Reflux In Patients Research Articles

Short-term outcomes of the conversion of one anastomosis gastric bypass to Roux-en-Y gastric bypass in symptomatic reflux patients without revising the size of the gastric pouch.

Background:Revising the size of the gastric pouch during the conversion of one anastomosis gastric bypass (OAGB)/mini-gastric bypass to Roux-en-Y gastric bypass (RYGB) is an important point. Even in patients undergoing RYGB, marginal ulcer is regarded as a known complication.Materials and Methods:In our Centre of Excellence in Bariatric and Metabolic Surgery, 2492 patients underwent OAGB from February 2012 to January 2019. Twelve of 2492 patients were enrolled in this clinical case series because of persistent gastroesophageal reflux-like symptoms which underwent conversional RYGB. All patients regularly received proton-pump inhibitors (PPIs) for 6 months after the surgery. After this period, the cases with symptomatic reflux were invited to be visited in the clinic by a bariatric surgeon and a gastroenterologist and received 6 months of PPI therapy until their symptoms disappeared. Twelve refractory reflux cases underwent conversional RYGB after 1 year. An enteroenterostomy was created in all the patients 75 cm distal to the gastrojejunostomy without resizing the gastric pouch, and the jejunal loop was cut just before the gastrojejunostomy.Results:Before conversional surgery, mean ± standard deviation (SD) body mass index (BMI) and gastroesophageal reflux disease (GERD)-Q score were found to be 26.45 ± 2.34 kg/m2 and 10.08 ± 0.56, respectively. At 1 year after conversion, mean ± SD BMI in the patients was 28.12 ± 4.71, and GERD-Q score was 5.08 ± 1.5.Conclusion:It seems that resizing the gastric pouch is not necessary during the conversion of OAGB to RYGB.

Laryngopharyngeal reflux, gastroesophageal reflux and dental disorders: A systematic review.

To investigate the role of gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) in the development of dental disorders. The first outcome was review of the role of reflux in the development of dental disorders in adults. The second outcome was review of the potential pathophysiological mechanisms underlying the association between reflux and dental disorders. Three investigators screened publications for eligibility and exclusion based on predetermined criteria through a literature search conducted on PubMed, Cochrane Library, and Scopus according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). From 386 publications, 24 studies were kept for analysis. Objective approaches were used in 16 studies to confirm GERD diagnosis. Pharyngeal reflux episodes (LPR) were considered in 2 studies. No study considered nonacid reflux. The study results supported a higher prevalence of dental erosion and caries in reflux patients compared with healthy individuals. Patients with dental erosion have a higher prevalence of reflux than controls. The pathophysiological mechanisms would involve changes in the saliva physiology. No study investigated the microbiota modifications related to reflux although the findings are supporting the critical role of microbiota change in the development of dental disorders. There is an important heterogeneity between studies about diagnostic methods and clinical outcome evaluation. The involvement of reflux in the development of dental disorders is not formally demonstrated and requires future investigations considering pharyngeal acid and nonacid reflux episodes and in particular their potential impact on oral microbiota.

The Correlation between the Characteristic of Reflux Based on 24 Hours-Multichannel Intraluminal ImpedancePh Monitoring with the Quality of Life of Refractory Laryngopharyngeal Reflux Patients

The evaluation of the quality of life of LPR patients is crucial to assess the success of medical therapy and help with diagnosis. Assessment of life quality of patients with refsractory LPR by using the selected LPR HRQL questionnaire because it is more practical to use, easy to set scoring and analyze data. Objective: This study aims at investigating the reflux characteristic and the correlation with refractory Laryngopharyngeal Reflux (LPR) patients quality of life. Method: The examination is performed on ten refractory LPR patients using 24hour - MultichanneI Intraluminal Impedance pH monitoring, then grouped according to the characteristics of the reflux acid, non-acidic, and mixed. Furthermore, the assessment of life quality by using LPR-HRQL questionnaire. Data analysis using Chi-Square and Spearman’s Rho methods. Results: The sampleLPR refractory is generally female (66.7%), while males (33.3%). Mixed reflux type as much as 44.4%, then 33.3% acid reflux, and a non-acidic reflux 22.2%. LPR occurrence of majority at upright position (66.7%). Non-acid reflux patients consistently for all symptoms/complaints, indicating quality of life is disrupted based on questionnaires found in the LPR-HRQL (100%). Conclusion: The quality of life of non-acid reflux patients is more disturbed than the acidic and mixed reflux group.

Straight leg raise metrics on high‐resolution manometry associate with esophageal reflux burden

Straight leg raise (SLR) is a provocative maneuver that assesses esophagogastric junction (EGJ) barrier function during high-resolution manometry (HRM). We evaluated the value of SLR in symptomatic reflux patients undergoing ambulatory reflux monitoring. Adult patients being evaluated for reflux symptoms with esophageal physiologic testing off antisecretory therapy over a 12month period were studied. Demographics, clinical presentation, HRM studies, and reflux monitoring studies were analyzed. Intra-abdominal and intra-esophageal pressures were extracted at baseline and during SLR from HRM studies. Acid exposure time (AET) was derived from reflux monitoring studies, and EGJ morphology and tone from HRM studies. SLR pressure metrics predicting abnormal AET were evaluated. Of 122 patients, 70 (57.4%) had ≥50% peak intra-abdominal pressure increase during SLR (58.0±1.4years, 75.7% female). Peak intra-esophageal pressure gradient between baseline and SLR predicted pathologic AET when ≥100% (AUC 0.78, sensitivity 71%, specificity 75%, P<.001), seen in 60.7% with AET>6%, but only 23.7% with AET<4% (P=.01). Peak intra-esophageal pressure gradient ≥100% was most discriminative in identifying abnormal acid burden in type 1 EGJ morphology (P=.005) but trended toward significance in type 2 and type 3 morphology (P=.1). Normal and abnormal EGJ contractile integral did not associate with peak intra-esophageal pressure gradient either collectively or when subdivided by EGJ morphology (P≥.2). Analysis of intra-esophageal pressure gradients during SLR, a simple HRM maneuver, may augment evaluation of symptomatic GERD, and provide adjunctive evidence supporting GERD.

Role of Rapid Drink Challenge During Esophageal High-resolution Manometry in Predicting Outcome of Peroral Endoscopic Myotomy in Patients With Achalasia.

Background/AimsPeroral endoscopy myotomy (POEM) is effective to treat achalasia. We aim to determine POEM effect on esophageal function and search for predictive factors of response to POEM and co-occurrence of gastroesophageal reflux disease (GERD).MethodsA total of 64 untreated achalasia patients who underwent high-resolution manometry (HRM) before and 3 months after POEM were retrospectively included. Response to treatment was defined as an Eckardt score < 3. Reflux symptoms and patient's satisfaction were evaluated. Data were compared using paired t test, Chi-square test or log rank test.ResultsThe 2-year success rate in response to POEM was 90%. All responders reported being satisfied while only 33% of non-responders did (P < 0.001) and 64% of patients with reflux symptoms were satisfied versus 96% of those without (P = 0.009). On HRM, the integrated relaxation pressure and the contractile pattern changed significantly after POEM but were not predictive of response. Between pre and post POEM HRM, a decrease in maximal esophageal pressurization during rapid drink challenge (RDC) was associated with a better response rate than an increase of pressurization (91% vs 50%, P = 0.004). As evidenced by pH monitoring performed after POEM, GERD was pathological or borderline in 50% of patients (18/36) while only 19% (11/59) reported clinically significant reflux symptoms. On post POEM HRM, maximal esophageal pressurization during RDC was lower in patients with pathological or borderline GERD compared to those without (P = 0.054).ConclusionsEsophageal HRM parameters changed significantly after POEM. Maximal esophageal pressurization during RDC may be useful to predict outcome.

Age-related outcomes in laparoscopic hiatal hernia repair: Is there a "too old" for antireflux surgery?

Minimally invasive antireflux surgery has been shown to be safe and effective for the treatment of gastroesophageal reflux (GERD) in elderly patients. However, there is a paucity of data on the influence of advanced age on long-term quality of life (QoL) and perioperative outcomes after laparoscopic antireflux surgery (LARS). A retrospective study of patients undergoing LARS between February 2012 and June 2018 at a single institution was conducted. Patients were divided into four age categories. Perioperative data and quality of life (QOL) outcomes were collected and analyzed. A total of 492 patients, with mean follow-up of 21months post surgery, were included in the final analysis. Patients were divided into four age-determined subgroups (< 50:75, 50-65:179, 65-75:144, ≥ 75:94). Advancing age was associated with increasing likelihood of comorbid disease. Older patients were significantly more likely to require Collis gastroplasty (OR 2.09), or concurrent gastropexy (OR 3.20). Older surgical patients also demonstrated increased operative time (ß 6.29, p < .001), length of hospital stay (ß 0.56, p < .001) in addition to increased likelihood of intraoperative complications (OR 2.94, p = .003) and reoperations (OR 2.36, p < .05). However, postoperative QoL outcomes and complication rates were parallel among all age groups. Among older patients, there is a greater risk of intraoperative complications, reoperation rates as well as longer operative time and LOS after LARS. However, a long-term QoL benefit is demonstrated among elderly patients who have undergone this procedure. Rather than serving as an exclusion criterion for surgical intervention, advanced age among chronic reflux patients should instead represent a comorbidity addressed in the planning stages of LARS.

Predictors of reflux aspiration and laryngo-pharyngeal reflux.

Gastro-esophageal reflux disease (GERD) can present with typical or atypical or laryngo-pharyngeal reflux (LPR) symptoms. Pulmonary aspiration of gastric refluxate is one of the most serious variants of reflux disease as its complications are difficult to diagnose and treat. The aim of this study was to establish predictors of pulmonary aspiration and LPR symptoms. Records of 361 consecutive patient from a prospectively populated database were analyzed. Patients were categorized by symptom profile as predominantly LPR or GERD (98 GER and 263 LPR). Presenting symptom profile, pH studies, esophageal manometry and scintigraphy and the relationships were analyzed. Severe esophageal dysmotility was significantly more common in the LPR group (p = 0.037). Severe esophageal dysmotility was strongly associated with isotope aspiration in all patients (p = 0.001). Pulmonary aspiration on scintigraphy was present in 24% of patients. Significant correlation was established between total proximal acid on 24-h pH monitoring and isotope aspiration in both groups (p < 0.01). Rising pharyngeal curves on scintigraphy were the strongest predictors of isotope aspiration (p < 0.01). Severe esophageal dysmotility correlates with LPR symptoms and reflux aspiration in LPR and GERD. Abnormal proximal acid score on 24-h pH monitoring associated with pulmonary aspiration in reflux patients. Pharyngeal contamination on scintigraphy was the strongest predictor of pulmonary aspiration.

Machine Learning Aided Diagnosis of Diseases Without Clinical Gold Standard: A New Score for Laryngopharyngeal Reflux Disease Based on pH Monitoring

Objective: Laryngopharyngeal Reflux Disease (LPRD) is prevalent and has a range of symptoms. However, diagnosing LPRD is difficult because of the lack of specific symptoms or clinical gold standard. An objective and reliable test, which does not rely on a perfect clinical gold standard, is required in clinical practice. Methods: 60 normal volunteers and 74 confirmed Laryngopharyngeal Reflux (LPR) patients were labelled based on the combined consideration of the reflux symptom index, reflux finding score, 24h oropharyngeal pH monitoring and results of anti-reflux treatment. 72 candidate features were extracted from pH recordings and the most efficient feature combination was detected using a stepwise wrapper method. The labelled data were combined with 1552 unlabelled data for feature selection and model training using semi-supervised learning. A latent class model method was used to assess the proposed model based on 64 additional validation data and an imperfect clinical reference test. Results: A new score (named W score), which significantly improved the sensitivity of the LPRD test (82.67% vs. 24.09%) and has a relatively high specificity (80.19%), was proposed. W score concurs with the complicated clinical test. Conclusion: W score which significantly improves LPRD diagnostic efficiency, can aid the clinical diagnosis of LPRD. W score provides an objective, efficient, and reliable indicator for the application of anti-reflux treatment in clinical practice. Significance: More LPRD patients can benefit from anti-reflux treatment in clinical practice and fewer patients may suffer from, for example, the side effects of unnecessary long-term Proton Pump Inhibitors (PPI) treatments.

Gastroesophageal reflux in laryngopharyngeal reflux patients: Clinical features and therapeutic response.

To investigate the clinical features and the therapeutic response of laryngopharyngeal reflux (LPR) patients with or without gastroesophageal reflux disease (GERD). Patients with LPR symptoms were enrolled from three European Hospitals. The diagnosis of LPR and GERD was made through impedance-pH monitoring (MII-pH). A gastrointestinal endoscopy was realized in patients with digestive complaints or ≥60 years old. The 3- to 6-month treatment was based on the association of diet, pantoprazole, alginate, and magaldrate regarding the MII-pH characteristics. Reflux Symptom Score (RSS) and Reflux Sign Assessment (RSA) were used to evaluate the clinical evolution throughout treatment. The gastrointestinal endoscopy findings, clinical features, and therapeutic response were compared between patients with LPR and GERD (LPR/GERD) and patients with LPR. One hundred and eleven LPR patients were included, 54 being LPR/GERD. LPR/GERD patients had a higher number of proximal reflux episodes compared with LPR patients. The prevalence of esophagitis, hernia hiatal, and lower esophageal sphincter insufficiency did not differ between groups. The presence of GERD was strongly associated with acid LPR. Patients without GERD had a higher proportion of nonacid and mixed LPR compared with LPR/GERD patients. The pre- to posttreatment evolutions of RSS and RSA were quite similar in both groups, with the exception of the 3- to 6-month improvement of digestive symptoms, which was better in LPR/GERD group. The therapeutic success rates were 79.6% and 77.2% in GERD/LPR and LPR group, respectively. GERD is predictive of acid LPR. The clinical evolution and the therapeutic response rates were quite similar in both groups. 4 Laryngoscope, 130: E479-E489, 2020.

Validation of Peptest™ in Patients with Gastro-Esophageal Reflux Disease and Laryngopharyngeal Reflux Undergoing Impedance Testing

Pepsin in the gastric refluxate is a marker for a prior reflux event and rapid detection might be achieved using the Peptest™, an in vitro diagnostic medical device. The aim of this study was to validate the use of Peptest™ to reliably diagnose reflux in patients with gastro-esophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) disease diagnosed with multichannel intraluminal impedance/ pHmetry (MII-pH). 20 reflux patients were recruited of whom 10 had classical GERD and 10 had LPR. All patients underwent MII-pH and provided expectorated saliva samples when a MII-pH reflux event was observed, or reflux symptoms were experienced, and all were tested for the presence of pepsin using the Peptest™. Pepsin was detected in 31 out of 45 samples (68.9%). At least 1 positive pepsin result was seen in 16 patients (80%) and this was the same, irrespective of the GERD or LPR diagnosis. Peptest™ had a positive predictive value of 69% to detect MII-pH reflux events. Peptest™ is a good first-line diagnostic procedure to use in reflux sufferers to confirm the presence of reflux.

Nissen fundoplication and dyspeptic symptoms: is the water load test useful?

The water load test is a simple, cheap and standardized method to evaluate gastric distension and gastric motility responses. We have previously shown that in patients with mild erosive or non-erosive esophagitis this test is frequently abnormal, suggesting an altered gastric function. The aim was to evaluate the water load test score before and after Nissen fundoplication in reflux patients. Thirty-one patients (16 men, 15 women, mean age 46.5 y) were studied before and 3 months after Nissen fundoplication by stationary esophageal manometry, wireless Bravo pH system monitoring (48 hours), and water load test. A dyspepsia symptom questionnaire was also completed before and after surgery. Data were compared with those of 35 controls. All patients had pH-monitoring positive for pathological acid exposure and/or related-reflux symptoms in the absence of motility disorders. Basal symptoms scores were higher in patients compared to controls and improved after surgery, except than postprandial fullness, early satiation, and bloating, that were significantly increased. At baseline, all patients ingested significantly lower water volumes than controls, with a tendency to early onset of fullness and nausea, respectively. After surgery, the water volumes were significantly lower than presurgery. In patients with reflux-related symptoms, with or without esophagitis, the water load test is frequently abnormal, suggesting an altered gastric function. Nissen fundoplication is associated with a relatively higher incidence of bloating, epigastric pain and fullness. These preliminary data could explain the incomplete resolution of symptoms after surgery in some patients, and suggest the use of additional studies to explore the gastric function in presurgical evaluation.

552 Exploring the Role of Gastrointestinal Motility and Non-Acid Reflux in Lung Transplant Prognosis and Risk of Acute Rejection

INTRODUCTION: Lung transplant patients are at risk of developing acute rejection leading to bronchiolitis obliterans syndrome (BOS). Lung transplant patients are also known to have and/or develop gastroesophageal reflux. Acid gastroesophageal reflux has been correlated with risk of acute rejection and consequently BOS. There is however a paucity of data correlating non-acid reflux with risk of acute rejection. Our study investigated the role of non-acid reflux with lung transplant rejection. METHODS: 131 lung transplant recipients who had post-transplant evaluation between 2012 and 2019 were studied. A total of 64 lung transplant recipients had at least 3 months of post-transplant follow up consisting of 24 hour impedance pH testing, and high-resolution manometry (HREM). Patient characteristics were summarized with counts and percentages, means and SD, or medians and interquartile ranges (IQR) as appropriate to scale and distribution. The characteristics of those with and without rejection diagnoses was compared with Fisher's exact test for categorical variables and the Wilcoxon rank sum test for quantitative variables. Analyses were conducted in the open source R software environment. RESULTS: 60 of 64 patients (94%) were alive at one-year post- lung transplant. The majority of patients had bilateral transplants and were Caucasian males with average age of 59 years. At one year there were 12 deaths. Patients with a diagnosis of acute rejection were less likely to exhibit gastroparesis (1% vs. 9%) and abnormal pH (28% vs. 45%). Acute rejection patients were more likely to exhibit GERD (53% vs. 45%), more non-acid episodes (median 19 vs. 15.5), higher reported symptom association (51% vs. 41%), on impedance pH; abnormal UES (56% vs. 45%), and abnormal body (86% vs. 77%) on HREM (Table 1). However, no differences were statistically significant (all P &gt; .18), and conclusions cannot be generalized. CONCLUSION: Patients undergoing lung transplantation were found to have a high incidence of abnormal gastroesophageal motility studies, including both acid and non-acid reflux. Developing a protocolized pre- and post- transplant motility evaluation process for lung transplant patients may help identify those at greatest risk for acute rejection. Continued evaluation post-transplantation to establish therapeutic interventions in both acid and non-acid reflux patients to prevent lung transplant rejection appears warranted.

Characteristics of upright versus supine reflux pattern in patients with laryngopharyngeal reflux

IntroductionMany laryngeal-related problems have been attributed to laryngopharyngeal reflux including dysphonia, frequent throat clearing, chronic cough, and globus sensation. However, there is still controversy regarding diagnosis and clinical presentation of this disorder. ObjectiveThe main objective of this study is to describe laryngopharyngeal reflux characteristics of different reflux position patterns in laryngopharyngeal reflux patients diagnosed with oropharyngeal pH monitoring. MethodsA retrospective chart review was conducted for 161 laryngopharyngeal reflux patients diagnosed with 24h oro-pharyngeal pH monitoring. Study subjects were categorized into upright and supine laryngopharyngeal reflux groups based on the pH results. The two groups were compared regarding the clinical presentation and pH characteristics. ResultsSignificant higher rates of upright laryngopharyngeal reflux position than supine laryngopharyngeal reflux position (P<0.0001) were reported among the study group. Reflux symptoms index results were significantly higher in the upright larybgopharyngeal reflux group compared to the supine laryngopharyngeal reflux group. 24h oropharyngeal pH measurements composite Ryan score was significantly higher in the upright group compared to the supine group (P<0.0001). No significant difference was found between the upright and supine laryngopharyngeal reflux groups regarding the frequency of clinical presentation or voice handicap index ratings. ConclusionLaryngopharyngeal reflux was found to be more prevalent occurring in the upright position among the study group. Reflux-related characteristics including pH parameters were more evident in the upright laryngopharyngeal reflux position.

Role of fundoplication in treatment of patients with symptoms of hiatal hernia

Gastroesophageal reflux disease (GERD) is often associated with hiatal hernia (HH). However, the need for fundoplication during hiatal hernia repair (HHR) remains controversial. The objective of this study was to evaluate the effect of HHR with concomitant laparoscopic Nissen fundoplication (HHR-LNF) in HH patients. A total of 122 patients with symptomatic HH were randomized to receive either HHR (n = 61) or HHR-LNF (n = 61). The measures of evaluating outcomes included DeMeester scores (DMS), complications, Reflux Diagnostic Questionnaire and patients’ satisfaction 24 months following surgery. Despite comparable values in both groups at randomization, the DMS, total numbers of reflux episodes and percentage of time with pH < 4 were significantly higher in HHR group than in HHR-LNF group (P = 0.017, P = 0.002 and P = 0.019, respectively) at 6 months after surgery. One months postoperatively, complications were higher in the HHR-LNF group than in the HHR group (all P < 0.001), and there was no difference between the two groups at 6 months. By the end of the 2-year follow-up, HHR-LNF group showed a significantly lower reflux syndrome frequency-intensity score and greater percentage of satisfaction compared with HHR group (all P < 0.001). Laparoscopic HHR should be combined with a fundoplication in GERD patients with HH. HHR-LNF is safe and effective, not only improve reflux-related symptom, but also reduce the incidence of complications.

Saliva pepsin level of laryngopharyngeal reflux patients is not correlated with reflux episodes.

To investigate the relationship between the laryngopharyngeal reflux (LPR) episodes at the multichannel intraluminal impedance-pH monitoring (MII-pH) and the concentration of pepsin in the saliva of LPR patients. Patients with LPR were enrolled from the polyclinic of Poitiers, France. Patients benefited from 24-hour MII-pH that allowed a correlation study between reflux episodes and symptoms. Patients reported the occurrence of the critical symptoms during the testing period through a recording device. Simultaneously, they collected a first saliva sample 30 minutes after the symptoms and a second saliva collection a few hours after the first collection. The patient symptoms were assessed with reflux symptom score (RSS). The relationship between pepsin concentration in the saliva, symptoms, and the reflux episode characteristics at the MII-pH was investigated through multiple linear regression. A total of 65 patients with LPR were recruited. The mean concentrations of the first and the second pepsin samples were 92.0 ± 108.1 and 101.8 ± 131.0, respectively. Peptest (RD Biomed, Milan, Italy) was positive in 51 LPR patients (78.5%). Concentrations of both pepsin samples were significantly correlated (P = 0.019). There was no significant association between pepsin concentrations in saliva samples, RSS, key symptoms during the test period, and MII-pH findings. The level of pepsin saliva concentration is not associated with the reflux episodes at the MII-pH. Future studies are needed to better understand the relationship between the extracellular pepsin concentration, mucosal inflammation, and related laryngopharyngeal symptoms. 4 Laryngoscope, 130:1278-1281, 2020.

The influence of gastroesophageal reflux symptoms on patient satisfaction after sleeve gastrectomy

BackgroundSleeve gastrectomy has become the most common procedure performed for weight loss. But emerging data indicate that this procedure can result in lifestyle-limiting gastroesophageal reflux disease. The influence of these gastroesophageal reflux disease symptoms on patient satisfaction with the procedure has not been explored. MethodsUsing a statewide, bariatric-specific data registry, we studied 6,608 patients who underwent laparoscopic sleeve gastrectomy from 2013 to 2017. We used the Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaire, which is 10 questions, each ranging from 0 (no symptoms) to 5 (severe symptoms). To assess the impact of sleeve gastrectomy on patient satisfaction, we calculated the change in this score at baseline versus 1 year after the procedure. We stratified the change in the gastroesophageal reflux disease score into 5 even-sized groups (quintiles). We then examined the relationship between change in the gastroesophageal reflux disease score and patient satisfaction at 1 year. We used generalized linear mixed models to assess the variation in patient satisfaction explained by the change in the gastroesophageal reflux disease score, excess body weight loss at 1 year, and other patient outcomes (serious complications, readmission, and reoperations). We controlled for patient factors (age, sex, race, and comorbidities) and year of sleeve gastrectomy. ResultsThe average change in the gastroesophageal reflux disease score was 1.62 (range: –48 to 48); however, the change in the gastroesophageal reflux disease score varied across quintiles with a –7.3-point (range: –48 to –3) worsening in the bottom quintile versus a 2.6-point (range: 7 to 48) improvement in the top quintile. Overall, 77.7% of patients were satisfied, but the proportion of patients satisfied was highly dependent on whether their reflux symptoms improved or worsened. Only 48.9% in the bottom quintile were satisfied, compared with 78.1% in the top quintile (<.0001). In the multivariate model, changes in patient-reported gastroesophageal reflux disease score were the most predictive of patient satisfaction, explaining 10.1% of the variation in 1 year satisfaction. Among patients in the bottom quintile, reflux symptoms explained 30.2% of variation compared with 2.3% in quintiles with little change or improvement in reflux. Moreover, excess body weight loss explained only 2% of variation in satisfaction and <1% was explained by patient outcomes (serious complications, readmissions, reoperations, or surgical complications). ConclusionIn this statewide study of sleeve gastrectomy, we demonstrated that gastroesophageal reflux symptoms are an important determinant of 1 year satisfaction, particularly among patients whose symptoms worsened the most.

DNA copy number variations in children with vesicoureteral reflux and urinary tract infections.

Vesicoureteral reflux (VUR) is a complex, heritable disorder. Genome-wide linkage analyses of families affected by VUR have revealed multiple genomic loci linked to VUR. These loci normally harbor a number of genes whose biologically functional variant is yet to be identified. DNA copy number variations (CNVs) have not been extensively studied at high resolution in VUR patients. In this study, we performed array comparative genomic hybridization (aCGH) on a cohort of patients with a history of both VUR and urinary tract infection (UTI) with the objective of identifying genetic variations responsible for VUR and/or UTI susceptibility. UTI/VUR-associated CNVs were identified by aCGH results from the 192 Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) patients compared to 683 controls. Rare, large CNVs that are likely pathogenic and lead to VUR development were identified using stringent analysis criteria. Because UTI is a common affliction with multiple risk factors, we utilized standard analysis to identify potential disease-modifying CNVs that can contribute to UTI risk. Gene ontology analysis identified that CNVs in innate immunity and development genes were enriched in RIVUR patients. CNVs affecting innate immune genes may contribute to UTI susceptibility in VUR patients and may provide the first step in assisting clinical medicine in determining adverse outcome risk in children with VUR.

The management of suspected or confirmed laryngopharyngeal reflux patients with recalcitrant symptoms: A contemporary review.

To summarise current knowledge about the prevalence, aetiology and management of recalcitrant laryngopharyngeal reflux (LPR) patients-those who do not respond to anti-reflux medical treatment. A literature search was conducted following the PRISMA guidelines to identify studies that reported success of anti-reflux medical treatment with emphasis on studies that attempted to be rigorous in defining a population of LPR patients and which subsequently explored the characteristics of non-responder patients (ie aetiology of resistance; differential diagnoses; management and treatment). Three investigators screened publications for eligibility from PubMED, Cochrane Library and Scopus and excluded studies based on predetermined criteria. Design, diagnostic method, exclusion criteria, treatment characteristics, follow-up and quality of outcome assessment were evaluated. Of the 139 articles screened, 45 met the inclusion criteria. The definition of non-responder patients varied substantially from one study to another and often did not include laryngopharyngeal signs. The reported success rate of conventional therapeutic trials ranged from 17% to 87% and depended on diagnostic criteria, treatment scheme, definition of treatment failure and treatment outcomes that varied substantially between studies. The management of non-responders differed between studies with a few differential diagnoses reported. No study considered the profile of reflux (acidic, weakly acid, non-acid or mixed) or addressed personalised treatment with the addition of alginate or magaldrate, low acid diet, or other interventions that have emerging evidence of efficacy. To date, there is no standardised management of LPR patients who do not respond to traditional treatment approached. A diagnostic and therapeutic algorithm is proposed to improve the management of these patients. Future studies will be necessary to confirm the efficacy of this algorithm through large cohort studies of non-responder LPR patients. 2a.

Hiatal hernia and morbid obesity—‘Roux-en-Y gastric bypass’ the one step solution

Obesity and hiatal hernia go hand in hand as siblings. Morbidly obese patients commonly have gastroesophageal reflux (GERD) and associated hiatal hernias (HH). The gold standard for all symptomatic reflux patients is still surgical correction of the paraesophageal hernia, hiatal closure and fundoplication. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is an effective surgical treatment for morbid obesity and is known to effectively control symptoms of gastroesophageal reflux (GERD). It appears to be safe and feasible and becoming more common. Moreover, LRYGB plus Hiatus hernia repair (HHR) appears to be a good alternative for HH patients suffering from morbid obesity as well than antireflux surgery alone because of the additional benefit of significant weight loss and improvement of obesity related co-morbidity. One patient suffering from giant hiatal hernia and morbid obesity where a combined LRYGB and HHR without mesh was performed is presented in this paper.

Clinical Significance of Esophageal Outflow Resistance Imposed by a Nissen Fundoplication

Attention has been focused on the amplitude of esophageal body contraction to avoid persistent dysphagia after a Nissen fundoplication. The current recommended level is a contraction amplitude in the distal third of esophagus above the fifth percentile. We hypothesized that a more physiologic approach is to measure outflow resistance imposed by a fundoplication, which needs to be overcome by the esophageal contraction amplitude. The esophageal outflow resistance, as reflected by the intra-bolus pressure (iBP) measured 5 cm above the lower esophageal sphincter (LES), was measured in 53 normal subjects and 37 reflux patients with normal esophageal contraction amplitude, before and after a standardized Nissen fundoplication. All were free of postoperative dysphagia. A test population of 100 patients who had a Nissen fundoplication was used to validate the threshold of outflow resistance to avoid persistent postoperative dysphagia. The mean (SD) amplitude of the iBP in normal subjects was 6.8 (3.7) mmHg and in patients before fundoplication was 3.6 (7.0) mmHg (p= 0.003). After Nissen fundoplication, the mean (SD) amplitude of the iBP increased to 12.0 (3.2) mmHg (p < 0.0001 vs normal subjects or preoperative values). The 95th percentile value for iBP after a Nissen fundoplication was 20.0 mmHg and was exceeded by esophageal contraction in all patients in the validation population, and 97% of these patients were free of persistent postoperative dysphagia at a median 50-month follow-up. Nissen fundoplication increases the outflow resistance of the esophagus and should be constructed to avoid an iBP > 20 mmHg. Patients whose distal third esophageal contraction amplitude is >20 mmHg have a minimal risk of dysphagia after a tension-free Nissen fundoplication.