Gastroesophageal Reflux Disease-related Symptoms Research Articles

Clinical efficacy of Yukgunja-tang combined with a proton pump inhibitor for refractory gastroesophageal reflux disease: study protocol for randomized, double-blind, double-dummy clinical trial

BackgroundYukgunja-tang (YGJ) is an herbal prescription used to treat the symptoms of gastroesophageal reflux disease (GERD). Although many preclinical and clinical studies on YGJ have been conducted on GERD, there is a lack of evidence from blinded studies to exclude placebo effects. Therefore, this protocol proposes a clinical trial that is single-centered, randomized, double-blinded, double-dummy to objectively evaluate the efficacy and safety of co-administered YGJ and rabeprazole (RPZ) in patients with GERD previously treated with proton pump inhibitors (PPIs) and still experiencing symptoms.MethodsA total of 86 participants with refractory GERD (rGERD) will be randomized in a 1:1 ratio to the treatment [YGJ and RPZ (10 mg/d)] and control groups [double-dose RPZ (20 mg/d)] for 4 weeks of treatment (weeks 0–4) followed by 4 weeks of follow-up (weeks 4–8). The Frequency Scale for the Symptoms of GERD will be analyzed for the primary endpoint. Reflux Disease Questionnaire, Reflux Symptom Score, GERD-Health Related Quality of Life, Overall Treatment Evaluation, Spleen Qi Deficiency Questionnaire, Damum Questionnaire, and dyspepsia Visual Analogue Scale will be used to evaluate treatment effects on GERD related symptoms and quality of life and to compare treatment effects by subgroups. Safety tests will be analyzed by investigating adverse events.DiscussionThis clinical trial will be the first rigorous double-blind, double-dummy, placebo-controlled study to precisely evaluate the efficacy and safety of the combination of YGJ and PPIs in the treatment of rGERD. The results of this study will provide a reliable clinical basis for selecting botanical drug treatments for patients with rGERD.Trial registrationClinical Research Information Service (registration number: KCT0008600, July 13, 2023, https://cris.nih.go.kr).

Laparoscopic Hiatal Hernia Repair with RefluxStop: Outcomes in 30 Patients with a Minimal Follow-Up of 12 Months

Abstract Background Laparoscopic hiatal hernia repair with RefluxStop is an innovative technique to treat patients with gastroesophageal reflux disease (GERD). While feasibility and safety of this technique have already been demonstrated, consistent 12-months follow-up data is lacking. Aims To report 12-months outcomes and complications of a novel surgical anti-reflux technique with RefluxStop. Methods Among the 60 patients who underwent hiatal hernia surgery with RefluxStop since 2020 at our institution, we performed a retrospective chart review of the first 30 patients who achieved a minimal follow-up of 12 months. Follow-up data were reviewed until December 2022. Primary outcome was the clinical improvement of GERD related symptoms (heartburn and regurgitation) at 3 and 12 months after surgery. Secondary outcomes were need for dilatations and occurrence of implant related complications. Results The median follow-up was 19.5 months (range, 13-31). Preoperatively, 23 patients (76.7%) presented with esophageal dysmotility, and the median length of the concomitant hiatal hernia was 4cm (range, 2-8). Mean GERD-HRQL score (0-75 points) was 37.6 ± 15.8 before surgery, 4.2 ± 7.1 at 3 months, and 4.4 ± 6.9 at 12 months (p<0.001). Three patients (10%) required postoperatively balloon dilatation due to persistent dysphagia. One patient experienced an asymptomatic partial migration of the implant, one patient presented with a recurrence of hiatal hernia after 2 years who required surgical repair, and in one case the implant was removed after 16 months to due persisting left thoracic pain. Conclusions This study confirmed excellent clinical outcomes beyond 1 year with significant improvement of reflux symptoms in all patients.

GASTRIC PLICATION ASSOCIATED WITH FUNDOPLICATION IN INDIVIDUALS WITH CLASS I OBESITY AND GASTROESOPHAGEAL REFLUX DISEASE: WEIGHT LOSS OUTCOMES, REFLUX-RELATED SYMPTOMS, ENDOSCOPIC AND pH MONITORING FINDINGS.

The association of gastric plication with fundoplication is a reliable option for the treatment of individuals with obesity associated with gastroesophageal reflux disease. To describe weight loss, endoscopic, and gastroesophageal reflux disease-related outcomes of gastric plication with fundoplication in individuals with mild obesity. A retrospective cohort study was carried out, enrolling individuals who underwent gastric plication with fundoplication at a tertiary private hospital from 2015-2019. Data regarding perioperative and weight loss outcomes, endoscopic and 24-hour pH monitoring findings, and gastroesophageal reflux disease-related symptoms were analyzed. Of 98 individuals, 90.2% were female. The median age was 40.4 years (IQR 32.1-47.8). The median body mass index decreased from 32 kg/m2 (IQR 30,5-34) to 29.5 kg/m2 (IQR 26.7-33.9) at 1-2 years (p<0.05); and to 27.4 kg/m2 (IQR 24.1-30.6) at 2-4 years (p=0.059). The median percentage of total weight loss at 1-2 years was 7.8% (IQR -4.1-14.7) and at 2-4 years, it was 16.4% (IQR 4.3-24.1). Both esophageal and extra-esophageal symptoms showed a significant reduction (p<0.05). A significant decrease in the occurrence of esophagitis was observed (p<0.01). The median DeMeester score decreased from 30 (IQR 15.1-48.4) to 1.9 (IQR 0.93-5.4) (p<0.0001). The gastric plication with fundoplication proved to be an effective and safe technique, leading to a significant and sustained weight loss in addition to endoscopic and clinical improvement of gastroesophageal reflux disease.

Successful laparoscopic repair for large paraesophageal hiatal hernia presenting cardiopulmonary problems: Two case reports

Large paraesophageal hiatal hernia, which is a type III hiatal hernia, involves the combined herniation of both the esophagogastric junction and fundus. Different symptoms are noted in patient with hiatal hernia, the most common being gastroesophageal reflux disease-related symptoms. Herein, we present two cases of large paraesophageal hiatal hernia with symptoms mimicking cardiopulmonary disease, which were successfully treated by laparoscopic hernia repair.

Use of vonoprazan, a novel potassium-competitive acid blocker, for the treatment of proton pump inhibitor-refractory reflux esophagitis in patients with systemic sclerosis.

Proton pump inhibitor-refractory reflux esophagitis is one of the intractable conditions of systemic sclerosis for which new treatments are required. Vonoprazan is a novel potassium-competitive acid blocker and has been shown to have several advantages over conventional proton pump inhibitors, including a long duration of gastric acid suppression. To investigate the efficacy of vonoprazan for treating proton pump inhibitor-refractory reflux esophagitis in patients with systemic sclerosis, 10 patients with proton pump inhibitor-refractory reflux esophagitis who were switched to vonoprazan were selected from our systemic sclerosis database. Reflux esophagitis was evaluated by endoscopy, and gastroesophageal reflux disease-related symptoms were assessed by the frequency scale for the symptoms of gastroesophageal reflux disease questionnaire before and after switching from proton pump inhibitor to vonoprazan at an average interval of 3.5 [2-5.5] months. After switching patients to vonoprazan, the endoscopic findings of reflux esophagitis were significantly improved (p = .033), and six patients (60%) achieved mucosal healing. The total frequency scale for the symptoms of gastroesophageal reflux disease score was also significantly decreased (p = .043), mainly by improving the acid reflux score. Vonoprazan was well tolerated and was continued for 15.5 [11.25-23.75] months in all patients. Vonoprazan is a potential treatment option for treating proton pump inhibitor-refractory reflux esophagitis in systemic sclerosis patients.

Therapeutic Efficacy of Nasoenteric Tube Feeding in Children Needing Enteral Nutrition.

Background: There is limited information on therapeutic benefits and tube-related complications of pediatric nasoenteric (NE) tube feeding. We viewed, from different clinical aspects, NE tube feeding in children who are under intolerable conditions.Methods: A 10-years retrospective study enrolled 77 pediatric patients who underwent an endoscopic-guided placement of the NE tube for enteral nutrition. The evaluated data, including growth parameters, feeding volume, parenteral nutrition (PN) dependence, and nutritional markers [serum hemoglobin (Hb) and albumin] before and after NE tube feeding were compared. Tube-related complications and major adverse events were also recorded.Results: A total of 77 patients (including 50 males) underwent 176 endoscopic-guided placements of the NE tube with an average duration of 133.7 (6.0–1,847.3) days. The gastroesophageal reflux disease-related symptoms (vomiting, desaturations, and aspiration pneumonia) improved in 71.4% of patients. Feeding volume increased significantly after intervention, especially in patients with delayed gastric emptying, from 144.8 ± 28.5 to 1,103.1 ± 524.7 ml/days (p < 0.001). Weaning from PN was successfully achieved in 84.3% of patients with an average of 9.33 ± 7.30 days. About 16 patients (20.8%) were subsequently highly compatible with oral feeding after NE tube placement for an average of 24.7 ± 14.1 days. Patients either without neurologic dysfunction or with no ventilator-dependent status had a higher chance of shifting to oral feeding. Weight-for-age z-scores increased by 0.15 ± 1.33 after NE tube intervention. One NE tube-related adverse event, which caused bowel perforation at 6 days post-insertion, was recorded. No direct tube-related mortality was observed.Conclusions: Endoscopic-guided NE tube placement is a relatively safe, non-invasive procedure for pediatric patients who require enteral nutrition. Feeding via NE tube showed beneficial effects such as improvement in symptoms, PN weaning, and maintenance of body growth without major tube-related complications.

878 CLINICAL OUTCOMES OF ENDOSCOPIC ANTI-REFLUX TREATMENT METHODS; ANTI-REFLUX MUCOSECTOMY (ARMS) AND ANTI-REFLUX MUCOSAL ABLATION (ARMA)

Gastroesophageal reflux disease (GERD) is a common disorder with an increasing prevalence worldwide. Proton pump inhibitors (PPIs) are effective in achieving symptom control, however, approximately 30-40% of patients are reported to have persistent symptoms despite PPI therapy. While the surgical intervention such as Laparoscopic Nissen Fundoplication remains the gold standard treatment for refractory GERD, minimally invasive anti-reflux therapies are gaining its popularity to fill in the “gap” of conventional medical therapy and surgery. In 2014, we reported Anti-reflux mucosectomy (ARMS) which utilizes ESD or EMR-C to rebuild the flap valve at the gastric cardia by scarring of the artificial ulcer. In 2018, we developed Anti-reflux mucosal ablation (ARMA) where we apply ablation instead of mucosectomy as an alternative therapy for PPI-refractory GERD. The aim of this study is to evaluate the clinical outcomes of ARMS and ARMA. This is a retrospective, single center study from a prospectively collected database performed between April 2012 and November 2019. The indication of ARMS/ARMA is PPI refractory GERD patients without prominent sliding hernia. In ARMS, ESD or EMR-C at the gastric cardia mucosa was performed in order to create artificial ulcer. In ARMA, mucosal ablation using Triangle Tip Knife with spray coagulation mode (50W-120W, effect 2) was utilized to create the ulcer. The efficacy was evaluated by the patient’s symptom score (Frequent Scale for the Symptoms of GERD: FSSG) and the objective findings; Acid Exposure Time (AET) and DeMeester composite score by 24h multi-channel intraluminal impedance-pH monitoring, before and 2-3 months after procedure. A total of 109 patients (Age 54.0±15.7, M:F 63:46) underwent ARMS, and 24 patients (57.6±15.9, M:F 16:8) underwent ARMA. Mean procedure time (minutes) were 54.7 vs. 35.6, respectively. FSSG score improved from 25.1 to 11.6 (p<0.01) by ARMS and from 25 to 10.5 (p<0.01) by ARMA. By ARMS, AET and DeMeester composite score improved from 20.8 to 6.9 (p < 0.01, n=27) and 64.4 to 24.9 (p < 0.01, n=27), respectively. By ARMA, median AET showed a decreasing trend from 9 to 0.5 (p=0.068, n=8), and the DeMeester composite score significantly improved from 33.5 to 2.8 (p<0.05, n=8). Both ARMS and ARMA were effective anti-reflux therapy methods for PPI-refractory GERD which improved GERD related symptoms and objective acid reflux parameters. ARMA may be advantageous on its easiness and simplicity regarding operative time. A larger study with long-term follow-up is required to confirm these results.

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.

СТРЕС І ГАСТРОЕЗОФАГЕАЛЬНА РЕФЛЮКСНА ХВОРОБА

Gastroesophageal reflux disease (GERD) is one of the commonest conditions managed by clinicians. Regurgitation and heartburn are considered the cardinal symptoms of GERD. In recent decades, an increasing association has been noted between stress and GERD and our knowledge about the pathophysiology of this relationship is constantly evolving. Both acute and chronic stress can accentuate GERD related symptoms. Subjects exposed to chronic life stressors are more likely to complaint of GERD symptoms. Current data suggests that acute stress exacerbates GERD symptoms by enhancing the perceptual responses to intra-esophageal acid stimulivia central mechanisms without increasing the amount of acid reflux. This process is likely mediated by an increase in esophageal mucosal permeability. Treatment with proton pump inhibitors attenuates the effect of acute stress on esophageal perception thresholds for pain. However, the effect of anti-reflux therapy in patients experiencing chronic stress remains to be elucidated.

Symptom characteristics and esophageal motility of patients with different types of gastroesophageal junction

Objective To investigate the symptom, esophageal motility characteristics and the prevalence of gastroesophageal reflux disease (GERD) in patients with type Ⅰ, Ⅱ and Ⅲ gastroesophageal junction (EGJ) diagnosed by high resolution esophageal manometry (HREM). Methods From 6th January to 27th December in 2012, the clinical data of 171 patients with reflux symptoms and received HREM were retrospectively analyzed. According to the Chicago classification V. 3.0, the patients were divided into EGJ type Ⅰ, Ⅱ and Ⅲ groups. The age, body mass index (BMI), GERD related symptoms, esophageal motility parameters and the incidence of GERD were compared among the three groups. Chi-square test, t test and analysis of variance were used for statistical analysis. Relationship between EGJ types and other variables were analyzed by Spearman rank correlation. Results In 171 patients, 136 cases (79.5%) with type Ⅰ EGJ, 22 cases (12.9%) with type Ⅱ EGJ and 13 cases (7.6%) with type Ⅲ EGJ. The age of patients with type Ⅱ EGJ was significantly older than that of patients with type Ⅰ EGJ ((56.5±2.3) years vs (48.6±1.0) years, t=2.992, P=0.003), however the differences were not statisticant when compared with type Ⅲ EGJ patients ((51.2±3.8) years, P>0.05). The BMI of patients with type Ⅲ EGJ was higher than that of type Ⅰ and type Ⅱ EGJ patients ((26.0±1.3) kg/m2 vs (21.9±0.3) kg/m2 and (23.5±0.6) kg/m2), and the difference was statistically significant (t=4.082 and 2.108, both P<0.05). The resting pressure of lower esophageal sphincter (LES) of patients with type Ⅱ and Ⅲ EGJ were lower than that of type Ⅰ EGJ ((10.6±1.5) mmHg (1 mmHg=0.133 kPa) and (3.4±0.7) mmHg vs (17.1±0.7) mmHg), and the resting pressure of LES of type Ⅲ EGJ was lower than that of type Ⅱ EGJ ((3.4±0.7) mmHg vs (10.6±1.5) mmHg), and the differences were all statistically significant (t=-3.882, -6.411 and -2.769, all P<0.01). The amplitude of contraction at 11 cm above LES and distal contractile integral (DCI) of patients with type Ⅲ EGJ were both lower than those of patients with type Ⅰ EGJ ((32.2±5.4) mmHg vs (48.5±2.5) mmHg, and (392.0±94.1) mmHg·s·cm vs (805.1±61.4) mmHg·s·cm), and the differences were statistically significant (t=-2.580 and -2.041, both P<0.05). The incidences of GERD in patients with type Ⅰ, Ⅱ and Ⅲ EGJ were 68.4%(93/136), 77.3%(17/22) and 10/13, respectively, and the difference was not statistically significant (χ2 =1.021, P=0.600). EGJ types were positively correlated with age and BMI (r=0.214 and 0.290, both P<0.01). However, EGJ types were negatively correlated with the LES resting pressure, contraction amplitudes at 7 cm and 11 cm above the LES, and DCI (r=-0.474, -0.182, -0.333 and -0.191, all P<0.05). Conclusions Aging, overweight and obesity are risk factors of the LES and crural diaphragm separation. EGJ types are not predictable based on symptoms. The esophageal motility seems to decrease in patients with type Ⅱ and Ⅲ EGJ, the incidence of GERD in patients with type Ⅰ, Ⅱ and Ⅲ EGJ are all high. Key words: Gastroesophageal reflux; Gastroesophageal junction types; High resolution esophageal manometry

Correlation between oropharyngeal pH-monitoring and esophageal pH-impedance monitoring in patients with suspected GERD-related extra-esophageal symptoms.

24-hour esophageal pH-impedance (pH-MII) is not totally reliable for laryngopharyngeal reflux (LPR). Oropharyngeal (OP) pH-monitoring with the Dx-pH probe may detect LPR better. The correlation between these two techniques is not thoroughly established. Aim of this study is to examine the correlation between OP pH-metry and esophageal pH-MII monitoring. Thirty-six consecutive patients with suspected gastroesophageal reflux disease-related extra-esophageal symptoms were evaluated using 24-h OP-pH and concomitant esophageal pH-MII monitoring. OP events were defined as: drop in pH below thresholds of 5.5, 5.0, 4.5, 4.0 or drop in pH of at least 10% from a running baseline. Temporal relationship between OP and esophageal reflux events and outcomes of the two tests were evaluated. 2394 refluxes were detected by pH-MII; of these only 120 were detected also by OP Dx-probe. On the other hand, the proportion of OP-pH events which were temporally related to an episode of distal reflux ranged from 0% to 17%, depending on the proximal pH criteria used. In 8/36 patients both tests were pathological, while in 10/36 they were both normal; 14/36 patients had pathological OP reflux, but a normal pH-MII test; 4/36 patients had pathological pH-MII, but a normal OP reflux. The correlation between OP pH-metry and pH-MII was weak. At present, the absence of a reliable gold standard for the diagnosis of LPR and the uncertain etiology of the pharyngeal pH alterations make it difficult to decide which is the most reliable technique for the diagnosis of true LPR.

Relief of Night-time Symptoms Associated With Gastroesophageal Reflux Disease Following 4 Weeks of Treatment With Pantoprazole Magnesium: The Mexican Gastroesophageal Reflux Disease Working Group

Background/AimsTo evaluate the effectiveness of pantoprazole magnesium (pantoprazole-Mg) 40 mg in the relief of esophageal and extra-esophageal symptoms of gastroesophageal reflux disease (GERD), particularly night-time symptoms.MethodsPatients (aged 18-50 years) with 3-month history of heartburn and/or acid regurgitation plus at least one other symptom in the last week were enrolled in a nationwide, prospective and observational study in Mexico. Patients received pantoprazole-Mg 40 mg once daily during 4 weeks. Symptoms were assessed through a physician-administered structured interview and the patient-completed ReQuest in Practice™ questionnaire. Night-time GERD was defined as arousal from sleep during the night due to GERD-associated symptoms.ResultsOut of 4,343 patients included at basal visit, 3,665 were considered for the effectiveness per protocol analysis. At baseline, patients had a median of 8 GERD related symptoms. Patients with night-time GERD symptoms (42.7%) were more likely to have extra-esophageal symptoms (P < 0.001) than other GERD patients. Pantoprazole-Mg 40 mg once daily for 4 weeks improved a broad range of GERD-associated symptoms from baseline (80% reduction on physicians assessments; 68-77% reduction on ReQuest in Practice™ dimensions), including both day- and night-time GERD symptoms; improvements were the greatest for extra-esophageal symptoms in patients with night-time symptoms. Pantoprazole-Mg was well tolerated.ConclusionsPantoprazole-Mg 40 mg significantly improved a broad range of esophageal and extra-esophageal GERD related symptoms including sleep disturbances, as well as well-being, in patients with daytime or night-time GERD, making it a good option for patients with GERD, especially when extra-esophageal and night-time symptoms are present.

Characterization of Esophageal Motility Following Esophageal Atresia Repair Using High‐Resolution Esophageal Manometry

Esophageal dysmotility, a considerable issue following esophageal atresia (EA) repair, has been reported but has not been precisely described and characterized. Using high-resolution esophageal manometry (HREM), we characterized the esophageal motility patterns in children with repaired EA and compared these patterns of dysmotility with symptomatology. HREM was performed as an outpatient procedure in patients with repaired EA. The tracings were analyzed using the software provided by the company and were then reviewed visually. Charts were reviewed for medical/surgical histories and symptoms were assessed by a standardized questionnaire. Forty patients (25 boys, 15 girls) with a median age of 8 years (11 months-18 years) underwent an HREM. Thirty-five patients had type C EA and 5 had type A EA. Only 7 patients were asymptomatic at the time of the examination. HREM results were abnormal in all of the patients. Three different esophageal motility patterns were derived from HREM tracing analysis: aperistalsis (15 patients, 38%), pressurization (6 patients, 15%), and distal contractions (19 patients, 47%). Distal contractions pattern was found exclusively in type C EA. Dysphagia was encountered in the 3 groups. Gastroesophageal reflux disease-related symptoms predominated in the aperistalsis group. HREM improves our understanding and allows precise characterization of esophageal dysmotility in patients who have undergone EA repair.

Oropharyngeal pH Monitoring for Laryngopharyngeal Reflux: Is It a Reliable Test Before Therapy?

Current methods of measuring pharyngeal pH are problematic. The aim of the study was to assess the ability of the oropharyngeal pH monitoring (Restech) in predicting the response to proton pump inhibitor (PPI) therapy in patients with gastroesophageal reflux disease-related laryngopharyngeal symptoms. The study design is prospective and uncontrolled. Twenty-two consecutive naive patients with chronic laryngeal symptoms were enrolled. Reflux symptom index, fibrolaryngoscopy, and 24-hour oropharyngeal pH monitoring were performed. Both patients and laryngoscopist were blinded by the results of Restech. All the patients were given a 3-month therapy with pantoprazole of 40mg twice a day and then repeated both the reflux symptom index and fibrolaryngoscopic evaluation. Patients were considered as responders if a five-point decrease in symptom score was recorded. Thirteen of the 22 patients (59.1%) responded to therapy. Laryngoscopic findings did not correlate with the clinical improvement after the 3 months of PPI. Nine patients (40.9%) had a pathologic Restech study, and all resulted responsive to PPI; nine patients (40.9%) with a negative Restech were nonresponsive to PPI, and four patients (18.2%) despite a negative Restech resulted responsive to therapy. Responsive patients showed both a higher oropharyngeal acid exposure in orthostatic position and a higher Ryan score, compared with nonresponders (49.74±58.11 vs 2.12±0.0, P=0.002). Considering responsiveness to medical therapy as the gold standard of laryngopharyngeal reflux (LPR) for the diagnosis of LPR, Restech showed a sensitivity of 69% and a specificity of 100%. The high specificity and reasonable sensitivity of this technique make the Restech an interesting tool before therapy of patients with pharyngoesophageal reflux.

A Preliminary Investigation of Laparoscopic Fundoplication Treatment on Gastroesophageal Reflux Disease-related Respiratory Symptoms

Extraesophageal syndromes are more difficult to identify and treat than the usual esophageal symptoms. The current study explores the efficacy of laparoscopic Nissen fundoplication (LNF) on gastroesophageal reflux disease (GERD)-related respiratory symptoms (RSs) during a 12-month follow-up observation. From April 2008 to September 2009, LNF was performed on 198 patients (107 men and 91 women) with GERD-related RSs according to underlying esophageal motility. A questionnaire form ranging from 0 to 5 was the basic requirement for recording pretreatment and posttreatment and for making detailed evaluation of the symptoms. All scores of GERD-related RSs, such as heartburn, regurgitation, coughing, breathe holding, wheezing, shortness of breath, and choking, significantly decreased at the 12th month. All the patients who participated in the current study were adults and elders aged 22 to 84 years with a mean age of 49 ± 12.89. The median length of stay was 4.3 days with a range of 2 to 8 days. The median score of heartburn, regurgitation, coughing, wheezing, shortness of breath, choking, and chest pain decreased from 4.92 ± 1.99, 4.98 ± 1.81, 7.23 ± 1.87, 7.50 ± 1.88, 5.83 ± 2.13, 5.94 ± 2.22, and 4.92 ± 1.88 to 1.62 ± 2.33, 0.64 ± 1.43, 2.79 ± 2.82, 2.53 ± 2.96, 1.37 ± 2.10, 1.28 ± 2.09, and 1.57 ± 2.55 (P<0.01), respectively. A total of 173 patients had various relieved symptom scores, 16 patients (8.1%) had different scale recurrence of symptoms after laparoscopic fundoplication treatment, and 13 patients had to retreat to omeprazole as an auxiliary medical therapy. Three other patients rejected any therapy, and no deaths occurred. A single patient converted from laparoscopic surgery to open surgery. Several short-term symptoms included retrosternal uneasiness or pain (n = 63; 31.8%), dysphagia (n = 45; 22.7%), abdominal distension (n = 87; 43.9%), and diarrhea (n = 23; 11.6%). Early dysphagia lasting <6 weeks was common, and 45 patients (22.7%) underwent an early esophagogastroduodenoscopy or contrast swallow. Five patients (2.5%) who had prolonged dysphagia during the 6-month clinical review required esophageal dilatation, and the outcomes were successful. LNF can be an effective means for treating RSs in patients with GERD.

Physicians and Patients Measure Different Dimension on Assessment for Gastroesophageal Reflux Disease-related Symptoms

Background/AimsGastroesophageal reflux disease is a highly prevalent disease. Assessing treatment efficacy is critical in that clinical endpoints are properly evaluated. Clinical tools for symptoms severity assessment should be discriminative, predictive and evaluative.MethodsIn this study we compared a patient-oriented symptoms evaluation (ReQuest™) vs a structured interview assessment initiated by a physician (sickness impact profile [SIP]). Both questionnaires were analyzed in a multidimensional space using latent factors. Five dimensions were found: 1 for the short ReQuest™ questionnaire and 4 for SIP.ResultsWe included 1,522 women and 1,296 men; mean age was 36 ± 7 years, and mean body mass index was 26 ± 4. The score questionnaire assessment evaluation by physicians and patients did not correlate between them (between r = 0.03 and 0.26) except nausea and sleep disorder (r = 0.45 and 0.51) but both were sensitive enough to detect changes after treatment (P < 0.05). Medical specialty of the physician showed effect on the score of both, ReQuest™ and SIP evaluation. Questionnaire variance decomposition due to specialist was only 2% (P < 0.05).ConclusionsWhile both evaluations are orthogonal (non-correlated), meaning patients and physicians measured diverse aspects of the same disease, they both were able to measure patient's improvement with treatment.

Fundoplication combined with mediogastric plication

BackgroundThe purpose of this pilot study was to demonstrate the feasibility and procedural safety of laparoscopic fundoplication combined with mediogastric plication in patients with a body mass index of 32–35 kg/m2. MethodsSixteen patients underwent laparoscopic fundoplication combined with mediogastric plication. All procedures were performed with the patient under general anesthesia. The 1-year follow-up results encompassed gastroesophageal reflux disease recovery and excess weight loss. ResultsThe procedure time varied from 65 to 95 minutes. No serious procedure-related complications occurred. Gastroesophageal reflux disease-related symptoms resolved in all patients (P = .000). The excess weight loss was 10 ± 4 kg (58%) 1 year after the procedure. The 1-year follow-up excess weight was significantly less than the baseline excess weight (P = .000). The average body mass index decreased from 33.8 ± 1.9 kg/m2 at baseline to 27.2 ± 1.7 kg/m2 at 1 year (P = .02). Of the 16 patients, 14 had an excess weight loss of 62%, and 2 sweet-eaters had an excess weight loss of 33%. At 1 year of follow-up, the excess weight in those who smoked (n = 10) was greater than that of nonsmokers (n = 6; P = .02). However, smoking did not seem to significantly affect excess weight loss (P = .065). ConclusionFundoplication combined with mediogastric plication produced a total recovery from gastroesophageal reflux disease and an excess weight loss of 62% in 87.5% of patients after 1 year of follow-up. This procedure is technically feasible, and no serious procedure-related complications occurred. The follow-up is ongoing to investigate the efficacy and long-term durability of the procedure.

Esophageal manifestations of celiac disease

Celiac disease (CD) may often be associated with various motor disorders affecting the different segments of the digestive tract, including the esophagus. Although it has not been universally reported, some available evidences indicate that pediatric and adult celiac patients could manifest a higher frequency of esophagitis and gastroesophageal reflux disease-related symptoms compared to nonceliac patients. In addition, several published studies have consistently shown the efficacy of a gluten-free diet in rapidly controlling esophageal symptoms and in preventing their recurrence. Since the participation of gluten in the esophageal symptoms of CD seems clear, its intimate mechanisms have yet to be elucidated, and several hypothesis have been proposed, including the specific immune alterations characterizing CD, the reduction in nutrient absorption determining the arrival of intact gluten to distal gastrointestinal segments, and various dysregulations in the function of gastrointestinal hormones and peptides. Recent studies have suggested the existence of a possible relationship between CD and eosinophilic esophagitis, which should be more deeply investigated.

Effect of laparoscopic fundoplication treatment on gastroesophageal reflux disease-related respiratory symptoms

Gastroesophageal reflux disease (GERD) was diagnosed and fundoplication was performed, which relieved the symptoms. This paper explores the effect of fundoplication on GERD-related respiratory symptoms. From January 2007 to October 2008, 64 patients with respiratory symptoms related to GERD were consecutively enrolled for laparoscopic fundoplication. Of these, 60 patients had respiratory symptoms mainly combined with gastroesophageal reflux, while four had respiratory symptoms only. All patients had GERD confirmed, and medical treatment provided before surgery resulted in an insufficiently favorable effect or even producing further complications. All the patients were requested to fill a questionnaire form regarding the severity of symptoms and their medication so as to make an evaluation score for the follow-up. The outcome of respiratory symptoms after surgery was as follows: excellent in 23 cases (35.9%); good in 28 (43.8%); fair in 5 (7.8%); poor in 8 (12.5%). The mean respiratory symptom score decreased from 6.3±2.65 to 2.33±2.37. Laparoscopic fundoplication can be an effective treatment for the majority of patients with GERD-related respiratory symptoms.

Outcomes of surgical treatment of intrathoracic stomach

The purpose of this study is to assess the long-term outcomes after surgical repair of intrathoracic stomach. Prospectively collected data was retrospectively reviewed. Patients underwent a phone questionnaire 1 year postoperatively to assess gastroesophageal reflux disease-related symptoms and surgical satisfaction. In addition, objective evaluation for integrity of hiatal hernia repair was undertaken either by esophagram or endoscopy. Any recurrence was considered a failure. Forty-one patients underwent surgical repair of a large paraesophageal hernia with intrathoracic stomach during the study period. Thirty-four patients underwent a laparoscopic repair, and seven patients underwent a transthoracic repair. An antireflux procedure was performed on 28 patients, and 13 patients had only hernia reduction and hiatal closure. In the laparoscopic group, two patients required conversion to open laparotomy, as one was unable to tolerate the pneumoperitoneum, and the other had mediastinal bleeding. Thirty-eight (93%) were available for 1-year follow-up. There were three (7.8%) recurrences, one requiring emergency transabdominal repair, and the other two being asymptomatic 1-cm recurrences. All patients report a high degree of satisfaction with surgery. There is a high incidence of short esophagus in patients with intrathoracic stomach. The surgical repair is safe and durable, with high patient satisfaction at 1-year follow-up.