Distal Esophageal Acid Exposure Research Articles

Mucosal impedance as a diagnostic tool for gastroesophageal reflux disease: an update for clinicians.

Mucosal impedance is a marker of esophageal mucosal integrity and a novel technique for assessing esophageal function and pathology. This article highlights its development and clinical application for gastroesophageal reflux disease (GERD), Barrett's esophagus, and eosinophilic esophagitis. A narrative review of key publications describing the development and use of mucosal impedance in clinical practice was conducted. A low mean nocturnal baseline impedance (MNBI) has been shown to be an independent predictor of response to anti-reflux therapy. MNBI predicts medication-responsive heartburn better than distal esophageal acid exposure time. Patients with equivocal evidence of GERD using conventional methods, with a low MNBI, had an improvement in symptoms following the initiation of PPI therapy compared to those with a normal MNBI. A similar trend was seen in a post fundoplication cohort. Strong clinical utility for the use of mucosal impedance in assessing eosinophilic esophagitis has been repeatedly demonstrated; however, there is minimal direction for application in Barrett's esophagus. The authors conclude that mucosal impedance has potential clinical utility for the assessment and diagnosis of GERD, particularly when conventional investigations have yielded equivocal results.

Esophageal pH-monitoring in nonbrachycephalic dogs; a reference.

To establish parameters that describe acidic gastroesophageal reflux (GER) events in nonbrachycephalic, hospitalized dogs without gastrointestinal disease following short total intravenous anesthesia, to establish upper reference limits for parameters that describe GER. Clinical prospective study. Healthy, client-owned dogs presenting for elective orthopedic surgery. Dogs were sedated with IM methadone (0.2 mg/kg) and medetomidine (5 ug/kg), followed by alfaxalone total intravenous anesthesia. The Digitrapper esophageal dual pH monitoring probe was placed transnasally into the esophagus. Dogs were unsedated during the subsequent recording period. A GER event was defined as esophageal pH less than 4.0. Parameters that described GER were: (1) number of GER events per hour, and (2) cumulative esophageal acid exposure (percentage of recording duration) at each sensor. Upper reference limits were calculated for each parameter. Thirty-five dogs were included (median age 7 years, range 1-12). The median recording duration was 21.1 h (range 13.6-29.3). Productive regurgitation was not noted in any dog. The median number of distal and proximal GER events per hour was 0.3 (range 0-4.3) and 0 (range 0-1), respectively. The median cumulative distal and proximal esophageal acid exposure was 0.2% (range 0.3-9%) and 0% (range 0%-1%), respectively. Upper reference limits for distal and proximal GER per hour was 2.4 and 0.4, respectively, and, for cumulative distal and proximal esophageal acid exposure, 2.3% and 0%, respectively. Dogs undergoing esophageal pH monitoring in a similar hospital setting with parameters above these upper reference limits have excessive GER.

Su1282 ELDERLY SUBJECTS WITH HIGHER DISTAL ESOPHAGEAL ACID EXPOSURE HAVE DIAPHRAGM AND RECTUS ABDOMINIS MUSCLES WEAKNESSES

Su1282 ELDERLY SUBJECTS WITH HIGHER DISTAL ESOPHAGEAL ACID EXPOSURE HAVE DIAPHRAGM AND RECTUS ABDOMINIS MUSCLES WEAKNESSES

Novel Diagnostic Techniques in the Evaluation of Gastroesophageal Reflux Disease (GERD).

In our present clinical paradigm, patient symptoms and presentation in the setting of traditional findings from endoscopy (erosive esophagitis, Barrett's esophagus, reflux-mediated stenosis), esophageal high-resolution manometry, and/or ambulatory reflux monitoring (distal esophageal acid exposure time, numbers of reflux events, reflux-symptom association) guide the care of patients with suspected GERD. However, novel metrics and techniques acquired from or performed at endoscopy, manometry, or pH-impedance monitoring, beyond conventional evaluation, are of great interest to the gastroenterology community given the frequent (and sometimes challenging) presentation of suspected GERD. These novel and evolving diagnostic approaches have the potential to enhance the evaluation of these patients and optimize their management. In this invited review, we discuss the present evidence and potential clinical utility of selected GERD metrics and techniques of interest at endoscopy (dilated intercellular spaces, mucosal impedance), manometry (contractile integral, impedance analysis, straight leg raise, multiple rapid swallow maneuvers), and reflux monitoring (mean nocturnal baseline impedance, post-reflux swallow-induced peristaltic wave indices), and how these tools may be most optimally adopted and utilized for clinical care (Fig.1).

Long-term clinical and functional results of magnetic sphincter augmentation.

Magnetic sphincter augmentation (MSA) was introduced in 2007 as an alternative surgical procedure for patients with gastroesophageal reflux disease (GERD). The majority of data since MSA's introduction has focused on short and intermediate-term results, demonstrating safety and high efficacy in terms of reflux symptom control, freedom from proton pump inhibitor use and normalization of distal esophageal acid exposure. However, GERD is a chronic condition that demands a long-term solution. Limited available data from studies reporting outcomes at 5years or later following MSA demonstrate that the promising short- and mid-term efficacy and safety profile of MSA remains relatively constant in the long term. Compared with Nissen fundoplication, MSA has a much lower rate of gas-bloat and inability to belch at a short-term follow-up, a difference that persists in the long-term. The most common complaint after MSA at a short-term follow-up is dysphagia. However, limited data suggest dysphagia rates largely decrease by 5years. Dysphagia is the most common indication for dilation and device removal in both early- and long-term studies. However, the overall rates of dilation and removal are similar in short- and long-term reports, suggesting the majority of these procedures are performed in the short-term period after device implantation. The indications and standard practices of MSA have evolved over time. Long-term outcome data currently available are all from patient cohorts who were selected for MSA under early restricted indications and outdated regimens. Therefore, further long-term studies are needed to corroborate the preliminary, yet encouraging long-term results.

Feasibility and Efficacy of Magnetic Sphincter Augmentation for the Management of Gastroesophageal Reflux Disease Post-Sleeve Gastrectomy for Obesity

BackgroundPatients with medically intractable GERD after laparoscopic sleeve gastrectomy (LSG) have limited surgical options. Fundoplication is difficult post-LSG. Roux-en-Y gastric bypass may be used as a conversion procedure but is more invasive with potential for serious complications. Magnetic sphincter augmentation (MSA) is a less invasive GERD treatment alternative. The objective of this study was to assess safety and efficacy outcomes of MSA after LSG.MethodsThe primary outcome of this observational, multicenter, single-arm prospective study was the rate of serious device and/or procedure-related adverse events (AEs). The efficacy of the LINX device was measured comparing baseline to 12-month post-implant reductions in distal acid exposure, GERD-HRQL score, and average daily PPI usage.ResultsThirty subjects who underwent MSA implantation were followed 12 months post-implant. No unanticipated adverse device effects were observed. There were two adverse events deemed serious (dysphagia, pain, 6.7%) which resolved without sequelae. GERD-HRQL scores showed significant improvement (80.8%, P < 0.001), and reduction in daily PPI usage was seen (95.8%, P < 0.001). Forty-four percent of subjects demonstrated normalization or > = 50% reduction of total distal acid exposure time (baseline 16.2%, 12 months 11%; P = 0.038).ConclusionsPost-LSG, MSA showed an overall improvement of GERD symptoms, and reduction in PPI use with explants within anticipated range along with improvement in distal esophageal acid exposure time.Graphical

2020 Seoul Consensus on the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the “proven GERD” with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barrett’s mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time &gt; 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis. Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs.

2020 Seoul Consensus on the Diagnosis and Management of Gastroesophageal Reflux Disease.

Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the “proven GERD” with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barrett’s mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time > 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis.Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval, 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs.

Therapeutic effect of laparoscopic fundoplication for patients with GERD from the viewpoint of Lyon Consensus.

The Lyon Consensus was conducted in 2017, leading to a revision of the diagnostic criteria of GERD. Conclusive GERD was defined as cases in which the distal esophageal acid exposure time (AET) is greater than 6% and there exists either peptic esophagitis, constriction, or long-segment Barrett's mucosa with a Los Angeles classification of grade C or D. Borderline GERD is defined as cases in which AET is between 4 and 6% and there exists peptic esophagitis with a Los Angeles classification of either grade A or B. All other cases were defined as Inconclusive GERD. We conducted a retrospective investigation of the treatment results of laparoscopic fundoplication (LF) for GERD according to the Lyon Consensus and evaluated whether or not it is an effective treatment predictor. From among the cases of primary LF conducted on patients with GERD-related illnesses at our university hospital from June 2008 to March 2020, the subjects included 215 individuals who underwent upper gastrointestinal endoscopy and 24h multichannel intraluminal impedance pH (MII-pH) testing prior to surgery. We compared the pathophysiology of the Conclusive GERD Group (Group A), Borderline GERD Group (Group B), and Inconclusive GERD Group (Group C), and then investigated the treatment results of each group. We used AFP classification for pathophysiological evaluation. For the acid reflux evaluation, we conducted MII-pH measurements using Sleuth, manufactured by Sandhill. The postoperative evaluation period was set to 3 months following surgery. The data are expressed using median values, with a statistical significance defined as p < 0.05 using the Kruskal-Wallis, Mann-Whitney, Wilcoxon signed-rank, and Chi-squared tests. Group A: 92 cases (43%, male 69 cases, age 57), Group B: 48 cases (22%, male 20 cases, age 52), and Group C: 75 cases (35%, male 69 cases, age 57). Regarding the patient backgrounds, while there were no significant differences in terms of gender or disease duration, those in Group A were significantly older than the other two groups, and there was a significant difference in Body Mass Index (BMI) between Group A and Group C. The results of each factor were: A factor (1 vs.1 vs. 1, p < 0.001), F factor (2 vs. 0 vs. 0, p < 0.001), and P factor (2 vs. 1 vs. 0, p < 0.001), with AET of 10.0 vs. 2.9 vs. 0.6, p < 0.001, and the disease had progressed more in Group A. There were also no differences in terms of surgical methods, hemorrhage volume, and intraoperative/postoperative complications; however, the use of mesh was higher and surgery duration was longer in Group A. There were obvious improvements in the A, F, and P factors and AET of each group following surgery (other than F and P of Group C, p < 0.001). The rate of recurrence was 15% in Group A, 8% in Group B, and 6% in Group C. It tended to be higher in Group A, but this was not statistically significant. The classification of GERD pathophysiology based on the Lyon Consensus is satisfactory, with no significant differences in the rate of effect of LF. The Lyon Consensus is effective for ascertaining the severity and pathophysiology of GERD; however, we were unable to forecast the treatment results of LF.

Chicago Classification update (v4.0): Technical review of high-resolution manometry metrics for EGJ barrier function.

Esophagogastric junction (EGJ) barrier function is of fundamental importance in the pathophysiology of gastroesophageal reflux disease. Impaired EGJ barrier function leads to excessive distal esophageal acid exposure or, in severe cases, esophagitis. Hence, proposed high-resolution manometry (HRM) metrics assessing EGJ integrity are clinically important and were a focus of the Chicago Classification (CC) working group for inclusion in CC v4.0. However, the EGJ is a complex sphincter comprised of both crural diaphragm (CD) and lower esophageal sphincter (LES) component, each of which is subject to independent physiological control mechanisms and pathophysiology. No single metric can capture all attributes of EGJ barrier function. The working group considered several potential metrics of EGJ integrity including LES-CD separation, the EGJ contractile integral (EGJ-CI), the respiratory inversion point (RIP), and intragastric pressure. Strong recommendations were made regarding LES-CD separation as indicative of hiatus hernia, although the numerical threshold for defining hiatal hernia was not agreed upon. There was no agreement on the significance of the RIP, only that it could localize either above the LES or between the LES and CD in cases of hiatus hernia. There was agreement on how to measure the EGJ-CI and that it should be referenced to gastric pressure in units of mmHgcm, but the numerical threshold indicative of a hypotensive EGJ varied widely among reports and was not agreed upon. Intragastric pressure was endorsed as an important metric worthy of further study but there was no agreement on a numerical threshold indicative of abdominal obesity.

The Role of the Transdiaphragmatic Pressure Gradient (TGP) in the Pathophysiology of Proximal Reflux

IntroductionAn increased transdiaphragmatic pressure gradient (TGP) is a main element for distal gastroesophageal reflux disease (GERD). The role of TGP for proximal reflux is still unclear. This study aims to evaluate the presence, severity, and importance of proximal reflux in relationship to the TGP, comparing healthy volunteers, obese individuals, and patients with chronic obstructive pulmonary disease (COPD). MethodsWe studied 114 individuals comprising 19 healthy lean volunteers, 47 obese individuals (mean body mass index 45 ± 7 kg/m2), and 48 patients with COPD. All patients underwent high-resolution manometry and dual-channel esophageal pH monitoring. Esophageal motility, thoracic pressure (TP), abdominal pressure (AP), TGP, DeMeester score, and % of proximal acid exposure time (pAET) were recorded. ResultsPathologic distal GERD was found in 0, 44, and 57% of the volunteers, obese, and COPD groups, respectively. pAET was similar among groups, only higher for obese individuals GERD + as compared to obese individuals GERD − and COPD GERD −. pAET did not correlate with any parameter in healthy individuals, but it correlated with AP in the obese, TP in the COPD individuals, and TGP and DeMeester score in both groups. When all individuals were analyzed as a total, pAET correlated with AP, TGP, and DeMeester score. DeMeester score was the only independent variable that correlated with pAET. ConclusionsOur results show that (a) TGP is an important mechanism associated with distal esophageal acid exposure and this fact is linked with proximal acid exposure and (b) obesity and COPD both seem to be primary causes for GERD but not directly for proximal reflux.

Distinct Physiological Characteristics of Isolated Laryngopharyngeal Reflux Symptoms

Patients with isolated laryngopharyngeal reflux symptoms (LPRS) defined as those without concomitant typical reflux symptoms (CTRS) are clinically challenging to manage due to unclear pathophysiology. We investigated esophageal physiology in patients with isolated LPRS and their response to proton-pump inhibitors (PPI) therapy. This is a multi-center observational study conducted in referral hospitals in Taiwan. Patients with predominant LPRS, but without common non-reflux causes, underwent esophageal manometry, 24-hr ambulatory esophagopharyngeal pH testing, and Bernstein test, followed by a 12-week esomeprazole 40 mg twice-daily treatment. Participants with pathological reflux were divided into the isolated LPRS group (ie, LPRS without CTRS, n= 40) and the CTRS group (ie, LPRS with CTRS, n= 66). Participants without pathological reflux or esophagitis (n= 132) served as the nonreflux controls. The PPI-responsiveness was similar between the isolated LPRS group and CTRS group (63% vs 57%, P= .8), but lower in the nonreflux controls (32%, P= .005). Despite similar distal esophageal acid exposure time (P= .7) when compared to those with CTRS, the isolated LPRS group had a lower prevalence of both positive Bernstein test (P= .001) and ineffective esophageal motility disorder (P= .03), and fewer pharyngeal acid reflux episodes (P < .0001). Our findings indicate similar distal esophageal acid exposure and PPI-responsiveness between LPRS patients with and without CTRS. The lack of CTRS in the isolated LPRS group is likely due to esophageal acid hyposensitivity and fewer pharyngeal acid reflux episodes, thus implicating distinct pathophysiology of isolated LPRS from those with CTRS.

Intestinal metaplasia at the gastroesophageal junction is associated with gastroesophageal reflux but not with Helicobacter pylori infection

Objective: Studies of the etiology of intestinal metaplasia (IM) at a normal appearing gastroesophageal junction (GEJ) are conflicting as associations with both H. Pylori (HP) infection and gastroesophageal reflux has been reported. The aim of this study was to investigate whether IM at the GEJ is associated with gastroesophageal reflux or HP infection.Material and methods: Fifty asymptomatic volunteers and 149 patients with reflux symptoms underwent endoscopy with biopsies obtained from the gastric antrum and the squamocolumnar junction (SCJ). All subjects underwent wireless 48 h pH monitoring with the electrode placed immediately above the SCJ and a fecal antigen test for HP infection. Clinical characteristics and the pattern of reflux were compared in subjects with and without IM.Results: Three asymptomatic volunteers and 35 patients who had clearly irregular SCJs with short extensions of columnar mucosa were excluded from the study. In the remaining 47 asymptomatic volunteers and 114 patients, variables that reached a significance level of 0.1 or less on univariate analyses were used in a binomial regression analysis to assess their relative importance for the finding of IM. IM at the GEJ was significantly associated with abnormal distal esophageal acid exposure (5.5 (1.2–24.6), p = .026), the frequency of reflux episodes/hour (1.5 (1.1–2.2), p = .031), and an endoscopic appearance of the SCJ corresponding to ZAP grade I (4.6 (1.4–15.6), p = .013). There was no association with HP infection.Conclusion: The finding of IM at an endoscopically normal-appearing GEJ is associated with gastroesophageal reflux but not with HP infection.

Clinical Impact of Increasing the Threshold for Distal Esophageal Acid Exposure Time (AET)

Introduction: A wireless pH capsule study with a composite score is a reliable method to quantify acid exposure in the distal esophagus. The optimal cut-off value for pathological acid exposure time is not standardized and ranges from 4.4% - 5.8% in different studies. We evaluated the reflux burden and symptom association of patients when the threshold for acid exposure time (AET) is varied from 4% to 6%. Methods: All 96-hour wireless pH capsule studies in our urban, academic gastroenterology practice between January 2016 and December 2017 were analyzed using AET greater than 4%, 5%, and 6% as the threshold for abnormal acid reflux to evaluate the differential yield of pathologic acid exposure with these alternative thresholds. All antacids or acid suppression medications were held for at least 7 days prior to the examinations. Results: A total of 257 consecutive patients (94 male, mean age 52.6 years (19-84 years) were included for analysis. Using the 4%, 5%, and 6% threshold values for overall AET; 19.8% (51), 27.6% (71), and 33% (85) patients did not have evidence of abnormal acid reflux respectively, over a 96-hour period. The evaluation of the 34 patients who were “missed” by increasing the AET from 4% to 6% showed: Median symptom association probability (SAP) for heartburn and regurgitation was 98.6 (IQR 84.3) and 72.4 (IQR 97.3), respectively. The median symptom index (SI) for heartburn and regurgitation was 26.8 (IQR 37) and 12.3 (IQR 25.7) respectively and the mean DeMeester score was 19.5 (range: 12.9 - 27). At 5% threshold value (14 out of 34 missed patients), SAP was positive (>95%) in 8 and 4 patients for heartburn and regurgitation respectively. The SI was positive (>50%) in 1 patient for heartburn and none for regurgitation. At 4% threshold value for AET (20 out of 34 missed patients), SAP was positive in 12 and 5 patients for heartburn and regurgitation respectively. The SI was positive in 3 patients for heartburn and 3 patients regurgitation. Conclusion: Increasing the percent AET from 4% to 6% reduces the identification of pathologic acid reflux by 14%. Using 6% as the AET threshold primarily reduces the identification of positive SAP and SI for heartburn and regurgitation symptoms to acid reflux. Patients in this group may represent a subgroup of reflux patients that specific targeted therapies may improve therapeutic outcomes and warrants further study.

RA06.01: PATHOLOGICAL IMPLICATIONS OF SWALLOW-ASSOCIATED TRANSIENT LOWER ESOPHAGEAL SPHINCTER ELEVATION

Abstract Background We have previously reported that swallow-induced transient hiatal hernia (tHH) is associated with pathological gastroesophageal reflux. In this study, we built upon our previous study of tHH, assessing the pathological implications of swallow-induced tHH in a new, larger cohort. Methods We queried a prospectively maintained database to identify patients who underwent both 24-hour pH monitoring and high-resolution manometry (HRM) between January 2017 and December 2017. We excluded patients with end-stage lung disease, inadequate LES relaxation, major esophageal motility disorders, or manometric hiatal hernia. Significant swallow-induced LES–CD separation was defined as ≥ 1 cm separation in ≥ 30% swallows or ≥ 2 cm separation in ≥ 10% swallows. We used HRM to separate patients into 3 groups, as follows: 1. Persistent tHH (p-tHH): Significant LES–CD separation at the 2nd inspiration after the conclusion of swallow-induced esophageal peristalsis. 2. Incident tHH (i-tHH): Significant LES–CD separation at the 1st inspiration after the conclusion of peristalsis without meeting p-tHH criterion. 3. Non-tHH: Neither p-tHH nor i-tHH was observed. Results In total, 472 patients underwent both HRM and a 24-hour pH study during the study period. Of these, 74 patients met inclusion criteria. The mean age was 51.6 years, and 45 patients (60.8%) were women. Forty-two patients (56.8%) had an abnormal DeMeester score (ie, &gt; 14.72). Fourteen patients (18.9%) were categorized into the p-tHH group, 36 (48.6%) were in the i-tHH group, and 24 (32.4%) were in the non-tHH group. LES pressure, LES pressure integral, esophageal peristaltic vigor, and prevalence of dysmotility were similar among the groups. No significant differences were observed in the pH studies for patients with i-tHH and non-tHH; however, patients in the p-tHH group had a higher prevalence of abnormal DeMeester score and longer total acid reflux time than patients in the non-tHH cohort (78.6 vs 45.8%, P &lt; 0.05; 8.0 vs 3.8%, P = 0.016, respectively). Conclusion We confirm that p-tHH is associated with pathological distal esophageal acid exposure and appears to be an early indicator of LES dysfunction. Disclosure All authors have declared no conflicts of interest.

Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders.

Peroral endoscopic myotomy (POEM) is a novel operation for the treatment of achalasia and other esophageal motility disorders. While POEM has shown excellent short-term safety and efficacy, the long-term symptomatic outcomes after the procedure are unknown. Patients from a single center that underwent POEM for treatment of esophageal motility orders and were greater than 5 years removed from their operation were studied. Patients were contacted to assess current symptoms and encouraged to undergo repeat endoscopyfor objective follow-up. Thirty-six patients underwent POEM from October, 2010 to February, 2012 and current symptom scores were obtained from 29 patients at median 65-month follow-up. In the 23 patients with achalasia, Eckardt scores were significantly improved from preoperative baseline (mean current 1.7 vs. preoperative 6.4, p<0.001). Nineteen patients (83%) with achalasia had a symptomatic success (Eckardt ≤3) and none required retreatment for symptoms. Eckardt scores were dramatically improved at 6months and maintained at 2years; however, there was a small but significant worsening of symptoms between 2 and 5-years. Of the five patients with EGJ outflow obstruction, all had current Eckardt scores ≤3 but two needed reintervention for persistent or recurrent symptoms, one with a laparoscopic Heller myotomy and another with an endoscopic cricomyotomy and proximal esophageal myotomy extension. At 6-month follow-up, repeat manometry showed decreased EGJ relaxation pressures and esophagram demonstrated improved emptying. 24-h pH monitoring showed abnormal distal esophageal acid exposure in 38% of patients. Fifteen patients underwent endoscopy at 5-years, revealing erosive esophagitis in two (13%), new hiatal hernia in two, and new non-dysplastic Barrett's esophagus in one. The patient with Barrett's underwent a subsequent laparoscopic hiatal hernia repair and Toupet fundoplication. POEM resulted in a successful palliation of symptoms in the majority of patients after 5years, though these results emphasize the importance of long-term follow-up in all patients.

Association Between Response to Acid-Suppression Therapy and Efficacy of Antireflux Surgery in Patients With Extraesophageal Reflux.

The effectiveness of antireflux surgery (ARS) varies among patients with extraesophageal manifestations of gastroesophageal reflux disease (GERD). By studying a cohort of patients with primary extraesophageal symptoms and abnormal physiologic markers for GERD, we aimed to identify factors associated with positive outcomes from surgery, and compare outcomes to those with typical esophageal manifestations of GERD. We performed a retrospective cohort study to compare adult patients with extraesophageal and typical reflux symptoms who underwent de novo ARS from 2004 through 2012 at a tertiary care center. All 115 patients (79 with typical GERD and 36 with extraesophageal manifestations of GERD) had evidence of abnormal distal esophageal acid exposure based on pH testing or endoscopy. The principle outcome was time to primary symptom recurrence after surgery, based on patient reports of partial or total recurrence of symptoms at follow-up visits. Patients were followed up for a median duration of 66 months (interquartile range, 52-77 mo). The median time to recurrence of symptoms in the overall cohort was 68 months (11.5 months in the extraesophageal cohort vs >132 months in the typical cohort). Symptom recurrence after ARS was associated with having primarily extraesophageal symptoms (adjusted hazard ratio, 2.34; 95% confidence interval, 1.31-4.17) and poor preoperative symptom response to acid-suppression therapy (AST) (hazard ratio, 3.85; 95% confidence interval, 2.05-7.22). Patients with primary extraesophageal symptoms who had a full or partial preoperative AST response experienced lower rates of symptom recurrence compared to patients with poor AST response (P < .01). The rate of symptom recurrence was lowest among patients with primary typical reflux symptoms who had a partial or full symptom response to AST (P < .01). The severity of acid reflux on pH testing, symptom indices, severity of esophagitis, and hiatal hernia size were not associated with symptom response. In a retrospective study, we found the effectiveness of ARS to be less predictable in patients with extraesophageal symptoms of GERD than in patients with typical GERD. Response to AST before surgery was associated with ARS effectiveness in patients with extraesophageal reflux symptoms. Caution should be exercised when advocating ARS for patients with extraesophageal symptoms that do not respond to AST.

The normal squamocolumnar junction is circumferentially even and minimal irregularities are manifestations of gastroesophageal acid reflux

Background: The macroscopic appearance of the normal squamocolumnar junction (SCJ) is often described as serrated with short projections of columnar mucosa that extend into the esophagus. As studies of the normal SCJ are sparse, the aim of this study was to test the hypothesis that the normal SCJ is even and that irregularities are manifestations of acid reflux.Method: Fifty asymptomatic subjects and 149 patients with symptoms suggestive of gastroesophageal reflux disease underwent endoscopy and 48-h pH monitoring with a pH electrode positioned immediately above the SCJ. The shape of the SCJ was assessed according to the Z-line appearance classification and correlated with clinical characteristics and the degree of esophageal acid exposure in the most distal esophagus.Results: Even SCJs without irregularities were significantly more common in asymptomatic subjects compared with patients (50% versus 10%, p < .001) and were never found in patients with erosive esophagitis. The median degree of distal esophageal acid exposure in individuals with an even SCJ was within normal limits. With increasing degree of irregularity of the SCJ, the frequency and duration of reflux episodes, the degree of distal esophageal acid exposure, and the prevalence of abnormal acid exposure increased progressively and significantly.Conclusion: The shape of the normal SCJ is even and also minimal irregularities are a consequence of acid reflux, likely due to the formation of small areas of metaplastic columnar mucosa.

Esophagogastric Junction Morphology and Distal Esophageal Acid Exposure.

The Chicago classification has recently added a morphological subclassification for the esophagogastric junction (EGJ). Our aim was to assess the distal esophageal acid exposure in patients with this new Chicago EGJ-type IIIa and IIIb classification. From a prospectively collected high-resolution manometry (HRM) database, we identified patients who underwent 24-h pH study between October 2011 and June 2015 and were diagnosed with EGJ-type III based on HRM. Chicago EGJ-type III is defined as the inter-peak nadir pressure ≤gastric pressure and a lower esophageal sphincter (LES)-crural diaphragm (CD) separation >2cm [IIIa-pressure inversion point (PIP) remains at CD level and IIIb-PIP remains at LES level]. We classified the patients into reflux group [DeMeester score >14.72 or Fraction time pH (<4)>4.2%] and non-reflux group based on 24-h pH study. Fifty patients were identified that satisfied the study criteria, of which 37 patients (74%) were EGJ-type IIIa. In those with EGJ-type IIIb, abdominal LES length (AL) in reflux group was significantly shorter than the non-reflux group (0.8 vs. 1.8, p<0.05). EGJ-type IIIa patients showed significantly higher value for DeMeester score and Fraction time pH and more often had a positive pH study than EGJ-type IIIb patients (DeMeester score: 26.7 vs. 11.7, p<0.05; Fraction time pH: 7.9 vs. 2.6, p<0.05; positive pH study: 81.1 vs. 30.8%, p<0.001). Reflux was more common in LES-CD≥3cm than that in LES-CD<3cm (85 vs. 56.7%, p<0.05). A subset of patients with >2-cm LES-CD separation (type IIIb) maintain a physiological intra-abdominal location of the EGJ and are less likely to have reflux. A LES-CD≥3cm seems to discern a hiatus hernia of clinical significance.

Transoral incisionless fundoplication: current status.

Purpose of reviewTransoral incisionless fundoplication (TIF) performed with the EsophyX device (Redmond, Washington, USA) is a totally endoscopic procedure with the objectives to mechanically repair a defective gastroesophageal valve and to reduce small hiatal hernias. The recent publication of randomized controlled trials and long-term follow-up data offers the opportunity to reevaluate this treatment modality and its role in the management of patients with chronic gastroesophageal reflux disease (GERD).Recent findingsRandomized controlled trials have confirmed the ability of TIF to eliminate troublesome GERD symptoms, heal esophagitis, and improve distal esophageal acid exposure in appropriately selected patient populations. These studies establish TIF's superiority to conventional medical therapy, especially in clinical scenarios where proton-pump inhibitors fail to provide complete symptom relief across the spectrum of classic and atypical GERD manifestations, including regurgitation and laryngopharyngeal reflux. Long-term data indicate sustained positive outcomes and durability up to 6 years after procedure. These results were achieved with a low rate of serious adverse events and usually without introducing troublesome dysphagia, gas bloat, or flatulence.SummaryBased on the most recent data, TIF appears to be a valuable treatment alternative for the management of appropriately selected patients with moderate to severe chronic GERD symptoms.