Reflux Patterns Research Articles

A Retrospective Cohort Study of Patient Risk Factors and Pelvic Venous Reflux Patterns on Treatment Outcomes With Pelvic Vein Embolisation.

To identify the effects of patient risk factors and pelvic venous reflux (PVR) patterns on treatment outcomes of Pelvic Vein Embolisation (PVE) for Pelvic Venous Disorder (PeVD). We performed a retrospective cohort review assessing population, intervention, comparison, and outcomes (PICO) for women undergoing PVE for PVR January 2017-January 2021. We identified 190 patients who had completed both questionnaires and who had given consent for their information to be used for research (Median age 46, IQR 40-52). The distribution of pathological pelvic venous reflux found on transvaginal duplex ultrasound (TVDUS) was analysed for all patients. Pre- and post-procedure symptom burden scores were studied using a standardised questionnaire protocol. We used inferential univariate non-parametric statistics to describe our data. 190 cases were reviewed; 62.6% (119/190) premenopausal, 11.1% (21/190) perimenopausal, 25.3% (48/190) postmenopausal and menopausal status not documented 1% (2/190). 10.1% (19/188) were nulliparous (average age 34 years; range 20-55 years). There was a statistically significant improvement in all symptoms and in the appearance of varicosities on TVDUS post-PVE (P < 0.05) of the ovarian vein plexus, uterus plexus, arcuate veins, vaginal wall, peri-urethral, peri-anal, haemorrhoids, labial and proximal thigh. The locations of veins requiring embolisation having demonstrated reflux were analysed; 82.8% (154/186) underwent embolisation of at least one internal iliac vein tributary and ovarian vein embolisation. Age, parity, menopausal status and previous laparoscopy did not affect symptom improvement (P > 0.05). No significant complications such as coil migration were observed. PVE is an effective treatment for pelvic pain due to PeVD and its diagnosis should not be limited to multiparous women of childbearing age, as a significant proportion of patients who benefited from PVE were either nulliparous and/or postmenopausal.

Atypical telencephalic reflux pattern in a cavernous sinus dural AV fistula related to an anatomical variation of the basal vein of Rosenthal

Atypical telencephalic reflux pattern in a cavernous sinus dural AV fistula related to an anatomical variation of the basal vein of Rosenthal

Non-Acid GERC: Pathogenesis, Diagnosis and Management

Total Recent investigations have highlighted the pivotal influence of non-acid reflux in the etiology of chronic cough associated with gastroesophageal reflux disease (GERC). Differentiation between acid and non- acid GERC is effectively achieved through esophageal pH monitoring, with non-acid reflux drawing attention for its linkage to non-standard symptoms and the intricacies involved in its management. The combination of multi-channel intraluminal impedance with pH monitoring (MII-PH) and its related metrics, including acid exposure time (AET), symptom association probability (SAP), and symptom index (SI), as well as the quantity, pH, nature of reflux, its spread, and acid clearance time, alongside innovative measures such as mean nocturnal baseline impedance (MNBI) and post- reflux induced peristaltic wave index (PSWPI), is pivotal in precisely delineating reflux patterns and identifying the temporal connection between non-acid reflux occurrences and episodes of coughing. The prevailing reliance on proton pump inhibitors (PPIs) for treatment has encountered constraints in effectively managing non-acid GERC, underscoring the necessity for personalized treatment modalities that confront the unique pathophysiology of non-acid GERC to ameliorate patient outcomes. As research continues to deepen our understanding and enhance treatment methods for this multifaceted condition, the pursuit of effective treatment strategies becomes crucial. Our review aims to delineate the spectrum of therapeutic options, advancements in diagnostics, and an improved grasp of the pathogenesis of non-acid GERD. The focus of this review is to further the advancement of patient care management and to inspire continued research in this intriguing domain of gastroenterology.

Enhancing NICU Care and Communication: Perspectives of Moderately Preterm Infant Parents.

Moderately preterm infants (MPTI) comprise a large proportion of NICU admissions and are an understudied population. The unique experience of families with MPTIs has yet to be examined in the literature. Describing MPTI parent needs and preferences may inform interventions to improve care and outcomes for this population. Semistructured qualitative interviews were performed with English-speaking birth parents of infants born between 32 and 34 weeks gestation to describe their NICU experience and identify areas for improvement specifically surrounding care team inclusion, education, discharge, and communication. Interviews were recorded, transcribed, and analyzed using directed content analysis. Enrollment ceased when the data reached thematic saturation. Sixteen birth parents participated. Four themes emerged around parent-medical team connectedness, parental confusion, discharge readiness, and the desire for a use of a mix of in-person and electronic communication methods (e-mail, texting, apps, etc) for communication. MPTI parents valued a strong connection with the medical team; however, they described a lack of knowledge regarding the reasons for admission and ongoing management. Near discharge, parents desired more information regarding feeding, reflux, and breathing patterns. Parents preferred in-person discussions but described a role for electronic methods to improve their understanding of their infant and discharge readiness. From the MPTI parent perspective, clinicians can focus improvement efforts on communication, specifically around reasons for admission, discharge planning, and anticipatory guidance. These results may serve as a foundation for initiatives to improve the MPTI parent experience and potentially parent and MPTI outcomes.

The sonographic features of lymph node venous networks and flow patterns in patients with primary chronic venous disease.

Our study aims to enhance the understanding of lymph node venous networks (LNVNs) by summarising their anatomical, sonographic features, and reflux patterns. We examined 241 legs from 141 patients with primary chronic venous disease (CVD) using duplex ultrasound. The findings indicated variations in the shape, size, vascularity, and echogenicity of LNVN. The superficial inguinal lymph node with reflux appeared slightly larger, exhibiting higher velocities in the hilar artery. Regarding connections, venous flow within LNVN was predominantly drained through the saphenofemoral junction (SFJ), anterior accessory great saphenous vein (AAGSV), and great saphenous vein (GSV). A significant number of LNVNs were observed to be associated with anterolateral thigh tributaries. The study also identified valve cusps within LNVN. This study revealed a 12% prevalence of primary LNVN. Understanding the anatomical and haemodynamic features of LNVN informs treatment strategies and potentially helps prevent the recurrence of varicose veins.

Prolonged acid reflux monitoring using acid exposure time and DeMeester score: two days are not enough.

Wireless pH monitoring allows for a definitive GERD diagnosis, which is essential for optimal medical or surgical management of the patient. However, there is no guideline recommendation on whether prolonged pH testing (72 or 96h) provides additional benefit when compared to the standard 48-h testing. We aimed to assess whether prolonged pH monitoring diagnoses more patients with GERD, as well as compare the DeMeester score to acid exposure time as diagnostic criteria for GERD. This was a retrospective analysis of consecutive adult patients who underwent wireless esophageal pH monitoring between August 2018 and July 2021. The primary outcome was the additional diagnoses of GERD (predominant acid exposure pattern) in patients who underwent 48-h versus 96-h pH monitoring. Secondary outcomes included comparison of the DeMeester score to acid exposure time and internal agreement between the first and second 48-h blocks of a prolonged96-hpH study. When comparing 48-h versus 96-h pH testing, the prolonged monitoring group was more likely to have a predominant reflux pattern and thus be diagnosed with definitive GERD by elevated DeMeester score (58.8% vs. 40.8%, p = 0.003) or acid exposure time > 6% (44.7% vs. 32.4%, p = 0.039). For patients who underwent prolonged testing, the results of monitoring beyond 48h led to a clinically meaningful change in study interpretation in 24.8% of patients. The study data from Days 3 to 4 yielded only a 56.6% agreement with the first 2days. In patients undergoing extended pH monitoring, almost half were found to have an abnormal pH study after a normal study on Day 1. An additional 25% of patients had a change in study interpretation by extending the study beyond 48h. Our findings suggest only 48h of pH monitoring will miss a diagnosis of GERD in a clinically important number of patients.

O018 Determining the relationships between venous reflux patterns, clinical severity, and health-related quality of life

Abstract Introduction Various classification systems have been created to describe the anatomical distribution of venous reflux, including the VEIN-TERM and Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification. It is still unclear whether different reflux patterns correlate with health-related quality of life (HRQoL) and clinical severity. Methods Some 507 chronic venous disease patients and 105 asymptomatic controls underwent duplex ultrasound assessment. Patients were stratified according to VEIN-TERM and the CEAP classification systems. The Aberdeen Varicose Vein Questionnaire (AVVQ) score was used to compare HRQoL and the Venous Clinical Severity Score (VCSS) was used to compare clinical severity between groups. Results Patients were significantly older than controls (p&amp;lt;0.00001). All VEIN-TERM reflux patterns had significantly greater VCSS than no reflux (p&amp;lt;0.001). Superficial axial and combined axial reflux were associated with significantly greater VCSS than superficial segmental reflux (p&amp;lt;0.001, p=0.042 respectively). All VEIN-TERM reflux types had significantly worse AVVQ scores than no reflux (p&amp;lt;0.03). However, there were no significant differences in AVVQ scores across all VEIN-TERM reflux patterns. Most CEAP reflux patterns had increased VCSS and worse AVVQ scores when compared to no reflux (all p&amp;lt;0.05), except for deep reflux, and deep and perforator reflux only. The deep, superficial and perforator reflux group had significantly higher VCSS (p=0.013) and AVVQ (p&amp;lt;0.001) versus the superficial reflux only group. Conclusion When compared to no reflux, both classification systems show associations of any reflux pattern with worse VCSS and AVVQ scores. Combined reflux patterns were associated with the greatest clinical severity and worst HRQoL scores.

Elucidation of gastric motor function caused by gastroesophageal reflux in Rumination syndrome

Rumination syndrome (RS) is a disease of the gastrointestinal (GI) tract characterised by repeated regurgitation of recently digested food back into the mouth. It can be difficult to distinguish from gastro-oesophageal reflux disease (GERD) and it is likely that many RS patients are treated for GERD due to being misdiagnosed. Assistant Professor Kenichiro Nakagawa is leading a team of experts based in the Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan, investigating the causes of gastroesophageal reflux. The researchers have already found that RS and GERD are very different in terms of pathology. They are using high-resolution impedance manometry (HRIM) as a diagnostic tool to comprehensively assess the motor function and bolus transit of food through the oesophagus. They are also utilising oesophageal multichannel intraluminal impedance-pH (MII-pH) monitoring to assess the pH of targeted oesophageal and gastric regions of the GI tract. In doing so, the team can pinpoint gastroesophageal reflux patterns, in turn highlighting the differences in gastroesophageal reflux patterns between RS and GERD patients and healthy control subjects. Using oesophagogastric scintigraphy, the researchers can compare the ratio of regurgitated food during gastroesophageal reflux in their three test groups, analysing where the food residue in RS and GERD patients and healthy control subjects localises in the proximal stomach.

MP43-18 ADOLESCENT VARICOCELE: EFFECTS OF VEIN SIZE AND ARTERIAL FLOW RATE ON SEMINAL PARAMETERS

You have accessJournal of UrologyCME1 Apr 2023MP43-18 ADOLESCENT VARICOCELE: EFFECTS OF VEIN SIZE AND ARTERIAL FLOW RATE ON SEMINAL PARAMETERS Selin Ocal, Alina Sheikh, Joseph Pizzuti, Alexander Fang, Joseph Boroda, Steven Friedman, Ronnie Fine, Mark Horowitz, Ronnie Fine, Richard Sclussel, Lori Dyer, Paul Zelkovic, Jaime Freyle, Israel Franco, and Jordan Gitlin Selin OcalSelin Ocal More articles by this author , Alina SheikhAlina Sheikh More articles by this author , Joseph PizzutiJoseph Pizzuti More articles by this author , Alexander FangAlexander Fang More articles by this author , Joseph BorodaJoseph Boroda More articles by this author , Steven FriedmanSteven Friedman More articles by this author , Ronnie FineRonnie Fine More articles by this author , Mark HorowitzMark Horowitz More articles by this author , Ronnie FineRonnie Fine More articles by this author , Richard SclusselRichard Sclussel More articles by this author , Lori DyerLori Dyer More articles by this author , Paul ZelkovicPaul Zelkovic More articles by this author , Jaime FreyleJaime Freyle More articles by this author , Israel FrancoIsrael Franco More articles by this author , and Jordan GitlinJordan Gitlin More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003289.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Varicocele severity has been associated with larger testicular vein size but the relationship to decreased fertility remains debatable. In clinical practice, largest vein diameter is used to screen for surgical intervention, yet more recent studies have found venous reflux patterns and total testicular volume (TTV) to be associated with total motile sperm count (TMSC). This study compares largest testicular vein size and arterial flow rates to identify patients at risk for reduced seminal parameters. METHODS: We conducted a retrospective single institution chart review over 14 years of 487 Tanner V adolescents. 148 met inclusion criteria of palpable, non-operated left sided varicoceles who underwent at least one SA and color doppler ultrasonography. Abnormal TMSC was defined by WHO 2010 criteria. Descriptive statistics, ROC analysis, univariate and multivariate logistic regression were performed using SPSS. RESULTS: Data on 148 Tanner V adolescent males with mean age 18.24±1.38 years were evaluated. Median diameter of largest left testicular vein was 3.5 mm (IQR 3.1-4.6), median peak systolic velocity (PSV) of left testicular artery was 10.4 cm/s (IQR 9.1-12.5), median end diastolic velocity (EDV) of left testicular artery was 5.1 cm/s (IQR 4.3-5.9), median value of PSV/EDV was 2.1 (IQR 1.8-2.3) and median TMSC was 37.4 million sperm/ejaculate (IQR 15.8-84.2). On ROC analysis regarding prediction of abnormal TMSC (<9 million sperm/ejaculate), left testicular PSV was found to have the greatest AUC at 0.73 (95% CI 0.62-0.85) with Youden index analysis determining cutoff of 10.22 cm/s while largest vein diameter was found to have an AUC of 0.48. On univariate logistic regression, PSV<10.22 cm/s resulted in a significantly greater likelihood of abnormal TMSC (OR: 5.51 [1.84-16.46], p=0.002), which persisted on multivariate logistic regression with adjustment for age (OR: 5.49 [1.83-16.43], p=0.002). CONCLUSIONS: Left testicular PSV was most significantly correlated to TMSC. PSV <10.22 cm/s was predictive of an abnormal TMSC. No significant association was found between larger veins and greater risk for abnormal TMSC. When assessing varicocele, left testicular artery PSV may help stratify future fertility risk, allowing for improved surveillance regarding surgical intervention. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e608 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Selin Ocal More articles by this author Alina Sheikh More articles by this author Joseph Pizzuti More articles by this author Alexander Fang More articles by this author Joseph Boroda More articles by this author Steven Friedman More articles by this author Ronnie Fine More articles by this author Mark Horowitz More articles by this author Ronnie Fine More articles by this author Richard Sclussel More articles by this author Lori Dyer More articles by this author Paul Zelkovic More articles by this author Jaime Freyle More articles by this author Israel Franco More articles by this author Jordan Gitlin More articles by this author Expand All Advertisement PDF downloadLoading ...

Patterns of Reflux in C2 Venous Disease Compared With C5/6 Venous Disease

Patterns of Reflux in C2 Venous Disease Compared With C5/6 Venous Disease

Hemodynamic and neurobiological factors for the development of chronic pelvic pain in patients with pelvic venous disorder

ObjectiveThe study was aimed at the identification of hemodynamic and neurobiological factors for the development of chronic pelvic pain (CPP) in patients with pelvic venous disorder (PeVD) using ultrasound, radionuclide, and enzyme immunoassay methods. MethodsThis cohort study included 110 consecutive patients with PeVD and 20 healthy controls. Seventy patients with PeVD had symptoms (CPP in 100% of cases, discomfort in hypogastrium, dyspareunia, vulvar varices, and dysuria), and 40 were asymptomatic. Patients underwent clinical examination, duplex ultrasound study of the pelvic veins and lower extremities, and single-photon emission computed tomography of the pelvic veins with in vivo labeled red blood cells. The prevalence, duration, severity, and pattern of reflux in the pelvic veins, as well as the severity of pelvic venous congestion, were evaluated. Healthy controls underwent only clinical and duplex ultrasound examination. All 130 patients were assessed using enzyme immunoassays to determine plasma levels of calcitonin gene-related peptide (CGRP) and substance P (SP). ResultsSymptomatic patients with PeVD had a higher prevalence of reflux in the ovarian veins (OVs) than asymptomatic ones (45.7% vs 10%, respectively; P = .001) and a greater reflux duration (4.1 ± 1.7 seconds vs 1.4 ± 0.3 seconds; P = .002), although no differences in the OV diameter were found. Similar results were obtained when comparing the diameters of the parametrial veins (PVs) and the duration of reflux in them. Type II/III reflux (greater than 2 seconds) was identified in 41.4% of symptomatic and in only 5% of asymptomatic patients (P = .001). Among patients with CPP, 24.2% had a combined reflux in the OVs, PVs, and uterine veins, and 45.7% had a combined reflux in the OVs and PVs, whereas 90% of patients without CPP had only an isolated reflux in the PVs. The pelvic venous congestion was moderate or severe in 95.7% of patients with CPP and in only 15% patients without CPP (P = .001). In patients with PeVD, the presence of CPP was associated with higher levels of CGRP and SP compared with asymptomatic patients (CGRP: 0.48 ± 0.06 vs 0.19 ± 0.02 ng/mL, respectively, P = .001; SP: 0.38 ± 0.08 vs 0.13 ± 0.03 ng/mL, P = .001). ConclusionsIn patients with PeVD, significant hemodynamic and neurobiological factors for the CPP development were found to be reflux in the pelvic veins greater than 2 seconds, involvement of several venous collectors, and increased plasma levels of CGRP and SP.

Evaluatıng the Impact of Great Saphenous Veın Reflux Pattern on Clınıcal Severıty and Treatment Modalıty

Objectives: This research aimed to determine the impact of reflux patterns in patients with great saphenous vein (GSV) insufficiency on clinical severity and management. Methods: We evaluated 771 lower extremities of 452 patients having GSV insufficiency with Doppler Ultrasound. We characterized the reflux patterns like previously done in the literature: type 1, GSV reflux without the involvement of perimalleolar region or saphenofemoral junction (SFJ); type 2, GSV reflux involving perimalleolar region; type 3, GSV reflux involving SFJ; type 4, GSV reflux involving both perimalleolar region and SFJ. Then we conducted a study to evaluate the relationship between GSV reflux type and age, gender, venous clinical severity score (VCSS), clinical, etiological, anatomical and pathophysiological elements (CEAP), body mass index (BMI) and gave an effort to compare the groups by therapeutic strategies. Results: The mean age was 44±11 years. The male-to-female ratio was 0.49. The most commonly observed reflux pattern was type 3 (48%) in patients with GSV insufficiency and varicose veins. Patients with type 1 reflux were younger, had lower BMI, and had a better clinical situation (p=0.002). VCSS was associated with perimalleolar region involvement, as increased in type 2 reflux than type 1, and higher VCSS was related to SFJ involvement as defined in type 3 reflux. Type 4 reflux patients had the highest VCSS that means the most severe clinical presentation. Sclerotherapy was the most common treatment modality in type 1 reflux (p&lt;0.001). Also, in type 2 and type 4 reflux, sclerotherapy was more preferred than type 3 (p&lt;0.001). Type 4 reflux pattern required mostly radiofrequency ablation, compared with type 3 (28.2% vs 20.5%; p&lt;0.05) after initial diagnosis. Cyanoacrylate glue embolization was the appropriate therapeutic option in only 3.2% of type 4 reflux patients, which was significantly lower than type 3. Conclusion: According to the reflux pattern classification system based on SFJ and malleolar region involvement as practiced in this study, we described a correlation between VCSS, CEAP, BMI, and the extent of venous insufficiency. This correlation with consideration of cosmetic reasons and vein diameter measurements can suggest further treatment modality. Advances in knowledge: We investigated a practical, clinically applicable, and widely accepted standard method for classifying GSV insufficiency. Mapping venous insufficiency with such a system is essential to determine the clinical severity and the most appropriate treatment modality.

Подходы к терапии ГЭРБ с учетом разнообразия ее клинических форм

Approximately one third of gastroesophageal reflux disease (GERD) patients are resistant or partially responsive to proton pump inhibitors (PPIs). It is assumed that non-acid reflux is the cause of 15–62% of cases concerning the PPI therapy inefficacy in GERD patients. The review reveals the issues on the prevention and therapy of non-acid GERD types, ways to improve the treatment efficacy. Understanding the patterns of reflux and pathogenetic mechanisms of non-acid GERD types makes it possible to choose the right drugs. For the prevention and treatment of bile reflux, it is necessary to normalize esophageal, gastric and duodenal motility, as well as biliary system function, and prescribe adequate antisecretory and cytoprotective therapy. The basic drugs for the GERD treatment are PPIs. In order to elevate the GERD therapy effect, drugs are used that can enhance the protective factors of the mucous membranes, i.e., cytoprotectors. UDCA drugs are the basis of GERD therapy with a predominance of bile reflux. Prokinetics are used in the treatment of duodenogastroesophageal reflux to normalize the biliary system function, as well as the motor-evacuation function of the stomach and intestines. Heterogeneity of pathogenesis, including the possibility of acid and non-acid gastroesophageal reflux, necessitates GERD differentiated therapy. KEYWORDS: GERD, reflux, prokinetic, gastroprotectors, cytoprotector, proton pump inhibitors. FOR CITATION: Seliverstov P.V., Lazareva Yu.A., Egorov D.V. Methods for GERD therapy according to its clinical form diversity. Russian Medical Inquiry. 2023;7(7):432–438 (in Russ.). DOI: 10.32364/2587-6821-2023-7-7-5.

Patterns of Saphenous Vein Reflux and Treatment Plan

Patterns of Saphenous Vein Reflux and Treatment Plan

Great Saphenous Vein Insufficiency Evaluating the Impact of Reflux Pattern on Clinical Severity and Treatment Modality

Great Saphenous Vein Insufficiency Evaluating the Impact of Reflux Pattern on Clinical Severity and Treatment Modality

Characteristics of venous leg ulcer patients at a tertiary wound care center

ObjectiveThe objective of this study was to assess patient, wound, care, and reflux characteristics of venous leg ulcers (VLUs) to update and improve knowledge of disease etiology, identify barriers to healing, and improve treatment. MethodsPatients diagnosed with VLUs treated at the Stanford Advanced Wound Care Center between 2018 and 2019 were identified from the Healogics iHeal database. We identified 327 VLU entries, of which 133 were patients who had multiple or recurring wounds. An additional 27 patients were labeled as misdiagnosis, resulting in a final patient sample of 167. Patient demographics, wound, care, and ultrasound data for these patients were extracted from the Stanford electronic medical records regarding characteristics. The initial data analysis suggested possible differences in VLU characteristics depending on patient age and body mass index (BMI), which was then further analyzed. ResultsOf the 167 VLU patients assessed, 53.9% were male and 46.1% were female. The mean age was 74.7 years, and the average BMI was 30.2 kg/m2, including 41.1% of patients with a BMI over 30 kg/m2. Approximately 50% of wounds were presented in multiples, had cellulitis, or were recurring, and 39.5% were caused by trauma. Most common venous reflux patterns on duplex ultrasound examination were below-knee great saphenous vein reflux and calf perforator reflux, which was identified in 37.7% and 29.3% of the patients, respectively. Axial great saphenous vein reflux was detected in 14.4% of patients. When looking at the patient sample under 60 years of age, 67.7% were male, 61.3% presented with venous skin changes, and 51.6% had diabetes. In the patients older than 60, only 51.9% were male, 37.6% presented with venous skin changes, and 31.6% had diabetes. BMI was greater in the patients under age 60, with an average of 39.2 kg/m2, compared with 28.2 kg/m2 in those above 60. Of the patients with a BMI ≥30 kg/m2, 64.3% had multiple wounds, 61.4% had recurring wounds, and 56.5% had venous skin changes. In contrast, in patients with BMI <30 kg/m2, 47.4% had multiple wounds, 39.2% had recurring wounds, and 32.0% had venous skin changes. ConclusionsVLU pathology appears to differ depending on patient demographics and characteristics. Different drivers may influence disease cause, progression, and prognosis, making a standard approach to VLUs difficult. Our findings suggest that identifying different subtypes of VLUs and adapting an algorithm of care with a personalized treatment may help optimize management of these patients.

S414 POEM Is Associated with Increased Reflux in All Positions Compared to Heller Myotomy

Introduction: Achalasia is an esophageal motility disorder that results from a disruption of the neuromodulatory responses of the esophagus and lower esophageal sphincter (LES). A common consequence of treating the hypercontractile LES is worsened gastroesophageal reflux (GER). It is well-established that peroral endoscopic myotomy (POEM) leads to a higher absolute rate of GER than Laparoscopic Heller Myotomy with Dor fundoplication (LHM); however, the exact patterns of reflux have not been well-described. Methods: The charts of patients who underwent LHM or POEM between 2017 and 2019 at our institution were reviewed, and patients who had completed a 2-month post-treatment esophageal pH study off acid-lower agents were included. We also included patients who underwent EGD but did not undergo pH monitoring due to finding erosive esophagitis. Patients with a history of prior myotomy or who underwent Heller without Dor fundoplication were excluded. Results: Of the 236 patients included, 85 (36%) had undergone POEM while 151 (64%) had undergone LHM. Overall, 45% of POEM patients experienced more than 30 reflux episodes per day compared to 12% for LHM, p< 0.001. POEM patients had more GER in all positions compared to LHM, identified by a mean total % time spent in reflux of 9.3% vs 3.2%, upright 7.8% vs 2.6%, and supine 10.1% vs 3.5%, p< 0.001 for all. POEM patients also developed significantly more long refluxes (episodes > 5 minutes) per day (4.0 vs 1.7, p< 0.001). 47% of POEM patients experienced at least one reflux episode longer than 30 minutes, compared to 19% of LHM patients (p< 0.001). POEM patients who developed relatively more reflux in the supine position than upright comprised 41.1% compared to 21.7% of LHM, p=0.007. Conclusion: This study sheds light on the pattern of reflux in POEM as compared to LHM. POEM patients had evidence of significantly more esophageal acid exposure across all indices. POEM patients on average spent 9.3% of their day in reflux as compared to 3.2% for LHM. POEM patients had higher supine to upright ratios of reflux exposure. The finding of abnormal reflux in both the upright and supine position, with relative skew towards supine reflux after POEM may help to better tailor anti-reflux therapies in this population (Table). Table 1. - Reflux pattern differences between POEM and LHM. p-value significant if p<0.05 Characteristic POEM LHM p-value TOTAL Number of refluxes /24h 40.0 15.4 < 0.001 Percent time in reflux 9.3% 3.2% < 0.001 Number of long refluxes /24h 4.0 1.7 < 0.001 Average of longest reflux (mins) 45.7 19.0 < 0.001 UPRIGHT Number of refluxes /1h 1.8 0.6 < 0.001 Percent time in reflux 7.8% 2.6% < 0.001 Number of long refluxes /1h 0.18 0.06 < 0.001 Average of longest reflux (minutes) 19.0 9.9 < 0.001 SUPINE Number of refluxes /24h 1.4 0.5 0.003 Percent time in reflux 10.1% 3.5% < 0.001 Number of long refluxes /1h 0.2 0.1 0.001 Average of longest reflux (minutes) 35.8 12.4 < 0.001 OVERALL DeMeester Score 37.2 13.2 < 0.001 % Time reflux in supine/upright >1 41.1% 21.7% 0.007

Squamous Cancer of the Esophagus in Africa: A Causal Pathway Established

Squamous cancer of the esophagus has been endemic in much of East, Central and Southern Africa since the 1940s. Much research has concentrated on attempts to identify major carcinogenic influences, and failure to do so has made it clear that the problem in high incidence areas (HIAs) is not primarily of potent environmental carcinogens, but of population susceptibility. In Africa the association with maize is constant and strong. Research in the last decade has helped to explain that association. Considered along with historical findings there is now enough evidence to establish causal associations of a nutritionally deficient maize diet and use of maize meal with squamous cancer of the esophagus. Evidence is available in a high incidence area of degenerating maize meal resulting in excess production of PGE2, gastric hypochlorhydria and a predominant pattern of non-acid gastroesophageal reflux. This pathway explains the existence of major population susceptibility: a poor maize-based diet provides specific nutritional deficiencies and n-6 fatty acid dominance which cause failure of homeostasis of the arachidonic acid cascade; with this background chemically degenerating maize meal then triggers duodenogastric reflux and non-acid gastro-esophageal reflux; non-acid reflux causes squamous cancer of the esophagus. Within a susceptible population, environmental carcinogens including tobacco increase individual risk. There is sufficient evidence that this is an active pathway, and the dominant pathway to SCCE in high incidence areas in Africa.There is sufficient evidence to justify appropriate preventative measures.

Near Infrared Fluorescence Imaging to Demonstrate Reflux in the Superficial Microvenous Network of the Leg

Reflux within the superficial microvenous network may play a critical role in the development of skin changes which can be associated with chronic venous insufficiency. This study aimed to determine if near infrared fluorescence (NIRF) imaging could be used to accurately determine superficial venous reflux in the leg. A total of nine limbs were examined exvivo from patients undergoing limb amputation for peripheral arterial disease. Cannulation of the distal great saphenous vein was used to sequentially perform Xray contrast enhanced venography, NIRF imaging, and venous corrosion casts. Fluorescence imaging visualised a range of different microvenous reflux patterns exvivo, which were generally not evident by Xray venography but were consistent with retrograde resin vascular casts. These included both focal and diffuse regions of fluorescence within the skin and, consistent with previous observations, the vascular casts indicated that regions of venous reflux were typically associated with incompetent valves. The findings from this study suggest a potential method for investigating early stage superficial venous disease, prior to the appearance of visible signs of advanced venous disease, such as skin changes. However, further studies are required to confirm the invivo clinical utility of these observations.

Effect of hiatus hernia on reflux patterns and mucosal integrity in patients with non-erosive reflux disease.

Hiatus hernia (HH) contributes to development of gastroesophageal reflux disease, Barrett's esophagus and esophageal adenocarcinoma. This study was aimed to investigate the influence of HH on reflux patterns and distal esophageal mucosal integrity in non-erosive reflux disease (NERD). We retrospectively analyzed PPI-refractory NERD patients referred to three tertiary referral centers who underwent high-resolution manometry and off-PPI 24-h impedance-pH monitoring (with or without bile spectrophotometry). Patients with HH ≥2cm (HH group, n=42) or no HH (non-HH group, n=40) with similar esophageal acid exposure time (AET 6%-12%) were included. Age, gender, BMI, esophageal motility, AET, and esophageal clearance were similar between the two groups. The HH group had higher numbers of total reflux episodes (p=0.015) with similar proportion of acid/non-acid reflux compared with the non-HH group. Mean nocturnal baseline impedance (MNBI) in the distal esophagus was significantly lower in the HH group than the non-HH group at both 5cm (p=0.002) and 3cm (p=0.015) above the lower esophageal sphincter. Multivariable regression analysis showed that HH, less non-acid reflux and lower post-reflux swallow-induced peristaltic wave index (PSPWI) were independently associated with lower MNBI. Among 31 patients tested with bile spectrophotometry, the HH group had significantly longer bile exposure time than the non-HH group (p=0.011), and bile reflux inversely and significantly correlated with MNBI (rho=-0.75, p &lt; 0.001). Hiatus hernia, less non-acid reflux and lower PSPWI were associated with lower MNBI. HH impairs distal esophageal mucosal integrity, the mechanism of which we speculate to be through excessive bile reflux.