Pathological Reflux Research Articles

Correlation of the Endoscopic Gastroesophageal Flap Valve with Gastroesophageal Reflux Disease

INTRODUCTION: Hill Grade (HG) characterizes the gastroesophageal flap valve and abnormal HGs (III/IV) correlate with GERD. Although considered normal, many patients with HG II have GERD in clinical practice. The aim of this study was to correlate the incidence of GERD across HGs and determine the incidence of GERD in patients with HG II. METHODS: A retrospective review was performed on 365 patients who underwent EGD and BRAVO pH monitoring between August 2018 and August 2021. Of 365 patients, 187 (51.2%) had a HG reported and were further reviewed for the association with pathologic acid exposure defined as overall acid exposure time (AET): 4.9% and DeMeester score (DMS): 14.7. RESULTS: Of the 187 patients, 37 (19.8%) had HG I; 80 (42.8%) HG II; 49 (26.2%) HG III, and 21 (11.2%) HG IV. The proportion of abnormal AET increases with increasing HG (p = 0.023): I (37.8%), II (55.0%), III (63.7%), IV (76.2%); and the median AET also increases with HG (p = 0.008): I (1.6%), II (5.9%), III (8.3%), IV (9.5%). The proportion of abnormal DMS increases with HG (p = 0.022): I (43.2%), II (66.3%), III (71.4%), IV (76.2%); and the median DMS also increases with HG (p = 0.003): I (7.2), II (20.6), III (27.6), IV (34.3) (Table 1). Table 1. - Comparison of the Findings of 24-Hour pH Monitoring According to Hill Grade Variable Hill grade Median Mean Kruskal-Wallis test p Value DeMeester score 1 7.2 18.01 0.003 2 20.60 27.29 3 27.60 37.02 4 34.30 32.44 Acid exposure time overall (%) 1 1.6 5.11 0.008 2 5.95 7.50 3 8.30 10.34 4 9.50 8.96 CONCLUSION: Increasing HG is associated with higher median AET and DMS. HG II, which has been considered normal, correlates with pathologic reflux. Efforts are needed to educate endoscopists on the importance of accurately documenting the HG within the context of GERD management.

Comparative Analysis of Heller Myotomy With Dor Versus Toupet Fundoplication for Achalasia Cardia

Background Heller myotomy (HM) with partial fundoplication is the standard of care for achalasia cardia. However, the choice of partial fundoplication is controversial. In this study, we compared both types of fundoplication concerning subjective and objective parameters. Methodology This prospective comparative study comprised a total of 30 consecutive patients who underwent laparoscopic/robotic HM with either Dor fundoplication (DF) (n = 15) or Toupet fundoplication (TF) (n = 15). Preoperative baseline characteristics, intraoperative details, and postoperative complications were recorded. Patients were followed with Eckardt score, quality of life-related scores, 24-hour pH study, and high-resolution manometry (HRM) at the one-year follow-up. Results There was no significant difference between the two groups regarding preoperative baseline parameters, length of hospital stay, and postoperative complications. The HM+DF group had four (27%) patients with recurrence/failure with none in the HM+TF, but it was not significant (p = 0.79). Symptom scores were similar between the groups at six and 12 months of follow-up. One patient in the HM+DF group and two in the HM+TF group had significant pathological acid reflux (p = 0.483). On HRM, HM+TF showed a trend toward significance in terms of esophagogastric junction (EGJ) relaxation (p = 0.058) with a non-significant difference in median integrated relaxation pressure (p = 0.081). Conclusions The study showed a trend toward lower failure rates and improved EGJ relaxation with similar reflux rates in patients who underwent HM+TF compared to HM+DF. However, long-term follow-up is required to validate our findings with well-defined subjective and objective criteria.

Efficacy of laparoscopic fundoplication in patients with chronic cough and gastro-oesophageal reflux

BackgroundThe outcome of anti-reflux surgery in patients with suspected gastro-oesophageal reflux-induced cough is frequently uncertain. The aims of this study were to assess the efficacy of laparoscopic fundoplication for controlling cough in patients with chronic cough without asthma, who have pathologic gastro-oesophageal reflux, and to identify predictors of response.MethodsFrom a prospective database of 1598 patients who have undergone laparoscopic fundoplication, 66 (4%) with proven gastro-oesophageal reflux disease (GORD) and chronic cough without asthma were studied. All patients underwent gastroscopy and 24-h pH monitoring before operation. Heartburn and regurgitation were assessed using a modified DeMeester score. Severity of cough before and after surgery was self-assessed by the patient using a visual analog scale at a minimum of 12 months post-operatively (median 43 mo; range: 14–104 mo). Patients were considered to have responded to fundoplication if they had no cough or the cough had improved by 50% or more after operation.ResultsCough and heartburn/regurgitation were relieved in 61% (40/66) and 90% (44/49) of the patients, respectively. The presence of typical GORD symptoms or oesophagitis, and pH study variables did not predict the response of the cough to fundoplication.ConclusionRefinement in the aetiological diagnosis of chronic cough due to GORD is necessary for improved outcome. Patients diagnosed with GORD-related chronic cough need to be counseled regarding their expectations from anti-reflux surgery.

Gastroesophageal refl ux disease and broncho- obstructive syndrome in children — a “vicious circle” or comorbidity?

This article is devoted to the comorbidity of diseases of the digestive tract and respiratory system in children. Comorbidity (polymorbidity) in the pathology of the gastrointestinal tract is widely described in modern scientific literature, however, the relationship between the digestive and respiratory systems seems to be less studied.The purpose of the study was to analyze the endoscopic signs of refl ux pathology of the digestive tract in children with a comorbid condition — GERD and respiratory diseases occurring with broncho-o bstructive syndrome (BOS).Materials and methods. An in-depth examination of 180 children from 6 to 16 years old with comorbid pathology (respiratory diseases with BOS and GERD) was carried out. Performed: X-ray examination, spirometry, intracavitary pH-metry, EFGDS and ultrasound of the gastrointestinal tract. To study the morphological features of the esophageal mucosa in this comorbidity, biopsies were examined 1 cm above the Z-line; at the same time, a biopsy of the mucosa of the antrum of the prepyloric part of the stomach was performed.Results. Respiratory diseases with biofeedback in the examined groups of patients were most often (43.9%) combined with GERD at the age of 12–14 years. The predominance of endoscopically positive grade 1 GERD is typical for patients with broncho- obstructive syndrome caused by moderate and severe persistent BA, acute and prolonged pneumonia, and recurrent bronchitis. Infl ammatory diseases of the digestive system (chronic gastritis, chronic gastroduodenitis) in BA were detected in 40.6% of patients, in pneumonia — in 45.7%, in recurrent bronchitis — in 33.3% of patients. Based on the data of a general morphological study of biopsy specimens, regardless of age and type of bronchopulmonary pathology, two variants of infl ammation were identifi ed, which are more common than others — with a predominance of dystrophic changes and with a predominance of infl ammation itself, which largely depended on the duration of the disease. In patients suff ering from both BA and pneumonia with biofeedback, morphological changes in the esophageal mucosa corresponded to the catarrhal nature of the infl ammation.

Revision paraesophageal hernia repair outcomes in patients with typical and atypical reflux.

Revision laparoscopic anti-reflux surgery (RLARS) is effective in alleviating the typical symptoms of gastroesophageal reflux disease (GERD). RLARS outcomes in patients with atypical GERD symptoms has not been well established. A composite Reflux Symptom Index (RSI) score greater than 13 indicates extraesophageal manifestation of pathological reflux. In this study, we analyzed the differences in quality-of-life (QOL) and perioperative outcomes between patients with atypical versus typical GERD who underwent RLARS. A retrospective review was conducted of a prospectively maintained database of patients with pathologic reflux who underwent RLARS from February 2003 to October 2019. The cohort was divided into two groups, those with typical versus atypical manifestations of GERD, as defined by their RSI score. Patients with a RSI score of > 13 were assigned to the Atypical group and those ≤ 13 were assigned to the Typical group. Patient QOL outcomes were prospectively followed using the RSI survey. Significance was defined by p-value less than 0.05. A total of 133 patients (Typical 61, Atypical 72) were included in the final analysis. The two groups were similar (p > 0.05) in mean age (58.1 ± 13.3 vs. 55.3 ± 15.5years), body mass index (29.6 ± 5.0 vs. 30.3 ± 5.4), female sex distribution (60.7% vs. 59.7%) and age adjusted Charlson score (1.76 ± 1.58 vs. 1.98 ± 1.94). The Typical group had a higher frequency of type III hiatal hernia (62.3% vs. 29.2%) and Collis gastroplasty (29.5% vs. 5.6%). The groups had similar rates of partial and complete fundoplication with similar median length of stay (Typical: 3.0 ± 3.4days vs. Atypical: 2.4 ± 1.7days). After a mean follow-up of 30.2 ± 33.6months, both groups reported similar rates of improvement in RSI outcome from baseline (58.1% vs 43.3%, p = .149). However, the RSI outcome at the latest follow-up for the Typical group was significantly better than the Atypical group after RLARS (2.8 ± 5.3 vs. 15.9 ± 11.1, respectively). Patients who undergo revision paraesophageal hernia repair with objective findings of GERD and subjective complaints of atypical reflux symptoms may show long-term improvement in QOL outcomes. However, these results are contingent on proper patient selection and a thorough work-up for pathological reflux in this population. Further research is needed to determine universal diagnostic criteria to assist in the early detection and surgical treatment of patients with atypical GERD.

320. EFFICACY OF LAPAROSCOPIC FUNDOPLICATION IN PATIENTS WITH CHRONIC COUGH AND GASTRO-OESOPHAGEAL REFLUX

Abstract The outcome of anti-reflux surgery in patients with cough suspected to be induced by gastro-oesophageal reflux disease is frequently uncertain. The aims of this study were to assess the efficacy of laparoscopic fundoplication (LF) for controlling cough in a patient population suffering chronic cough when alternative aetiologies (e.g. asthma) had been excluded and pathologic gastro-oesophageal reflux had been confirmed on ambulatory pH monitoring, and to identify predictors of response. From a prospective database of 1,598 patients who had undergone laparoscopic fundoplication, 66 (4%) had a principal presenting symptom of chronic cough as well as objective evidence of gastro-oesophageal reflux disease (GORD). Patients completed questionnaires for GORD symptoms (modified DeMeester score) and severity of cough (visual analog scale) both before and after LF, and had pre-operative gastroscopy and 24-hour pH monitoring before operation. Patients were considered to have responded to LF if they had no cough or the cough had improved by 50% or more after operation. Follow-up data was available for 66/66 patients (100%), with a median follow-up time of 43 months (range 14–104 months) after operation. Cough was relieved in 40/66 (61%), while typical GORD symptoms (heartburn, regurgitation) was relieved in 44/49 (90%). The presence of typical GORD symptoms, oesophagitis, or pH study variables did not predict the response of the cough to LF. At 1 year, 67% of patients were satisfied with the results of their surgery, 20% were not and 13% were unsure. For comparison, the 1430/1598 patients in the database with no laryngopharyngeal symptoms had a satisfaction rate of 94%. Based on our study and available literature, it appears there are no reliable pre-operative clinical predictors of a satisfactory response of cough to LF. This probably reflects a current inability to obtain an accurate aetiological diagnosis of chronic cough, even in the presence of known abnormal gastro-oesophageal reflux disease. Regardless, in a well-chosen cohort of patients with chronic cough, LF can yield good patient satisfaction rates, albeit less than for patients with typical GORD symptoms.

Bile Reflux Gastritis: Insights into Pathogenesis, Relevant Factors, Carcinomatous Risk, Diagnosis, and Management.

Bile reflux gastritis (BRG), a kind of gastrointestinal disorder in clinical practice, is characterized by regurgitation and inflammation. However, lack of guidelines leads to simple cognition and even ignorance of this disease for clinicians. Primarily, making the pathogenesis of BRG clear contributes to a correct and general understanding of this disease for physicians. Next, although recently there has been an increasing awareness among researchers in terms of the relevant factors for BRG, further studies involving large samples are still required to certify the relationship between them explicitly. Besides, researches have established that BRG is closely associated with the development of precancerous lesions and gastric cancer. Till now, there is still no golden standard for diagnosis of BRG. Nevertheless, advances in techniques, especially extensive applications of endoscopy and chemical analysis of reflux contents, have improved our ability to identify the occurrence of this disease as well as distinguishing physiological reflux from pathological reflux. Finally, it is fortunate for patients that more and more importance has been attached to the treatment of BRG. From lifestyle modification to drug therapy to surgery, all of them with the view of realizing symptomatic relief are employed for patients with BRG. In this review, we briefly evaluate this disorder based on the best available evidence, offering an overview of its complicated pathogenesis, diverse relevant factors, potential carcinomatous risk, modern diagnostic investigations, and effective therapeutic plans.

Potential factors of Helicobacter pylori resistance to clarithromycin.

A comparative dissolution kinetics test (CDKT) and bioequivalence studies of generic proton pump inhibitors (PPIs) do not model pharmacological acid suppression (PAS) and pathological duodenogastric reflux (PDGR). This study aimed to model them in CDKT to assess drugs stability and potential pantoprazole-clarithromycin interactions. In CDKT, PDGR (dissolution medium pH 7.00±0.05, preexposure at pH 1.20±0.05) and PAS (pH 4.00±0.05) were modelled for original pantoprazole (OP) and its generics (GP1-4). In CDKT with high-performance liquid chromatography, dissolution gastric medium in adequate (pH 4.00±0.05) and inadequate (pH 1.20±0.05) PAS were modelled for original clarithromycin (OC) and its generics (GC1-4). After exposure in pH 7.00±0.05, pantoprazole was released from GP1 within 10min in the amount of 68.8%. In рН 4.00±0.05, 83.0% and 81.5% of pantoprazole were released from GP1 and GP4. When OP, GP2 and GP3 were placed in pH 7.00±0.05, pantoprazole was released in amount: 99.4%, 88.0% and 98.2%. Clarithromycin releasing from OC, GC1, GC2, GC3, GC4 in pH 4.00±0.05 was 93.5%, 91.6%, 92.9%, 79.4% and 83.0%. In pH 1.20±0.05: 9.7%, 6.7%, 8.5%, 33.3%, 28.8%. Destruction of enteric coats of some local pantoprazole generics in CDKT-models might be a potential factor for inadequate therapy.

FEATURES AND STRUCTURE OF THE COMPLICATIONS OF ENDOVENOUS LASER ABLATION

The aim of the research work: to analyze the structure, frequency and features of complications after endovenous laser ablation in patients with varicose veins of the lower extremities. An open, prospective study was conducted, which included 208 consecutive patients with varicose veins of the lower extremities. All patients underwent endovenous laser ablation of varicose veins and investigated the structure and features of the development of postoperative complications. Pathological reflux of blood in the trank of the great saphenous vein of the lower extremity was diagnosed in 206 cases, isolated reflux in the trank of the small saphenous vein was observed in 24 (10.4 %) limbs, in 16 patients EVLA was performed simultaneously in the small and large saphenous veins). One or more adverse events were reported by 94 patients (45.2%) during the first 2 weeks after treatment, and pain was the most common symptom in the study patients, with complaints reported by 82 (39.4 %) patients with a mean value immediately after treatment). The second most common complication of endovenous laser ablation was ecchymosis, which developed in 44 (19.1% extremities). Tissue induration and hyperpigmentation along the coagulated vein were observed in 5.2% and 3.9%, respectively. Manifestations of transient paresthesia and wound infection were observed in 0.4% of cases, in 2 (0.9 %) patients after EVLA in the great saphenous vein. In the postoperative period serious adverse events developed, such as EHIT II and in 3 (1.4 %) cases asymptomatic distal deep vein thrombosis. Endovenous laser ablation is an effective method of treating varicose veins of the lower extremities with a high safety profile. Clear standardization of the procedure and postoperative monitoring will minimize the risks of postoperative complications and eliminate them in a timely manner.

ANALYSIS OF TREATMENT OPTIONS FOR STASIS DERMATITIS

im: 1) To analyze the effectiveness of various treatment methods for stasis dermatitis. 2) To evaluate the effectiveness of various components of conservative therapy. Methods: 80 patients (52 women and 28 men) aged 43 to 82 years old with CEAP class C4a varicose veins of the lower extremities, complicated by stasis dermatitis, were enrolled in the study. The patients were divided into two groups of 40 people each, comparable in terms of the main clinical and anamnestic data. The patients of the first group underwent surgical elimination of pathological reflux followed by conservative therapy. In patients of the second group surgical intervention was postponed or contraindicated. Patients of the second group were randomly divided into two subgroups of 20 patients using a random number generator. Patients of the second group received various options of conservative therapy. Results: In the first group, 34 patients (85%) showed complete remission of stasis dermatitis in the control periods, in 6 patients (15%) the area decreased to 11mm2. In subgroup 2A, complete remission was observed in 13 patients (65%). In the rest (7) the affected area was 13.8±mm2. In subgroup 2B, complete remission was not observed. The affected area averaged 14.1±mm2. Conclusions: The best result in the treatment of stasis dermatitis was observed in the group that received surgical treatment followed by conservative therapy. In two subgroups receiving conservative therapy, the subgroup treated with venotonics, showed the best clinical result. The study confirms the need for an integrated approach to the treatment of chronic venous insufficiency complicated by stasis dermatitis.

MR lymphangiography of lymphatic abnormalities in children and adults with Noonan syndrome

Noonan syndrome is associated with complex lymphatic abnormalities. We report dynamic-contrast enhanced MR lymphangiography (DCMRL) findings in children and adults with Noonan syndrome to further elucidate this complex disease spectrum. A retrospective evaluation of patients with confirmed Noonan syndrome and clinical signs of lymphatic dysfunction undergoing DCMRL between 01/2019 and 04/2021 was performed. MRL included T2-weighted imaging (T2w) and DCMRL. Clinical history/presentation and genetic variants were recorded. T2w-imaging was evaluated for central lymphatic abnormalities and edema distribution. DCMRL was evaluated regarding the presence of cisterna chyli/thoracic duct, lymphatic leakages, pathological lymphatic reflux and abnormal lymphatic perfusion. The time from start of contrast-injection to initial enhancement of the thoracic duct venous junction was measured to calculate the speed of contrast propagation. Eleven patients with Noonan syndrome with lymphatic abnormalities (5 female, 6 male; 7 infants, 4 adults; mean age 10.8 ± 16.4 years) were identified (PTPN11 n = 5/11 [45.5%], RIT1 n = 5/11 [45.5%], KRAS n = 1/11 [9%]). Patients had a chylothorax (n = 10/11 [91%]) and/or pulmonary lymphangiectasia [dilated pulmonary lymph vessels] (n = 9/11 [82%]). Mediastinal/pulmonary edema was depicted in 9/11 (82%) patients. The thoracic duct (TD) was (partially) absent in 10/11 (91%) cases. DCMRL showed lymphatic reflux into intercostal (n = 11/11 [100%]), mediastinal (n = 9/11 [82%]), peribronchial (n = 8/11 [73%]), peripheral (n = 5/11 [45.5%]) and genital lymphatics (n = 4/11 [36%]). Abnormal pulmonary/pleural lymphatic perfusion was seen in 8/11 patients (73%). At infancy peripheral/genital edema was more prevalent in patients with RIT1 than PTPN11 (n = 3/5 vs. n = 0/5). Compared to patients with PTPN11 who had fast lymphatic enhancement in 4/5 patients, enhancement took markedly longer in 4/5 patients with RIT1-mutations. Thoracic duct dysplasia, intercostal reflux and pulmonary/pleural lymphatic perfusion are characteristic findings in patients with Noonan syndrome presenting with chylothorax and/or pulmonary lymphangiectasia. Central lymphatic flow abnormalities show possible phenotypical differences between PTPN11 and RIT1-mutations.

Role of esophageal symptoms in the diagnosis of gastroesophageal reflux disease in children with recurrent and chronic respiratory diseases

Gastroesophageal reflux disease (GERD) is one of comorbid diseases, that worsen the course and outcomes of respiratory pathology. The study aimed to determine role of esophageal symptoms in the diagnosis of GERD in children with recurrent and chronic respiratory diseases (RCRD). The study included 125 children (70 boys, 55 girls), median 3,75 years (interquartile range, IQR – 1,21-9,38 years), with RCRD, refractory to standard therapy. GERD was diagnosed on the basis of clinical and complex instrumental examination, including fluoroscopy esophagus with contrast, esophagogastroduodenoscopy (EGDS), 24-hour esophageal pH-monitoring, dual pH-multichannel intraluminal impedance (pH-MII). In children with RCRD, the frequency of GERD was 86,4%. Among children without esophageal manifestations of GERD, pathological reflux was confirmed by instrumental methods in 81% of patients; in children with esophageal manifestations - 92%, with no statistically significant differences (p = 0,0637). Nonacid reflux is more common in patients without esophageal manifestations of GERD. The frequency of GERD in children with RCRD is very high. It is possible to screen GERD in children with RCRD, independent on the presence of clinical esophageal symptoms.

Robotic surgery for the treatment of achalasia

ObjectiveTo describe the experience of the robotic approach for achalasia surgery in a tertiary center. Material and methodsPatients with achalasia who underwent robotic surgery between May 2010 and April 2019 were analyzed. The study variables were collected in a prospective database and a descriptive analysis was performed. Results45 patients (55.6% male) with a mean age of 44 years were included. The main symptom at diagnosis was dysphagia. 19 patients (42.2%) received endoscopic treatment prior to surgery, mostly pneumatic dilation (84.2%). Heller's myotomy associated with Toupet fundoplication was the surgical technique of choice, with a mean operative time of 211 min. The average stay was 5 days. There were 2 postoperative perforations (4.4%). Perioperative mortality was 0%. The mean follow-up was 64 months. At 3 and 5 years, a significant decrease in the Eckardt score was observed and the manometric study showed a decrease in the lower esophageal sphincter pressure at rest of 58% and 70%, respectively, with persistence of hypomotility of the esophageal body. Pathological gastroesophageal reflux was diagnosed in two patients (5.4%) and 4 (10.8%) presented recurrence of symptoms, requiring endoscopic pneumatic dilations. In 2 cases, the dilations were not effective, so an endoscopic myotomy was considered. ConclusionsIn our experience, robotic surgery is a safe and effective procedure for the treatment of achalasia.

Laparoscopic Heller Myotomy with Dor Fundoplication: An Operation that has Withstood the Test of Time.

Achalasia is a primary esophageal motility disorder characterized by aperistalsis and defective relaxation of the lower esophageal sphincter in response to swallowing. Patients' symptoms include dysphagia, regurgitation, weight loss, chest pain and aspiration. The disease is idiopathic, and the goal of treatment is to eliminate the resistance determined by the abnormal lower esophageal sphincter, therefore allowing passage of the ingested food from the esophagus into the stomach. Three effective treatment modalities are available today-pneumatic dilatation, peroral endoscopic myotomy, and laparoscopic Heller myotomy with a partial fundoplication. We described the technique to perform a laparoscopic Heller myotomy and a Dor fundoplication. Five steps to perform a laparoscopic Heller myotomy and a Dor fundoplication were described. The surgical approach is favored in many centers as it is very effective in relieving symptoms, while avoiding pathologic gastroesophageal reflux in most patients.

New approaches of patients with varicocele for different forms of pathospermia depending on age

Introduction. Varicocele is a testicular varicose vein caused by pathological venous reflux. It is most common in infertile men. Clinically, varicocele is found in 15% of the male population, while in 35% of men with primary infertility and in 70–81% of men with secondary infertility. Varicocele, not accompanied by pain, is the most common cause of the development of pathospermia and infertility. Varicocele is detected at the age of 10 years in 1% of boys, increasing to puberty up to 15%. At the age of 50–80 years, the incidence of varicocele increases to 75–77.3%, thus adding an average of 10% every 10 years of life.Aim is to investigate the fertility restoration after surgical procedures and the prognostic criteria for its restoration depending on age and the proposed medical rehabilitation.Materials and methods. In the urological hospital for a short stay of the state autonomous healthcare institution of the Stavropol Territory “Regional Clinical Specialized Uro-Andrology Center” from 2011–2019. 1143 varicocelectomies were performed (244 laparoscopic varicocelectomy, 975 microsurgical varicocelectomy). The study is based on a comparative analysis of the results of examination of 100 patients with pathospermia and varicocele in the period from 2011 to 2019, who received surgical treatment and did not have concomitant pathology. All patients were followed up for 18 months after surgery.Results and discussion. The pain syndrome was stopped in 100% of cases in the studied patients. Progression of hypotrophy of the left testicle in the postoperative period was not detected. Relapses and other complications were not noted. Patients in the control group were also observed for 1.5 years with an interval of 6 months. Deterioration of spermatogenesis in this group was not detected.Conclusions. It was revealed that varicocele was the main cause of spermatogenesis and fertility disorders in the studied groups. Surgical treatment is a pathogenetically grounded and statistically proven method of restoring fertility in varicocele. After varicocelectomy, adequate medical rehabilitation allows to normalize the qualitative and quantitative parameters of sperm in most clinical cases as soon as possible (up to 3 months).

Results of laparoscopic Heller esophagocardiomyotomy with Dor fundoplication in patients with stages 3 and 4 of the esophageal achalasia

INTRODUCTION. The choice of a treatment method in patients with stages 3–4 of the esophageal achalasia remains an actual topic.The OBJECTIVE was to evaluate the long-term results of Heller esophagocardiomyotomy with Dor hemiesophagofundoplication at stages 3–4 of the esophageal achalasia by comparing the results of patient survey with data of instrumental methods of diagnosis of esophageal function.METHODS AND MATERIALS. The results of the operation were analyzed in 67 patients, including 35 patients with stage 3 and 32 patients with stage 4 of the disease. The period of postoperative follow-up was 1–5 years. The results of X-ray examination of the esophagus and stomach, esophageal manometry, 24-hour pH-metry and the data of the Eckardt and GIGLI scale questionnaires were evaluated.RESULTS. The data of X-ray examination of the esophagus and stomach, in the long-term period, showed a complete restoration of the esophagus evacuation function in all patients (p=0.001), according to manometric data, a significant decrease in the tone of the lower esophageal sphincter in all patients to normal values (p=0,001) was revealed, esophageal atony was noted in three patients with stage 4 of the disease. Pathological gastroesophageal reflux before and after surgery was not registered by pH-metry, the De Meester index was within the normal range in all groups (less than 14.72). Dysphagia in the long-term period decreased in all patients. Long-term results on the Eckardt scale in patients with stage 3 improved by 83.5 %, with stage 4 by 78.3 % (p=0.001), according to the GIGLI questionnaire, patients with stage 3 scored 83.5 %, with stage 4 by 78.3 % more than before surgery.CONCLUSION. Laparoscopic Heller esophagocardiomyotomy with Dor fundoplication reduces symptoms of the disease in patients with stages 3–4 of the esophageal achalasia, increases the gastrointestinal index of quality of life, which makes it advisable to perform organ-preserving surgery at stage 4 of the disease.

Characterizing reflux on high resolution esophageal manometry with impedance

BackgroundIn some patients, reflux at esophagogastric junction (EGJ) can be seen on the impedance portion of the high-resolution esophageal manometry with impedance (HREMI) studies. How this correlates with reflux on conventional esophageal reflux monitoring studies is unknown. We aimed to: (1) determine prevalence of reflux seen on HREMI, (2) correlate reflux during HREMI with reflux on esophageal reflux monitoring studies.MethodsPatients undergoing HREMI and ambulatory reflux monitoring (7/2019 to 2/2020) were studied. Healthy volunteers (HVs) underwent HREMI.Key resultsSixteen HVs underwent HREMI (no reflux on HREMI = 13, reflux on 1 swallow on HREMI = 3). Of 229 patients (mean age 56.4 ± 1.0, 68.1% females) undergoing HREMI, 47 (20.5%) had pathologic reflux at EGJ on HREMI (reflux on ≥ 2 swallows). The patients with reflux on HREMI had more frequent reflux events on multichannel intraluminal impedance-pH (MII-pH) than patients without reflux on HREMI (63.5 ± 7.1 vs 42.1 ± 2.3, p = 0.01). On ambulatory pH monitoring, 113 (49.3%) had GERD and 42 (18.3%) borderline results. Patients with reflux on HREMI more commonly had GERD (56.3% vs 48.6%) and borderline results (28.1% vs 18.3%) than patients without reflux on HREMI (p = 0.01). Reflux on ≥ 2 swallows on HREMI had a specificity of 83.6% and sensitivity of 24.8% for GERD. Reflux on ≥ 5 swallows on HREMI improved specificity to 91.4%, with sensitivity of 14.2% for GERD.Conclusions and inferencesAmongst patients undergoing HREMI, 20.5% had pathologic reflux at EGJ on HREMI. Patients with reflux on HREMI more frequently had GERD on ambulatory pH monitoring. Reflux on HREMI had good specificity but low sensitivity for GERD.

Association Between Antibodies Against Lung Self-Antigens and Gastroesophageal Reflux in Lung Transplant Candidates

Gastroesophageal reflux (GER) and pretransplant antibodies against lung self-antigens (SAbs) collagen-V and/or k-alpha 1 tubulin are both independently associated with allograft dysfunction after lung transplantation (LTx). The role of GER in inducing lung injury and SAbs is unknown. We aimed to study the association between pre-LTx GER and SAbs. After IRB approval, we retrieved SAb assays conducted between 2015 and 2019 and collected 24 hour GER data for these patients. Patients were divided into 2 groups: no reflux (GER-) and pathologic reflux (GER+) to compare the prevalence of SAbs. Multivariate analysis was used to study the association between GER and SAbs in the whole cohort and in restrictive lung disease (RLD) and obstructive lung disease (OLD) subsets. Proximal esophageal reflux (PER) events ≥5 was considered abnormal. Patients (n=134; 73 men) were divided into groups: GER- (54.5%, n=73) and GER+ (45.5%, n=61). The prevalence of GER was higher in the RLD than in the OLD subset (p < 0.001). The overall prevalence of SAbs was 53.7% (n=72), higher in the GER+ than the GER- group (65.6% vs 43.8%, p=0.012), but comparable between RLD and OLD subsets. Overall, SAbs were associated with GER (p=0.012) and abnormal PER (p=0.017). GER and abnormal PER increased the odds of SAbs in the RLD subset (OR [95% CI]: 2.825 [1.033-7.725], p=0.040 and OR [95% CI]: 3.551 [1.271-9.925], p=0.014, respectively) but not in the OLD subset. LTx candidates have a high prevalence of SAbs, which are significantly associated with GER and abnormal PER in patients with RLD.

Contribution of the Elastic Component and Venous Wall Arterialization in Patients with Venous Reflux

Chronic venous disease (CVeD) is defined as a set of disorders affecting the venous system mainly manifested in the form of varicose veins. CVeD is characterized by a sustained venous hypertension, leading to a plethora of functional and structural changes in the vein that may cause valve incompetence and pathologic reflux. In turn, venous reflux aggravates the venous hypertension and enhances the progression of CVeD into the most advanced stages. Previous studies have proposed that there are several alterations in the venous wall preceding the valve dysfunction and venous reflux. Besides, it has also been identified that young patients with CVeD present premature aging and changes in the venous wall composition that may be related to the presence of venous reflux. In this context, the aim of the present study is to examine the possible pathophysiological role of elastic fibers and their precursors in the venous wall of patients with reflux in comparison to those without reflux, considering the variable age in both groups (<50 years and ≥50 years). We performed immunohistochemical and quantitative polymerase chain reaction (PCR) in order to assess the protein and gene expression of tropoelastin, fibrillin-1, fibulins 4 and 5, lysyl oxidase and lysyl oxidase like 1, respectively. In parallel, we assessed the elastin content through histological techniques (orcein stain) in this group of patients. Our results show significant changes in elastic fibers and their precursors in young patients with pathologic reflux when compared with elder patients with reflux and young patients without reflux. These variations suggest that the venous system of young patients with venous reflux appears to present an enhanced dynamism and arterialization of the venous wall, which may be associated with a premature aging and pathological environment of the tissue.

Quantifying physiologic parameters of the gastroesophageal junction during re-operative anti-reflux surgery.

Hiatal hernia re-approximation during index anti-reflux surgery (ARS) contributes approximately 80% of overall change in distensibility index (DI) and, potentially, compliance of the gastroesophageal (GEJ), while sphincter augmentation contributes approximately 20%. Whether this is seen in re-operative ARS is unclear. We quantify the physiologic parameters of the GEJ at each step of robotic re-operative ARS and compare these to index ARS. Robotic ARS with hiatal hernia repair was performed on 195 consecutive patients with pathologic reflux utilizing EndoFLIP™, of which 26 previously had ARS. Intra-operative GEJ measurements, including cross-sectional area (CSA), pressure, DI, and high-pressure zone (HPZ) length were collected pre-repair, post-diaphragmatic re-approximation, post-mesh placement, and post-lower-esophageal sphincter (LES) augmentation. Both cohorts were similar by sex and BMI and underwent similar procedures. The re-operative cohort was older (60.6 ± 15.3 vs. 52.7 ± 16.2years, p = 0.03), had more frequent pre-operative dysphagia (69.2% vs. 42.6%, p = 0.01) and esophageal dysmotility on barium swallow (75.0% vs. 35.0%, p < 0.001) but lower rates of hiatal hernia on endoscopy (30.8% vs. 68.7%, p < 0.001) compared to index procedures. Among the re-operative cohort, the CSA decreased by 34 (IQR - 80, - 15) mm2 and DI 1.1 (IQR - 2.4, - 0.6) mm2/mmHg (both p < 0.001). Pressure increased by 11.2 (IQR 4.7, 14.9) mmHg and HPZ by 1.5 (1,2) cm (both p < 0.001). These changes were similar to those seen in index ARS. Diaphragmatic re-approximation contributed to a greater percentage of overall change to the GEJ than did the augmentation procedure, with 72% of the change in DI occurring during hiatal closure, similar to that seen during index ARS. During re-operative ARS, dynamic intra-operative monitoring can quantify the effects of each operative step on GEJ physiologic parameters. Diaphragmatic re-approximation appears to have a greater effect on GEJ physiology than does LES-sphincter augmentation during both index and re-operative ARS.