgitate. Maintenance of anesthesia with any of the 3 commonly used inhalant agents is associated with a similar risk for development of GER in dogs.