Improvement In Reflux Symptoms Research Articles

BN SO25 - Laparoscopic Management of Achalasia and Iatrogenic Mucosal Perforation in a Patient with Severe Reflux Following Multiple Therapeutic Dilatations

Abstract Background Laparoscopic Heller's cardiomyotomy (LHC) is the gold standard intervention for achalasia. Owing to its well-established complications of reflux symptoms, some surgeons perform an additional fundoplication surgery, although the consensus regarding the clinical benefits of this approach remains unclear.1 A meta-analysis showed that posterior fundoplication has proven to be superior to anterior fundoplication in controlling reflux symptoms.2 Method A gentleman in his 60s reported ongoing severe reflux symptoms following multiple Rigiflex ballon dilatations for achalasia, on manometry and pH studies showed features of pathological acid reflux, incomplete lower oesophageal sphincter relaxation and defective peristalsis. As shown in the video, type 1 sliding hiatus hernia, submucosal fibrosis and peri-oesophagitis were seen intraoperatively. A short cardiomyotomy was performed, which was complicated by iatrogenic oesophageal perforation. Anterior fundoplication with mucosal closure was performed. Results Following the surgery, no leak was observed on the swallow test and the patient reported a massive improvement in reflux symptoms. The addition of fundoplication to LHC in patients with achalasia and reflux symptoms has improved clinical outcomes. Conclusion Concomitant LHC and anti-reflux surgery should be considered in patients presenting with achalasia and gastro-oesophageal reflux symptoms.

Subjective Improvement of Reflux Symptoms After Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass and Concomitant Repair of Hiatal Hernia

BackgroundSymptoms of reflux after SG are common and may be refractory to medical treatment. ObjectivesTo assess outcomes of conversion of SG to RYGB with concomitant repair of hiatal hernias on symptoms of reflux. SettingTertiary Community Hospital MethodsWe reviewed data from all consecutive patients (2018-21) who underwent conversion from SG to RYGB for refractory reflux symptoms. Concomitant hiatal hernias were diagnosed endoscopically or radiographically. Improvement in reflux symptoms, nausea, vomiting, dysphagia, or abdominal pain and post-op PPI use were compared with McNemar statistical test. Data are mean± standard deviation. Results64 patients (92% female; 48±10 years) underwent conversion from SG to RYGB and repair of concomitant hiatal hernias 4±3 years after the index SG. A hiatal hernia was detected preoperatively in 57/64 patients (89%) by either UGI, CT scan or EGD.At 29±14 months post-conversion to RYGB, TBWL was 14±9%, EWL was 37±29%, BMI decreased from 37±7 to 32±6 Kg/m2. Symptoms of reflux and use of PPI improved during the early follow up period (median: 14 months; p<0.001) and was sustained at late follow up (median: 32 months; p<0.01). Improvement of nausea and dysphagia reached statistical significance at late follow up (median: 32 months; p<0.01). Vomiting and abdominal pain decreased with time but did not reach statistical significance.Post-op complications were deep surgical site infection (n=3), pulmonary embolism (n=1), bleeding (n=5), reoperation (n=3), and 30-day readmission (n=6). ConclusionsConversion of SG to RYGB and repair of concomitant hiatal hernia improves reflux symptoms, nausea, and dysphagia, reduces PPI use, and confers additional weight loss.

Effectiveness of Omeprazole in Acid Peptic Disease: A Real-World, Patient-Reported Outcome Measures Study.

Objectives This prospective study assessed the effectiveness and patient satisfaction of four-week omeprazole therapy in acid peptic disease (APD). Methods This was an observational, post-marketing, real-world evidence, patient-reported outcome(PRO) measures study. Patients visiting the five study sites across India with symptoms ofAPD, andwho were prescribed oral omeprazole (20/40 mg per day) for at least four weeks were enrolled after obtaining informed consent. Study assessments includedfrequency and severity of symptoms and overall satisfaction reported by the patients using the Patient Assessment of Gastrointestinal Disorder Symptom Severity Index (PAGI-SYM) questionnaire. The satisfaction with therapy was reported by the patients using the Treatment Satisfaction Questionnaire for Medication (TSQM) questionnaire. Both PAGI-SYM and TSQM were reported by patients on days 14 and 28. Omeprazole safety was assessed based on the adverse events reported by the patients. Results A total of 96 (62 males and34 females) patients were included in the study, of which 38.54% had significant findings related to APD at baseline.The proportion of patients with symptoms reduced to 16.67% on day 14and 8.33% on day 28 with omeprazole therapy. The PAGI-SYM total scores at baseline were 41.32 (15.487), which reduced to 20.86 (11.620) on day 14 (p < 0.0001), and to 8.93 (8.361) on day 28 (p < 0.0001). Significant reductions were also seen in individual symptom scores. The TSQM total scores increased to 36.67 (range: 13 to 63) on day 28 from 34.69 (range: 12 to 58) on day 14. Improvement in scores for all domains of TSQM (effectiveness, convenience, and global satisfaction) was seen on day 28. Improvement in reflux symptoms was reported by 46.74% and 68.48% of patients on day 14 and day 28, respectively. Four (4.17%) patients reported adverse events, which were of mild severity and were unrelated to omeprazole. Conclusions Omeprazole provides significant improvement in PAGI-SYM and TSQM questionnaires on day 14 and day 28.Patients reported the omeprazole-based therapy as effective, convenient, and satisfactory. Omeprazole therapy is safe and effective for the treatment of APD and shows good improvement in APD in patients suffering from duodenal ulcers, gastric ulcers, and reflux oesophagitis.

156. ANTI-REFLUX RADIOFREQUENCY THERAPY USING STRETTA FOR REFRACTORY GORD IS FEASIBLE AND REDUCES THE NEED FOR MINIMALLY INVASIVE SURGERY

Abstract Radiofrequency (RF) therapy of the lower oesophageal sphincter using STRETTA strengthens the reflux barrier across the gastro-oesophageal junction. Numerous studies have shown improvement in reflux symptoms, reduction in proton pump inhibitor (PPI) dependence and need for surgical treatment for gastro-oesophageal reflux disease (GORD). We present the largest series from Europe, and aim to assess long term outcomes of STRETTA for patients with medically refractory GORD. Data for all patients who underwent STRETTA from October 2014 till April 2021 were prospectively maintained on a database and was analysed retrospectively. Patients and primary care doctor practices were contacted to obtain information on PPI free period (PFP) after STRETTA therapy, which was defined as the time between STRETTA and recommencement of prescribed and daily consumption of PPI medication. As required medication use was not considered for PFP calculation. Statistical analysis and graphical presentation were carried out using Minitab® and GraphPad Prism®. Mann–Whitney test was used to compare two sets of non-parametric data and a p &amp;lt; 0.05 was considered significant. From 195 patients (median age 55, 116 females (59%)) who underwent STRETTA, PFP data were available for 144 (74%) patients. Sixty-six patients (45%) remained without PPI after a median follow-up of 4.5 years (52 months). Six patients (3%) went on to have a further intervention. There was a significant negative correlation between PFP and age (p = 0.023) with no differences between the genders (p = 0.90). Patients &amp;lt;55 years had a longer PFP than &amp;gt;55 years (p = 0.012). Younger males had a significantly longer PFP than older males (0.03). However, this was not observed in the female cohort (p = 0.14). Our findings suggest STRETTA as a safe and feasible option for treating medically refractory GORD, especially in younger patients. STRETTA does reduce the need for long term PPI and lessens the frequency of further interventions such as surgery. Further studies are required to investigate the mechanisms by which STRETTA is beneficial in the younger patient.

Laparoscopic magnetic sphincter augmentation device placement for patients with medically-refractory gastroesophageal reflux after sleeve gastrectomy.

The use of the magnetic sphincter augmentation (MSA) in patients with de novo or persistent gastroesophageal reflux disease (GERD) after sleeve gastrectomy has not been thoroughly investigated. The aim of this study is to evaluate the efficacy of MSA device placement in improving GERD symptoms and reducing anti-reflux medication usage in patients with persistent or de novo GERD after sleeve gastrectomy. This is a retrospective analysis of patients who underwent laparoscopic MSA device placement between January 2018 and July 2020 after sleeve gastrectomy. A total of twenty-two patients met inclusion criteria. Twenty patients were female (91%) and two patients were male (9%). All patients were taking anti-reflux medications daily to control GERD symptoms prior to MSA device placement. There was a significant improvement in the mean GERD-HRQL survey scores when comparing scores prior to (43.8) and after (16.7) MSA device placement (p < 0.0001). Majority of the patients did well without any post-operative complications (77%). Nearly 82% of patients were no longer taking any anti-acid medications after MSA device placement (p < 0.0485). There were no patients that required MSA device removals. There were no adverse events such as MSA device erosions or device-related mortalities. MSA device placement in patients with medically refractory GERD after sleeve gastrectomy is a safe and viable alternative to Roux-en-Y gastric bypass without conferring additional risks. We show an improvement in reflux symptoms after MSA device placement as evidenced by decreased post-operative GERD-HRQL scores, decreased anti-acid medication usage, and overall patient satisfaction with the procedure. Further prospective and comparative studies with longer term follow-up are needed to validate the use of MSA in patients who have undergone sleeve gastrectomy.

Effect of continuous positive airway pressure on gastroesophageal reflux in patients withobstructive sleep apnea: a meta-analysis.

Gastroesophageal reflux disease (GERD) often occurs inpatients with obstructive sleep apnea (OSA). Although continuous positive airway pressure (CPAP) is considered to be the preferred treatment for OSA, the effectof CPAP therapy on reflux events remains controversial. In this study, we utilized meta-analysis to investigate whether or notCPAP treatment reduces the incidence of reflux. Two independent reviewers obtained the data sources from the database of PubMed, Elsevier, Cochrane library, and CNKIusing search terms, and then filtered the target articles based on the inclusion and exclusion criteria. RevMan (version 5.3) and STATA (version 12.0) were used for data synthesis. The effect of CPAP treatment on GERD was studied by calculating the weighted mean difference (WMD) and standard deviation (SD) before and after CPAP treatment. Ten studies involving a total of 272 participants were included in this study. The results showed that the total of WMD before and after CPAP was - 17.68 (95% CI - 30.67 to - 4.69) for percentage time pH < 4, - 24.66 (95% CI - 36.15 to - 13.18) for the longest reflux duration, - 27.53 (95% CI - 49.53 to - 5.52) for number of reflux events, - 49.76 (95% CI - 60.18 to - 39.35) for DeMeester score, - 1.85 (95% CI - 3.00 to - 0.71) for reflux diseases questionnaire (RDQ) score, and - 8.95 (95% CI - 16.00 to - 1.89) for reflux symptom index (RSI). The subgroup analysis demonstrated that the improvement of reflux symptoms was more obvious with the extension of treatment time. This meta-analysis showed that CPAP treatment significantly reduces the incidence of reflux events inpatients with OSA.

Efficacy of a high-dose proton pump inhibitor in patients with gastroesophageal reflux disease: a single center, randomized, open-label trial

BackgroundThe extraesophageal manifestations of gastroesophageal reflux disease (GERD) are more difficult to manage than the typical symptoms. The efficacy of high-dose and standard-dose proton pump inhibitors against these atypical symptoms is not yet established.MethodsIn this single center, randomized, open-label study, patients with GERD received rabeprazole for 8 weeks, either 20 mg once daily (standard-dose group) or 20 mg twice daily (high-dose group). Patients were assessed before treatment and at weeks 4 and 8 with a 5-graded scale questionnaire consisting of 2 typical symptoms (heartburn and acid regurgitation) and 8 atypical symptoms (chest pain, cough, globus, wheezing, laryngopharyngitis, hoarseness, belching, and dysphagia). Sufficient improvement of reflux symptoms was defined as ≥50% reduction from the initial questionnaire score.ResultsFinal analyses included 35 patients in the standard-dose group and 38 patients in the high-dose group. The rate of sufficient improvement for typical symptoms was significantly higher in the high-dose group than in the standard-dose group (100.0% vs. 84.0%, P = 0.040). For atypical symptoms, the rate of sufficient improvement tended to be higher in the high-dose group than in the standard-dose group (82.4% vs. 63.0%, P = 0.087). Scores of typical and some atypical symptoms (cough and globus) improved after treatment, with significant inter-group differences in time-course changes.ConclusionsHigh-dose rabeprazole is more effective for relieving typical GERD symptoms and some atypical symptoms such as cough and globus than a standard-dose regimen.Trial registrationThis research was enrolled in a registry of clinical trials run by United States National Library of Medicine at the National Institutes of Health (ClinicalTrials.gov Protocol Registration and Results system ID: NCT04001400). This study was registered on June 26, 2019 - Retrospectively registered.

2201 Innovative Endoscopic Management of a Bariatric Surgery Complication

INTRODUCTION: Vertical Banded gastroplasty (VBG) is a purely restrictive bariatric surgery that was the predominant weight loss procedure in the 1980s. The following case describes a well-known complication of VBG that was managed with an innovative endoscopic technique. CASE DESCRIPTION/METHODS: A 56-year-old lady with a history of open VBG 18 years ago presented with several years of recurrent vomiting, heartburn, and excessive weight loss. An upper GI series revealed a large distend proximal gastric pouch above the mesh with severe stasis that produced a mass effect and resultant compression of the rest of the stomach. She was offered a conversion to Roux en y gastric bypass, however she declined. She was subsequently referred to a GI for further evaluation and potential endoscopic intervention. An Upper GI endoscopy was performed, which revealed mild esophagitis, evidence of vertical banded gastroplasty, and gastric pouch distention with copious amount of food debris. The lumen through the band was identified and was noted to be very narrowed and was not easily traversable with the upper endoscope. Therefore, a decision was made to perform an EUS guided gastro-gastrostomy with placement of a lumen opposing metal stent. The distal pouch was punctured under EUS guidance and a 15 × 10 mm AXIOS Stent was deployed adjacent to the previously placed band, creating a larger lumen for food content to pass. The stent was serially dilated to 18 mm using a through the scope (TTS) dilator. Contrast injected proximally was seen to flow freely from the gastric pouch into the antrum and the duodenum through the stent. Patient had an uneventful post-procedure course and was discharged the next day. She later reported significant improvement in reflux symptoms, gained 15 pounds, and was more than elated. DISCUSSION: VBG quickly gained popularity in the 1980s because it was the only bariatric surgery that did not have malabsorptive side effects. Over time, however, patients began experiencing post procedural nausea, vomiting, and heartburn from pouch dilatation, band erosion, staple line disruption, marginal ulceration, and is now rarely used as a bariatric surgical option. The versatility of endoscopic stents have made them useful in the management of many bariatric surgical complications, including fistulas, leaks, obstructions, strictures, and stenoses. To our knowledge, this was the first case of severely symptomatic pouch dilatation following VBG that was successfully managed endoscopically.

Efficacy and safety of standard and anti-reflux self-expanding metal stent: A Systematic review and meta-analysis of randomized controlled trials

BACKGROUNDSelf-expanding metal stents are the main palliative treatment modality for unresectable esophageal cancer. Gastroesophageal reflux is a common adverse outcome after placement of esophageal stent for cancer involving the gastroesophageal junction and the gastric cardia. Anti-reflux stents with valve have been designed to prevent the acid reflux. The superiority of anti-reflux stent over standard stent in preventing gastroesophageal reflux has not been established well. This study compares the anti-reflux stent and the standard stent in terms of their efficacy to prevent acid reflux.AIMTo compare the standard and the anti-reflux stents in terms of their efficacy, safety, and complications.METHODSThe meta-analysis included 8 randomized clinical trials (RCTs) to compare pooled outcomes of total 395 patients. Primary outcomes include improvement in reflux symptoms and dysphagia score. Secondary outcomes include complications of stent migration, occlusion, and bleeding.RESULTSA total of eight RCTs were included in the meta-analysis. Compared to the standard stent, the anti-reflux stent showed a trend towards reduction in the dysphagia score without reaching a statistical significance [Standardized mean difference (SMD): -0.33 (-0.71, 0.05); P = 0.09, I2: 37%]. There was no statistical difference in the gastrointestinal reflux (GER) scores between the two types of stents [SMD: -0.17 (-0.78, 0.45); P = 0.008, I2: 74%]. Compared to standard stent, anti-reflux stent showed no difference in the risk of stent migration [OR: 1.37 (0.66, 2.83); P = 0.40, I2: 0 %], bleeding [OR: 1.43 (0.40, 5.13); P = 0.59, I2: 0 %], and obstruction [OR: 1.66 (0.60, 4.60); P = 0.33, I2: 0 %].CONCLUSIONTraditional self-expanding standard esophageal stent and anti-reflux stent with valve are similar in terms of outcomes and complications.

Heller Myotomy: To Wrap or Not to Wrap?

Heller myotomy (HM) is widely recognized as the most effective treatment of achalasia. Although effective in improving dysphagia symptoms, HM is associated with reflux. Over a five-year period, 63 laparoscopic HM were performed. Patients underwent myotomy alone or HM plus reconstitution of the angle of His without any fundoplication, anterior, or posterior partial fundoplication. Two postoperative outcomes were examined: dysphagia and reflux. Twenty-two patients received no fundoplication (34.9%). Forty-one (65.1%) antireflux procedures were performed, including 21 reconstitutions of the angle of His (33.3%), nine (14.3%) anterior fundoplications, and 11 (17.5%) posterior fundoplications. All patients demonstrated preoperative dysphagia. Postoperative dysphagia was present in 23 of 63 (36.5%). Of these, 13 (56.5%) patients had an antireflux procedure, whereas 28 of 40 who had an antireflux procedure (70%) had no postoperative dysphagia (P = 0.28). Thirty-nine of 62 (62.9%) had symptomatic esophageal reflux preoperatively, and postoperative reflux was reported in 22 of 63 (34.9%). Reflux was present in 72.7 per cent of patients who had an antireflux procedure versus 61 per cent of those without the addition of an antireflux procedure (P = 0.415). However, HM independently improved reflux status regardless of whether an antireflux procedure was performed using the exact McNemar's test (P = 0.0014). Although the performance of an antireflux procedure did not appear to alter the reflux status after HM for achalasia, neither was it associated with postoperative dysphagia. More importantly, HM was independently associated with an improvement of reflux symptoms regardless of the type of antireflux procedure performed or whether one was used or not.

Laparoscopic redo fundoplication improves disease-specific and global quality of life following failed laparoscopic or open fundoplication.

Laparoscopic fundoplication is associated with failure rates of up to 30% and redo operation rates of 5-8%. Redo fundoplication improves patient symptoms, but its impact on patient quality of life remains unclear. We hypothesized that laparoscopic redo fundoplication improves disease-specific and global quality of life in patients with recurrent symptoms following failed laparoscopic or open fundoplication. Data for all patients undergoing a redo fundoplication between August 2009 and June 2014 were collected prospectively. Reflux symptoms and quality of life were assessed using the Gastroesophageal Reflux Symptom Scale (GERSS), the Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL), and the global quality of life Short Form-36 (SF-36) questionnaires obtained at 4weeks and 16months post-operatively. Forty-six patients underwent laparoscopic redo fundoplication during the study period for symptomatic hernia (n=11), GERD (n=18), or dysphagia (n=17). GERSS improved from 41 at baseline to 9 at late follow-up (p<0.001), and GERD-HRQL scores improved from 30 at baseline to 7 at late follow-up (p<0.001). Median dysphagia scores decreased from 4.5 to 1 (p=0.035). SF-36 scores demonstrated a significant improvement in general health (p=0.016) and emotional well-being (p=0.036) and a trend toward improved physical function (p=0.068) in the post-operative period, but these improvements were not statistically significant at longer-term follow-up. Overall, 82% of patients reported satisfaction with their operation, and 96% reported that they would have the operation performed again given the benefit of hindsight. While associated with long operative times and significant complications, laparoscopic redo fundoplication produces a durable improvement in reflux symptoms and disease-specific quality of life. These procedures also improve global quality of life in the short term and are associated with high patient satisfaction.

Demography and treatment response in patients with predominant non-erosive reflux disease or functional dyspepsia.

Non-erosive reflux disease (NERD) and functional dyspepsia (FD) share some common features, and the appropriateness of managing these diseases independently has been questioned. A post-hoc subgroup analysis of the LEGEND study was performed to compare demographics and treatment response between patients with NERD and patients with FD. Patients with reflux and dyspepsia symptoms who had no endoscopic evidence of mucosal breaks and/or erosions were included and divided into groups with predominant NERD (n = 1546) or FD (n = 614). Patients received lansoprazole for 4 weeks, and their symptoms were evaluated using questionnaires. FD patients were significantly younger than NERD patients (54 vs 60 years), more likely to have a body mass index < 25 kg/m(2) (72.4% vs 67.1%), less likely to have a hiatal hernia (24.0% vs 31.2%), and more likely to feel continuous stress (54.7% vs 48.0%). After 4 weeks of treatment, > 60% of both patients reported an improvement in reflux symptoms and in most dyspepsia symptoms. The improvement rate for reflux symptoms was lower in FD patients than in NERD patients (P < 0.05), whereas the improvement rate for dyspepsia symptoms did not differ between patient groups. Although no clinically significant differences in pathophysiology exist between NERD and FD, there are some between-group differences in demographic characteristics and improvement rates for reflux symptoms after treatment with lansoprazole. It remains to be discussed whether it is necessary to make a strict differential diagnosis between these two conditions.

Laparoscopic adjustable gastric banding outcomes in patients with gastroesophageal reflux disease or hiatal hernia.

Gastroesophageal reflux disease (GERD) and hiatal hernia (HH) are classically considered contraindications to bariatric restrictive procedures. Despite the high number of studies that have been published, the relationship between laparoscopic adjustable gastric banding (LAGB) and GERD/HH is still not clear. We have retrospectively analyzed the outcomes of LAGB in patients operated in 2010 with HH and/or GERD. The gastroesophageal reflux was diagnosed if the patients had heartburn and regurgitation more than once a week, and hiatal hernia was assessed by esophagogastroduodenoscopy and/or upper GI radiogram with swallow. Data on heartburn, assumption of antacid medication, weight loss, and rate of complications in both patients with and without GERD or HH were collected. One hundred and twenty patients that underwent LAGB at our department were enrolled in our study; 40 had symptoms of GERD and 25 had hiatal hernia preoperatively. There was no difference of percentage excess weight loss (%EWL) at 12 months (45.4 ± 20.4 vs 4.6 ± 19.5 kg/m(2)) and 36 months follow-up (49.4 ± 16.5 vs 48.6 ± 18.9 kg/m(2)) between asymptomatic patients and patients with HH or GERD symptoms. The number of patients with preoperative heartburn (40 to 10) and/or assumption of antacid drugs (38 to 7) significantly decreased after LAGB CONCLUSIONS: LAGB is an effective and safe surgical treatment for morbidly obesity in patients with GERD or HH, since it induces both a significant weight loss and an improvement of reflux symptoms.

S33 Does anti-reflux surgery symptomatically improve extra-oesophageal symptoms and quality of life in gastro-oesophageal reflux disease

IntroductionExtra-oesophageal (ie laryngeal, pharyngeal and pulmonary) symptoms of gastro-oesophageal reflux (GOR) are common clinical problems. GOR can cause a chronic cough and its prevalence is higher in asthmatics than in...

Radiofrequency Energy Delivery to the Lower Esophageal Sphincter Reduces Esophageal Acid Exposure and Improves GERD Symptoms

Studies of endoscopic application of radiofrequency energy to the lower esophageal sphincter for gastroesophageal reflux control have produced conflicting reports of its effectiveness. This study aimed to conduct a meta-analysis of randomized controlled trials and cohort studies to assess the impact of this treatment. Twenty studies were included. Outcomes analyzed included gastroesophageal reflux disease (GERD) symptom assessment, quality of life, esophageal pH, and esophageal manometry. A total of 1441 patients from 18 studies were included. Radiofrequency treatment improved heartburn scores (P=0.001), and produced improvements in quality of life as measured by GERD-health-related quality-of-life scale (P=0.001) and quality of life in reflux and dyspepsia score (P=0.001). Esophageal acid exposure decreased from a preprocedure Johnson-DeMeester score of 44.4 to 28.5 (P=0.007). Radiofrequency ablation of the lower esophageal sphincter produces significant improvement in reflux symptoms and may represent an alternative to medical treatment and surgical fundoplication in select patients.

Gastroesophageal Reflux Symptoms in Patients With Celiac Disease and the Effects of a Gluten-Free Diet

Celiac disease (CD) patients often complain of symptoms consistent with gastroesophageal reflux disease (GERD). We aimed to assess the prevalence of GERD symptoms at diagnosis and to determine the impact of the gluten-free diet (GFD). We evaluated 133 adult CD patients at diagnosis and 70 healthy controls. Fifty-three patients completed questionnaires every 3 months during the first year and more than 4 years after diagnosis. GERD symptoms were evaluated using a subdimension of the Gastrointestinal Symptoms Rating Scale for heartburn and regurgitation domains. At diagnosis, celiac patients had a significantly higher reflux symptom mean score than healthy controls (P < .001). At baseline, 30.1% of CD patients had moderate to severe GERD (score >3) compared with 5.7% of controls (P < .01). Moderate to severe symptoms were significantly associated with the classical clinical presentation of CD (35.0%) compared with atypical/silent cases (15.2%; P < .03). A rapid improvement was evidenced at 3 months after initial treatment with a GFD (P < .0001) with reflux scores comparable to healthy controls from this time point onward. GERD symptoms are common in classically symptomatic untreated CD patients. The GFD is associated with a rapid and persistent improvement in reflux symptoms that resembles the healthy population.

Effects of adjustable gastric banding on gastroesophageal reflux and esophageal motility: a systematic review

Controversial opinions exist concerning the effect of laparoscopic adjustable gastric banding on gastroesophageal reflux. MEDLINE and EMBASE databases were searched for relevant studies on patients undergoing adjustable gastric banding. Data are expressed in mean (range). Twenty studies were identified with a total of 3307 patients. The prevalence of reflux symptoms decreased postoperatively from 32.9% (16-57) to 7.7% (0-26.9) and medication use from 27.5% (16-38.5) to 9.5% (3.1-19.2). Newly developed reflux symptoms were found in 15% (6.1-20) of the patients. The percentage of esophagitis decreased postoperatively from 33.3% (19.4-61.6) to 27% (2.3-60.8). Newly developed esophagitis was observed in 22.9% (0-38.4). Pathological reflux was found in 55.8% (34.9-77.4) preoperatively and postoperatively in 29.4% (0-41.7) of the patients. Lower esophageal sphincter pressures increased from 12.9 to 16.9 mmHg (11.3-21.4). Lower esophageal sphincter relaxation decreased from 100% to 79.7% (58-86). The percentage of dysmotility increased from 3.5% (0-10) to 12.6% (0-25). Adjustable gastric banding has anti-reflux properties resulting in resolution or improvement of reflux symptoms, normalized pH monitoring results and a decrease of esophagitis on short term. However, worsening or newly developed reflux symptoms and esophagitis are found in a subset of patients during longer follow-up.

M1913 A Randomized, Comparative Trial of the Speed of Onset of Symptom Relief of Gastroesophageal Reflux Disease By the Proton Pump Inhibitors: Rabeprazole vs Lansoprazole vs Omeprazole

vantaged SES. Univariate analyses did not show associations of lifestyle factors (BMI, smoking, alcohol, marital status) and change in SSS. However, employment status was associated with improvement of SSS (p=.029). In Multiple Linear Regression the set of possible predictors did not explain a significant proportion of differences in symptom severity (p=.099) only SES & employment status were significant. Employed status was associated with less improvement in SSS (2.6 pts < unemployed; p=.008) as was average SES compared to advantaged (3.6 pts < advantaged SES; p=.021). CONCLUSIONS: a) The improvement in reflux symptoms after diagnostic work-up and initiation of therapy in a routine clinical setting can be partly explained by sociodemographic factors b) Paradoxically, advantaged SES and unemployment are each associated with greater improvement of reflux symptoms.

Effect of Roux-en-Y gastric bypass in obese patients with Barrett’s esophagus: attempts to eliminate duodenogastric reflux

To assess the effect of Roux-en-Y gastric bypass (RYGB) at a tertiary referral Center of Excellence for bariatric surgery on the length and presence of dysplasia in morbidly obese patients with Barrett's esophagus (BE). Esophageal reflux of gastroduodenal contents (acid, bile) contributes to the development of BE and progression in the dysplasia-carcinoma sequence. Obese patients have a high prevalence of gastroesophageal reflux and might be at an increased risk of developing BE and esophageal adenocarcinoma. The effect of eliminating duodenogastroesophageal reflux on BE is not known. We performed a retrospective review of all patients with pre-existing, biopsy-proven, long-segment (>3 cm) BE undergoing RYGB at our institution. Only patients with >1 year of endoscopic, biopsy-controlled follow-up (mean 34 mo) were included. Five patients (3 men and 2 women) were identified. The mean +/- standard error of the mean preoperative length of BE was 6 +/- 2 cm; 2 patients had low-grade dysplasia and 1 indeterminate dysplasia. At the postoperative follow-up (>1 yr) examinations, the length of BE had decreased in 4 patients; the overall length was 2 +/- 1 cm; and only 1 patient had dysplasia. All patients experienced a decrease in the length of BE (n = 4), complete disappearance of BE (n = 2), or improvement in the degree of dysplasia (n = 3). The body mass index had decreased from 43 +/- 4 kg/m(2) to 33 +/- 3 kg/m(2), and all experienced subjective improvement in reflux symptoms postoperatively. RYGB resulted in complete or partial regression of BE in 4 of 5 patients and improvement in reflux symptoms in all. Our results suggest that RYGB might be the procedure of choice in morbidly obese patients with BE requiring surgical treatment for gastroesophageal reflux disease.

OPTIMIZATION OF OUTCOME AFTER LAPAROSCOPIC ANTIREFLUX SURGERY

Laparoscopic fundoplication has emerged as an effective treatment for gastro-oesophageal reflux disease. The majority of patients who have undergone antireflux surgery report an improvement in reflux symptoms and in quality of life. However, some patients are dissatisfied with the outcome of antireflux surgery, and attempts have been made by surgeons to improve the results of this surgery. Careful case selection based on objective evidence of acid reflux, refinement of the surgical technique and 'tailoring' the wrap to suit the patient by selective use of a partial fundoplication may help to optimize the outcome from laparoscopic antireflux surgery.