Gastroesophageal Reflux Disease Research Articles

Sliding hiatus hernia (intrathoracic sleeve migration) post-laparoscopic sleeve gastrectomy: A case series and review of literature.

Intrathoracic sleeve migration (ITSM) is a complication that uncommonly occurs post-sleeve gastrectomy, with an incidence rate anecdotally ranging from 5% to 45%. Its treatment has established difficulties by bariatric surgeons worldwide. Sixteen cases were shown in this case series that commonly encountered the symptoms of weight gain, gastro-oesophageal reflux disease (GERD), epigastric pain, globus sensation, nausea and vomiting as their initial complaints before their diagnosis. Moreover, these symptoms began a few years after the gastric sleeve. The confirmatory results through gastrografin and computed tomography abdomen were performed where relevant findings of Grade I or II GERD, sliding hiatal hernia and post-sleeve anatomy were appreciated. In literature, the most common modality used to treat ITSM was the conversion to Roux-en-Y bypass. However, other treatment modalities were also utilised for the cases presented due to the different patients' preferences, including mini-gastric bypass and laparoscopic hiatal hernia repair with/without posterior cruroplasty and buttress plication with the falciform ligament. In addition, anchoring to pre-pancreatic fascia post-gastric sleeve has been shown to prevent such presentations further in the future. Postoperatively, all patients were stable with no complications acutely or after 3 months follow-up. Hence, this concludes that despite Roux-en-Y being considered the golden standard treatment of ITSM, laparoscopic hiatal hernia repair with cruroplasty and plication reflects an equivalent, cost-effective and valuable alternative to treating relevant patients.

The Link Between Metabolic Dysfunction-Associated Steatotic Liver Disease and Gastroesophageal Reflux Disease.

Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly nonalcoholic fatty liver disease (NAFLD), and gastroesophageal reflux disease (GERD) are prevalent chronic conditions with escalating global incidence. This study delves into the intricate interplay between MASLD and GERD. The primary objective is to comprehensively explore the association between MASLD and GERD, investigating how various factors contribute to the coexistence and potential exacerbation of these conditions. We conducted a literature search in PubMed and Google Scholar of only human studies over the past 10 years. The search included systematic review, meta-analysis, editorial, and cross-sectional studies of patients with MASLD and GERD. The prevalence of GERD in patients with MASLD was higher, with various risk factors coming into play. Obesity was identified as an independent risk factor for both GERD and MASLD. However, obese patients predominantly had higher disease progression. Lifestyle factors like physical activity and dietary modifications emerge as promising strategies to mitigate risk.

Endoscopic Sleeve Gastroplasty for the Treatment of Obesity: A Single-Centre Experience and Literature Review.

In the world, obesity is constantly increasing, and so are the types of medical and surgical therapies. However, to cope with the increase in costs associated with surgical procedures and certain complications, such as gastroesophageal reflux disease, the number of bariatric endoscopic (BE) procedures has been increasing in recent years. Endoscopic sleeve gastroplasty (ESG) is one of the most rapidly increasing BEprocedures, given its benefits in terms of patient quality of life and reduced costs. In fact, it is a procedure characterised by minimal postoperative complications and is applicable to different types of bariatric patients. However, the number of studies on BE is not comparable to that on bariatric surgery. We analyzed the results of 84 ESG performed in our centre and compared them with those presented in the literature. We evaluated 36-Item Short Form Health Survey (SF-36)to 0, six and 13 months, signs and symptoms of patients undergoing ESG on the first and second postoperative day (POD), in terms of abdominal pain, nausea and vomiting. We found a reduction of these outcomes from POD 1 to POD 2. Finally, we measured total body weight loss percentage (TBWL%) and excess weight loss percentage (EWL%) at three, six and 12 months both in patients undergoing bariatric surgery for the first time (specifically, ESG) and in patients previously undergoing bariatric surgery and then undergoing ESG. Using the SF-36 score, we observedan improvement in the physical (mean score from 46.4 at time 0 to 53.6 at 12 months from the ESG) and mental (mean score from 37 at time 0 to 39.9 at 12 months from the ESG) status of the patients.Furthermore, we observed a 0 to 12-month increase in TBWL% and EWL% from the ESG procedure. Furthermore, we observed an increase in TBWL% and EWL% at three, six and 12 months both in patients undergoing bariatric surgery for the first time (specifically ESG) and in patients previously undergoing bariatric surgery and then undergoing ESG. ESG was an effective, reversible, and repeatable surgical procedure for bariatric patients.

Secondhand smoke is associated with peptic ulcer disease and gastroesophageal reflux disease in non-smokers in a large Taiwanese population study.

Active smokers are known to be at an increased risk of both gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD), however the role of passive smoking remains unclear. In this study, we aimed to examine whether secondhand smoke (SHS) is associated with PUD and GERD. In this population-based study, we conducted a large-scale analysis with 88,297 never-smokers (male: 18,595; female: 69,702; mean age 50.1 ± 11.0 years) from the Taiwan Biobank. The exposure group was comprised of those who had been exposed to SHS, and the no exposure group as those without SHS exposure. According to the frequency of exposure, we further divided the participants into "no exposure," "<1 h per week," and "≥1 h per week" groups. A cutoff point of 1 h per week was chosen according to the median exposure time in our participants. Associations between SHS and SHS frequency with PUD and GERD were assessed. Of the 88,297 enrolled participants, 11,909 (13.5%) had PUD and 76,388 (86.5%) did not. In addition, 11,758 (13.3%) had GERD and 76,539 (86.7%) did not. Multivariable analysis showed a significant association between SHS with PUD (odds ratio [OR] = 1.166; 95% confidence interval [CI] = 1.084-1.254; p < 0.001), and GERD (OR = 1.131; 95% CI = 1.053-1.216; p = 0.001). Furthermore, those exposed to SHS ≥ 1 h per week (vs. no exposure) were associated with higher risks of PUD (OR = 1.232; 95% CI = 1.121-1.355; p < 0.001) and GERD (OR = 1.200; 95% CI = 1.093-1.319; p < 0.001). SHS was significantly associated with PUD and GERD. Furthermore, exposure to SHS ≥ 1 h per week (vs. no exposure) was associated with a 1.23-fold higher risk of PUD and 1.20-fold higher risk of GERD. This study represents the largest population-based investigation to explore the association between SHS with PUD and GERD in Taiwanese never-smokers.

TikTok and Bilibili as health information sources on gastroesophageal reflux disease: an assessment of content and its quality.

Gastroesophageal reflux disease (GERD) is a global chronic disease. Short video platforms make it easy for patients with GERD to obtain medical information. However, the quality of information from these videos remains uncertain. This study aimed to systematically assess videos related to GERD on TikTok and Bilibili. We conducted a search and gathered 241 Chinese videos related to GERD and recorded the essential information. Two independent evaluators assessed each video based on the completeness of six components of the GERD guidelines, and assessed the quality and reliability of the information in the videos using recognition tools. Finally, videos from different sources were compared. The uploaders of most videos were medical professionals (86.7%, n = 209). The content was mainly about symptoms and treatment. The quality of the videos information varied depending on the sources. Among videos posted on Bilibili, those posted by medical professionals had a lower content score for definition (P < 0.001). Videos produced by non-gastroenterologists had the highest mean modified DISCERN. (The DISCERN scoring tool was initially created for assessing written publications, but nowadays, it is frequently leveraged for appraising various health-related videos. Details can be found in the text) quality of the videos information was acceptable; however, the content varied significantly depending on the type of source used. Videos with broad content should be carefully screened to meet more needs.

BariClip: Outcomes and Complications from a Single-Center Experience.

Laparoscopic BariClip gastroplasty (LBCG) is a new reversible bariatric procedure designed to replicate the restrictive effects of laparoscopic sleeve gastrectomy (LSG) by placing a clip vertically on the stomach. This technique achieves gastric lumen restriction without the need for resection, ensuring organ preservation and reversibility. However, concerns have arisen regarding potential complications such as gastroesophageal reflux disease (GERD), slippage, or erosion of the stomach. The aim of the study is to evaluate the outcomes and complications of LBCG. This is a monocentric retrospective study. We analyzed 149 patients who underwent LBCG procedure between July 2021 and November 2023. A minimum follow-up period of 6months was observed for all patients, recording clinically relevant GERD through GERD-Q score questionnaires. Weight loss was monitored through body mass index (BMI) and % total weight loss (%TWL), registered during follow-up visits. Overall, 149 patients were eligible for this study. Overall complication rate was 8% (12/149). The average BMI went from 40 ± 4.37kg/m2 to 28 ± 4.29kg/m2 (p < 0.05) in 6months, while the mean %TWL was 22.6% after at least 6months of follow-up. Clinically relevant GERD went from 18.1% (27/149) to 10.7% (16/149), p = 0.1262. As expected, also the PPI usage was not altered significantly (17.8% vs 16.4%), p = 0.8714. LBCG remains an experimental procedure that must be approached with caution. Nonetheless, the potential of LBCG to reproduce the effects of LSG while reducing GERD makes it a promising new reversible option for the treatment of morbid obesity.

Global Transcriptomic Analysis of Topical Sodium Alginate Protection against Peptic Damage in an In Vitro Model of Treatment-Resistant Gastroesophageal Reflux Disease.

Breakthrough symptoms are thought to occur in roughly half of all gastroesophageal reflux disease (GERD) patients despite maximal acid suppression (proton pump inhibitor, PPI) therapy. Topical alginates have recently been shown to enhance mucosal defense against acid-pepsin insult during GERD. We aimed to examine potential alginate protection of transcriptomic changes in a cell culture model of PPI-recalcitrant GERD. Immortalized normal-derived human esophageal epithelial cells underwent pretreatment with commercial alginate-based anti-reflux medications (Gaviscon Advance or Gaviscon Double Action), a matched-viscosity placebo control, or pH 7.4 buffer (sham) alone for 1 min, followed by exposure to pH 6.0 + pepsin or buffer alone for 3 min. RNA sequencing was conducted, and Ingenuity Pathway Analysis was performed with a false discovery rate of ≤0.01 and absolute fold-change of ≥1.3. Pepsin-acid exposure disrupted gene expressions associated with epithelial barrier function, chromatin structure, carcinogenesis, and inflammation. Alginate formulations demonstrated protection by mitigating these changes and promoting extracellular matrix repair, downregulating proto-oncogenes, and enhancing tumor suppressor expression. These data suggest molecular mechanisms by which alginates provide topical protection against injury during weakly acidic reflux and support a potential role for alginates in the prevention of GERD-related carcinogenesis.

8355 Pheochromocytoma In The Elderly: A Mini Case Series

Abstract Disclosure: S. Nabi: None. A. Golash: None. P. Panwar: None. G. Powner: None. C. Schiteanu: None. C. George: None. M. Vallabhaneni: None. B.G. Issa: None. A. Clark: None. D. Bailey: None. J. Waldron: None. F.W. Hanna: None. Diagnosis and management of pheochromocytoma in the older population is challenging due to the co-morbidities and general age-related frailty. We present a mini case series of four patients aged 72 to 86 years who presented to our tertiary referral center at the University Hospitals of North Midlands UK, between 2019 and 2022.The case series documents the challenges of managing pheochromocytoma in this population, emphasizing how close monitoring, regular follow ups and collaboration between different members of the multidisciplinary team helped to achieve the desirable outcomes in these cases. Case 1: Adrenal incidentaloma in 84-year-old female. Background of hypertension and diabetes mellitus. History of occasional palpitations. Investigations showed raised plasma and urinary metanephrines. MIBG scan confirmed pheochromocytoma and after adequate alpha and beta blockade underwent successful laparoscopic surgery. No intra or post operative complications and showed good recovery. Discharged on the 5th day post operative. Case 2: 82-year female under cardiology with non-ST elevation myocardial infarction. Background of hypertension, chronic kidney disease and gastroesophageal reflux disease. Initial presentation with shortness of breath, sweating and swelling lower limbs. Normal coronary arteries on angiography, so investigated for possible excess catecholamine production. Had significantly raised 24-hour urinary normetadrenaline. Paraaortic paraganglioma confirmed on MIBG SPECT scan. Initially opted for medical treatment however quality of life worsened over the next year and eventually underwent robot assisted excision. Procedure was uneventful with good post-operative recovery. Was able to go home 2 days after the procedure. Case 3: 72-year-old female referred with right adrenal incidentaloma. Background of hypertension, diabetes mellitus, hypothyroidism, asthma, arthritis and Ca breast treated 10 years ago. Results showed raised plasma metanephrines, subsequently, MIBG scan revealed a 3 cm right adrenal nodule with increased uptake. Full alpha and beta blockade achieved before she underwent surgical treatment with no complications. Discharged on the 3rd day post op. Case 4: An 80-year-old male was referred with left adrenal incidentaloma. History of diabetes, chronic kidney disease, ischemic heart disease and heart failure, recent myocardial infarction and atrial fibrillation. Biochemical and radiological investigations confirmed pheochromocytoma. He was started on alpha blockade that proved difficult to achieve due to underlying co-morbidities. The patient needed close monitoring by the endocrine team and was finally established on adequate alpha and beta blockade. Due to significant risks associated with the procedure, the patient decided not to proceed with the surgery and opted for medical management. Remains under active follow up. Presentation: 6/2/2024

8269 Euglycemic Diabetic Ketoacidosis Secondary to Rapid Weight Loss in a Patient on Dapagliflozin

Abstract Disclosure: A. Sridhar: None. A. Iqbal: None. A. Prabha Kumar: None. F. Haider: None. M. Babic: None. Background: Euglycemic DKA (eDKA) is a potentially life-threatening complication in patients taking SGLT 2 inhibitors (SGLT2i). Common precipitating factors include strenuous exercise, carbohydrate restriction, starvation, and alcohol use. Clinical case: The patient is a 71-year-old female with past medical history of Type 2 diabetes mellitus (DM), gastro-esophageal reflux disease, hypertension, hyperlipidemia, coronary artery disease and chronic pain syndrome. She presented with complaints of nausea, vomiting, reduced appetite and generalized weakness for the past 4 days. She also reported an intentional weight loss of 35 pounds in the last 6 weeks achieved with daily exercise and a carbohydrate restricted diet. She had been taking Dapagliflozin-Metformin 5-1000 mg twice daily and pioglitazone 30 mg once daily for 2 years and Ozempic subcutaneous injection 1 mg weekly for 6 months. Physical examination in the ED showed normal vital signs, dry mucous membranes, and trace bilateral lower extremity edema. Blood work was significant for venous blood gas pH 7.24, bicarbonate 9 mmol/L, anion gap 30 mmol/L, blood glucose 94 mg/dL, HbA1c 5.8 % and WBC 13.2 K/uL. Urinalysis was positive for glucose and ketones. The patient was admitted for management of eDKA and was started on intravenous 10% dextrose infusion and insulin infusion. Endocrinology was consulted and they recommended following DKA protocol and stopping Dapagliflozin at discharge. She was maintained on insulin infusion for 48 hours after which her anion gap normalized, and she was transitioned to subcutaneous insulin with Lantus 8 units and sliding scale insulin. During this time the patient’s symptoms resolved, and she was able to tolerate oral diet. She eventually resumed her home medications with oral Metformin 1000 mg twice daily and pioglitazone 30 mg once daily. Dapagliflozin and Ozempic were discontinued at discharge. Strenuous exercise and carbohydrate restriction which caused rapid weight loss, were likely the triggers for eDKA in our patient. A diabetes educator was involved at discharge and the patient was counseled to avoid possible triggers and identify warning signs and symptoms in the future. The patient was discharged with a follow up appointment with her Endocrinologist. Conclusion: High index of clinical suspicion is important to promptly diagnose eDKA in patients taking SGLT2i. Patient education on avoiding precipitating factors and early recognition of signs and symptoms is necessary to reduce mortality. Presentation: 6/3/2024

8257 Pancreatic Neuroendocrine Tumor Presenting As Carcinoid Syndrome

Abstract Disclosure: D. Phung: None. Introduction Pancreatic neuroendocrine tumors (NETs) are rare tumors that arise in neuroendocrine cells of the pancreas. These tumors secrete a wide array of hormones. Carcinoid syndrome is a result of well-differentiated neuroendocrine tumors that secrete biologically active amines and peptides that cause the clinical manifestation of flushing, diarrhea, cardiac involvement, and wheezing. Case Presentation A 57-year-old male presented to the clinic for symptoms of tachycardia, shortness of breath, dizziness, and sweating for the past year. He had past medical history of chronic kidney disease, history of previous cardiac arrest, history of previous myocardial infarction, congestive heart failure, hypertension and gastric reflux disease. No history of tobacco, alcohol, or drug consumption. No previous surgeries. Family history with heart disease and prostate cancer in his father. His symptoms began over the course of the past year. Initially began with shortness of breath, chest pain, weight gain which then developed into dizziness with standing, episodes of night time sweating. He had associated headaches that were occurring daily. Vomiting would occur intermittently three to four times weekly. He noted episodes of flushing with rash occurring in the upper chest and bilateral arms. Diarrhea and loose bowel movements would occur occasionally. On examination he had tachycardia with heart rate at 103 BPM. Lung fields clear throughout. Abdomen was soft, nontender, without masses palpated. On biochemical testing chromogranin A was highly elevated and remained elevated upon repeat testing. Initial imaging with CT abdomen and pelvis with contrast was negative. PET scanning confirmed and localized his NET, revealing increased tracer uptake and hypervascularity in the neck of pancreas as well as two regions in the right lower lobe of the liver. Following confirmation and localization of his tumor he was then referred for surgical evaluation and treatment. Discussion In our presented case, the patient presented with symptoms suggestive of carcinoid syndrome which was confirmed biochemically with elevated chromogranin A. Clinical suspicion remains critical in diagnosis of NETs. The patient presented with clinically suspicious carcinoid syndrome, but initial testing with CT scan was negative and required further PET-based tracing to uncover tumors. Our case highlights the importance of clinical examination and acumen in diagnosing neuroendocrine tumors. Presentation: 6/2/2024

8257 Pancreatic Neuroendocrine Tumor Presenting as Carcinoid Syndrome

Abstract Disclosure: D. Phung: None. Introduction Pancreatic neuroendocrine tumors (NETs) are rare tumors that arise in neuroendocrine cells of the pancreas. These tumors secrete a wide array of hormones. Carcinoid syndrome is a result of well-differentiated neuroendocrine tumors that secrete biologically active amines and peptides that cause the clinical manifestation of flushing, diarrhea, cardiac involvement, and wheezing. Case Presentation A 57-year-old male presented to the clinic for symptoms of tachycardia, shortness of breath, dizziness, and sweating for the past year. He had past medical history of chronic kidney disease, history of previous cardiac arrest, history of previous myocardial infarction, congestive heart failure, hypertension and gastric reflux disease. No history of tobacco, alcohol, or drug consumption. No previous surgeries. Family history with heart disease and prostate cancer in his father. His symptoms began over the course of the past year. Initially began with shortness of breath, chest pain, weight gain which then developed into dizziness with standing, episodes of night time sweating. He had associated headaches that were occurring daily. Vomiting would occur intermittently three to four times weekly. He noted episodes of flushing with rash occurring in the upper chest and bilateral arms. Diarrhea and loose bowel movements would occur occasionally. On examination he had tachycardia with heart rate at 103 BPM. Lung fields clear throughout. Abdomen was soft, nontender, without masses palpated. On biochemical testing chromogranin A was highly elevated and remained elevated upon repeat testing. Initial imaging with CT abdomen and pelvis with contrast was negative. PET scanning confirmed and localized his NET, revealing increased tracer uptake and hypervascularity in the neck of pancreas as well as two regions in the right lower lobe of the liver. Following confirmation and localization of his tumor he was then referred for surgical evaluation and treatment. Discussion In our presented case, the patient presented with symptoms suggestive of carcinoid syndrome which was confirmed biochemically with elevated chromogranin A. Clinical suspicion remains critical in diagnosis of NETs. The patient presented with clinically suspicious carcinoid syndrome, but initial testing with CT scan was negative and required further PET-based tracing to uncover tumors. Our case highlights the importance of clinical examination and acumen in diagnosing neuroendocrine tumors. Presentation: 6/2/2024

Intrathoracic Sleeve Migration Following Sleeve Gastrectomy: Incidence and Outcomes.

With laparoscopic sleeve gastrectomy (LSG) taking its place as the primary metabolic bariatric procedure in the past decade, de novo or persistent gastroesophageal reflux disease (GERD) has come into the spotlight as one of the most debilitating postoperative complications. Among the causes of GERD, intrathoracic migration (ITM) of the sleeve has become an understated yet significant phenomenon. This study aims to analyze the actual incidence of spontaneous ITM at our center, as well as its relationship to the baseline characteristics of patients and perioperative outcomes. A retrospective chart review of 206 patients who had undergone LSG at our center from July 2019 to December 2022 was done. At 1-year follow-up, a non-enhanced abdominopelvic computed tomography (CT) scan and esophagogastroduodenoscopy (EGD) were performed, and these exams were repeated annually. Baseline characteristics and perioperative outcomes including the clinical disease course of GERD were compared. The incidence of ITM was 14% (n = 29). There was a significant correlation between ITM and postoperative reflux symptoms (p = 0.001). The mean duration of anti-reflux medication use was also significantly longer in the ITM group than in the no ITM group at 17 and 11months, respectively (p = 0.004). A significantly higher number of patients in the ITM group were diagnosed with esophagitis on postoperative EGD than in the no ITM group (p = 0.002). The incidence of ITM using non-enhanced CT was 14%. ITM was significantly correlated to clinical reflux and EGD-confirmed esophagitis.

Solid versus liquid pulmonary micro-aspiration of reflux disease. Does it make a difference in determining the need for intervention?

Pulmonary micro-aspiration (PMA) is a feared complication of gastroesophageal reflux disease (GORD). A novel scintigraphic test for GORD has been developed and validated. It can demonstrate contamination of the upper and lower airways by refluxate. Current observations have led to the hypothesis that prolongation in solid gastric emptying (SGE) is crical in pulmonary micro-aspiration. Standard LGE and SGE studies and the novel reflux test were evaluated in paired studies in patients with severe GORD to measure rates of PMA after each meal. Either water labeled with 99m Technetium Phytate for the LGE or a labeled egg sandwich for the solid meal was utilized. Major symptoms were noted and the cough and reflux severity index (CSI & RSI) was obtained in all patients. A total of 131 patients were enrolled (59M/72F) with age range of 21-83 years (mean: 52 years). Patients were in the overweight range for BMI (mean: 26.8). Major symptoms were bloating, nausea, belching, and dyspepsia (< 20% had heartburn). SGE was abnormal in 92% (mean 766 min) and LGE abnormal in 53% (mean 82 min). PMA was shown in 35% after the SGE and in 71% after the LGE. PMA+ patients were older. A significant correlation was found between SGE and PMA (P < 0.00) but not LGE. The only significant symptom in the PMA group was bloating. RSI was abnormal in 64% and CSI in 46%. The majority of patients with PMA do not complain of heartburn. Bloating in patients with severe GORD should raise the possibility of gastroparesis and PMA.

Causal Relationship Between Gastroesophageal Reflux Disease and the Risk of Chronic Rhinosinusitis: Insights from Multivariable and Mediation Mendelian Randomization Analysis.

Background: Previous studies have shown an association between chronic rhinosinusitis (CRS) and gastroesophageal reflux disease (GERD). However, the findings of these studies are controversial, and evaluating this association could help in the treatment of CRS. Thus, we aimed to clarify the relationship between GERD and CRS. Methods: We conducted a Mendelian randomization (MR) study. Pooled data on CRS, GERD, and their associated risk factors were extracted from large genome-wide association studies. Independent single-nucleotide polymorphisms were rigorously screened as instrumental variables. Causal associations between GERD and CRS were assessed, and mediation analyses were performed using multivariate and 2-step MR. Asthma served as a mediator because of its association with both CRS and GERD. Sensitivity tests were also performed. Results: MR analysis showed that genetically predicted GERD was associated with an increased risk of CRS (P < .001). Multivariate MR analysis showed that the effect of GERD on CRS was relatively independent. Mediation analysis showed that asthma mediated the association with a mediation effect of 21.07% (95% CI, 2.70%-40.18%). Sensitivity analyses did not reveal any significant effects of pleiotropy and heterogeneity. Conclusions: We found a causal relationship between genetically predicted GERD and an increase in the risk of CRS. As a mediator, asthma contributed to the effect of GERD on CRS. This study provides high-quality causal evidence for the prevention of CRS.

Some pathogenetic relationships in gastroesophageal reflux disease in children

Objective. To study the relationship of the upper gastrointestinal tract acidity index and collagen metabolites and proteoglycans in children with GERD. Materials and methods. 62 children with GERD were observed. The control group included 32 children. All children underwent esophagogastroduodenoscopy with parietal endoscopic pH-metry. The content of free hydroxyproline (FHOP), peptide-bonded hydroxyproline (PSHOP), glycosaminoglycans (GAG), as well as a-mannosidase activity in gastric juice were studied. Results. The hyperacidity of the pH in the esophagus, the gastric “lake” and the body of the stomach in children with GERD was revealed. A relationship between hyperacidity and the breakdown of collagen in the mucous membrane of the gastroesophageal area demonstrated by high levels of GAG, FHOP, and PSНOP a-mannosidase in the gastric juice has been shown. Conclusions. In children with GERD, the dynamic balance of aggressive-protective factors in the gastroduodenal area is disturbed. As a result of it, degradation of collagen in the mucous and submucous layer of the esophagus and stomach is observed.

Simultaneous treatment of large hiatal hernias during Roux-en-Y gastric bypass: technical considerations and outcome.

Roux-en-Y gastric bypass (RYGB) is the preferred surgical option for patients with proven gastroesophageal reflux disease and obesity grade ≥ II (BMI ≥ 35kg/m2). Data on simultaneous treatment of larger hiatal hernias during RYGB are scarce. From 2012 until 2022, data from all consecutive patients undergoing gastric bypass procedures were collected and retrospectively analyzed. The characteristics and surgical outcomes of patients undergoing RYGB alone (RYGBa) versus RYGB with simultaneous treatment of a large hiatal hernia (RYGB-HH) were compared. Out of 573 patients who received RYGB, we identified 12 simultaneously treated for large hiatal hernia. The characteristics of RYGB-HH versus RYGBa patients were higher age (55 vs. 44years; p = 0.004) and lower BMI (39.2 vs. 46.9kg/m2; p = 0.001). Duration of surgery in the RYGB-HH group was longer (144min vs. 98min; p < 0.001), while complications > Clavien-Dindo II were similar compared to the RYGBa group (8.3 vs. 9.4%, p = 0.56). Length of stay did not differ among the groups (4 vs. 5.5days, p = 0.051). At a median follow-up of 12months, there was no clinical recurrence of hiatal hernia in the RYGB-HH group. Simultaneous treatment of large hiatal hernias during Roux-en-Y gastric bypass surgery prolongs operation time but seems feasible and safe in the hands of experienced surgeons.

Cerebral cortex changes in FD, IBS, and GERD: A Mendelian randomization study

BackgroundProspective and cross-sectional studies have reported an association between functional gastrointestinal disorders and anxiety and depression. However, the causal relationship is unclear. Therefore, we used Mendelian randomization (MR) to determine the causal effects of common gastrointestinal disorders on cortical structures. MethodsGenome-wide association study (GWAS) data for functional dyspepsia (FD), irritable bowel syndrome (IBS), and gastroesophageal reflux disease (GERD) were obtained from 329,262, 16,792, and 602,604 Europeans, respectively. GWAS cerebral cortical architecture data for cortical thickness (TH) and surface area (SA) were obtained from 51,665 MRI scans. MR was used to analyze the casual relationship between FD, IBS, GERD, and cortical structures. Inverse-variance weighted, weighted median, and MR–Egger tests were performed as assessment indicators. We also evaluated heterogeneity and pleiotropy. ResultsThe results revealed that FD significantly decreases the TH in the rostral anterior cingulate cortex (βTH = −0.022 mm; 95%CI: −0.035 mm to −0.009 mm2; PTH = 6.89 × 10−4), and IBS significantly decreases the SA of the pars triangularis (βSA = −21.91 mm2; 95%CI: −32.99 mm to −10.83 mm2; PSA = 1.06 × 10−4), precuneus (βSA = −47.53 mm2; 95%CI: −73.57 mm to-21.48 mm2; PSA = 3.48 × 10−4) and superior frontal regions (βSA = −78.70 mm2; 95%CI: −122.61 mm to −34.78 mm2; PSA = 4.4 × 10−4). At the local functional level, GERD significantly increases the SA of the inferior temporal region (βSA = −113.58 mm2, 95%CI: −113.58 mm to −39.01 mm2, PSA = 6.05 × 10−5). ConclusionsFD, IBS and GERD can affect the cerebral cortex architecture through the brain-gut axis, thus increasing the risks of mental illness and cognitive dysfunction.

Peroral Endoscopic Myotomy: Short Versus Long Esophageal Myotomy for Achalasia Cardia: A Randomized Controlled Noninferiority Trial.

The appropriate length of esophageal myotomy in peroral endoscopic myotomy (POEM) for achalasia cardia remains unclear. This study aimed to compare the outcome of short (≤3cm) and long (≥6cm) esophageal myotomy in patients with type I and II achalasia cardia. This single-blinded, randomized controlled noninferiority trial was conducted at a tertiary center between July 2021 and December 2021. Patients with achalasia types I and II were randomized into short (≤3cm) and long (≥6cm) esophageal myotomy groups. The primary outcome of the study was clinical success (Eckardt score ≤3) 1 year after the procedure. The secondary outcomes included a comparison of technical success, operating duration, occurrence of intraoperative adverse events, alterations in integrated relaxation pressure (IRP), change in barium column height after 5 minutes (1mo), and gastroesophageal reflux disease (3mo) between the groups. Fifty-four patients were randomized into the short (n=27) or long (n=27) esophageal myotomy groups. Technical success rates were 100% (27/27) and 96.3% (26/27) in short myotomy (SM) and long myotomy (LM) groups, respectively. The clinical success rates were 96.3% (26/27) and 96.2% (25/26) in the SM and LM groups, respectively ( P =0.998). The mean (±SD) length of the esophageal myotomy was 2.75±0.36cm in the SM and 6.69±1.35cm in the LM groups ( P <0.001). The mean (±SD) procedure time for the SM and LM groups was 61.22±8.44 and 82.42±14.70 minutes ( P <0.001), respectively. The mean integrated relaxation pressure (IRP), Eckardt score, adverse events, reflux esophagitis, symptomatic gastroesophageal reflux disease, and esophageal acid exposure (>6%) did not differ significantly between the 2 groups following POEM treatment. Short myotomy is noninferior to long myotomy in terms of clinical success, gastroesophageal reflux disease, and intraoperative adverse events at the short-term follow-up ( P >0.05). Short myotomy resulted in a reduced operative time ( P <0.05).

Impact of Surgical Technique on Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy: A Nationwide Observational Study

BackgroundLaparoscopic sleeve gastrectomy (LSG) has gained increasing popularity worldwide, yet concerns persist regarding the development of gastroesophageal reflux disease (GERD) postoperatively. ObjectiveThis study aimed to evaluate the influence of technical aspects of LSG, specifically bougie size and distance from the pylorus to resection line edge, on the risk of developing symptomatic GERD within two years following surgery. SettingData from the Scandinavian Obesity Surgery Registry and the National Prescribed Drug Register were utilized for this analysis. MethodA retrospective observational study was conducted encompassing all LSG patients in Sweden between 2012 and 2020 who did not receive preoperative proton pump inhibitor (PPI) prescriptions. Patients were categorized based on bougie size and pyloric distance. Regular PPI use, defined as a dispensed prescription of more than 300 tablets per year, was employed as a proxy measure of symptomatic GERD and was compared between the groups. ResultsThe study included 7435 patients with complete data on dispensed PPI prescription both preoperatively and throughout the two-year follow-up period. Information on Bougie size and pyloric distance was available for 97.4% and 84.9%, respectively. Narrower bougie size and greater pyloric distance were associated with increased risk of regular PPI use post-surgery. Advanced age and female sex were independent risk factors for post-LSG regular PPI use, while initial BMI, total weight loss, and comorbidities showed no significant associations. ConclusionUsing a narrow bougie and initiating resection at a greater distance from the pylorus were associated with higher risk of symptomatic de novo GERD following LSG.

Nissen sleeve gastrectomy: 5-year follow-up results

BackgroundNissen sleeve gastrectomy is a new bariatric procedurebased on the combination of two well-known surgical techniques (vertical sleeve gastrectomy and Nissen fundoplication). It was conceived as a means of preventing the major drawback of the sleeve gastrectomy (SG), the gastroesophageal reflux disease (GERD), while preserving the advantages of SG in terms of weight loss and remission of obesity-related comorbidities. ObjectivesThe objectives of this study are to present the long-term (5 years) follow-up results on weight loss, evolution of GERD and other comorbidities and the complication rate of the Nissen sleeve gastrectomy. SettingMontpellier University Hospital, France. MethodsThis is a prospective analysis of patients who underwent Nissen sleeve gastrectomy as a first-line bariatric procedure between January 2018 and February 2019. A subgroup analysis of patients with no further surgery during follow-up was also performed. ResultsA total of 144 patients underwent a Nissen sleeve gastrectomy: After adjusting for exclusion criteria, 133 patients comprised the initial study population, 81.9% of whom had complete follow-up for weight and GERD clinical symptom outcomes at 5 years. The mean total weight loss (TWL%) was 22 (± 12.3)% and the mean excess weight loss percentage (EWL%) was 59.4% (± 34.2)%. Of the 63 patients with preoperative clinical symptoms of GERD, we observed an 85.5% 5-year clinical remission rate; however only 25 patients had a gastroscopy at 5 years. The cumulative short- and long-term reoperation rate was 8.1% and the mortality rate was zero. ConclusionsThe Nissen sleeve gastrectomy achieves a satisfactory long-term TWL% and a significant improvement in comorbidities, particularly regarding the incidence of GERD. The rate of complications requiring surgical reoperation is low.