Lower Esophageal Sphincter Function Research Articles

Comparing Pre- and Post-Operative Findings in Patients Who Underwent Laparoscopic Proximal Gastrectomy With a Double-Flap Technique: A Study on High-Resolution Manometry, Impedance pH Monitoring, and Esophagogastroduodenoscopy Findings.

Laparoscopic proximal gastrectomy (LPG) is a viable choice for treating proximal gastric lesions. However, the occurrence of severe reflux has limited its widespread adoption. To address this issue, the double flap technique (DFT), which incorporates artificial lower esophageal sphincteroplasty, has been developed to prevent reflux problems after proximal gastrectomy. In this study, we aimed to investigate the usefulness of this technique using high-resolution manometry (HRM), impedance pH monitoring, and esophagogastroduodenoscopy (EGD). The findings of pre- and postoperative 6-month HRM, pH monitoring, and EGD were compared for 9 patients who underwent LPG with DFT for various proximal gastric lesions at Incheon St. Mary's Hospital from January 2021 to December. A total of 9 patients underwent proximal gastrectomy. Approximately half of the patients had Hill's grade under II preoperatively, whereas all patients had Hill's grades I and II in EGD findings. In the HRM test, there was no significant difference between distal contractile integral (1,412.46±1,168.51 vs. 852.66±495.62 mmHg·cm·s, P=0.087) and integrated relaxation pressure (12.54±8.97 vs. 8.33±11.30 mmHg, P=0.27). The average lower esophageal sphincter (LES) pressure was 29.19±14.51 mmHg preoperatively, which did not differ from 19.97±18.03 mmHg after the surgery (P=0.17). DeMeester score (7.02±6.36 vs. 21.92±36.17, P=0.21) and total acid exposure time (1.49±1.48 vs. 5.61±10.17, P=0.24) were slightly higher, but the differences were not statistically significant. There is no significant functional difference in HRM and impedance pH monitoring tests after DFT. DFT appears to be useful in preserving LES function following proximal gastrectomy.

Esophageal Infusion of Menthol Does Not Affect Esophageal Motility in Patients with Gastroesophageal Reflux Disease.

Menthol is thought to trigger gastroesophageal reflux disease (GERD) symptoms by influencing esophageal peristalsis and lower esophageal sphincter (LES) function. We evaluated the effect of esophageal menthol infusion on esophageal motility and the LES in healthy volunteers and in patients with GERD. High resolution manometry (HRM) catheter with attached thin tube for menthol infusion was placed transnasally. Protocol which included baseline recording, 16 water swallows (5ml, 10ml, and 15ml) and the multiple rapid swallows was performed before and after esophageal infusion of menthol (3mM, 20min, 8ml/min). We evaluated the effect of this infusion on the HRM parameters of esophageal peristalsis (distal contractile integral, distal latency, contractile front velocity) and the lower esophageal sphincter (LES) barrier function (integrated relaxation pressure and the inspiratory augmentation of the LES). Simultaneously we evaluated the quality and intensity of the symptoms during the menthol infusion. Esophageal infusion of menthol did not appreciably affect HRM measurements characterizing esophageal peristalsis and LES pressure in healthy subjects (N = 13) or GERD patients (N = 11). The magnitude of the distal contractile integral (5ml) was changed neither in the healthy volunteers' group, (735 ± 127 vs. 814 ± 117mmHg, p = 0.5), nor in the GERD patients (295 ± 78 vs. 338 ± 96mmHg, p = 0.99). In healthy volunteers menthol did not change the inspiratory augmentation of the LES (8.67 ± 1.09 vs. 7.69 ± 0.96mmHg, p = 0.15) and neither did for GERD patients (8.8 ± 1.18 vs. 8.22 ± 0.91mmHg, p = 0.43). We observed no significant difference in any HRM parameter following menthol infusion, except for distal latency in 10ml swallows. By contrast, menthol infusion induced significantly more intense discomfort in GERD patient than in healthy volunteers. Our results suggest no significant temporal effect of menthol on the esophageal motility or LES function, neither in healthy volunteers, nor in GERD. Arguably, other mechanisms are responsible for menthol-related heartburn.

Comparative Study of Reflux Esophagitis as a Complication between Mini-Gastric Bypass vs Sleeve Gastrectomy

Abstract Background All currently commonly performed bariatric operations involve manipulation and alteration of gastroesophageal anatomy, resulting in change of multiple physiologic parameters, such as gastric emptying and even the function of the lower esophageal sphincter (LES) itself. Reflux control involves a complex interplay of LES function, esophageal function, and gastric emptying. While all 3 can be affected by any foregut procedure, LES function and gastric emptying are most directly altered in bariatric surgery Aim and Objectives was for discussing the post-operative reflux esophagitis in both Mini gastric bypass & sleeve gastrectomy in the Treatment of Morbid Obesity. Subjects and Methods This prospective comparative study was carried out at ASU Hospital (El-Demerdash Hospital), Al Haram Hospital & other authorized hospitals between July 2017 and March 2019 and ethically approved. The study involved 40 Patients who were targeted to be recruited & randomly ordered to receive either Group 1 (MGBP (n = 20) or Group 2 Results After 6 months of follow up, we found that reflux esophagitis symptoms remained postoperatively among patients who performed SG operation compared to the MGB group (15% vs 5%). This was statistically insignificant (p = 0.737). Although the resolve rate was higher in the SG group compared to the MGB group (15% vs 5%), this was statistically insignificant (p = 0.605). Conclusion LSG and LMGB are both safe and effective procedures for the surgical management of morbid obesity. Bleeding and leakage are the most common and most serious complications in both procedures. The incidence of complications between both procedures is not significantly different.

Herbal Combination 'HAGE-101912' Ameliorates Gastroesophageal Reflux Disease in Rats.

Gastroesophageal reflux disease (GERD) is a chronic, relapsing disorder. In this era of modern and fast-track lifestyle and food habits, the incidence of GERD is rapidly increasing. Currently, proton pump inhibitors (PPIs) are the primary choice of treatment. However, the associated side effects and a high relapse rate give rise to the need to explore alternative therapies. The study aimed to evaluate HAGE-101912, an herbal combination, in different experimental models of GERD. Antacid activity was assessed based on H+/K+ATPase inhibitory activity of parietal cells using artificial gastric juice. Tonic contraction of the lower esophageal sphincter (LES) was evaluated using an AD Instrument. A GERD model of the pylorus and fundus ligation (preventive and curative models) in rats was selected to assess the efficacy of HAGE-101912 at a dose of 250 mg/kg body weight, and various parameters such as the gastric pH, gastric volume, total acidity, gross esophageal ulcer index, and histopathological changes were evaluated. The prokinetic activity was assessed using the phenol red method. HAGE-101912 increased the acid-neutralizing capacity (P < 0.001), decreased H+/K+ATPase activity (P < 0.01), and increased the contraction of the LES. In the preventive model, HAGE-101912 significantly reduced the gastric acid volume (P < 0.01), total acidity (P < 0.001), and gross esophageal ulcer index (P < 0.01); increased the gastric acid pH (P < 0.01); and protected the esophageal epithelium. In addition, HAGE-101912 increased gastric emptying and gastrointestinal transit through its prokinetic activity (P < 0.05). HAGE-101912 has a beneficial effect in GERD as it effectively inhibits the H+/K+ATPase, increases the gastric pH, restores the LES function, protects the esophageal epithelium, and increases gastric emptying and transit.

S507 Esophageal Function Assessment Using Endoscopic Functional Luminal Imaging Probe (ENDOFLIP) in Patients With Different Obesity Classes

Introduction: Patients with obesity have been found to have a higher prevalence of esophageal motor disorders compared to the general population, with abnormal lower esophageal sphincter (LES) function and altered peristalsis on manometry. Patients with class 3 obesity can experience minimal symptoms despite abnormal manometry suggesting abnormal visceral sensation. Endoscopic functional luminal imaging probe (EndoFLIP) assesses luminal distensibility and peristalsis during endoscopy. This study aims to evaluate esophageal characteristics using EndoFLIP in patients with obesity and esophageal symptoms and determine clinical differences between obesity classes. Methods: We conducted retrospective chart review of patients with obesity and esophageal symptoms who had undergone EndoFLIP testing at a single tertiary care center between 2020-2022. Data was collected on patient demographics, symptoms, medical history, and EndoFLIP measurements. Statistical analysis was performed using Fisher exact testing. Results: 33 patients with a BMI ≥30 were included (81% women, mean age 50.2 years, mean BMI 39.4). 9 (27%) had class 3 obesity, 9 (27%) class 2 obesity and 15 (45%) class 1 obesity. Most common symptoms were dysphagia (72%), heartburn (48%), reflux (48%), and regurgitation (42%). On EndoFLIP, 8 (24%) had reduced esophagogastric junction distensibility index (EGJ-DI), of which 2 (13%) were classified as obesity class 1, 4 (44%) obesity class 2 and 2 (22%) obesity class 3 (Table). 17 (52%) had normal repetitive antegrade contractions (RACs), 7 (21%) diminished/disordered contractile response (DDCRs) and 9 (27%) absent contractility. Abnormal contractility patterns were seen in 7 (47%) obesity class 1, 4 (44%) obesity class 2 and 5 (56%) obesity class 3. There were no significant differences between obesity classes with regards to medication use, co-morbidities, symptoms, endoscopy and EndoFLIP findings. Conclusion: In this cohort, symptomatic patients in different obesity classes did not have significantly different LES function or peristalsis on EndoFLIP. EGJ distensibility was reduced in a quarter of the study population and seen more frequently in patients with class 2 obesity. Nearly half of the patients had abnormal peristalsis with DDCRs and absent contractility, with similar representation between obesity classes. Prospective controlled studies with EndoFLIP comparing symptomatic and asymptomatic patients in different obesity classes are needed to validate these findings. Table 1. - Comparison of patient characteristics and EndoFLIP findings by obesity class Class 1 Obesity BMI 30-35 (N=15) Class 2 Obesity BMI 35-40 (N=9) Class 3 Obesity BMI >40 (N=9) p-value MEDICATIONS N (%) PPI 8 (53) 6(67) 5 (56) 0.67 H2 blocker 5 (33) 1 (11) 2 (22) Opiods 2 (13) 0 2 (22) Benzodiazepines 0 1 (11) 0 SYMPTOMS N (%) Reflux 6 (40) 6 (67) 4 (44) 0.57 Dysphagia 12 (80) 7 (78) 5 (56) Heartburn 7 (47) 4 (44) 5 (56) Regurgitation 3 (20) 4 (44) 7 (78) Belching/Nausea 2 (13) 1 (11) 1 (11) Epigastric abdominal pain 4 (27) 2 (22) 2 (22) Vomiting 1 (7) 2 (22) 1 (11) EGD FINDINGS N (%) Esophagitis 4 (27) 2 (22) 3 (33) 0.78 Gastritis 8 (53) 4 (44) 5 (56) Fluid in esophagus 1 (7) 2 (22) 3 (33) ENDOFLIP FINDINGS EGJ-distensibility index N (%) [mean] Normal 13 (87) [5.4] 5 (56) [4.65] 7 (78) [4.98] 0.26 Reduced 2 (13) [2.27] 4 (44) [0.91] 2 (22) [2.82] Contractility pattern N (%) RACs 8 (53) 5 (56) 4 (44) 1 DDCRs 3 (20) 2 (22) 2 (22) Absent contractility 4 (27) 2 (22) 3 (33) BMI = Body Mass Index; PPI = Proton pump inhibitor; H2 blocker = histamine 2 blocker (eg. famotidine); EGD = Esophagogastroduodenoscopy; EGJ = Esophagogastric Junction; RACs = Repetitive Antegrade Contractions; DDCRs = Diminished or Disordered Contractile Responses

Association between endoscopic pressure study integrated system (EPSIS) and high-resolution manometry.

Background and study aims The endoscopic pressure study integrated system (EPSIS), a novel diagnostic tool for gastroesophageal reflux disease (GERD), allows evaluation of the anti-reflux barrier using endoscopy by monitoring the intragastric pressure (IGP) during insufflation. In this study, we evaluated the association between EPSIS results and lower esophageal sphincter (LES) function measured by high-resolution manometry (HRM) to elucidate whether EPSIS can evaluate the LES function. Patients and methods A retrospective, single-center study of patients with GERD symptoms who underwent endoscopy, pH-impedance monitoring, EPSIS, and HRM was conducted. The primary outcome was basal LES pressure and the secondary outcomes were end-respiratory LES pressure and integrated relaxation pressure (IRP). As EPSIS parameters, the following were measured: 1) pressure difference (mmHg), the difference between maximum and basal IGP; and 2) pressure gradient (mmHg/s), calculated by dividing pressure difference by the insufflating time. Pressure difference < 4.7 mmHg or pressure gradient < 0.07 mmHg/s was defined as an EPSIS GERD pattern. Results Forty-seven patients (median age: 53 years, 37 female) were analyzed. Pressure difference and pressure gradient significantly correlated with basal LES pressure (ρ = 0.29; P = 0.04 and ρ = 0.29; P = 0.04). Patients with EPSIS GERD pattern showed significantly lower basal LES pressure [13.2 (4.8–26.6) vs 25.3 (10.4–66.7) mmHg, P = 0.002], lower end-respiratory LES pressure [8.5 (1.1–15.9) vs 15.5 (1.9–43.9) mmHg, P = 0.019] and lower IRP [5.9 (1.0–12.0) vs 9.8 (1.3–17.8) mmHg, P = 0.020]. Conclusions This study showed a close association between EPSIS results and LES pressures measured by HRM. This indicates that EPSIS can evaluate the LES function during endoscopy and endorse the role of EPSIS as a diagnostic tool for GERD.

Gastroesophageal reflux disease in patients with morbid obesity

Aim. To study the prevalence and manifestations of gastroesophageal reflux disease (GERD) in patients with morbid obesity based on endoscopic, X-ray findings and the function of the lower esophageal sphincter. Materials and methods. The study involved 98 obese patients with a mean body mass index (BMI) of 55.6 ± 10.3 kg/m2. Of these, 30 were men (34.48 %) and 68 were women (65.52 %) aged 18–64 years, mean age – 42.3 ± 8.5. All the patients subsequently underwent fibroesophagogastroduodenoscopy, esophagomanometry, 24-hour esophageal pH monitoring, X-ray examination and bariatric surgery. The presence and severity of pathological gastroesophageal reflux were assessed using esophageal pH monitoring data based on the DeMeester score. In addition, the lower esophageal sphincter function was assessed, the number of refluxes and the duration of the longest reflux episode were calculated according to the data of esophagomanometry and 24-hour esophageal pH monitoring. Statistical data processing was carried out using the StatPlus 2007 software package. Results. In this paper, we studied the prevalence and manifestations of gastroesophageal reflux in 98 obese patients. The mean BMI was 55.6 ± 10.3 kg/m2, the maximum was 72 kg/m2. GERD was diagnosed in 37 (37.76 %) patients, including 8 (8.16 %) patients with a hiatal hernia. The erosive form prevailed in the GERD pattern – in 24 (24.48 %) patients. In 32 (32.65 %) examined patients, pathological reflux was diagnosed during the daytime, especially after eating. Conclusions. The study results indicate that 37.76 % of obese patients are diagnosed with GERD arising from anatomical features and function of the gastroesophageal junction with the predominance of erosive forms of GERD. The state of the gastroesophageal junction in obese patients should be considered when choosing the optimal bariatric or metabolic surgery.

Impact of Feeding Strategies With Acid Suppression on Esophageal Reflexes in Human Neonates With Gastroesophageal Reflux Disease: A Single-Blinded Randomized Clinical Trial.

INTRODUCTION:Aims were to test hypothesis that esophageal provocation-induced reflexes are superior with acid suppression plus feeding modifications vs acid suppression alone among infants treated for gastroesophageal reflux disease (GERD).METHODS:Infants (N = 49, 41.3 ± 2.6 of postmenstrual age) with acid reflux index >3% underwent longitudinal motility testing (weeks 0 and 5) with graded midesophageal provocation to test randomly allocated therapies (4 weeks' proton pump inhibitor [PPI] ± feeding modifications) on sensory-motor aerodigestive reflexes. Feeding modification included restricted fluid volume <140 mL/kg per day, fed over 30 minutes in right lateral position and supine postprandial position. Primary motility outcome was frequency-occurrence of peristaltic reflex. Secondary outcomes included upper esophageal sphincter contractile reflex, lower esophageal sphincter (LES) relaxation reflex, respiratory change, and symptom characteristics.RESULTS:Treatment groups did not differ for primary outcome (odds ratio = 0.8, 95% confidence interval 0.4–1.6, P = 0.99) or secondary outcomes (all P > 0.05). For both treatment groups at follow-up, distal esophageal contraction and LES tone decreased, and LES relaxation reflex occurrence is less frequent (all P < 0.05). In a subgroup analysis, comparing infants with PPI washout (N = 40) vs with continued (N = 9) PPI therapy, no differences were noted for aerodigestive reflex response frequency-occurrence (all P > 0.05).DISCUSSION:In infants with GERD, feeding modification with acid suppression is not superior to acid suppression alone in modifying aerodigestive reflexes (frequency, sensation, or magnitude). Contiguous areas targeted by GER, i.e., LES and distal esophageal functions, worsened at follow-up for both groups despite PPI therapy. Maturation is likely the key factor for GERD resolution in infants, justifying the use of placebo in clinical trials for objectively determined GERD.

Effects of Lixisenatide Versus Liraglutide (Short- and Long-Acting GLP-1 Receptor Agonists) on Esophageal and Gastric Function in Patients With Type 2 Diabetes

Short-acting glucagon-like peptide 1 receptor agonists (GLP-1 RAs) decelerate gastric emptying more than long-acting GLP-1 RAs. Delayed gastric emptying is a risk factor for gastroesophageal reflux disease. We aimed to measure esophageal reflux and function as well as gastric emptying and acid secretion during treatment with short-acting (lixisenatide) and long-acting (liraglutide) GLP-1 RAs. A total of 57 subjects with type 2 diabetes were randomized to a 10-week treatment with lixisenatide or liraglutide. Changes from baseline in the number of reflux episodes during 24-h pH registration in the lower esophagus, lower esophagus sphincter pressure, gastric emptying (13C-sodium octanoate acid breath test), and gastric acid secretion (13C-calcium carbonate breath test) were analyzed. Gastric emptying half-time was delayed by 52 min (Δ 95% CI 16, 88) with lixisenatide (P = 0.0065) and by 25 min (3, 46) with liraglutide (P = 0.025). There was no difference in the number of reflux episodes (mean ± SEM 33.7 ± 4.1 vs. 40.1 ± 5.3 for lixisenatide and liraglutide, respectively, P = 0.17) or the extent of gastroesophageal reflux (DeMeester score) (35.1 ± 6.7 vs. 39.7 ± 7.5, P = 0.61), with similar results for the individual GLP-1 RAs. No significant changes from baseline in other parameters of esophageal motility and lower esophageal sphincter function were observed. Gastric acidity decreased significantly by -20.7% (-40.6, -0.8) (P = 0.042) with the GLP-1 RAs. Lixisenatide exerted a more pronounced influence on gastric emptying after breakfast than liraglutide. Neither lixisenatide nor liraglutide had significant effects on esophageal reflux or motility. Gastric acid secretion appears to be slightly reduced by GLP-1 RAs.

Clinical course of gastroesophageal reflux disease and impact of treatment in symptomatic young patients.

In symptomatic young patients with gastroesophageal reflux symptoms, early identification of progressive gastroesophageal reflux disease (GERD) is critical to prevent long-term complications associated with hiatal hernia, increased esophageal acid and nonacid exposure, release of proinflammatory cytokines, and development of intestinal metaplasia, endoscopically visible Barrett's esophagus, and dysplasia leading to esophageal adenocarcinoma. Progression of GERD may occur in asymptomatic patients and in those under continuous acid-suppressive medication. The long-term side effects of proton-pump inhibitors, chemopreventive agents, and radiofrequency ablation are contentious. In patients with early-stage disease, when the lower esophageal sphincter function is still preserved and before endoscopically visible Barrett's esophagus develops, novel laparoscopic procedures, such as magnetic and electric sphincter augmentation, may have a greater role than conventional surgical therapy. A multidisciplinary approach to GERD by a dedicated team of gastroenterologists and surgeons might impact the patients' lifestyle, the therapeutic choices, and the course of the disease. Biological markers are needed to precisely assess the risk of disease progression and to tailor surveillance, ablation, and management.

Endoscopic pressure study integrated system reflects gastroesophageal junction competence in patients with erosive esophagitis and Barrett´s esophagus.

The endoscopic pressure study integrated system (EPSIS) is a novel diagnostic tool for gastroesophageal reflux disease (GERD) by monitoring intragastric pressure (IGP). Evaluation of the lower esophageal sphincter (LES) function may be achieved endoscopically by utilizing this newly developed diagnostic tool. This study aimed to evaluate the association between EPSIS results and gastroesophageal reflux-related diseases, e.g., erosive esophagitis (EE) and Barrett's esophagus (BE). This was a retrospective, single-center study. All patients who underwent EPSIS between November 2016 and July 2018 were included. EPSIS was performed during esophagogastroduodenoscopy with a dedicated electronic device and a through-the-scope catheter. The maximum IGP (IGP-max) and IGP waveform pattern (flat or uphill) were recorded with this system. Evaluation of an EE and BE was based on the Los Angeles classification and Prague classification, respectively. A total of 104 patients were enrolled; 29 (28%) had EE and 42 (40%) had BE. Patients with EE had lower IGP-max values (16.0 vs 18.8mmHg, P=0.01) and an EPSIS flat pattern was seen more frequently (82.8% vs 37.3%, P<0.001). Similarly, patients with BE displayed a lower IGP-max (15.7 vs 19.6mmHg, P<0.001) and presented with an EPSIS flat pattern in a higher proportion (69% vs 37.1%, P<0.001). These differences remained significant on multivariate analysis. The EPSIS, as a novel diagnostic tool, was shown to exhibit a relation with EE and BE, implying that EPSIS is a promising modality to evaluate gastroesophageal reflux-related diseases and LES function endoscopically.

A budget impact analysis of a magnetic sphincter augmentation device for the treatment of medication-refractory mechanical gastroesophageal reflux disease: a United States payer perspective.

Medication-refractory gastroesophageal reflux disease (GERD) is sometimes treated with laparoscopic Nissen fundoplication (LNF); however, this is a non-reversible procedure associated with important side effects and the need for repeat surgery. Removable magnetic sphincter augmentation (MSA) devices are an alternative, effective, and safe treatment option for such patients who have some lower esophageal sphincter function. The objective of this study was to assess the economic impact of introducing MSA technology (i.e., LINX Reflux Management System) into current practice from a US-payer perspective. An economic budget impact model was developed over a 1-year time horizon that compared current treatment of GERD patients who are medically managed (but refractory) or receiving LNF to future treatment of GERD patients that included a mix of patients treated with medical management only, LNF, or MSA. Resources included within the analyses were index procedures (inpatient and outpatient use), reoperations (revisions and removals), readmissions, healthcare visits, diagnostic tests, procedures, and medications. Medicare payment rates were typically used to inform unit costs. Assuming a hypothetical commercial insurance population of 1 million members, the base-case analysis estimated a net cost savings of $111,367 with introduction of the MSA. This translates to a savings of $0.01 per member per month. Results were largely driven by avoided inpatient procedures with use of the MSA device. Alternative analyses exploring the potential impact of increasing surgical volumes predicted that results would remain cost saving if the proportion of MSA market share taken from LNF was ≥ 90%. This study predicts that the introduction of the MSA device would lead to favorable budget impact results for the treatment of medication-refractory mechanical GERD for commercial payers. Future analyses will benefit from inclusion of middle-ground treatments as well as longer time horizons.

Evaluation of upper gastrointestinal system in acromegaly

PurposeAcromegaly causes multiple comorbidities, including gastrointestinal disorders. The present study evaluated the frequency of hiatal hernia and other upper gastrointestinal pathologies in patients with acromegaly, given that visceromegaly and reduced nitric oxide levels in acromegaly may impact diaphragm and lower esophageal sphincter function and thus possibly the development of hiatal hernia. MethodsThirty-nine acromegaly patients followed our center for the previous 6months were recruited. Upper gastrointestinal endoscopy was performed once in all patients to evaluate hiatal hernia, esophagitis, gastroduodenitis and ulcer. ResultsTwenty-three patients were male and 16 female. Upper gastrointestinal endoscopy found hiatal hernia, esophagitis and gastroduodenitis or gastric ulcer in 3 (7.6%), 2 (1.7%) and 31 (79.4%) patients, respectively. Pathologic examination of gastric antrum biopsy found intestinal metaplasia in 12 (30.7%) patients, and Helicobacter pylori was positive in 13 (33.3%). There were no significant correlations between age, gender, disease duration or preoperative adenoma size on the one hand and hiatal hernia or other endoscopic findings on the other. Similarly, neither surgical success nor recurrence was associated with endoscopic findings. ConclusionsThe study showed that prevalence of gastritis, duodenitis, peptic ulcer and intestinal metaplasia is higher and prevalence of hiatal hernia lower in acromegaly patients than in the healthy population. Various unknown disease-related pathophysiological conditions may play a role; there is a need for further studies.

PGI8 BUDGET IMPACT ANALYSIS OF LINX REFLUX MANAGEMENT SYSTEM FOR THE TREATMENT OF MEDICATION-REFRACTORY MECHANICAL GASTROESOPHAGEAL REFLUX DISEASE: A U.S. PAYER PERSPECTIVE

In the U.S., the prevalence of gastroesophageal reflux disease (GERD) ranges from 18-27%, with an annual economic burden of $15-20 billion. While proton pump inhibitors are the first-line treatment, up to 44% of GERD patients are refractory to medication. Treatment of medication-refractory GERD may involve surgery with laparoscopic Nissen Fundoplication (LNF), a non-reversible procedure with adverse side-effects. Removable magnetic sphincter augmentation devices such as the LINX Reflux Management System are an alternative surgical option that have demonstrated clinical benefits for medication-refractory patients with some lower esophageal sphincter function; however, economic data are limited. The objective of this study is to assess the economic impact of introducing LINX into current practice from a U.S. payer perspective. A budget impact model comparing two treatment practices over a 1-year time-horizon was developed: 1) current practice, which included patients who are medically managed but refractory to their medication or those who receive LNF; and 2) future practice, which included patients managed with current practice or those who receive LINX. Resources included those related to the index procedure, reoperations, readmissions, and general healthcare use (healthcare visits, diagnostic tests, and medications). Eligible patient population, market share, and resource use were estimated using market research, published literature, and a survey of 99 clinicians. Costs were informed from Medicare payments in 2018. One percent of a hypothetical commercial insurance population of one million members were eligible for treatment, specifically those with medication-refractory mechanical GERD. The base-case analysis estimated use of LINX could save $48,116 (i.e., $5.01 per patient), primarily driven by avoided inpatient procedures and reoperations with LINX. Analyses predicted approximate budget neutrality with alternative plausible future scenarios. Results of the analysis predicted the introduction of LINX may lead to favorable budget impact for payers. Future analyses will benefit from inclusion of middle-ground treatments and longer time-horizons.

Results of 24-hour esophageal impedance-pH monitoring in 141 patients with gastroesophageal reflux disease

Objective To analyze the relationship between body type, age, gender, esophageal motility function, lower esophageal sphincter pressure (LESP) and clinical classification and type of reflux contents of patients with gastroesophageal reflux disease (GERD). Methods From September 2015 to July 2016, at Beijing Tongren Hospital of China Capital Medical University, the results of 24-hour esophageal impedance-pH monitoring of 141 patients with GERD were retrospectively analyzed. The differences of reflux contents were compared in patients with GERD among different body type, age, gender, esophageal motility function, LESP and clinical classification. Mann-Whitney test was performed for comparison between groups. Results Acid reflux was more common in obese patients (body mass index more than 23.9 kg/m2) compared with patients with normal body type (body mass index from 18.5 to 23.9 kg/m2) (18.5, 7.0 to 45.3 vs. 10.0, 2.0 to 32.0), and the difference was statistically significant (Z=-2.320, P=0.020). Patients under 65 years old had more numbers of weak acid reflux, non-acid reflux and gas reflux than patients over 65 years old (58.5, 32.8 to 95.0 vs. 40.0, 24.0 to 71.0; 19.5, 6.0 to 47.5 vs. 8.0, 3.0 to 19.0; 46.0, 23.8 to 79.3 vs. 35.0, 11.0 to 56.0), and the differences were statistically significant (Z=-2.690, -3.286 and -2.091, all P 0.05). Patients with reflux esophagitis(RE)and /or Barrett′s esophagus (BE) had more weak acid reflux, non-acid reflux and gas reflux compared with patients with non-erosive reflux disease (NERD) (61.0, 31.3 to 102.5 vs. 44.0, 24.5 to 66.5; 18.0, 8.0 to 36.5 vs. 8.0, 2.0 to 22.0; 49.5, 27.5 to 86.5 vs. 26.0, 11.0 to 47.0), and the differences were statistically significant (Z=-2.585, -2.942 and -3.278, all P<0.05). Patients with lower esophageal sphincter (LES) relaxation were more likely to have weak acid reflux than patients with normal LES function (57.0, 32.3 to 87.0 vs. 40.0, 21.0 to 73.0), the difference was statistically significant (Z=-2.065, P=0.039). Conclusion Body type, age, gender, LESP and clinical classification are related to type of reflux contents in GERD patients, while esophageal peristalsis is irrelevant. Key words: Gastroesophageal reflux; 24-hour esophageal impedance pH monitoring; Patterns of reflux episodes

Peroral endoscopic myotomy versus pneumatic dilation - result from a retrospective study with 1-year follow-up.

On the basis of lesser rates of major adverse events and a short-term efficacy as Heller's myotomy, there is a growing enthusiasm in favor of peroral endoscopic myotomy (POEM), whereas study comparing POEM and pneumatic dilatation (PD) is quite rare. The aim of this study was to evaluate the efficacy of POEM and PD in Chinese achalasia patients in a retrospectively designed study. Patients with achalasia, who underwent either PD (n = 26) or POEM (n = 40) were retrospectively recruited from September 2010 through March 2016 at a single tertiary center. During the 1-year follow-up, clinical outcome and functional data of lower esophageal sphincter (LES) were recruited. Clinical symptoms were assessed by use of the Eckardt score. The primary outcome was therapeutic success (Eckardt score ≤ 3). Functional data of LES (4-second integrated relaxation pressure [4s-IRP], LES relax rate, and LESP) at baseline and 1 month after treatment were also evaluated. Data was analyzed by SPSS 13.0 version using a significance level of p < 0.05. The success rates were 24/26 (92.31 %), 25/26 (96.15 %), and 24/26 (92.31 %), respectively, with POEM, as compared with 35/40 (87.50 %), 29/40 (72.50 %), and 23/40 (57.50 %), respectively, with PD, 1 month, 3 months, and 1year after treatment. Statistically significant difference was observed between the 2 therapies (at 3 months, Fisher's exact test, p = 0.01; at 1 year, Fisher's exact test, p < 0.0001). Compared with PD, the Eckardt score was lower with POEM 1 month, 3 months, and 1 year after treatment. More patients in POEM group reported gastroesophageal reflux symptoms (after 3 months 7/26 (26.92 %) vs. 2/40 (5.00 %), Fisher's exact test, p = 0.01; after 1 year 6/26 (19.23 %) vs. 1/35 (2.86 %), Fisher's exact test, p = 0.02). The postoperative 4s-IRP and LESP were both lower with POEM than with PD, respectively. Type I achalasia had a better response with POEM than with PD. In this retrospective analysis with 1-year follow-up, POEM presents with a higher success rate and more reflux symptoms compared with PD. Change on LES function after treatment may explain the outcome in part. Type I achalasia may respond better to therapies compared with type II.

Tu1170 DIAGNOSTIC PERFORMANCE OF AN ENDOSCOPIC PRESSURE INTEGRATED SYSTEM (EPSIS): A NOVEL DIAGNOSTIC TOOL FOR GASTROESOPHAGEAL REFLUX DISEASE

Lower esophageal sphincter (LES) dysfunction is known to be the main cause of gastroesophageal reflux disease (GERD). Although esophageal pH monitoring is considered the gold standard for the diagnosis of GERD, it is laborious and time consuming. Currently, there is no diagnostic method that can directly assess the function of LES endoscopically. We have recently developed a new diagnostic tool: endoscopic pressure study integrated system (EPSIS) that enables us to evaluate LES function endoscopically. The aim of this study was to evaluate the diagnostic performance of this novel diagnostic system. We conducted a retrospective study of patients who underwent both EPSIS and 24-hour impedance-pH monitoring at a single tertiary referral center from April 2016 to October 2017. EPSIS was performed at the time of gastroscopy by using a through-the-scope catheter connected to the system to measure intra-gastric pressure (IGP). Carbon dioxide was insufflated until LES loosens to evacuate the pressure by belching. The maximum IGP and waveform pattern of IGP (uphill or flat pattern) were recorded (Figure 1). On 24-hour impedance-pH monitoring, percentage of total time pH < 4 over 4.2%, DeMeester composite score over 14.7, and distal reflux event over 48 times on impedance monitoring were considered positive for GERD. We hypothesized as follows: (i) maximum IGP below 20mmHg and (ii) flat waveform pattern would correlate with GERD based upon a previously conducted preliminary study performed at our institution. The diagnostic performance of these findings was evaluated based on aforementioned positive findings on esophageal pH monitoring. A total of 54 patients with PPI-refractory acid reflux symptoms underwent both EPSIS and esophageal pH monitoring. The additional time of gastroscopy needed to perform EPSIS was less than 5 minutes in all cases. Both maximum IGP < 20mmHg and flat waveform pattern significantly correlated with percent total time pH < 4 over 4.2% (p < 0.01) and DeMeester composite score over 14.7 (p < 0.01). Twenty-five patients (44%) were diagnosed positive for GERD on pH monitoring. Forty patients (74.0%) were considered positive with maximum IGP < 20mmHg or flat waveform pattern recorded on EPSIS. Sensitivity, specificity, overall accuracy of positive EPSIS findings were 91.7% (95% CI, 0.73-0.99), 40.0% (95% CI, 0.23-0.59), 62.9% (95% CI, 0.49-0.76), respectively in the diagnosis of GERD by pH monitoring. EPSIS may be a promising detection tool that can be utilized to determine the pretest probability of esophageal pH monitoring in less than 5 minutes during gastroscopy. With this rapid and easily performed examination, EPSIS could be performed prior to proceeding with other diagnostic investigations for GERD.

Correlation between novel 3D high-resolution manometry esophagogastric junction metrics and pH-metry in reflux disease patients.

We recently developed 2 novel 3D high-resolution manometry (HRM) metrics of esophagogastric junction (EGJ) contractility to differentiate the lower esophageal sphincter (LES) and crural diaphragm (CD) elements of EGJ pressure. This study aimed to compare these metrics to the EGJ-contractile integral (EGJ-CI) and to analyze their correlation with esophageal acid exposure time (AET) on pH-metry. Thirty-one gastro-oesophageal reflux disease (GERD) patients and 20 control subjects underwent 24-hour pH-metry and HRM using a 3D-HRM catheter. EGJ metrics were calculated during 3 consecutive respiratory cycles at rest. The EGJ-CI was calculated using the DCI tool in the ManoView software. 3D LES pressure (3D-LESP) and 3D-DHA, a metric quantifying the CD component of the 3D-HRM pressure topography, were calculated using a MATLAB program. Pearson correlation was used to calculate correlations with AET. 3D-LESP, 3D-DHA, and EGJ-CI were all significantly lower in GERD patients than in control subjects (P<.05) and all were significantly correlated with AET (R=-.48, -.42, -.52, respectively, all P<.01). The 3D-DHA and EGJ-CI also strongly correlated with each other (R=.84, P<.001). Both 3D-EGJ metrics were correlated with AET emphasizing the importance of both LES and CD function as a determinant of EGJ competence. 3D-DHA also strongly correlated with the EGJ-CI suggesting that EGJ-CI is strongly driven by the asymmetrical CD pressure component.

Thoracoabdominal pressure gradient and gastroesophageal reflux: insights from lung transplant candidates.

Advanced lung disease is associated with gastroesophageal reflux disease (GERD). The thoracoabdominal pressure gradient (TAPG) facilitates gastroesophageal reflux, but the effects of TAPG on gastroesophageal reflux in patients with pulmonary disease have not been well defined. Patients diagnosed with end-stage lung disease are expected to have the most extreme derangement in respiratory mechanics. The aim of this study is to explore the relationship between TAPG and reflux in lung transplant (LTx) candidates. We reviewed LTx recipients who underwent pretransplant esophageal high-resolution manometry and a 24-hour pH study. Patients were excluded if they were undergoing redo LTx, had manometric hiatal hernia, or had previously undergone foregut surgery. TAPG was defined as the intra-abdominal pressure minus the intrathoracic pressure during inspiration. Adjusted TAPG was calculated by the TAPG minus the resting lower esophageal sphincter (LES) pressure (LESP). Twenty-two patients with normal esophageal function tests (i.e., normal esophageal motility with neither manometric hiatal hernia nor pathological reflux on 24-hour pH monitoring) were selected as the pulmonary disease-free control group. In total, 204 patients underwent LTx between January 2015 and December 2016. Of these, 77 patients met inclusion criteria. We compared patients with obstructive lung disease (OLD, n=33; 42.9%) and those with restrictive lung disease (RLD, n=42; 54.5%). 2/77 patients (2.6%) had pulmonary arterial hypertension. GERD was more common in the RLD group than in the OLD group (24.2% vs. 47.6%, P=0.038). TAPG was similar between the OLD group and the controls (14.2 vs. 15.3 mmHg, P=0.850); however, patients in the RLD group had significantly higher TAPG than the controls (24.4 vs. 15.3 mmHg, P=0.002). Although TAPG was not correlated with GERD, the adjusted TAPG correlated with reflux in all 77 patients with end-stage lung disease (DeMeester score, rs=0.256, P=0.024; total reflux time, rs=0.259, P=0.023; total number of reflux episodes, rs=0.268, P=0.018). Additionally, pathological reflux was seen in 59.1% of lung transplant candidates with adjusted TAPG greater than 0 mmHg (i.e., TAPG exceeding LESP); GERD was seen in 30.9% of patients who had an adjusted TAPG≤0 mmHg. In summary, TAPG varies based on the underlying cause of lung disease. Higher adjusted TAPG increases pathological reflux, even if patients have normal antireflux anatomy and physiology (i.e., no hiatal hernia and manometrically normal LES function). Adjusted TAPG may provide further insights into the pathophysiology of GERD.

New Minimally Invasive Endoscopic and Surgical Therapies for Gastroesophageal Reflux Disease (GERD).

GERD has become one of the most frequent pathology of the upper GI tract. It is a spectrum disease and is a progressive disease as well. Serious and severe complications are possible. The mainstream therapy in most of the patients is the medical therapy with PPI's. The most severe cases with an impaired LES (Lower Esophageal Sphincter) function as well as important anatomical disruptions are of surgical indication, the gold standard being laparoscopic fundoplication, an elective therapy with long term follow up outcomes at the expense of de novo symptoms associated with fundoplications in general. 30% to 40% of the patients are PPI refractory with partial symptom control, but they are not willing to go for the laparoscopic fundoplication because of the invasive character and because of potential postfundoplications syndromes. There is a "treatment gap" for these patients with GERD. For a well selected patient population with GERD, with mild forms of the disease, without complications and without major anatomical disruptions (patients with small hiatal hernias), patients who are refractory on PPI medication, there are today new alternative therapies, minimally invasive. These therapies are less aggressive and basically with no side effects or new onset symptoms that Laparoscopic Fundoplications will give. These are endoscopic therapies which improve the LES function: Stretta utilizes radiofrequence therapy, a novel technique describes mucosal resection at the level of the cardia, while a partial fundoplication from within the stomach can be realized with EsophyX, Muse or Gerd-X. Form all these procedures, EsophyX is the most advanced with more than 20,000 patients treated worldwide, with good clinical outcomes and with no de novo symptoms. The laparoscopic techniques treat hiatal hernias larger than 2 cm. Linx utilizes a magnetic ring at the LES level. EndoStim utilizes electrodes in order to stimulate the LES muscle. These procedures are effective on short term and there are few patients treated with Linx or EndoStim. More research for Linx and EndoStim is necessary with randomized clinical trials, with improvement of the devices and with long term follow up.