Pathological Reflux Research Articles

American Foregut Society White Paper on the Endoscopic Assessment of the Gastroesophageal Valve after Anti-Reflux Surgery

Background: Pathologic reflux is a common debilitating digestive condition and anti-reflux surgery is an effective treatment option. Depending on the specifics of the procedure, anti-reflux surgery leads to distinct changes in the endoscopic appearance of the esophagogastric junction (EGJ). This American Foregut Society (AFS) white paper develops nomenclature for describing the endoscopic characteristics of the EGJ after commonly performed laparoscopic antireflux operations. Methods: The AFS Anti-Reflux Barrier Collaborative analyzed the anatomic manipulation and corresponding endoscopic appearance of the EGJ after commonly performed anti-reflux surgery including: (1) 360° anterior/posterior (AP) fundoplication (Nissen); (2) posterior partial fundoplication (Toupet); (3) anterior partial fundoplication (Watson, Dor); (4) magnetic sphincter augmentation; and (5) concomitant hiatal hernia repair with transoral fundoplication (cTIF). Results: Characteristics common to the anti-reflux surgery procedures include restoration of intra-abdominal esophageal length and crural diaphragm repair such that the hiatal aperture is no longer visible in the retroflexed endoscopic view. With regard to the geometry of anti-reflux procedures, the Collaborative established that when evaluated endoscopically in retroflection, the surgically constructed valve should be described in reference to the angle of His and the extent of anatomic change described in terms of (1) the depth of the anterior and posterior grooves, (2) the apposition of the valve collar to the endoscope, (3) the length of the valve, and (4) the position of the squamocolumnar junction relative to the lip of the valve. Conclusions: Current anti-reflux operations share much in common but employ varying degrees of valvular reconstruction leading to distinct endoscopic characteristics. Developing a consistent nomenclature for describing the appearance of the post-surgical valve is essential to develop a better understanding of how variables such as the tightness of the hiatal repair, tightness of the valve collar, and length of the valve can impact the outcome of anti-reflux surgery and predict reflux recurrence.

BN O01 - Hiatus hernia and gastro-oesophageal reflux disease. Does size matter?

Abstract Background Hiatus hernia occurs when part of the stomach bulges into the thoracic cavity through the hiatal opening of the diaphragm. In our study, we aimed to assess the impact of the hiatal hernia size on DeMeester score, symptom correlation, and presence of pathological reflux on PH studies. The study also looked at the impact of various characteristics including age, smoking, alcohol consumption, body mass index (BMI), and presence of oesophagitis and/or dysmotility on DeMeester score, symptom correlation, and presence of pathological reflux on PH studies. Method The study was conducted in an Upper Gastrointestinal surgery unit located in the North West of England. All patients aged over 18 who underwent laparoscopic fundoplication for gastro-oesophageal reflux disease between January 2017 and June 2023 were included. Patients who underwent fundoplication for para-oesophageal hiatus hernia, those who had fundoplication as a complementary step to Heller’s cardio-myotomy, or those who underwent revisional surgery were excluded. Results A total of 115 patients with a median age of 54 were included. Patients’ age was found to have a statistically significant association with hiatus hernia size above 2 cm, DeMeester score, and Symptom Association Probability with a P value of 0.011, 0.021, and 0.030 respectively. Hiatus hernia size above 2 cm was found to have a statistically significant association with pathological reflux (P=0.017). Smoking association with DeMeester score was found to be significant (P=0.027). Hiatus hernia size was not found to have a statistically significant association with DeMeester score, Symptom Index, or Symptom Association Probability (P=0.115, 0.315, 0.904) respectively. Conclusion Hiatus hernia size above 2 cm was found to have a statistically significant association with pathological reflux on PH studies but not statistically associated with elevated DeMeester score above 14.72 or symptom correlation indices. Thorough endoscopic assessment in addition to detailed oesophageal physiological studies are mandatory to evaluate patients with gastro-oesophageal reflux disease prior to considering surgery.

BN O05 - Physiological Transit Assessment of the Oesophagus In Patients With Anti-Reflux Surgery

Abstract Background High-resolution manometry (HRM) is the gold-standard investigation for oesophageal motility in patients with dysphagia. The HRM findings may influence surgical decision for myotomy or anti-reflux surgery (ARS). However, HRM pitfall is the inability to measure oesophageal transit in parallel to the motility during physiology testing. Both transit and motility are complementary that offer insights in the pathophysiology and aetiology of the dysphagia symptoms. This research evaluates the multichannel intraoesophageal impedance transit (MIIT) concept [1] to assess the oesophageal transit in symptomatic patients who undertook the postoperative oesophageal physiology testing between January 2020 and June 2024. Method This cross-sectional retrospective study selected patients with intact Nissen fundoplication (NF) wrap on gastroscopy or with known LINX implant in-situ. HRM with Chicago Classification (version 4.0)[2] compared the ARS cases with augmented antireflux barrier [AARB] from the surgery to healthy treatment naïve controls. The multichannel impedance-pH studies assessed both reflux and the MIIT [1]. MIIT >0.76 minutes were considered positive and comparable to GOJ outflow obstruction [1]. This project was approved by the NHS institution and the local research ethics committee (REC 18/NW/0120)(IRAS 333800). Results 60 patients were found (NF 54, LINX implant 6)(females 30, mean age 51.3 years). 11 patients(18.3%) had pathological reflux despite ARS(DeMeester scores >14.72); 2 patients (18.2%) demonstrated hypotensive AARB. Conversely, 6 patients(10%) showed poor relaxation from the AARB and were compatible to outflow obstruction (5 patients [83.3%] showed conformation with MIIT >0.76 minutes). Patients with ineffective oesophagus (20%) and absent contractility(11.7%) showed MIIT >0.76 minutes in respectively two-thirds with ineffective oesophagus and in all patients with absent contractility. Normal HRM study was observed in 35 patients (58.3%) with 27 patients (77.1%) demonstrating MIIT >0.76 minutes. Conclusion MIIT was able to explain the post-surgical dysphagia in majority of patients from the equivalent transit to outflow obstruction (n=52 patients, 86.7%). Half of these cases had a normal HRM study and would have been perceived as having functional dysphagia. We would recommend performing MIIT adjunctive testing as part of postoperative oesophageal physiology assessment in symptomatic patients. Incidentally, we observed 16 patients (26.7%) having hypotensive AARB post ARS comparing to healthy treatment naïve controls with 2 patients (12.5%) having persistent pathological reflux who may still benefit from surgical revision.

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

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

American Foregut Classification is Superior to Hill Classification in Evaluation of the Gastroesophageal Junction

Background: The American Foregut Society (AFS) classification is intended to be more comprehensive and accurate than the Hill grade in assessing the gastroesophageal junction. However, real-world data regarding predictive ability and interobserver variability are limited. Methods: We performed a multi-reader validation study on images collected from patients who underwent endoscopic evaluation of reflux with hernia provocation using both AFS and Hill classification. The primary outcome was inter-reader agreement, assessed using Fleiss K. Secondary outcomes were percentage of patients with pathologic reflux at each Hill grade or AFS grade, correlation between acid exposure time (AET) and individual components of the AFS grade, and difference in predictive ability based on expert versus non-expert graders. Results: Sixty-four eligible patients were identified. Inter-rater reliability was substantial for AFS classification ( K = 0.65) and fair for Hill classification ( K= 0.28). The AFS grade demonstrated moderate overall correlation with AET (ρ = .36) and the Hill grade demonstrated overall weak correlation (ρ = .28). No single component of the AFS score performed significantly better in predicting pathologic reflux than the AFS grade (AFS F = 9.93, P = .0025) and there was no significant difference in overall grading between expert- and non-expert readers (ρ = .38 vs ρ = .29). Conclusion: The AFS score can classify the GEJ with moderate interobserver agreement and is superior to the Hill grade in predicting acid exposure time. AFS grade has better predictive power than the individual components used in scoring and is robust to differences in reader experience.

Association between laryngopharyngeal reflux clinical scores and esophageal multichannel intraluminal impedance pH monitoring interpretation according to Lyon Consensus 2.0.

Laryngopharyngeal reflux remains a diagnostic challenge due to the lack of a definitive diagnostic tool. Esophageal multichannel intraluminal impedance (MII) pH monitoring has been proven reliable for detecting gastric reflux. This study aims to evaluate the association between clinical scores and MII/pH monitoring according to the Lyon Consensus 2.0. Patients with laryngo-pharyngeal symptoms (LPS) who had a reflux symptom index (RSI) ≥13 or reflux finding score (RFS) ≥7 underwent MII/pH monitoring. The findings were analyzed in comparison with clinical scores. A total of 100 patients meeting the inclusion criteria were recruited for this study. MII/pH monitoring revealed a median acid exposure time (AET) of 1.9% (interquartile range [IQR] = 0.2, 4.9), with 22% of patients recording an AET above 6%. The median number of reflux episodes was 29.5 episodes per day (IQR = 19.0, 43.8), with 7% experiencing more than 80 episodes per day. Gas reflux was identified as the most prevalent type. Based on the Lyon Consensus 2.0, 25 patients exhibited conclusive pathological reflux, while 75 patients showed no conclusive evidence of pathological reflux. No significant differences were found in RSI and RFS between these groups. Only gas reflux episodes showed a significant correlation with RSI (r = 0.255, P = 0.011). RSI and RFS among patients with LPS showed no statistically significant differences in identifying pathological reflux or no conclusive evidence of pathological reflux. This finding suggests that the pathophysiology underlying LPS may not be solely attributable to reflux.

Candy cane syndrome with or without concomitant hiatal hernia after Roux-en-Y gastric bypass: A hidden enemy leading to postoperative symptoms.

Candy cane syndrome (CCS) is a rare complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). It occurs due to redundancy in the blind loop at the gastro-jejunal anastomosis. To evaluate the type of symptoms, anatomic and functional findings, and outcome after treatment. A prospective case series study was conducted between 2010 and 2022, including symptomatic patients with CCS after LRYGB. Symptoms were correlated with anatomic and functional findings. Big gastric pouch was defined if its size was >5 cm, and a long candy cane loop was diagnosed if its length was >5 cm. Due to failure of medical treatment, revision surgery (RS) was indicated for resection of the elongated blind jejunal loop, resizing the redundant gastric pouch and repairing the hiatal hernia repair (HH) when necessary. The study included 23 patients, with a mean age of 49 ± 11 years. Twenty-one patients underwent primary LRYGB, and 2 were converted to this technique after sleeve gastrectomy (SG). The mean time from LRYGB to symptom onset was 7.6 ± 4.3 years. Pain and reflux symptoms were the most frequent, with no differences between patients with or without HH (P < .05). CCS coexisted with a large gastric pouch in 56.5% and HH in 52.2% of cases. A defective lower esophageal sphincter, abnormal esophageal motility, and pathological acid reflux test were observed. After surgery, improvement was observed in 86.9%. CCS can lead to gastrointestinal symptoms following LRYGB, regardless of the presence of HH. Complete examinations are crucial for diagnosis and to determine the surgical intervention, which is the best option for treatment.

Esophageal chest pain resembles heartburn in reflux metrics and response to proton pump inhibitor therapy.

Gastro-esophageal reflux disease (GERD) is the most common cause for noncardiac chest pain (NCCP), with an estimated prevalence rate ranging between 30% and 60%. Heartburn and NCCP may share common mechanisms. To assess whether particular patterns of impedance-pH variables characterize patients with dominant heartburn, regurgitation, or NCCP and their ability to predict proton pump inhibitor (PPI) response for each symptom, GERD patients, evaluated with high-resolution manometry (HRM) and impedance-pH, were included. In total, 109 NCCP, 68 heartburn, and 64 regurgitation patients were included. Pathological reflux episodes were observed in 28%, 19%, and 56% (p < 0.001). Pathological mean nocturnal baseline impedance (MNBI) values were observed in 55%, 53%, and 34% (p < 0.05). Hypomotility was more frequent in NCCP compared to heartburn patients (p < 0.05). When comparing NCCP with heartburn, hypomotility was associated with NCCP perception (OR: 2.34, 95% CI: 1.23-4.43; p < 0.01). When comparing NCCP with regurgitation, >80 refluxes and type 2/3 esophagogastric junction (EGJ) were associated with regurgitation perception (OR: 0.31, 95% CI: 0.16-0.59; p < 0.001, and OR: 0.5, 95% CI: 0.27-0.93; p < 0.05), while pathological MNBI was associated with NCCP perception (OR: 2.34, 95% CI: 1.23-4.43; p < 0.01). 45.5% NCCP patients, 45.6% with heartburn, and 36% with regurgitation responded to PPIs (p < 0.05). At multivariate analysis, pathological MNBI or PSPW index were associated with PPI responsiveness in patients with NCCP or heartburn, while in patients with regurgitation, pathological MNBI was associated with PPI responsiveness and a reflux number >80 to PPI refractoriness. We highlight the usefulness of an accurate clinical and functional evaluation of GERD patients, allowing to discriminate particular characteristics in patients with dominant heartburn, NCCP, or regurgitation, which may benefit of distinct therapeutic strategies.

Bolus exposure as a novel predictor of postoperative symptom resolution after laparoscopic nissen fundoplication: A two-institutional retrospective cohort study.

Even in the absence of definite evidence of pathological acid reflux, antireflux surgery (ARS) can still effectively improve gastroesophageal reflux symptoms. Nonetheless, predicting postoperative reflux symptom improvement has been primarily dependent on acid-based parameters. No objective index reflecting both acid and non-acid reflux was identified to select ARS candidates. Prospectively collected data of 121 patients with gastroesophageal reflux disease (GERD), who underwent laparoscopic Nissen fundoplication from two institutions, were retrospectively reviewed. The patients reported preoperative and postoperative GERD symptoms using the Korean version of the GERD questionnaire, along with the gastroesophageal reflux disease-health-related quality of life (GERD-HRQL). The patients assessed for reflux symptoms using bolus exposure, acid exposure time (AET), and DeMeester score (DMS) as measurements were selected. For each reflux parameter, its association, correlation, and predictive capacity of the degree of postoperative symptom resolution were analyzed using chi-squared tests, point-biserial correlations, logistic regression analyses, and receiver operating characteristic curve analyses. 72 patients were eligible for this study. Bolus exposure was superior to the other parameters in terms of the degree of association and correlation with resolution of typical symptoms. Bolus exposure also showed a higher diagnostic accuracy in predicting the resolution of epigastric pain (area under the curve [AUC]=0.723, P=0.013) and regurgitation (AUC=0.981, P<0.001). Secondary analyses were performed in patients without pathological reflux, defined as the DMS-negative (DMS<14.7) or AET-negative (AET<6%) groups. In the secondary analyses, bolus exposure showed considerable diagnostic accuracy with statistical significance for all typical symptoms in both in the DMS-negative (heartburn: AUC=0.717, P=0.025; epigastric pain: AUC=0.717, P=0.025; regurgitation: AUC=0.975, P<0.001) and AET-negative (heartburn: AUC=0.681, P=0.045; epigastric pain: AUC=0.749, P=0.009; regurgitation: AUC=0.975, P<0.001) groups. Bolus exposure, a parameter of total reflux, was superior to AET or DMS in defining candidates for ARS. Further studies investigating the surgical indications for ARS in patients with non-acid reflux using bolus exposure are required.

Collagen-V and K-α-1 Tubulin Antibodies as Potential Markers of Unsuspected GERD-Related Lung Damage: Insights from a Cross-Sectional Analysis

PurposeOur group has proposed that aspiration of gastric contents leads to exposure of normally sequestered lung self-antigens (SAgs), specifically collagen-V (Col-V) and K-α-1-tubulin (Kα1T), which elicits an immune response characterized by increasing concentrations of self-antibodies (SAbs) anti-Col-V and anti-Kα1T. We sought to establish the point prevalence of abnormally elevated concentrations of SAbs among patients with pathological gastroesophageal reflux disease (GERD) and/or hiatal hernia undergoing antireflux surgery (ARS).MethodsFor this cross-sectional study, we retrieved a plasma aliquot from the Norton Thoracic Institute BioBank from blood samples that were taken preoperatively from patients who underwent ARS between November 2019 and August 2022. Enzyme-linked immunosorbent assays were employed to detect and quantify anti-Col-V and anti-Kα1T.ResultsSamples from 43 patients (females, n = 34 [79.1%]; mean age, 62 ± 12 years; and mean BMI, 30.5 ± 7 kg/m2) were analyzed. Before ARS, 28 (65.1%, CI95: 50.3–80.0%) patients had abnormally elevated concentrations of anti-Col-V and 19 (44.2%, CI95: 28.7–59.7%) had elevated concentrations of circulating anti-Kα1T. Overall, 13 patients (30.2%) had low (i.e., normal) concentrations of both SAbs, 13 (30.2%) were positive only for one, and 17 (39.5%) were positive for both SAbs.ConclusionA relative high point prevalence of abnormally elevated circulating SAbs (i.e., anti-Col-V and/or anti-Kα1T) before ARS was found. This result suggests clinically unsuspected pulmonary parenchymal injury secondary to GERD-related aspiration. Further studies are required to confirm this hypothesis and to identify alternative non-invasive early biomarkers of GERD-related lung damage.

Evaluation of Gastroesophageal Reflux in Symptomatic Young Infants Using Multichannel Intraluminal pH-Impedance Testing: A large Cohort Study from a Single Center.

This study aimed to assess the use of combined multichannel intraluminal impedance and pH studies (MII-pH) in a large group of symptomatic young infants, to characterize the occurrence of gastroesophageal reflux disease (GERD), and to establish temporal association of the reflux behaviors with gastroesophageal reflux using symptom indices. This is a retrospective cohort study on 181 infants who underwent MII-pH studies for clinical behaviors that were suggestive of GERD. Symptom index (SI) and symptom association probability (SAP) were used to establish symptom association with reflux. More than 100 GER episodes in 24 hours or acid reflux index > 10% was considered pathological reflux. A total of 181 infants (median age: 60 days, interquartile range [IQR]: 34-108) underwent MII-pH studies with median study duration of 22.41 hours (IQR: 21.5-23.32). A total of 4,070 hours of data were analyzed, with 8,480 reflux events (2,996 [35%] acidic, 5,484 [65%] nonacidic). A total of 2,541 symptoms were noted, 894 (35%) were temporally related to reflux events. A total of 113 infants (62.4%) had positive symptom association with SI > 50% and/or SAP > 95% for at least one symptom. There was modest symptom association for choking and gagging, but apnea, bradycardia, and desaturations had poor symptom association. Only 29 infants (16%) had pathological reflux, and only 18 infants (10%) had both pathological reflux and positive symptom association. MII-pH can be used to characterize GERD in young infants, along with establishing temporal association with symptoms. Pathological reflux in symptomatic young infants is not common, but symptom association may occur without frequent or acidic reflux. · Gastroesophageal reflux (GER) disease can be studied in young infants using MII-pH, to characterize the frequency and nature of GER events.. · The probability of GER events being associated temporally with GER symptoms can also be determined using MII-pH in this population.. · Using frequency of GER events, reflux indices, and symptom association indices with MII-pH, infants having true GER disease can be identified, thereby reducing unnecessary therapy.. · Symptom association may occur even without frequent or severe acidic reflux..

743. HIATUS HERNIA AND GASTRO-OESOPHAGEAL REFLUX DISEASE. DOES SIZE MATTER?

Abstract Background Hiatus hernia occurs when part of the stomach bulges into the thoracic cavity through the hiatal opening of the diaphragm. In our study, we aimed to assess the impact of the hiatal hernia size on DeMeester score, symptom correlation, and presence of pathological reflux on PH studies. The study also looked at the impact of various characteristics including age, smoking, alcohol consumption, body mass index (BMI), and presence of oesophagitis and/or dysmotility on DeMeester score, symptom correlation, and presence of pathological reflux on PH studies. Methods The study was conducted in an Upper Gastrointestinal surgery unit located in the North West of England. All patients aged over 18 who underwent laparoscopic fundoplication for gastro-oesophageal reflux disease between January 2017 and June 2023 were included. Patients who underwent fundoplication for para-oesophageal hiatus hernia, those who had fundoplication as a complementary step to Heller’s cardio-myotomy, or those who underwent revisional surgery were excluded. Results A total of 115 patients with a median age of 54 were included. Patients’ age was found to have a statistically significant association with hiatus hernia size above 2 cm, DeMeester score, and Symptom Association Probability with a P value of 0.011, 0.021, and 0.030 respectively. Hiatus hernia size above 2 cm was found to have a statistically significant association with pathological reflux (P=0.017). Smoking association with DeMeester score was found to be significant (P=0.027). Hiatus hernia size was not found to have a statistically significant association with DeMeester score, Symptom Index, or Symptom Association Probability (P=0.115, 0.315, 0.904) respectively. Conclusion Hiatus hernia size above 2 cm was found to have a statistically significant association with pathological reflux on PH studies but not statistically associated with elevated DeMeester score above 14.72 or symptom correlation indices. Thorough endoscopic assessment in addition to detailed oesophageal physiological studies are mandatory to evaluate patients with gastro-oesophageal reflux disease prior to considering surgery.

493. EFFECTIVENESS OF TRANSORAL INCISIONLESS FUNDOPLICATION (TIF) WITHOUT OR WITH HIATAL HERNIA REPAIR (CTIF) IN PATIENTS WITH GERD AND CHRONIC COUGH

Abstract Background GERD is a common cause of chronic cough. Although barrier therapy with laparoscopic fundoplication is highly effective for typical GERD symptoms, the response rates are variable for chronic cough. We hypothesized that transoral incisionless fundoplication (TIF) or TIF with hiatal hernia repair (cTIF) may be a suitable alternative for medically refractory cough associated with GERD. Aim We prospectively s studied the effectiveness and safety of TIF/cTIF in patients with chronic cough and proven GERD. Methods Patients with GERD and extra-esophageal symptoms from 10 academic and community medical centers (TIF Registry), elevated GERD-HRQL score +/- Reflux Symptom Index (RSI) &amp;gt;13 and pathologic reflux by esophageal pH-metry, or erosive esophagitis/Barrett’s esophagus were evaluated before and after a minimum 6 months post TIF/cTIF performed by gastroenterologists and surgeons. Patients with history of prior foregut/bariatric surgery, chronic obstructive or interstitial lung disease, or prior lung transplant were excluded. The primary outcome was improvement in RSI score at last follow-up compared to baseline. Secondary outcomes were: 1) normalization of RSI (&amp;lt;13), 2) improvement in cough sub-scores of RSI (decrease ≥ 2 points or to 0 on a 5-point scale), 3) GERD symptom improvement (&amp;gt;50% decrease in GERD-HRQL, or &amp;lt; 2 in all sub-scores) 4) discontinuation of proton pump inhibitor (PPI), and 5) overall patient satisfaction. We further analyzed response in patients with cough-predominant phenotype (chief complaint of cough and RSI troublesome cough subscore ≥2). Results 198 patients with cough and GERD successfully underwent TIF/cTIF (Table 1) without serious adverse events. Greater than 6-month follow-up was available for 177 patients at a median of 12 months [IQR 6,12]. Median RSI score decreased from 18 [IQR 13, 27] to 5 [IQR 2, 11] (p &amp;lt; 0.0001), median change 11 [IQR5,11]. 83% of patients with elevated baseline RSI normalized their scores. 75% of patients had improvement of cough when lying down (median: 1 point [IQR 0,3]), and 72% of patients had improvement of troublesome cough (median: 1 point [IQR 1,3]). 83% of patients successfully discontinued or decreased PPI to occasional use. Patient satisfaction improved from a baseline of 5.6% to 68.8% (p &amp;lt;0.0001). Compared to patients without cough-predominant symptoms, cough-predominant patients (n=108) experienced an additional 4.2-point decrease in in RSI score (p = 0.01) and 1.5-point decrease in troublesome cough sub-scores (p&amp;lt;0.0001). Patients with regurgitation phenotype were more likely to have a favorable cough response at 6 months (p&amp;lt;0.0001). In appropriately selected patients, cTIF and TIF were comparable for cough, GERD-HRQL, RSI, and PPI responses. Conclusion TIF/cTIF are effective and safe alternative barrier therapies for patients with pH-positive cough-predominant GERD.

429. BARRETT'S ESOPHAGUS IN CHILDREN

Abstract Background In children, Barrett's esophagus (BE) is much less common than in adults and has its own characteristics. If in adult practice the treatment tactics are quite restrained, then in childhood they are, on the contrary, as radical as possible. Barrett's esophagus is a consequence of pathological gastroesophageal reflux disease, which is considered an obligate precancerous disease, which determines the relevance of research in this direction. Material and research methods 345 children with GERD were examined over 10 years. BE was detected in 52 children, which accounted for 14% of cases. Of these, 20 children had peptic stricture of the esophagus. They were included in the 2nd group of the study. The first group - 32 children without peptic stenosis of the esophagus. The treatment tactics for patients in the first group are fundoplication, after 3 months eradication of BE (electrodestruction or cryodestruction). In the second group - a course of bougienage, fundoplication, with destruction BE, or extirpation of the esophagus for extended peptic strictures of the esophagus. Results Of the 52 children, boys predominated (71%). The average age was 10.2 years In all cases in the first group, antireflux surgery produced a positive result, although it did not affect the regression of metaplasia in the category of patients with an endoscopically negative form. In all patients of the second group, a positive result was obtained, GER was stopped, stenosis and metaplasia of the esophagus were eliminated. Eradication of metaplasia in 45% (9 children) of cases was achieved by extirpation of the esophagus due to extensive peptic stenosis (4-6 cm), and in 55% (11 children) - postoperative endoscopic destruction BE. Conclusions BE detected in childhood is subject to eradication upon its detection, regardless of the absence of signs of high-grade dysplasia, which is more likely to occur in adulthood. Patients with an endoscopically negative form of BE require clinical observation with morphological control once a year. Extirpation of the esophagus with simultaneous coloesophagoplasty is indicated in children with peptic strictures (4-6 cm) that are not amenable to balloon dilatation against the background of fundoplication for 6 months or more.

Short esophageal myotomy versus standard myotomy for treatment of sigmoid-type achalasia: results of an international multicenter study

Patients with sigmoid-type achalasia can be challenging to treat with peroral endoscopic myotomy (POEM). A short myotomy improves technical success; however, outcomes have not previously been evaluated. This was a multicenter, international, retrospective study of patients who underwent POEM with short (≤4 cm) or standard esophageal myotomy. Outcomes included clinical and technical success, procedural adverse events, and reflux rates. A total of 109 patients with sigmoid achalasia (sigmoid, n= 74; advanced sigmoid, n= 35) underwent POEM across 13 centers (short myotomy, n= 59; standard, n= 50). Technical success was 100% across both groups. Patients who underwent short myotomy had a significantly shorter mean procedure time (57.7 ± 27.8 vs 83.1 ± 44.7 minutes, P= .0005). A total of 6 adverse events were recorded in 6 patients (5.5%; 4 mild, 2 moderate); the adverse event rate was not significantly different between short and standard groups. Ninety-eight patients had follow-up data (median, 3.6 months; interquartile range, 1-14 months). Clinical success was 94% (short, 93%; standard, 95%; P= .70) and did not differ based on achalasia subtype or sigmoid achalasia severity. Twenty-one (22%) patients reported post-POEM reflux and 44% (16 of 36) had objective evidence of pathologic reflux. Rates of pathologic reflux were significantly increased in the standard versus short group (odds ratio, 18.0; 95% confidence interval, 2.0-159.0; P= .009). POEM with short myotomy is effective and safe for the short-term treatment of sigmoid and advanced sigmoid achalasia. Short myotomy may lead to less reflux than standard myotomy.

Clinical Profile of Leg Symptoms and Reflux in the Legs From Varicose Veins Disease Reported at a Tertiary Healthcare Institute in Jharkhand, India.

Background Varicose veins, affecting 8-10% of the population, are categorized as primary or secondary, depending on the etiology. The aim of thestudy is to assess the clinical profile of leg symptoms and reflux in the legs of varicose veins disease among patients reported in a tertiary hospital. Patients and methods An institution-based cross-sectional exploratory study comprising 56 patients with reflux in legs of varicose veins disease selected through purposive sampling, conducted in the OPD (outpatient department), general surgery, AIIMS (All India Institute of Medical Sciences) Deoghar. The standardized study instrument includes the Aberdeen varicose veins questionnaire, and patients' symptoms and concerns questionnaire, followed by a brief clinical examination based on CEAP (clinical, etiological, anatomical, and pathophysiological)classification and VCSS (venous clinical severity score) for C5/6 and color-flow duplex imaging of both lower limbs. Descriptive and inferential statistics were used for data analysis using IBM SPSS Statistics for Windows, Version 23 (IBM Corp.,Armonk, NY). Results Bilateral presentation of the disease had been seen in 57.1% (n=32) participants, and the common history of present illness reported by participants included swelling along the veins (n=55, 98.2%), pain (n=51, 91.1%), and discoloration (n=33, 58.9%). The clinical grading revealed that most participants, i.e., 87.5% (n=49) had C2 and 75% (n=42) had C3 disease. The majority of participants 96.4% (n=54) suffered from primary varicose veins. Furthermore, all subjects exhibited superficial vein involvement, alongwith one individual having deep vein involvement and a few participants (n=35, 62.5%)having perforators. With this, the majority of participants (n=55, 98.2%) showed reflux pathology. Conclusion Varicose veins typically afflict men in their 40s and 50s who work in positions of extended standing. Limited awareness in the Santhal Pargana division, Jharkhand state, India may result in poor healthcare outcomes. Improving public awareness may help lessen disease-related consequences.

PHoenix score: development and validation of a novel approach to decrease the number of inconclusive GERD diagnoses

BackgroundThe Johnson–DeMeester composite score (DMS) is the historical gold standard for diagnosing gastroesophageal reflux disease (GERD). The Lyon Consensus outlines criteria for diagnosing GERD by pH monitoring, defining normal acid exposure time (AET) as < 4% and pathological as > 6%, presenting diagnostic uncertainty from 4 to 6%. We aimed to (i) calculate the proportion of borderline studies defined by total AET alone that are reclassified as normal or pathological by the DMS, (ii) determine the importance of supine AET for reclassification, and (iii) propose a new classification system using a composite score that considers positional changes.MethodsThis single-center, retrospective, observational study analyzed data from patients with an overall total AET from 2 to 6% on 48-h pH monitoring (Bravo pH capsule). Preselected predictors (supine and upright AET) were included in a model to create a composite score (i.e., pHoenix score) using the regression coefficients. The model was internally validated, and discriminative ability was tested against the DMS and compared to the total AET.ResultsWe identified 114 patients (80 [70.2%] women; median age, 55 years). Using the total AET, 26 (22.8%) were classified as normal and 88 (77.2%) as borderline; however, using the DMS, 45 (39.5%) were classified as normal and 69 (60.5%) as pathological. The new pHoenix score demonstrated strong discriminative ability (AUC: 0.957 [95% CI 0.917, 0.998]) with high sensitivity and specificity (lower threshold, 94.4% and 79.2%; upper threshold, 87 and 95.8%). Compared to the total AET alone, the pHoenix score significantly decreased the proportion of inconclusive cases (77.2% vs. 13.2%, p < 0.001).ConclusionTotal AET has low sensitivity to identify pathological reflux as it disregards supine versus upright reflux. The pHoenix score improves the distinction between normal and pathological cases and reduces ambiguity, offering an alternative approach to diagnosing GERD that addresses the limitations of using total AET alone or the DMS.Graphical abstract

Fluid dynamics and venous hemodynamics in the lower extremities.

Chronic venous disease is a vascular disorder characterized by impaired venous return and a progressive dysfunction of the venous system. Pathological reflux can occur due to abnormal dilation and weakening of the vein wall. The circulatory system is a natural structure in which physical laws, such as the law of closed containers and gravity, operate. The malfunctions in the system also adhere to these laws of nature. This article explains how the principles of fluid dynamics apply to the flow of blood in the veins of the legs. I am discussing the principles of Pascal's law, Torricelli's law, Bernoulli's law, and Poiseuille's law, and how they are relating to the anatomy and physiology of the venous system.

Bile reflux after laparoscopic mini/one anastomosis gastric bypass: the problem and prevention

Currently, laparoscopic mini-gastric bypass (LMGB) is a common bariatric surgical operation. One of the reasons for reoperations after LMGB is pathological bile reflux, which, in addition to a noticeable decrease in the quality of life of patients, poses a potential threat to the neoplastic processes in the stomach and esophagus. This study aimed to systematize and analyze modern literature information on terminology, diagnosis and frequency of detection, pathophysiological significance, and methods of preventing bile reflux post-LMGB. Russian and English full-text studies on bile reflux after LMGB in the bibliographic databases of the Russian Science Citation Index, PubMed, Google Scholar, and ScienceDirect were analyzed. The frequency of diagnosing bile reflux after LMGB varies from 2.0 to 57.9%, depending on the instrumental diagnostic methods used: flexible endoscopy, 24-hour pH impedance measurements, spectrophotometry of bilirubin in refluxate, and hepatobiliary scintigraphy. The pathogenetic effect of the contents of the small intestine on the mucous membrane of the stomach and esophagus after LMGB is noted because of the direct cytotoxic and receptor-mediated effects of bile acids. The safety of the main stages of LMGB (creation of a gastric pouch and formation of a single anastomosis) is currently being reviewed from the standpoint of minimizing the risk of developing bile reflux. Furthermore, novel techniques have been proposed to reduce the likelihood of intestinal contents entering the stomach and esophagus; however, their effectiveness remains controversial.

Influence of surgical treatment of varicocele on the pathospermia and the level of sperm DNA fragmentation

Introduction. Varicocele is a varicose vein in the testicle caused by pathological venous reflux. Clinically, varicocele is found in 15% of the male population, with 35% of men with primary infertility and 70-81% of men with secondary infertility. Uncontrolled, excessive amounts of reactive oxygen species (ROS) can cause single- and/ or double-strand breaks in sperm DNA, commonly referred to as sperm DNA fragmentation. The purpose of the study was to determine the effect of surgical treatment of varicocele on the level of DNA fragmentation and to develop prognostic criteria for restoring the fertility of patients.Materials and methods. The study is based on a comparative analysis of the results of examination and treatment of 93 patients without concomitant pathology, with pathospermia, increased levels of DNA fragmentation and varicocele, who received surgical treatment. All patients were followed up for 3–9 months after surgery. The control group did not receive postoperative therapy – 34 people, the main group (59 patients) received drug rehabilitation – a complex of spermatoprotectors and antioxidants – for 3 months after surgical treatment.Results of the study and their discussion. In patients who received surgical treatment, there was a normalization of the level of DNA fragmentation after 3 months in the postoperative period, on average the positive dynamics was 21% (from an average fragmentation level of 22.82% to 15.84%, p &lt;0.05), the prognosis for pregnancy in the couple became favorable. An improvement in DNA fragmentation indicators was observed in parallel with an improvement in spermogram indicators in the postoperative period. Progression of left testicular hypotrophy in the postoperative period was not detected. No relapses or other complications were noted.Conclusions. Treatment of varicocele improves fertility in patients with pathospermia, increased levels of DNA fragmentation, which is consistent with research data from other authors, which confirmed the fact of a significant improvement in ejaculate parameters (sperm concentration, motility and morphology) However, the dynamics of normalization of sperm DNA fragmentation occurs, according to our data, more dynamically (within 3 months in the postoperative period) than the improvement of pathospermia (OAT syndrome) and does not depend on the presence of postoperative drug rehabilitation.