Refractory Gastroesophageal Reflux Disease Research Articles

Current management of proton pump inhibitor-refractory gastroesophageal reflux disease

Here we review current concepts in diagnosis and treatment of proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (PPIGERD) which includes an insufficient response to daily PPI 8-week therapy in combination with pathological gastroesophageal reflux. Patients with PPI-GERD frequently suffer from non-acidic and asymptomatic gastroesophageal reflux. In developed countries, PPI-GERD accounts for 30-40% of all patients receiving PPIs. Diagnosis of PPIGERD is performed by means of clinical anamnesis, esophagogastroscopy and impedance-pH monitoring. PPI-GERD needs to be differentiated with functional heartburn, reflux hypersensitivity and nonerosive reflux disease. Functional heartburn is characterised by reference time with a esophageal pH < 4 and the absence of a link between reflux episodes and GERD symptoms. Reflux hypersensitivity is diagnosed with normal esophageal acid exposure and association of reflux episodes with symptoms of GERD. Nonerosive reflux disease can be diagnosed solely by evaluating pathological acid exposure (pH < 4 for > 6% of the time). Treatment of PPI-GERD includes diet and lifestyle modification to reduce weight in obese patients, optimization of PPI use, and administration of alginate, prokinetics, baclofen and other drugs. Surgical treatment is also widely used and provide good results.

A PROSPECTIVE STUDY INVOLVING COMPARISON OF ACOTIAMIDE WITH RABEPRAZOLE VS. DOUBLE DOSE RABEPRAZOLE IN PATIENTS HAVING OVERLAPPING SYMPTOMS OF PROTON PUMP INHIBITOR REFRACTORY GASTROESOPHAGEAL REFLUX DISEASE AND FUNCTIONAL DYSPEPSIA

Introduction: Gastroesophageal reflux disease (GERD) is a digestive disorder that affects the lower esophageal sphincter (LES). Functional dyspepsia (FD) is characterized by troublesome early satiety, epigastralgia or heart burn. It is often overlooked as the symptoms overlap with GERD. This study aims to compare the effectiveness of Acotiamide+Rabeprazole vs. a double dose of Rabeprazole in Indian population.
 Method: In this study 60 patients diagnosed with PPI refractory GERD (taking PPI>8weeks) and FD with no gastric or duodenal organic abnormalities were randomly allocated in two groups. Group 1 received a combination of Acotiamide (200mg/day) +Rabeprazole (20mg/day) and group 2 received a double dose of Rabeprazole (40mg/day). Follow ups were done every month for 3 consecutive months. The frequency and severity of symptoms were assessed using standard Izumo scale and FSSG scale.
 Results: The total score and GERD score from the baseline were significantly reduced in group 1 however the reduction in FD score from baseline did not differ significantly in the two treatment groups according to F-scale. The proportion of patients with ≥ 50% reduction in the total score for three upper gastrointestinal symptoms (heart burn, epigastralgia, and epigastric fullness) in the izumo scale was 96.7% in group 1 and 33.3% in group 2. Significant difference were noticed between the two groups. No serious adverse events were observed.
 Conclusion: The combination group of Acotiamide+Rabeprazole was found to be more effective than double dose of Rabeprazole in reducing the overlapping symptoms of PPI refractory GERD and FD.

981 RESECTION AND PLICATION (RAP): AN ENDOSCOPIC ANTI-REFLUX SOLUTION IN ALTERED ANATOMY

In recent years, significant advances have been made in the treatment of gastroesophageal reflux disease (GERD). Options for therapy have expanded in the surgical field, and new endoscopic options have emerged as alternative means of treating GERD in select populations. However, GERD remains a common problem in many polulations that do not quality for these new therapies, either due to severe co-morbidities or altered anatomy. The Resection and Plication (RAP) procedure is a novel endoscopic option for the treatment of medication refractory GERD. The RAP procedure can uniquely be empolyed in patietns unable to undergo surgical or alternate endoscopic anti-reflux therapies due to gastroesophageal junction (GEJ) anatomy that has been altered, for example in patients with prior nissen fundoplication, roux-en-Y gastric bypass, sleeve gastrectomy, or esophagectomy. The RAP procedure involves band endoscopic mucosal resection (EMR) semi-circumferential mucosectomy at the GEJ followed by full-thickness plication (RAP). Endoscopic suturing creats a gastro-gastric plication which serves to tighten the GEJ and decrease the rate of reflux into the esophagus. The following video demonstrates the RAP procedure in 2 patients with altered anatomy. Case 1, 66-year-old female with GERD previously treated with Nissen Fundoplication 10 years ago presents with refractory GERD symptoms. Case 2, 44-year-old female with history of morbid obesity treated with roux-en-Y gastric bypass with initial weight loss, now with significant weight gain and morbid obesity who is presenting with persistent GERD symptoms. 26 patients have undergone the RAP procedure at our institution. The average procedure time is 31 minutes. Ninety percent of were discharged the same day without major complications. Eighteen patients had altered anatomy (5 Fundoplication, 4 Gastric Bypass, 4 Esophagectomy, 2 failed TIF, 2 Endoscopic Sleeve Gastroplasty, 1 Sleeve Gastrectomy). We observed dramatic improvements in Reflux Disease Questionnaire (RDQ) and GERD Health Related Quality of Life (HRQL) questionnaires (RDQ Frequency 80%, RDQ Severity 76%, GERD-HRQL 85%). Sixty percent of patients were able to stop or decrease PPI use at follow-up. The average follow-up period was 6 months. The Resection and Plication (RAP) procedure is a novel endoscopic endoscopic anti-reflux procedure which results in gastro-gastric plications just below the level of the GEJ, thereby reducing the rate of reflux of gastric contents into the esophagus. This provides an effective endoscopic option in patients who otherwise cannot get other surgical or endoscopic therapies, specifically due to prior surgeries. This is a same day procedure and is overall safe, well tolerated and patients report a high degree of satisfaction following therapy.

878 CLINICAL OUTCOMES OF ENDOSCOPIC ANTI-REFLUX TREATMENT METHODS; ANTI-REFLUX MUCOSECTOMY (ARMS) AND ANTI-REFLUX MUCOSAL ABLATION (ARMA)

Gastroesophageal reflux disease (GERD) is a common disorder with an increasing prevalence worldwide. Proton pump inhibitors (PPIs) are effective in achieving symptom control, however, approximately 30-40% of patients are reported to have persistent symptoms despite PPI therapy. While the surgical intervention such as Laparoscopic Nissen Fundoplication remains the gold standard treatment for refractory GERD, minimally invasive anti-reflux therapies are gaining its popularity to fill in the “gap” of conventional medical therapy and surgery. In 2014, we reported Anti-reflux mucosectomy (ARMS) which utilizes ESD or EMR-C to rebuild the flap valve at the gastric cardia by scarring of the artificial ulcer. In 2018, we developed Anti-reflux mucosal ablation (ARMA) where we apply ablation instead of mucosectomy as an alternative therapy for PPI-refractory GERD. The aim of this study is to evaluate the clinical outcomes of ARMS and ARMA. This is a retrospective, single center study from a prospectively collected database performed between April 2012 and November 2019. The indication of ARMS/ARMA is PPI refractory GERD patients without prominent sliding hernia. In ARMS, ESD or EMR-C at the gastric cardia mucosa was performed in order to create artificial ulcer. In ARMA, mucosal ablation using Triangle Tip Knife with spray coagulation mode (50W-120W, effect 2) was utilized to create the ulcer. The efficacy was evaluated by the patient’s symptom score (Frequent Scale for the Symptoms of GERD: FSSG) and the objective findings; Acid Exposure Time (AET) and DeMeester composite score by 24h multi-channel intraluminal impedance-pH monitoring, before and 2-3 months after procedure. A total of 109 patients (Age 54.0±15.7, M:F 63:46) underwent ARMS, and 24 patients (57.6±15.9, M:F 16:8) underwent ARMA. Mean procedure time (minutes) were 54.7 vs. 35.6, respectively. FSSG score improved from 25.1 to 11.6 (p<0.01) by ARMS and from 25 to 10.5 (p<0.01) by ARMA. By ARMS, AET and DeMeester composite score improved from 20.8 to 6.9 (p < 0.01, n=27) and 64.4 to 24.9 (p < 0.01, n=27), respectively. By ARMA, median AET showed a decreasing trend from 9 to 0.5 (p=0.068, n=8), and the DeMeester composite score significantly improved from 33.5 to 2.8 (p<0.05, n=8). Both ARMS and ARMA were effective anti-reflux therapy methods for PPI-refractory GERD which improved GERD related symptoms and objective acid reflux parameters. ARMA may be advantageous on its easiness and simplicity regarding operative time. A larger study with long-term follow-up is required to confirm these results.

Mo1283 LEARNING CURVE OF TRANSORAL INCISIONLESS FUNDOPLICATION: A SINGLE ENDOSCOPIST EXPERIENCE

Transoral Incisionless Fundoplication (TIF) is a minimally invasive endoscopic technique proven to be safe and effective for treating Gastroesophageal Reflux Disease (GERD) in selected patients. The learning curve of this technique has not been studied. (1) To report the learning curve for TIF, by identifying a breakpoint or threshold number of procedures at which there is a significant decrease in procedure time, time taken per 2-set fastener placement and an increase in the valve circumference. Prospectively collected data on patients who had a TIF procedure at an academic medical center between September 2017 and November 2019 were analyzed. Routine pre-TIF work-up included upper endoscopy (EGD) with biopsies, cine-esophagram, high resolution esophageal manometry (HREM) and pH-monitoring. Patients who had prior per-oral endoscopic myotomy (POEM) were excluded. Learning curve analysis was done using STATA software v 15.1 and Power BI to calculate the threshold for learning assessed by time to reach specific endpoints of the TIF procedure. 51 patients (71% male, mean age 56.5±13.2 yr.) had TIF after testing confirmed appropriate criteria (ph-positive test, < 2cm hiatal hernia, Hill grade <=2, BMI< 35). Indications for TIF were refractory GERD (51%), laryngopharyngeal reflux disease (9%), failed Nissen fundoplication (9%) and GERD in PPI-averse patients (31%) (Table 1). Six (12%) patients had prior surgical fundoplication. All TIF procedures were performed by a single endoscopist after hands-on and supervised training. TIF was successfully completed in 50/51 (1 aborted due to technical failure) with no serious adverse events. Overall, mean procedure time was 56±15 minutes. Break point analysis revealed that the threshold procedure time was reached at 23 procedures, where time declined from 67±11 to 47±13 minutes (p<0.0001). The mean time to deploy set of 2 fasteners was 4.3±1.9 minutes and mean valve circumference was 285±24 degrees. The breakpoint analysis revealed that a threshold was reached at 18 procedures for both fastener deployment and valve wrap, with a decrease in the mean procedure time to deploy a set of 2 fasteners from 6.5±1.4 to 3.1± 0.8 minutes (p<0.0001) and an improvement in the mean valve circumference from 261±20 to 297±14 degrees (p<0.0001). There was a significant decrease in total procedure time and time to deploy 2-set fasteners as well as an improvement of the valve circumference with increased number of procedures (Figure 1). Our single-center analysis showed that the number of procedures needed for an endoscopist to achieve procedure times under 1-hour is 23 procedures. Furthermore, the number of procedures needed to achieve times under 4 minutes to deploy 2-set of fasteners and to achieve tighter valves is 18 procedures. Future larger studies are needed to validate these results.TIF learning curve breakpoint analysisView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Covering the Cover

Covering the Cover

Changes in the disease-specific quality of life following Dor fundoplication. A multicentre cross-sectional study

BackgroundGastrooesophageal reflux disease (GERD) is a spectrum of symptoms arising from the laxity of the cardio-oesophageal junction. Anti-reflux surgery is reserved for patients with refractory GERD. Anterior partial fundoplication (Dor) is a regularly performed anti-reflux surgery in Malaysia. We intend to determine the improvement in disease-specific quality of life in our patients after surgery. MethodsA multicentre cross-sectional study was conducted to assess patients’ improvement in disease-specific quality of life after Dor fundoplication. Ethics approval was obtained from our institutional review board. Patients between the ages of 18 and 65 years who underwent Dor fundoplication within the past five years were assessed using the GERD HRQL as well as the VISICK score via telephone interview. We excluded cases of revision surgery. ResultsOut of 129 patients screened, 55 patients were included. We found a significant improvement in patients’ GERD HRQL score with the pre-operative mean score of 28.3 ± 9.39 and 6.55 ± 8.52 post-operatively, p < 0.01.50.9% of patients reported a VISICK score of 1. However, we noticed a deterioration in the GERD HRQL and VISICK score in patients followed up four years after surgery. This consisted of 25.5% of total patients. ConclusionDor Fundoplication improves the overall disease-specific quality of life in patients with refractory GERD in the short term period. Recurrence of symptoms causing a deterioration in the quality of life is seen in patients followed up beyond four years of index surgery.

1060 Screening For Obstructive Sleep Apnea In Severe Gastroesophageal Reflux Disease Patients: A Forgotten Association?

Abstract Introduction Obstructive sleep apnea (OSA) is an emerging epidemic in the USA and remains underdiagnosed. Investigations of Gastroesophageal reflux disease (GERD) poses a substantial burden on patient-welfare and costs to the health system. Current literature has highlighted the association between severe GERD and OSA, and other sleep disorders. We conducted a retrospective analysis of patient records undergoing Bravo pH monitoring for refractory GERD to measure the prevalence of OSA and screening. Methods Records of patients who underwent outpatient Bravo pH monitoring at a teaching hospital were reviewed from August 2018 to May 2019. 72 records were reviewed in our analysis. Analysis variables included age, gender, body mass index, history of hypertension and OSA. Outpatient records were reviewed for documentation for OSA or screening and demographics were obtained for calculation of a partial STOP-BANG score (a validated OSA screening tool). Results 8 out of 72 (11%) were excluded due to incomplete documentation regarding their history. Of the remaining 64, 2 had a known diagnosis of OSA (3%) and 1 was due a sleep study for maintenance insomnia. Of the remaining 61 patients, none had documentation of a history pertaining to sleep complaints or full screening for OSA. 4 of the 8 components to the STOP-BANG criteria were documented and used to measure risk of OSA in these patients. 23 (39%) patients had a score of 3 or above characterizing them as intermediate risk. The other 4 components were not used due to a lack of clinical information. 13 of these patients had a positive Bravo test, 2 had an inconclusive result and 8 had a negative result. Of the 61 patients in total, 31 had a positive Bravo result and 9 had an inconclusive result. Conclusion In our study, we found that 39% of patients based on demographic data were of intermediate risk of OSA. Over half of these patients had a positive result for GERD. Despite the increased awareness of sleep disorders it is still neglected despite prevalent associated comorbid conditions. This study highlights the failure to screen for this modifiable risk factor within a teaching environment. Support None

Confocal Laser Endomicroscopic Findings of Refractory Erosive Reflux Disease versus Non-Erosive Reflux Disease with Anti-Reflux Mucosectomy: An in vivo and ex vivo Study.

Background/AimsTo date, there is no standard tool to diagnose gastroesophageal reflux disease (GERD). Typically, GERD is a non-erosive reflux disease (NERD) that does not present endoscopic abnormalities. Confocal laser endomicroscopy (CLE) has been shown to be an effective tool to identify and diagnose GERD. We aimed to investigate the cellular and vascular changes in vivo and ex vivo through CLE in patients with GERD. MethodsPatients with refractory GERD who underwent mucosectomy were recruited. The distal esophagus was observed in vivo using CLE. Mucosectomy tissue was stained with acriflavine and CLE image was obtained ex vivo. We compared cellular and vascular changes in CLE between erosive reflux disease (ERD), NERD, and a control group. ResultsEleven patients who underwent anti-reflux mucosectomy and five control patients were enrolled in the study. Patients with ERD and NERD presented greater dilated intercellular space than patients in the control group on CLE image. The diameter, number, and cross-sectional area of the intra-papillary capillary loops (IPCLs) were significantly larger in the ERD group than in the NERD group. The irregular shape of the IPCLs were observed in both patients with ERD and NERD. ConclusionsThe irregular shape of the IPCLs were significantly correlated with a positive diagnosis of GERD. CLE may diagnose NERD with high sensitivity and accuracy.

Efficacy and Safety of Dor Fundoplication in Patients with Severe Gastroparesis and Refractory Gastroesophageal Reflux Disease

Poor quality of life is a major problem in patients with gastroesophageal reflux disease (GERD). Delayed gastric emptying in patients with severe gastroparesis (GP) worsens GERD symptoms and particularly nocturnal heartburn and regurgitation refractory to medical therapy. With limited therapeutic options, a Nissen fundoplication may be considered but concerns for this surgery are inability to wretch and vomit post-op, increasing the risk of wrap rupture. Dor fundoplication, a 180–200 degree anterior wrap, may improve sphincter competency and provide symptom relieve while minimizing these concerns and avoiding vagal nerve damage.

PGI31 CAN CONSUMER PRICE INDEX BE USED TO ACCURATELY PREDICT FUTURE MEDICAL COSTS? A CASE STUDY IN REFRACTORY GASTROESOPHAGEAL REFLUX DISEASE

Refractory gastroesophageal reflux disease (rGERD–defined as persistent GERD symptoms despite PPI therapy) constitutes ∼30% of treated GERD patients. Consumer Price Index (CPI) is often used in health economics to adjust past cost data to present or future dollar values. This study evaluates CPI adjustment as a predictive tool for estimating present/future costs using data from a previous study of rGERD (Gerson et al. 2011 data collected 2004-2008) and a nearly identical current study (data collected 2011-2017). Average annual costs incurred by refractory and treatment-responsive GERD patients extracted from the previous and current studies were grouped into three categories: all-cause, GERD-related and GI-related. Costs from the previous study were inflated using CPIs of medical care and subcomponents (inpatient, outpatient [OP], emergency room [ER] and OP-pharmacy), using three adjustment models – end-to-end of the study periods (2008à2017), middle-to-middle of the study periods (2006à2014) and the ratio of average annual CPIs for the study periods. After CPI adjustments, model mean absolute deviations (MAD), standard absolute deviations (SAD) and root-mean-square deviations (RMSD) were calculated. All three models exhibited similar accuracies. Middle-to-middle had the lowest MAD and SAD but highest RMSD for all costs, and the lowest MADs in OP, ER and OP-pharmacy costs. Middle-to-middle predicted all-cause OP and total direct medical costs with <7% and <11% deviations, respectively. It also predicted GERD-related rGERD total cost within <2% deviation. The model, however, underestimated ER costs by >20%. When determining GERD-related costs, middle-to-middle overestimated inpatient and OP-pharmacy costs by >110% and >200%, respectively and underestimated ER and OP costs by >30%. All GI-related costs were underestimated (>10%) but inpatient costs were overestimated (>30%). CPI-adjustment inflation models accurately predicted costs of large bundles of costs (e.g., total, outpatient) but less accurately when the costs of interest were defined more specifically (e.g., disease-related or line-items of healthcare).

Treatment Pattern and Economic Burden of Refractory Gastroesophageal Reflux Disease Patients in Korea.

Background/AimsThe prevalence of gastroesophageal reflux disease (GERD) has increased in Korea, and the economic burden of this chronic disease is substantial. We aim to investigate the treatment pattern and economic burden in Korea of refractory GERD requiring long-term use of proton pump inhibitors (PPIs).MethodsWe conducted a cross-sectional analysis of nationally representative sample data obtained from 2012 to 2016 and provided by the Health Insurance Review and Assessment Service. The participants were 86 936 in the medication group and 40 in the surgery group. Age- and sex-standardized prevalence of refractory GERD requiring PPIs medication for more than 12 weeks were analyzed. Generalized linear models were used to estimate cost ratios for comparing the medical costs of the surgery and medication groups after adjustment for demographics and comorbidity.ResultsThe prevalence of refractory GERD increased from 1.2% in 2012 to 1.9% in 2016, and the estimated total number of GERD patients increased from 402 000 to 736 000 during this time period. The medical expenditures of the surgery group within 90 days of antireflux surgery (ARS) were 16.9-fold higher compared to those of the medication group; the significant difference in medical costs between the 2 groups disappeared after 90 days post-surgery.ConclusionsThe prevalence of refractory GERD requiring long-term use of PPIs has been trending upwards recently. Nevertheless, ARS is very rarely performed. Considering the increasing medical costs of long-term PPI use, further cost-effectiveness analysis is needed to compare ARS and PPI therapy for the treatment of GERD in Korea.

Peroral endoscopic fundoplication: a brand-new intervention forGERD.

Peroral endoscopic fundoplication: a brand-new intervention forGERD.

Clinical feasibility of a new antireflux ablation therapy on gastroesophageal reflux disease (with video)

New mucosal resective and ablative endoscopic procedures based on gastric cardiac remodeling to prevent reflux have appeared. We aimed to evaluate the feasibility of a new ablative technique named antireflux ablation therapy (ARAT) for control of GERD in patients without hiatal hernia. Patients with proton pump inhibitor (PPI)-refractory GERD without hiatal hernia underwent ARAT between January 2016 and October 2019. Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL), upper endoscopy, 24-hour pH monitoring, and PPI use were documented at 3, 6, 12, 24, and 36 months after ARAT. One hundred eight patients were included (61 men [56.5%]; median age, 36.5 years; range, 18-78 years). ARAT was performed on all patients. At the 36-month evaluation, 84 patients had completed the protocol. Median ARATtime was 35.5 minutes (range, 22-51 minutes), and median circumference ablation was 300° (range, 270°-320°). No major adverse events occurred, and 14 of 108 patients (12.9%) presented with stenosis that was responsive to balloon dilation (<5 sessions). At the 3-month evaluation, the acid exposure time (AET), DeMeester score, andGERD-HRQL score had decreased from 18.8% to 2.8% (P= .001), 42.5 to 9.1 (P= .001), and 36.5 to 10 (P=.02), respectively, and these values were maintained up to 36 months. Success (AET<4%) was achieved in 89% and72.2% at 3 and 36 months, respectively. Related factors at 36 months were as follows: pre-ARAT Hill typeII(odds ratio [OR], 3.212; 95% confidence interval [CI], 1.431-5.951; P= .033), post-ARAT 3-month Hill type I (OR, 4.101; 95% CI, 1.812-9.121; P= .042), and AET<4% at 3 months (OR, 5.512; 95% CI, 1.451-7.621; P= .021). ARAT is a feasible, safe, and effective therapy for early and mid-term treatment of GERD in patients without a sliding hiatal hernia. However, longer follow-up evaluations and randomized comparative studies are needed to clarify its real role. (Clinical trial registration number: NCT03548298.).

Peroral endoscopic myotomy (POEM) for dysphagia and esophageal motor disorder after antireflux fundoplication.

Laparoscopic fundoplication is the treatment of severe and refractory gastroesophageal reflux disease (GERD). It induces dysphagia in 5 % - 10 % owing to a tight valve ± esophageal motility disorders (EMD), with challenging management. We assessed the first case series assessing peroral endoscopic myotomy (POEM) in such a situation. A retrospective case series including eight patients with severe dysphagia after laparoscopic fundoplication who were treated by POEM. They were assessed clinically by Eckardt and Mellow - Pinkas dysphagia scores, and by high resolution manometry (HRM). The procedure was a regular esophageal POEM, mainly posterior, including a myotomy of the wrap. The objectives were to evaluate the clinical efficacy, technical difficulties, and complications of this approach. HRM showed aperistalsis in 6 /8 patients and raised lower esophageal sphincter (LES) pressure in 5 /8. The median preoperative Eckardt and dysphagia scores were 5 and 3.5, respectively. The procedure was completed in 7 /8 patients, with a clinical efficacy rate (normalization of both scores) of 75 % (6 /8). Although the submucosa seemed more fibrotic and vascularized, no severe complications occurred. POEM is a newly described therapeutic option to consider for managing dysphagia due to EMD after laparoscopic fundoplication.

Endoscopic Yield, Appropriateness, and Complications of Pediatric Upper Gastrointestinal Endoscopy in an Adult Suite: A Retrospective Study of 822 Children.

Background/AimsThis study aimed to study the endoscopic yield, appropriateness, and complications of pediatric endoscopy performed by adult gastroenterologists in an adult endoscopic suite. MethodsThis a retrospective study in which records of all the patients less than 18 years of age who underwent endoscopy in the last 5 years were studied. The indications of endoscopy in children were categorized as appropriate or inappropriate per the latest guidelines by American Society for Gastrointestinal Endoscopy and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Positive endoscopic yield was defined as the presence of any abnormality on endoscopy. ResultsAmong the total of 822 children (age <18 years), the most common indications were variceal surveillance/eradication in 157 (19.1%), followed by dyspepsia in 143 (17.4%), upper gastrointestinal (UGI) bleeding in 136 (16.5%), recurrent abdominal pain in 94 (11.4%), unexplained anemia in 74 (9%), recurrent vomiting in 50 (6.08%), chronic refractory gastroesophageal reflux disease in 34 (4.1%) and others; 780 out of 822 endoscopic procedures (94.9%) done in children were appropriate as per the guidelines. The endoscopic yield was 45.8%, highest in patients with UGI bleeding (71.3%), followed by variceal surveillance (54.8%), recurrent vomiting (38%), dyspepsia (37.8%), and recurrent abdominal pain (36%). Minor adverse events occurred in 7.3% of children. ConclusionsPediatric endoscopy performed by an experienced adult gastroenterologist may be acceptable if done in cooperation with a pediatrician.

Conversion to Roux-en-Y gastric bypass surgery through a robotic-assisted hybrid technique after failed sleeve gastrectomy: Short-term results

IntroductionLaparoscopic sleeve gastrectomy (LSG) is the most widely performed bariatric surgery worldwide but complications and failed procedures are on the rise. AimsTo determine the reasons for failed LSGs and report the results of conversion to gastric bypass surgery, comparing the outcomes with those of primary gastric bypass surgery. Materials and methodsPatients with failed LSG that underwent conversion to gastric bypass surgery through a robotic-assisted and laparoscopic (hybrid) technique were evaluated. Outcomes and follow-up related to weight loss failure (WLF) were compared with those in patients that underwent primary laparoscopic gastric bypass (pLGB) surgery. ResultsRevisional surgery was performed on 13 patients due to WLF, on 3 patients because of refractory gastroesophageal reflux disease, and on 2 patients due to gastric stricture. There were no differences between the preoperative characteristics of the patients with WLF before undergoing conversion to gastric bypass and the patients that underwent pLGB surgery. At postoperative month 36, the percentage of excess weight loss (%EWL) was greater in the patients that underwent pLGB surgery, than in those with WLF that underwent conversion to gastric bypass (69.17±23.73 vs. 54.17±12.48, respectively; p<0.05). Refractory GERD, symptoms due to gastric stricture, and comorbidities all improved after the revisional surgery. ConclusionRevisional surgery resulted in acceptable weight loss at 36 months of follow-up and favored comorbidity remission. In addition, it resolved symptoms of refractory GERD and gastric stricture.

Role of esophageal manometry and 24-h pH testing inpatients with refractory reflux symptoms.

A proportion of patients with gastroesophageal reflux disease (GERD) do not respond to proton pump inhibitor (PPI) therapy. To determine thefindings on high-resolution esophageal manometry (HREM) and 24-h pH recording in patients with typical GERD symptoms, refractory to PPI treatment. Retrospective analysis of prospectively maintained database of patients referred for HREM and 24-h pH recording was done. We selected patients who were referred for evaluation of refractory GERD symptoms despite > 8weeks of at least once-daily PPI treatment. Details noted were demographic profile, upper gastrointestinal endoscopy report, HREM findings and 24-h pH findings. Ninety-six patients had symptoms of GERD that were refractory to PPI therapy. Seven patients (7.1%) were diagnosedhaving diseases mimicking GERD: eosinophilic esophagitis (n=2), supragastric belching (n=4) and rumination (n=1). After excluding these patients and those with insufficient data, the final study cohort included 82 cases. Fifty patients (61%) had normal motility. Major motility disorders were detected in 8 (9.75%)patients: achalasia cardia (6) and distal esophageal spasm (2). Ineffective esophageal motility was noted in 24 patients. A total of 74 patients underwent 24-h pH testing. Significant acid reflux with good symptom correlation was noted in 56 patients. Eighteen patients did not have significant acid reflux (Johnson-DeMeester score < 14.7): hypersensitive esophagus (12) and functional heartburn (6). Fifty-six patients (68.3%) had definite diagnosis of GERD and 31.7% (26) had non-GERD conditions like motility disorders, functional heartburn and hypersensitive esophagus.

Gastroesophageal Reflux Disease Following Roux-en-Y Gastric Bypass

Background: Gastroesophageal reflux disease (GERD) is one of the most important obesity-related comorbidity, with prevalence >50% in obese population. Roux-en-Y gastric bypass (RYGB) is considered the gold standard for metabolic surgery in obese patients with GERD, but in a subgroup of patients this pathological GERD may be not really controlled after this technique. Aims of this article are to discuss surgical and endoscopic options to manage refractory GERD after RYGB. Materials and Methods: We realized a literature review using the PubMed database and searching articles published before December 2019 about GERD after RYGB. Results: We found six studies, four case reports, and two retrospective studies about surgical and endoscopic options to treat this subgroup of patients. Discussion: Pharmacological therapy and life style optimization are the first line of treatment. For resistant GERD, new surgical and endoscopic strategies are proposed in the past years to manage this subgroup of patients related to anatomic limitation of RYGB. Conclusion: More studies are needed to compare surgical and endoscopic solutions. The choice of treatment depends on local resources and skills, and if necessary refer the patient to a specialist center.

Rumination Syndrome in Children Presenting With Refractory Gastroesophageal Reflux Symptoms.

Up to 40% of children presenting with reflux symptoms do not respond to standard medical interventions. In adults, 20% of patients presenting with Proton Pump Inhibitors refractory Gastro-Esophageal Reflux Disease (GERD) have rumination syndrome. The management of GERD and rumination differ significantly. Our study aimed to identify rumination syndrome amongst children presenting with persistent GERD symptoms based on a distinct pattern on impedance-pH monitoring. The parameters of impedance-pH monitoring were compared between children with rumination syndrome (n = 12), diagnosed on high-resolution manometry impedance (HRM/Z), children with GERD (n = 18), children with an alternative diagnosis (non-GERD, n = 12) and children negative for rumination based on HRM/Z (n = 14). The parameters that distinguish the rumination group were identified and incorporated into a scoring system, which was blindly applied on a separate group of children with refractory GERD (n = 18) to define its sensitivity and specificity. Rumination syndrome presents in 44% of children with refractory GERD. Children with rumination syndrome present with a large number of proximal reflux episodes (>57.5 episodes/24 hours); a high frequency of nonacid reflux events in the postprandial period (>2/hour); and a highly positive symptom-reflux association analysis (SAP ≥ 95%). A score of ≥2 out of the 3 points distinguishes children with rumination syndrome with 75% sensitivity and 80% specificity. Children with rumination syndrome have a distinct pattern of impedance-pH monitoring and can be distinguished amongst children presenting with refractory GERD. Applying a simple scoring system during impedance-pH analysis could lead to early diagnosis of children with rumination syndrome.