Endoscopic Esophagitis Research Articles

381. MULTICENTER PAN-CANADIAN EXPERIENCE OF PER ORAL ENDOSCOPIC MYOTOMY (POEM) FOR THE TREATMENT OF ACHALASIA: A RETROSPECTIVE STUDY

Abstract Background Per oral endoscopic myotomy (POEM) has emerged as a modality for the surgical treatment of achalasia using a minimally invasive approach with similar clinical efficacy to laparoscopic Heller myotomy. Japanese, European, American and International clinical practice guidelines now cite POEM as a first line treatment for achalasia. In Canada, single-centre experiences with POEM have shown promising results. This study aims to capture the pan-Canadian national experience with POEM for the treatment of achalasia across multiple institutions. Methods This was a retrospective study of patients who underwent POEM for achalasia across four Canadian institutions (St. Joseph's Healthcare Hamilton, Kingston Health Sciences Centre, Surrey Memorial Hospital and Montreal Sacred Heart Hospital) between 2012 to 2022. Pre-operative, procedural and post-operative data was collected. Our primary outcome was the proportion of patients with normal Eckhardt score (≤ 3) at 4 weeks. Secondary outcomes included procedure related adverse events, length of stay in hospital, post-procedure lower esophageal sphincter pressures, post-procedure gastroesophageal reflux disease (GERD) and response rate at further timepoints. Outcomes are reported as either proportions (%) or medians (IQR). Results POEM was attempted in 369 patients with a success rate of 99%. The median duration of surgery was 64 (47 – 89) minutes and length of stay was ≤1 day in 88% of patients. Peri-operative complications occurred in 11% of patients, all of which were Clavien-Dindo Grade ≤III. The post-operative response rate (Eckhardt score ≤3) was 100%, 98% and 95% at 1, 6 and 12 months, respectively. Additional interventions for achalasia following POEM were required in 6% of patients. High DeMeester scores, endoscopic esophagitis and symptomatic GERD were reported in 36%, 43% and 44%, respectively. 93% of GERD was treated with PPI therapy. Conclusions POEM is safe and feasible in Canadian institutions with efficacy in keeping with current international literature.

Comparative clinical feasibility of antireflux mucosectomy and antireflux mucosal ablation in the management of gastroesophageal reflux disease: Retrospective cohort study.

No definitive treatment has been established for refractory gastroesophageal reflux disease (GERD). Antireflux mucosectomy (ARMS) and antireflux mucosal ablation (ARMA) using argon plasma coagulation are promising methods. However, no study has compared these two. This study compared the efficacy and safety of the two procedures. This multicenter, retrospective, observational study included 274 patients; 96 and 178 patients underwent ARMA and ARMS, respectively. The primary outcome was subjective symptom improvement based on GERD questionnaire (GERDQ) scores. The secondary outcomes included changes in the presence of Barrett's esophagus, Los Angeles grade for reflux esophagitis, flap valve grade, and proton pump inhibitor withdrawal rates. The ARMS group had higher baseline GERDQ scores (10.0 vs. 8.0, P < 0.001) and a greater median postprocedure improvement than the ARMA group (4.0 vs. 2.0, P = 0.002), and even after propensity score matching adjustment, these findings remained. ARMS significantly improved reflux esophagitis compared with ARMA, with notable changes in Los Angeles grade (P < 0.001) and flap valve grade scores (P < 0.001). Improvement in Barrett's esophagus was comparable between the groups (P = 0.337), with resolution rates of 94.7% and 77.8% in the ARMS and ARMA groups, respectively. Compared with the ARMA group, the ARMS group experienced higher bleeding rates (P = 0.034), comparable stricture rates (P = 0.957), and more proton pump inhibitor withdrawals (P = 0.008). Both ARMS and ARMA showed improvements in GERDQ scores, endoscopic esophagitis, flap valve grade, and the presence of Barrett's esophagus after the procedures. However, ARMS demonstrated better outcomes than ARMA in terms of both subjective and objective indicators.

Antireflux surgery in patients with gastroesophageal reflux but a negative 24-hour pH study: late outcomes

PurposePatients with gastroesophageal reflux disease often undergo a 24-hour pH test to confirm pathologic reflux before surgery. However, a negative pH test can occur in some individuals with reflux, and a case might still be made for antireflux surgery based on symptoms of reflux even in the absence of endoscopic esophagitis. The long-term outcomes in patients who underwent antireflux surgery despite negative preoperative test results were determined. MethodsPatients were selected from a prospective database. A total of 745 patients met the inclusion criteria, which included typical esophageal reflux symptoms, absence of a large hiatus hernia, preoperative 24-hour pH study performed, endoscopy, and postoperative symptom and satisfaction follow-up available at 5 years. Patients were divided into 3 groups based on 24-hour pH study and endoscopy results: negative pH and negative endoscopy (n = 65), negative pH and positive endoscopy (n = 72), and positive pH (n = 608). The negative pH and negative endoscopy group underwent surgery based on clinical assessment and typical esophageal reflux symptoms. Baseline and follow-up outcomes at 5 years were evaluated using 0 to 10 analog scores, which assessed heartburn, dysphagia, and satisfaction with the overall outcome. Data were analyzed to compare the groups. ResultsThe groups were well matched for demographics and preoperative symptom scores. At the median 5-year follow-up, clinical outcome scores were similar among the groups for heartburn, dysphagia, and overall satisfaction. The mean heartburn scores were 1.80 in the negative pH and negative endoscopy group, 1.88 in the negative pH and positive endoscopy group, and 1.91 in the positive pH group (P = .663). The mean satisfaction scores were high in all groups: 8.13, 7.31, and 7.72, respectively (P = .293). ConclusionNo difference in clinical outcome scores was observed. The negative pH and negative endoscopy group had high satisfaction scores and low heartburn and dysphagia scores. Our findings support antireflux surgery in well-selected symptomatic patients with a negative preoperative pH test.

Long versus short peroral endoscopic myotomy for the treatment of achalasia: results of a non-inferiority randomised controlled trial

ObjectivePeroral endoscopic myotomy (POEM) has become standard treatment for achalasia with comparable efficacy to surgery. In most of published series, the length of myotomy is 12–13 cm. Shorter cuts could...

Feasibility of laparoscopic proximal gastrectomy with piggyback jejunal interposition double-tract reconstruction for proximal gastric cancer: A propensity score-matching analysis.

The feasibility of using laparoscopic proximal gastrectomy (LPG) for the treatment of proximal early gastric cancer (EGC) has not been addressed. This study aimed to comparatively evaluate the effects on LPG with piggyback jejunal interposition double-tract reconstruction (PJIDTR) versus laparoscopic total gastrectomy (LTG) with Roux-en-Y reconstruction (overlap method) using propensity score matching for proximal EGC. We examined the clinical outcomes of LPG with PJIDTR for proximal EGC. We retrospectively collected data from patients with proximal EGC who were treated at Shanxi Cancer Hospital between January 2012 and December 2015. The complication rate, nutritional indicators, reflux oesophagitis incidence and overall survival were compared between LTG and LPG with PJIDTR. Of the 424 patients, 200 were excluded, and 50 of the remaining patients received LPG with PJIDTR. Fifty matched LTG patients were screened. The incidence of early complications was 14% in the LPG group and 16% in the LTG group (P > 0.05). At 1 year after surgery, nutrition indices in the LPG group were significantly better than those in the LTG group (P < 0.05). One year after surgery, the Visick score II rate was 2% and 4%, and the endoscopic oesophagitis rate was 4% and 6% in the LPG and LTG groups, respectively. No tumour recurrence was observed in either group. The 5-year overall survival rates of the two groups were 98% and 90% (P = 0.08). LPG with PJIDTR may be suitable for proximal EGC.

TU1.9 Oesophageal manometry and ambulatory pH monitoring prior to laparoscopic anti-reflux surgery – is it a necessity? An evaluation of a newly established anti-reflux surgery service at a district general hospital

Abstract Background Laparoscopic fundoplication is an effective surgical option for patients with symptoms of reflux refractory to proton-pump inhibitor (PPI) use. Oesophageal manometry and ambulatory pH monitoring are typically advocated as part of the evaluation of gastro-oesophgeal reflux disease, when anti-reflux surgery is considered. However, the requirement for these as a mandatory procedure remains controversial, particularly in the context of large hiatus hernia or presence of endoscopic reflux oesophagitis. Methods A retrospective review of all cases performed since the inception of the anti-reflux service at a single-centre district general hospital was undertaken. All patients who underwent an elective laparoscopic anti-reflux operation were included. Data pertaining to preoperative symptoms, preoperative investigations and postoperative outcomes (resolution of symptoms and PPI cessation) was collected. Results Over the three-year period, 22 anti-reflux operations were performed, of which 17 were followed up. The mean length of follow-up was 9.5 months. Most patients (91%) had typical reflux symptoms with a large hiatus hernia or endoscopic reflux oesophagitis. Only 4 (18.2%) patients underwent oesophageal manometry and ambulatory pH monitoring—each of these had either a normal preoperative OGD or barium swallow, or atypical symptoms. Alleviation of symptoms was achieved in 14 (82.3%) patients; 9 (52.9%) of which achieved complete resolution. PPI cessation was achieved in 12 (70.1%) patients, comparable with current literature. Conclusion Anti-reflux surgery can safely be performed without routine oesophageal manometry and ambulatory pH monitoring in the context of typical symptoms, a large hiatal defect or evidence of endoscopic reflux oesophagitis, as exemplified in our newly established anti-reflux service.

Effect of Laparoscopic Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass on Weight Loss, Comorbidities, and Reflux at 10 Years in Adult Patients With Obesity

Long-term results from randomized clinical trials comparing laparoscopic sleeve gastrectomy (LSG) with laparoscopic Roux-en-Y-gastric bypass (LRYGB) are limited. To compare long-term outcomes of weight loss and remission of obesity-related comorbidities and the prevalence of gastroesophageal reflux symptoms (GERD), endoscopic esophagitis, and Barrett esophagus (BE) after LSG and LRYGB at 10 years. This 10-year observational follow-up evaluated patients in the Sleeve vs Bypass (SLEEVEPASS) multicenter equivalence randomized clinical trial comparing LSG and LRYGB in the treatment of severe obesity in which 240 patients aged 18 to 60 years with median body mass index of 44.6 were randomized to LSG (n = 121) or LRYGB (n = 119). The initial trial was conducted from April 2008 to June 2010 in Finland, with last follow-up on January 27, 2021. LSG or LRYGB. The primary end point was 5-year percentage excess weight loss (%EWL). This current analysis focused on 10-year outcomes with special reference to reflux and BE. At 10 years, of 240 randomized patients (121 randomized to LSG and 119 to LRYGB; 167 women [69.6%]; mean [SD] age, 48.4 [9.4] years; mean [SD] baseline BMI, 45.9 [6.0]), 2 never underwent surgery and there were 10 unrelated deaths; 193 of the remaining 228 patients (85%) completed follow-up on weight loss and comorbidities, and 176 of 228 (77%) underwent gastroscopy. Median (range) %EWL was 43.5% (2.1%-109.2%) after LSG and 50.7% (1.7%-111.7%) after LRYGB. Mean estimate %EWL was not equivalent between the procedures; %EWL was 8.4 (95% CI, 3.1-13.6) higher in LRYGB. After LSG and LRYGB, there was no statistically significant difference in type 2 diabetes remission (26% and 33%, respectively; P = .63), dyslipidemia (19% and 35%, respectively; P = .23), or obstructive sleep apnea (16% and 31%, respectively; P = .30). Hypertension remission was superior after LRYGB (8% vs 24%; P = .04). Esophagitis was more prevalent after LSG (31% vs 7%; P < .001) with no statistically significant difference in BE (4% vs 4%; P = .29). The overall reoperation rate was 15.7% for LSG and 18.5% for LRYGB (P = .57). At 10 years, %EWL was greater after LRYGB and the procedures were not equivalent for weight loss, but both LSG and LRYGB resulted in good and sustainable weight loss. Esophagitis was more prevalent after LSG, but the cumulative incidence of BE was markedly lower than in previous trials and similar after both procedures. ClinicalTrials.gov Identifier: NCT00793143.

Predictors of histopathological esophagitis in infants and adolescents with esophageal atresia within a national follow-up programme.

PurposeEsophageal atresia (EA) is a congenital anomaly of the foregut. Although the survival has improved over the years there is a significant gastrointestinal morbidity affecting physical function and health-related quality of life. The aims of the study were to identify and evaluate predictors of histopathological esophagitis in infants and adolescents with EA.MethodsSingle centre, cross-sectional study including one and 15-year-old patients operated for EA that participated in the national follow-up programme between 2012 and 2020 according to a pre-established protocol including upper endoscopy with oesophageal biopsies and 24h-pH-test. Data was collected from patients’ medical records and pH-analysis software. Regression models were used to identify predictors of histopathological oesophagitis. Possible predictors were abnormal reflux index, endoscopic esophagitis, hiatal hernia, symptoms of gastroesophageal reflux (GER) and age.Results65 patients were included, 47 children and 18 adolescents. All children were treated with PPI during their first year of life. Symptoms of GER were reported by 13 (31.7%) of the infant’s caregivers, 34 of the children (72.3%) had abnormal reflux index and 32 (68.1%) had histopathological esophagitis. The corresponding numbers for adolescents were 8 (50%), 15 (83.3%) and 10 (55.6%). We found no significant associations between histopathological esophagitis and endoscopic esophagitis, symptoms of GER, hiatus hernia or age group. Abnormal reflux index was an independent predictor of histopathological esophagitis. Seven patients with normal reflux index had histopathological esophagitis, all grade I.ConclusionsWe found a high prevalence of histopathological esophagitis despite PPI treatment in accordance with recommendations. No significant difference between the two age groups was seen. Abnormal reflux index was an independent predictor of histopathological esophagitis. However, we cannot recommend the use of pH-metry as a substitute for esophageal biopsies; future studies are needed to elucidate if esophageal biopsies might be postponed in infants with normal reflux index.

Antireflux mucosectomy (ARMS) and antireflux mucosal ablation (ARMA) for gastroesophageal reflux disease: a systematic review and meta-analysis.

Background and study aims Antireflux mucosectomy (ARMS) and antireflux mucosal ablation (ARMA) are new endoscopic procedures for patients with gastroesophageal reflux disease (GERD). We conducted a meta-analysis to systematically assess the feasibility, clinical success, and safety of these procedures. Patients and methods We searched Embase, PubMed, and Cochrane Central from inception to October 2020. Overlapping reports, animal studies, and case reports were excluded. Our primary outcomes were clinical success and adverse events (AEs). Secondary outcomes included technical success, endoscopic esophagitis, 24-hour pH monitoring, and proton pump inhibitor (PPI) use. A random effects model was used to pool data. Results In total, 15 nonrandomized studies (12 ARMS, n = 331; 3 ARMA, n = 130) were included; 10 were conducted in patients with refractory GERD. The technical success rate was 100 %. The pooled short-term (first assessment within the first 6 months), 1-year, and 3-year clinical success rates were 78 % (95 % confidence interval [95 %CI] 70 %–85 %), 72% (95 %CI 47 %–92 %), and 73 % (95 %CI 65 %–81 %), respectively. ARMS and ARMA yielded similar clinical success. The proportion of patients off PPIs at 1 year was 64 % (95 %CI 52 %–75 %). There were significant drops ( P < 0.01) in validated clinical questionnaires scores, presence of esophagitis, and acid exposure time. The most common AE (11 %, 95 %CI 8 %–15 %) was dysphagia requiring dilation (7%, 95 %CI 5 %–11 %). Four cases of perforation were recorded, all in patients undergoing ARMS. Conclusions Our meta-analysis of nonrandomized studies suggests that ARMS and ARMA are safe and effective for patients with GERD.

Lifestyle- and comorbidity-related factors for the prescription of proton pump inhibitors after Helicobacter pylori eradication in Japan.

Background and AimThe aim of the present study was to examine the lifestyle‐ and comorbidity‐related determinant factors of the prescription of proton pump inhibitors (PPIs) for patients in whom Helicobacter pylori has been eradicated, and to evaluate the relationship between PPI prescription and the severity of endoscopic esophagitis.MethodsThis retrospective study included patients who underwent H. pylori eradication from May 2012 to September 2016 at Saiseikai Karatsu Hospital. All patients received upper gastrointestinal endoscopy before H. pylori eradication. Patients with open peptic ulcers and/or malignant diseases were excluded, and a final total of 389 patients were evaluated. Medical records were reviewed to determine the prescription of PPIs after H. pylori eradication, lifestyle‐related factors, and comorbidities. Lifestyle‐related factors were confirmed by a questionnaire.ResultsPPIs were administered to 124 of 389 patients (31.9%). The only lifestyle‐related risk factor for the prescription of PPIs after H. pylori eradication was older age (P < 0.01). Hypertension increased the prescription of PPIs (P = 0.034). The prescription of PPIs was not influenced by the presence of grade A esophagitis, whereas the PPI prescription rate was significantly increased in patients with grades B/C/D endoscopic esophagitis (P < 0.01). The grade of chronic gastritis before H. pylori eradication had no effect on the prescription of PPIs.ConclusionThe lifestyle‐ and comorbidity‐related risk factors for the prescription of PPIs after H. pylori eradication were older age and hypertension, while mild endoscopic esophagitis had no influence on PPI prescription.

633 CONVERSION TO TOUPET FUNDOPLICATION WITH DISTAL GASTRECTOMY AND ROUX-EN-Y GASTROJEJUNOSTOMY AFTER FAILED NISSEN FUNDOPLICATION

Abstract Laparoscopic Nissen Fundoplication fails in almost 15% of patients and most of them must be re-operated in order to improve reflux symptoms, esophagitis, or hiatal hernia. Surgical options are to redo LNF, distal gastrectomy alone or combination of both procedures. Redoing LNF, is associated with high rate of postoperative complications and re-failure. Purpose To present the early and medium-term postoperative outcomes of patients submitted to Laparoscopic Toupet Fundoplication combined with Distal Gastrectomy with Roux-en-Y gastrojejunostomy. Methods prospective study including 23 patients submitted to Laparoscopic Nissen Fundoplication who presented recurrence of gastroesophageal reflux after the operation. They were studied with endoscopy, barium swallow, manometry and 24 h pH monitoring in order to determine presence of esophagitis, anatomical deformities, defective Lower Esophageal Sphincter and pathologic acid reflux. Surgical process consisted on re-establishing the anatomy of the esophago-gastric junction, and then perform laparoscopic Toupet fundoplication combined with distal gastrecvtomy and Roux Y gastrojejunostomy. Results After surgery statistically significant improvement regarding heartburn (p &amp;lt; 0.0001), dysphagia (p &amp;lt; 0.0001) and retrosternal chest pain (p &amp;lt; 0.0001) as well as in the endoscopic esophagitis was observed. No significant LES pressure increase after the operation was observed. (from 7.88 + 2.7 to 10.5 + 3.36) (p = 0.15), but the abnormal acid reflux improved significantly after the reoperation, %time pH &amp;lt; 4 decreases from 12.00 + 6.62 to 4.3 + 4.04 (0.0004) and DeMeester score from 44.82 + 21.8 to 11.95 + 5.14 (0.0008) respectively. Conclusion The proposed procedure is safe option to treat successfully patients after failed Nissen fundoplication. Reflux symptoms, esophagitis, presence oh hiatal hernia and reflux score improved after the procedure.

Neutrophils, eosinophils, and intraepithelial lymphocytes in the squamous esophagus in subjects with and without gastroesophageal reflux symptoms

Whilst intraepithelial lymphocytes (IELs) are considered normal within the distal esophageal mucosa, they have an increasingly recognised role in the pathogenesis of reflux esophagitis, and IEL quantification establishes the diagnosis of lymphocytic esophagitis. Knowledge regarding the upper limit of a normal IEL count in health is lacking. We studied 117 non-healthcare seeking adult volunteers from a random community sample (the Kalixanda study) with esophageal biopsies 2 cm above the gastroesophageal junction. Subjects were divided into four groups based on the presence or absence of gastro-esophageal reflux symptoms and/or esophagitis on endoscopy. Asymptomatic subjects with no endoscopic esophagitis were selected as controls, and the cell counts in this group were used to define the upper limit of normal of IELs, eosinophils and neutrophils. The entire sample was used to identify independent predictors of increased cellular counts by logistic regression analysis. None of the healthy controls had an IEL count of more than three per five high power fields (HPF), and therefore this was considered as the upper limit of normal; no controls had eosinophils or neutrophils in esophageal biopsies. Independent predictors of an elevated IEL count were spongiosis on histology (OR 11.17, 95% CI 3.32-37.58, P < 0.01) and current smoking (OR 4.84, 95% CI 1.13-2.71, P = 0.03). A receiver operating characteristics analysis concluded that a threshold of 3 IELs/5HPFs performs best in predicting reflux symptoms when a normal esophageal mucosa is visualized on endoscopy (sensitivity = 100.0%, specificity = 35.2%). The healthy esophageal mucosa does not contain more than three IELs per five HPF in the distal esophagus.

Performance of the UCLA Scleroderma Clinical Trials Consortium Gastrointestinal Tract 2.0 instrument as a clinical decision aid in the routine clinical care of patients with systemic sclerosis

Background and objectivesThe University of California Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract Instrument 2.0 (UCLA GIT 2.0) is validated to capture gastrointestinal (GI) tract morbidity in patients with systemic sclerosis (SSc). The aims of this study were to determine in a large SSc cohort if the UCLA GIT 2.0 is able to discriminate patients for whom a rheumatologist with experience in SSc would recommend an esophago-gastro-duodenoscopy (EGD), and if it could identify patients with endoscopically proven esophagitis or with any pathologic finding on EGD.MethodsWe selected patients fulfilling the ACR/EULAR 2013 criteria for SSc from our EUSTAR center having completed at least once the UCLA GIT 2.0 questionnaire, and we collected data on gastrointestinal symptoms and EGD from their medical charts. We analyzed by general linear mixed effect models several parameters, including UCLA GIT 2.0, considered as potentially associated with the indication of EGD, as well as with endoscopic esophagitis and any pathologic finding on EGD.ResultsWe identified 346 patients (82.7% female, median age 63 years, median disease duration 10 years, 23% diffuse cutaneous SSc) satisfying the inclusion criteria, who completed UCLA GIT 2.0 questionnaires at 940 visits. EGD was recommended at 169 visits. In multivariable analysis, UCLA GIT 2.0 and some of its subscales (reflux, distention/bloating, social functioning) were associated with the indication of EGD. In 177 EGD performed in 145 patients, neither the total ULCA GIT 2.0 score nor any of its subscales were associated with endoscopic esophagitis, nor with any pathologic EGD findings.ConclusionsIn a real-life setting, the UCLA GIT 2.0 and its reflux subscale were able to discriminate patients with SSc who had an indication for EGD, but did not correlate with findings in EGD. We conclude that, while using the UCLA GIT 2.0 in the routine care of patients with SSc may help the rheumatologist to better understand the burden of GI symptoms in the individual patient, it should not be used as a stand-alone instrument to identify an indication of EGD.

Endoscopic full-thickness plication for the treatment of PPI-dependent GERD: results from a randomised, sham controlled trial

BackgroundThe majority of endoscopic antireflux procedures for GERD are cumbersome to use and randomised long-term data are sparse. We conducted such a trial to determine the efficacy and safety of...

Quality of Life After Operation for End-Stage Achalasia: Pull-Down Heller-Dor Versus Esophagectomy

Therapy for end-stage achalasia is debated, and data on long-term functional results of myotomy and esophagectomy are lacking. We compared quality of life and objective outcomes after pull-down Heller-Dor and esophagectomy. The study included 32 patients, aged 57 years (interquartile range [IQR], 49-70 years), who underwent the Heller-Dor operation with verticalization of the distal esophagus in case of first instance treatment or failed surgery caused by insufficient myotomy, and 16 patients, aged 58 years (IQR, 49-67 years; P= .806), who underwent esophagectomy after failed surgery for other causes. Data were extracted from a database designed for prospective clinical research. Postoperative dysphagia, reflux symptoms, and endoscopic esophagitis were graded by semiquantitative scales. Quality of life was assessed with the 36-Item Short Form Health Survey questionnaire. The median follow-up period was 68 months (IQR, 40.43-94.48 months) after pull-down Heller-Dor and 61 months (IQR 43.72-181.43 months) after esophagectomy (P= .598). No statistically significant differences were observed for dysphagia (P= .948), reflux symptoms (P= .186), or esophagitis (P= .253). No statistically significant differences were observed in the domains physical functioning (P= .092), bodily pain (P= .075) or general health (P= .453). Significant differences were observed in favor of pull-down Heller-Dor for the domains role physical (100 vs 100, P= .043), role emotional (100 vs 0, P= .002), vitality (90 vs 55, P< .001), mental health (92 vs 68, P= .002), and social functioning (100 v s75, P= .011). The pull-down Heller-Dor achieved objective results similar to those of esophagectomy with a better quality of life. This technique may be the first choice for end-stage achalasia in patients with null or low risk for cancer or after recurrent dysphagia caused by insufficient myotomy.

Potential roles of Helicobacter pylori treatment, body mass index and waist circumference in the causation of erosive esophagitis: a randomized clinical trial (HEROES-GERD)

In recent decades, the prevalence of gastroesophageal reflux disease (GERD) and obesity has been increasing while Helicobacter pylori infection has been decreasing. To evaluate if H. pylori treatment, excess body weight and other anthropometric measurements are associated with incident erosive esophagitis, as a secondary objective of a trial which tested the efficacy of treatment of H. pylori on the symptoms of functional dyspepsia. Upper gastrointestinal endoscopy and anthropometric assessments were performed, at baseline and after 12 months, in H. pylori positive patients with functional dyspepsia who had no baseline reflux symptoms or esophagitis. Patients were randomly assigned to receive omeprazole, amoxicillin, and clarithromycin (antibiotic group; n = 201) or omeprazole plus placebo (control group; n = 203). The primary outcome was the incidence of esophagitis 12 months after randomization, according to treatment groups, and the association of BMI and other anthropometric measurements. Four hundred and four patients were included (mean age, 46.1 years; 78.7% women). The 12-month follow-up endoscopic esophagitis rates for the antibiotic and control groups were 10.9% (22/201) and 9.4% (19/203), respectively (p = 0.60). The number needed to harm was 67. Baseline anthropometric measurements were performed in 94% (380/404) of patients. The 12-month follow-up esophagitis rates for overweight and normal body weight patients were 13.6% (29/213) and 6.0% (10/167), respectively (p = 0.015); rates for patients with and without increased baseline waist circumference were 15.4% (24/156) and 6.7% (15/224), respectively (p = 0.006). Following logistic regression, only the combination of increased baseline body mass index and waist, but not H. pylori treatment, was independently associated with new-onset esophagitis (OR 2.88; 95% CI: 1.28-6.45). Excess body weight and concomitant increased waist circumference, but not H. pylori treatment, predicts new-onset esophagitis.

Can Proximal Gastrectomy with Double-Tract Reconstruction Replace Total Gastrectomy? A Propensity Score Matching Analysis

BackgroundThis retrospective cohort study compared proximal gastrectomy (PG) with double-tract reconstruction (DTR) versus total gastrectomy (TG) with Roux-en-Y reconstruction in terms of clinical outcomes. MethodsAll consecutive patients with upper early gastric cancer (EGC) who underwent PG-DTR or TG in 2008–2016 were selected. TG patients who matched PG-DTR patients in age, sex, body mass index, clinical stage, and ASA score were selected by propensity score matching. Groups were compared in terms of clinicopathological characteristics, clinical outcomes, early (≤ 30 days), late (> 30 days), and severe (Clavien-Dindo grade ≥ III) postoperative complications, 1-year reflux morbidity, recurrence, and mortality. ResultsOf 322 patients, 52 underwent PG-DTR. A matching TG group of 52 patients was selected. The PG-DTR group had smaller tumors (p = 0.02), smaller proximal and distal resection margins (p = 0.01, p < 0.01), and fewer retrieved lymph nodes (p < 0.01). PG-DTR associated with shorter times to diet and hospital stay (both p = 0.02). Groups did not differ in early (11.3 vs. 19.2%, p = 0.19), late (1.9 vs. 5.7%, p = 0.31), or severe complication rates (7.7 vs. 13.5%, p = 0.34). At 1 year, the groups did not differ in reflux symptoms (Visick score) or endoscopic esophagitis (Los Angeles Classification). There were no recurrences. Five-year overall survival rates were 100 and 81.6% (p = 0.02), respectively. ConclusionPG-DTR associated with better clinical outcomes and survival. Complication and reflux rates were similar. PG-DTR may be suitable for upper EGC.

FAILURE AFTER FUNDOPLICATION: RE-FUNDOPLICATION? IS THERE A ROOM FOR GASTRECTOMY? IN WHICH CLINICAL SCENARIES?

ABSTRACT Background: Re-fundoplication is the most often procedure performed after failed fundoplication, but re-failure is even higher. Aim: The objectives are: a) to discuss the results of fundoplication and re-fundoplication in these cases, and b) to analyze in which clinical situation there is a room for gastrectomy after failed fundoplication. Method: This experience includes 104 patients submitted to re-fundoplication after failure of the initial operation, 50 cases of long segment Barrett´s esophagus and 60 patients with morbid obesity, comparing the postoperative outcome in terms of clinical, endoscopic, manometric and 24h pH monitoring results. Results: In patients with failure after initial fundoplication, redo-fundoplication shows the worst clinical results (symptoms, endoscopic esophagitis, manometry and 24 h pH monitoring). In patients with long segment Barrett´s esophagus, better results were observed after fundoplication plus Roux-en-Y distal gastrectomy and in obese patients similar results regarding symptoms, endoscopic esophagitis and 24h pH monitoring were observed after both fundoplication plus distal gastrectomy or laparoscopic resectional gastric bypass, while regarding manometry, normal LES pressure was observed only after fundoplication plus distal gastrectomy. Conclusion: Distal gastrectomy is recommended for patients with failure after initial fundoplication, patients with long segment Barrett´s esophagus and obese patients with gastroesophageal reflux disease and Barrett´s esophagus. Despite its higher morbidity, this procedure represents an important addition to the surgical armamentarium.

Gastroesophageal reflux disease is associated with high risk of obstructive sleep apnea syndrome

Objective: To investigate the relationship between gastroesophageal reflux disease (GERD) and obstructive sleep apnea syndrome(OSAS). Methods: Patients diagnosed as GERD and healthy controls without GERD related symptoms or endoscopic esophagitis were enrolled from October 2017 and December 2017. All subjects completed Berlin Questionaire to assess the risk of OSAS. Univariate and multivariate logistic regression models were applied to identify risk factors of OSAS. Results: A total of 177 subjects (97 GERD, 80 controls) were finally selected. Significantly more patients in GERD group had high risk OSAS than those in controls [36.1%(35/97) vs. 17.5%(14/80), P=0.005]. In GERD group, patients with erosive reflux diseases (ERD) had especially higher proportion of high risk OSAS compared with the non-ERD group and the healthy controls [53.3% (24/45) vs. 20.8% (10/48) and 17.5% (14/80), P=0.001]. On univariate analysis, male, aging and reflux esophagitis were identified as risk factors of OSAS (all P<0.01). On multivariate analysis, male (OR=12.156, 95%CI 1.382-106.905, P=0.024), aging (OR=1.132, 95%CI 1.051-1.220, P=0.001), acid regurgitation with reflux esophagitis (OR=5.157, 95%CI 1.327-20.034, P=0.018) were significant risk factors. Conclusions: More GERD patients are combined with high risk OSAS than controls, especially subjects with reflux esophagitis. Male and aging GERD patients with acid regurgitation and reflux esophagitis need further evaluation on OSAS screening.

A Case of Systemic Sclerosis Mimicking Achalasia

Systemic sclerosis (SS) may be associated with GERD symptoms and dysphagia related to esophageal dysmotility or a peptic stricture in 50 - 90% of patients. HRM may show esophageal aperistalsis of the smooth muscle with a low LESp. We present 2 cases of SS presenting with HRM findings characteristic of type I Achalasia; onepatient with symptomatic dysphagia and the other patient with symptomatic GERD and endoscopic esophagitis. Both patients have diffuse SS, Raynaud's phenomenon, interstitial lung disease, GERD and positive SS serologies. Case 1 is a 66 year-old female who developed dysphagia 8 years following SS diagnosis. BaS noted esophageal atony, no strictures and a patulous GEJ, with a normal EGD. GERD symptoms improved with PPIs but she developed progressive solid-food dysphagia without weight loss. Re-evaluation 4 years later revealed a normal EGD while HRM showed aperistalsis, normal LESp with a ?IRP mimicking type I achalasia. Timed BaS demonstrated mild mid-esophageal dilation (3 cm), tapering at the distal esophagus with minimal barium retention at 5 minutes (Fig. 1). Repeat EGD for possible pneumatic dilation, demonstrated a mildly patulous LES that was easily distended following air insufflation and no resistance w ith endoscopic passage through the GEJ. Case 2 is a 54 year old patient with an 11 year history of SSc and GERD but no dysphagia with a mildly dilated esophagus with intraluminal debris (Fig. 2). HRM showed aperistalsis, normal LESp, and elevated IRP (Fig 3). Most recent EGD revealed LA Class B esophagitis. Caution should be exercised in making the diagnosis of achalasia in SS patients. Full evaluation must include a timed barium study, and EGD to be certain that one is dealing with GEJ obstruction. Measurement of the LESp and relaxation are dependent upon: (1) the crural diaphragm which does not relax during swallowing, (2) the intrabolus pressure generated by the fluid passing through the GEJ, and (3) the cephalad movement of esophagus related to longitudinal muscle contraction which shortens the esophagus and momentarily pulls the stomach into the GEJ during swallowing. It is possible that in SS with a dilated esophagus and no muscle contraction, the esophagus did not shorten and LES remained stationary at the level of the crural diaphragm. Few cases exists of SS having HRM criteria for achalasia. These 2 cases presents a hypothesis for further research in SS patients having HRM criteria for achalasia.1722_A Figure 1. Mild esophageal dilation with distal esophageal tapering and minimal barium retention in case 11722_B Figure 2. Mild esophageal dilation with intraluminal debris in case 21722_C Figure 3. Representative esophageal topography of elevated IRP in case 2