Refractory Gastroesophageal Reflux Disease Research Articles

Overlap Between GERD and Functional Esophageal Disorders-a Pivotal Mechanism for Treatment Failure.

ᅟRefractory GERD is very common, and while many different underlying mechanisms have been identified, the main focus has remained on residual reflux (acidic or non-acidic). Recently, Rome IV introduced two new concepts with important impact on patients with refractory GERD. They include the introduction of the reflux hypersensitivity group and the proposal that GERD can overlap with a functional esophageal disorder. Recent studies have demonstrated that the latter affects approximately three quarters of the GERD patients who failed PPI once daily.

First Experience with Banded Anti-reflux Mucosectomy (ARMS) for GERD: Feasibility, Safety, and Technique (with Video)

BackgroundAnti-reflux mucosectomy (ARMS) is a relatively new endoscopic procedure for gastroesophageal reflux disease (GERD). A hemi-circumferential endoscopic mucosal resection (EMR) is performed around the gastroesophageal junction (GEJ), which then contracts and tightens during healing. The aim of this study was to assess the feasibility and safety of the procedure. A secondary aim was to assess short-term outcomes on PPI use and symptom resolution. MethodsIRB approval was obtained for retrospective review of a prospectively collected database including patients who underwent ARMS during a 2-year period. To be eligible for the procedure, patients required medically refractory GERD and a hiatal hernia no more than 2 cm. A 270-degree mucosal resection of the gastric cardia was performed in a retroflexed position using a multi-band EMR system. Demographics, preoperative workup, intraoperative factors, additional procedures, and other follow-up were collected by chart review. Voluntary validated surveys assessed symptomatic improvement over time. ResultsThere were 19 patients available for review. The procedure was technically completed in all cases. There was one muscle injury due to a deep resection that was repaired by endoscopic suturing. All patients were discharged on the day of the procedure. Early dysphagia was experienced by three patients (16%) which was addressed with endoscopic balloon dilation. GERD symptoms improved in 13 patients (68%) after discontinuing PPI therapy. Three of the six failures went on to have additional anti-reflux surgery. Among patients who did not have additional surgery, quality of life data showed significant symptomatic improvement by 6 months. ConclusionIn this ARMS case series, the procedure was technically successful in all patients with only one minor complication. Two thirds of patients showed symptomatic improvement and were able to discontinue their PPI. ARMS appears to be a safe procedure that does not hinder future laparoscopic anti-reflux surgery in case of failure. Additional tuning of technique and postoperative management may be able to reduce dysphagia rates and the need for dilation.

Magnetic Sphincter Augmentation After Gastric Surgery.

Background:Persistent or de novo gastroesophageal reflux disease (GERD) may be a significant clinical issue after gastric/bariatric surgical procedures. We investigated the effect of magnetic sphincter augmentation (MSA) in the treatment of GERD after previous gastric/bariatric surgery.Database:We conducted a systematic review according to the Preferred Reporting Items For Systematic Reviews and Meta-analyses statement. We searched multiple databases (PubMed, Cochrane, Embase, Scopus) up to May 2019. We also queried the prospectively collected database of patients who underwent MSA at our tertiary-care hospital and compared postsurgical to naïve patients operated during the same time period.Results:Seven studies (3 case series and 4 case reports), for a total of 35 patients, met the inclusion criteria in the systematic review. The most common index operation was a bariatric procedure, either sleeve gastrectomy or Roux-en-Y gastric bypass. After MSA implant, the Gastroesophageal Reflux Disease–Health-Related Quality of Life (GERD-HRQL) score significantly improved compared to baseline (P = .005). Two patients (5.7%) required laparoscopic device removal. In the local institutional cohort series of 67 patients treated by MSA, the prevalence of preoperative grade B esophagitis, operative time, size of MSA, and length of stay were greater in patients with prior gastric surgery compared to naïve patients.Conclusions:MSA is a safe, simple, and standardized antireflux procedure. It is also feasible in patients with refractory GERD following gastric/bariatric surgery. Further prospective and comparative studies are needed to validate the preliminary clinical experience in this subset of patients.

Evaluation of the Additive Effect of Domperidone on Patients with Refractory Gastroesophageal Reflux Disease; A Randomized Double Blind Clinical Trial.

BACKGROUND Gastroesophageal reflux disease (GERD) is a common problem with annoying symptoms. It is associated with negative impact on quality of life. Prokinetic agents may be used in combination with acid suppression agents as an adjunctive in patients with GERD refractory to proton pump inhibitors (PPI) therapy, rather than as sole treatment. This study aimed to evaluate the efficacy of combination of PPI with domperidone (a prokinetic agent) compared with PPI alone in the treatment of patients with refractory GERD. METHODS This study was a double blind clinical trial on 29 patients with GERD refractory to PPI during the period of one month. By randomization, the patients were divided into two groups. Group A was treated by pantoprazole 40 mg twice daily and domperidone three times a day for a month, while group B was treated by pantoprazole 40 mg twice daily and placebo three times a day. In this study endoscopy was performed to evaluate the prevalence of erosive esophagitis, non-erosive reflux, and hiatal hernia. Manometry was conducted to study the prevalence of dysmotility. GERD symptom questionnaires including the Gastrointestinal Symptom Rating Scale (GSRS), Carlson Dennett, and the Medical Outcomes Study Short Form-36 health survey (SF36) were used before and after treatment for screening GERD and assessing treatment response. RESULTS There were 17 (58.62%) women and 12 (41.37%) men. The prevalence of erosive esophagitis and non-erosive reflux, was 10.34% and 89.66%, respectively. There was a significant difference comparing reflux symptoms before and after treatment between the two groups according to reflux and Carlson Dennett questionnaires. At the end of the study, symptoms of reflux significantly improved by treatment. Although, the quality of life questionnaire scores improved by treatment, there was no statistically significant difference in response to treatment between the two groups. CONCLUSION In this research, we showed that adding domperidone to PPI could not make any improvement in patients with refractory reflux regarding the quality of life and improving the symptoms.

Redo Surgery after Failure of Antireflux Surgery

Surgery for refractory gastroesophageal reflux disease (GERD) has a satisfactory outcome for most patients; however, sometimes redo surgery is required. The Outcome and morbidity of a redo are suggested to be less successful than those of primary surgery. The aim of this study was to describe our experience, long-term results, and complications in redo surgery. From 2000 to 2016, 765 patients were operated on for GERD at our hospital. A retrospective analysis of 56 patients (7.3%) who underwent redo surgery was conducted. Large symptomatic recurrent hiatal hernia (50%) and dysphagia (28.6%) were the most frequent indications for redo. An open approach was chosen in 64.5 per cent of patients. Intraoperative and postoperative complication rates were 18 per cent and 14.3 per cent, respectively. Mortality rate was 1.8 per cent. Symptomatic outcome was successful in 71.4 per cent. Patients reoperated because of dysphagia and large recurrent hiatal hernia had a significantly higher failure rate (32.3% and 31.2%, respectively; P = 0.001). Complication rate was significantly lower in the laparoscopic group (0% vs 22.2%; P = 0.04). There were no statistical differences between expert and nonexpert surgeons. Laparoscopic approach has increased to 83.3 per cent in the last five years. Symptomatic outcome after redo surgery was less satisfactory than that after primary surgery. Complications were lower if a minimally invasive surgical approach was used.

Comparative Analysis of Laparoscopic Fundoplication and Magnetic Sphincter Augmentation for the Treatment of Medically Refractory GERD

We have recently introduced laparoscopic magnetic sphincter augmentation (MSA) combined with hiatal hernia repair for treatment of patients with medically refractory gastroesophageal reflux disease (GERD). MSA is a novel surgical approach to the treatment of severe GERD, in which magnetic beads are secured around the lower esophageal sphincter, augmenting the lower esophageal sphincter function as an anti-reflux barrier. We hypothesize that patients undergoing MSA will achieve GERD relief, equal to that obtained after laparoscopic Nissen fundoplication. The GERD Health Related Quality of Life (GERD HRQL) Questionnaire is a validated clinical tool that was used to quantify patient outcomes in terms of GERD-related symptoms both on and off proton pump inhibitors and after acute radiation syndrome. We retrospectively reviewed data from patients at our institution enrolled in a prospective institutional review board-approved database "Registry Outcomes Anti-Reflux Surgery" that applies objective and subjective information about patients undergoing anti-reflux surgery. Information from both the database and patient HRQL scores were used to compare the effectiveness of medical intervention with acute radiation syndrome (laparoscopic Nissen fundoplication and MSA) in decreasing GERD-related symptoms in patients. Results are expressed as mean ± SE, and single-factor ANOVA test was used to compare groups. We found that MSA and laparoscopic fundoplication both lead to a comparable decrease in HRQL score and an increase in patient satisfaction when compared with patient's preoperative symptoms with maximum proton pump inhibitor use. In addition, our study shows that MSA is a safe minimally invasive anti-reflux procedure without the negative side-effects, such as gas bloat, inability to belch, and inability to vomit, commonly associated with NF.

ARE THE PERSISTENT SYMPTOMS TO PROTON PUMP INHIBITOR THERAPY DUE TO REFRACTORY GASTROESOPHAGEAL REFLUX DISEASE OR TO OTHER DISORDERS?

Gastroesophageal reflux disease (GERD) is a clinical condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Transient lower esophageal sphincter relaxation is the main pathophysiological mechanism of GERD. Symptoms and complications can be related to the reflux of gastric contents into the esophagus, oral cavity, larynx and/or the lung. Symptoms and other possible manifestations of GERD are heartburn, regurgitation, dysphagia, non-cardiac chest pain, chronic cough, chronic laryngitis, asthma and dental erosions. The proton pump inhibitor (PPI) is the first-choice drug and the most commonly medication used for the treatment of GERD. The most widespread definition of Refractory GERD is the clinical condition that presents symptoms with partial or absent response to twice-daily PPI therapy. Persistence of symptoms occurs in 25% to 42% of patients who use PPI once-daily and in 10% to 20% who use PPI twice-daily. The objective is to describe a review of the current literature, highlighting the causes, diagnostic aspects and therapeutic approach of the cases with suspected reflux symptoms and unresponsive to PPI. Initially, the management of PPI refractoriness consists in correcting low adherence to PPI therapy, adjusting the PPI dosage and emphasizing the recommendations on lifestyle modification change, avoiding food and activities that trigger symptoms. PPI decreases the number of episodes of acid reflux; however, the number of "non-acid" reflux increases and the patient continues to have reflux despite PPI. In this way, it is possible to greatly reduce greatly the occurrence of symptoms, especially those dependent on the acidity of the refluxed material. Response to PPI therapy can be evaluated through clinical, endoscopic, and reflux monitoring parameters. In the persistence of the symptoms and/or complications, other causes of Refractory GERD should be suspected. Then, diagnostic investigation must be initiated, which is supported by clinical parameters and complementary exams such as upper digestive endoscopy, esophageal manometry and ambulatory reflux monitoring (esophageal pH monitoring or esophageal impedance-pH monitoring). Causes of refractoriness to PPI therapy may be due to the true Refractory GERD, or even to other non-reflux diseases, which can generate symptoms similar to GERD. There are several causes contributing to PPI refractoriness, such as inappropriate use of the drug (lack of patient adherence to PPI therapy, inadequate dosage of PPI), residual acid reflux due to inadequate acid suppression, nocturnal acid escape, "non-acid" reflux, rapid metabolism of PPI, slow gastric emptying, and misdiagnosis of GERD. This is a common cause of failure of the clinical treatment and, in this case, the problem is not the treatment but the diagnosis. Causes of misdiagnosis of GERD are functional heartburn, achalasia, megaesophagus, eosinophilic esophagitis, other types of esophagitis, and other causes. The diagnosis and treatment are specific to each of these causes of refractoriness to clinical therapy with PPI.

Transoral Incisionless Fundoplication: Effectiveness in Improving Typical and Atypical Symptoms of Gastroesophageal Reflux Disease Incompletely Controlled With Medical Therapy

Introduction: With increasing prevalence of gastroesophageal reflux disease (GERD) worldwide, reflux symptoms have been associated with the cancer risk and reduced quality of life. Anti-reflux surgery has been the mainstay of treatment in GERD refractory to standard medical therapy; however adverse events such as dysphagia, flatulence, inability to belch, and invasiveness of surgical procedure remain a concern. Transoral incisionless fundoplication (TIF) has been considered a minimally invasive procedure. Studies have reported good efficacy and safety profile making TIF a promising procedure to fill the gap between medical and surgical approach. Our purpose was to assess the efficacy of TIF in patients with chronic refractory GERD in controlling heartburn, regurgitation, dysphagia or atypical symptoms using quality of life questionnaire and scoring system that assesses laryngopharyngeal reflux (LPR). Methods: Forty-one participants with a long-standing history of GERD refractory to adequate acid suppressants underwent TIF after appropriate pre-operative assessment. Median follow-up period was 9 months. The primary outcome was patient satisfaction by assessing pre and post GERD Health Related Quality of Life Questionnaire (GERD-HRQL) and Reflux Symptom Index (RSI) scores along with the reduction in the use of proton pump inhibitors (PPI) or histamine antagonists (H2 blockers). Results: Our study showed a significant difference in the scores for heartburn pre-TIF (M=15.81) and post-TIF (M=5.69); t(40)=7.16, p < .001. Dysphagia and regurgitation scores were reduced considerably after TIF with p-values < .006 and < .001, respectively. Mean GERD-HRQL scores were 31.44 pre-TIF and 11.79 post-TIF (p < .001). In all patients, pre and post-TIF Reflux Symptom Index (RSI) scores demonstrated statistical significance (p < .001). In patients requiring acid suppressants after the TIF, mean GERD-HRQL scores were 35.09 pre-TIF and 17.56 post-TIF (p < .002), and mean RSI scores were 8.09 pre-TIF and 5.63 post-TIF (p < .047). Conclusion: In conclusion, TIF improves quality of life by reducing both typical and atypical symptoms. At short-term follow-up, TIF eliminates the need for PPI therapy in a majority of patients. After the TIF, quality of life in those who went back on acid suppressants improved. Our study supports the recent findings of TIF's superiority to conventional medical therapy and its effectiveness in yielding significant improvement in patients with refractory GERD symptoms.770_A Figure 1. Mean Pre-TIF and Post-TIF scores evaluated by GERD-HRQL (individual heartburn, dysphagia and regurgitation scores) and RSI questionnaires at the median age of 9 months follow up after TIF.770_B Figure 2. Mean Pre-TIF and Post-TIF scores evaluated by GERD-HRQL and RSI questionnaires at the median age of 9 months follow up after TIF in patients who started acid suppressants (PPI or H2 blockers) after TIF.

Treatment of Barrettʼs With Balloon Cryotherapy Is Feasible and Safe in Patients With Prior Magnetic Sphincter Augmentation Device (MSAD)

Barrett's esophagus is a complication of severe gastro-esophageal reflux disease (GERD) and is a risk factor for developing esophageal adenocarcinoma. The MSAD is a flexible band of interlinked titanium beads with a magnetic core that is implanted around the lower esophageal sphincter. It is a new therapy for treating refractory GERD, but does not address pre-existing Barrett's esophagus. The endoscopic cryoballoon focal ablation system (CbFAS) is a novel technique for ablation of Barrett's esophagus. We present the first case of successful CbFAS for Barrett's esophagus in a patient with prior MSAD. This is a 65-year-old female with cough and heartburn for >30 years, improved on twice daily proton pump inhibitor (PPI). Her family history is significant for esophageal cancer in her father. A high resolution esophageal manometry revealed a 4-cm hiatal hernia, but was otherwise normal. Her 24-hour pH impedance test was positive for refractory GERD with a DeMeester score of 20.3, despite her use of a BID PPI. An endoscopy showed C0-M2 non-dysplastic Barrett's esophagus with a 5-cm hiatal hernia. Due to the hernia and uncontrolled reflux, she underwent a hiatal hernia repair with MSAD placement. This improved her reflux symptoms and her PPI was discontinued. The decision was made to treat her Barrett's esophagus given her family history. CbFAS was chosen, given her abnormal anatomy and surgical history. An ablation was attempted with a standard ovoid balloon, but due to the MSAD, positioning at the gastro-esophageal junction (GEJ) was unsuccessful. The pear-shaped balloon was then inflated in the stomach and pulled back into the GEJ, allowing for successful delivery of cryotherapy. Her Barrett's was visually eradicated without adverse effects on 2 separate endoscopies. On surveillance endoscopy using volumetric laser endomicroscopy (VLE), wide area transepithelial tissue sample with computer assisted 3D analysis (WATS 3D), and Seattle protocol forceps biopsies, she had complete remission of intestinal metaplasia. This case demonstrates that treating post-MSAD patients with balloon cryotherapy for Barrett's esophagus is feasible and safe. Utilizing a pear-shaped balloon alleviates the extrinsic compression applied by the MSAD, providing good visualization and position at the GEJ.1816_A Figure 1. From left to right: Pre-treatment, during treatment, and post-treatment endoscopic views. Yellow arrows point to laser markings for targeted biopsies.1816_B Figure 2. Volumetric laser endomicroscopy (VLE) post-ablation with visualization of MSAD device

Endoscopic day case antireflux radiofrequency (Stretta) therapy improves quality of life and reduce proton pump inhibitor (PPI) dependency in patients with gastro-oesophageal reflux disease: a prospective study from a UK tertiary centre

BackgroundEndoscopic antireflux radiofrequency treatment (Stretta) offers a therapeutic alternative for patients suffering from refractory gastro-oesophageal reflux disease (GORD). Current evidence suggests that the treatment may improve symptoms of GORD and...

PS01.006: ROLE OF HIGH RESOLUSION MANOMETRY FOR DIAGNOSIS OF ESOPHAGEAL SPASTIC DISORDERS

Abstract Background Esophageal spastic disorders such as spastic (Type III) achalasia, distal esophageal spasm, and Jackhammer esophagus are rare clinical condition. Moreover, symptoms associated with esophageal spastic disorders such as dysphagia, chest pain, regurgitation, and heartburn is not specific to esophageal spastic disorders (Gastroenterol Clin North Am. 42:27–43, 2013.). Therefore, it is difficult to diagnose esophageal spastic disorders from symptoms. The aim of this study is to clarify diagnostic strategy for esophageal spastic disorders. Methods Patients who underwent all of esophagogastroduodenoscopy (EGD), High resolution manometry (HRM: Starlet®)) and esophagography in our Hospital for evaluation of symptoms such as dysphagia, chest pain, regurgitation, and heartburn from November 2013 to November 2017 were involved in the study. After approval by the research ethical committee (No.20150081), we retrospectively reviewed the clinical findings of these patients. Based on the Chicago classification (CC) v3.0 (Neurogastroenterol Motil. 27:160–174, 2015), findings obtained by HRM were classified. Patients who had past history of upper-gastrointestinal surgery were excluded from analysis. Results 174 patients (Mean age of 58.6 ± 15.4; 70male) were finally analyzed. Based on findings obtained by HRM, patients were classified as 25 achalasia, 15 Jackhammer esophagus, 0 distal esophageal spasm, 25 Esophagogastric junction outflow obstruction, 25 weak peristalsis, 6 failed peristalsis, 78 normal. Moreover, 23 patients with achalasia were classified as 8 Type I, 13 Type II, 4 Type III. In each subtype of achalasia, prevalence of esophageal dilation in EGD was 100%, 85%, 0%, respectively. In each subtype of achalasia, prevalence of liquid pool in esophagus in EGD was 100%, 69%, 0%, respectively. In esophagography, Compared with no findings group (15.5 ± 4.3cm), diameter of esophagus in patients with Type III achalasia(12.3 ± 4.8cm) were comparable, however that in patients with Type I(38.9 ± 18.6cm, P &lt; 0.05) or Type II(32.0 ± 10.4cm, P &lt; 0.01) achalasia were significantly wider. In patients with Jackhammer esophagus, prevalence of ring contractions in EGD and prevalence of corkscrew esophagus in esophagography were 33% and 13%, respectively. Conclusion With only EGD and esophagography, it was difficult to find visible findings which suggest esophageal spastic disorders. This suggests efficacy of HRM for diagnosis of this disorder and possibility of hidden esophageal spastic disorders in patients presumed as refractory GERD. Disclosure All authors have declared no conflicts of interest.

PS01.065: MAGNETIC SPHINCTER AUGMENTATION AS AN EFFECTIVE ALTERNATIVE TO ROUX-EN-Y CONVERSION AFTER BILLROTH II GASTRECTOMY

Abstract Background Background and hypothesis Conversion into a 60 cm Roux-en-Y jejunal loop is the most common remedial procedure in patients with gastroesophageal reflux after Billroth II gastrectomy. While this allows diversion of bilio-pancreatic secretions, symptomatic acid reflux may persist in the presence of a mechanically incompetent lower esophageal sphincter. We hypothesized that magnetic sphincter augmentation (MSA) may relieve symptoms and control esophagitis by reducing both acid and biliary reflux. Methods Methods A 70 year-old male patient presented with intractable reflux symptoms and grade B esophagitis 46 years after partial gastrectomy and Billroth II reconstruction for perforated gastric ulcer. The patient underwent extensive diagnostic evaluation. There was a 3 cm hiatus hernia, grade B esophagitis, and hyperemia of the gastrojejunal anastomosis. Biopsies were negative for malignancy and Helicobacter Pylori. pH-impedance testing showed combined acid and non-acid reflux; esophageal peristalsis was normal on high-resolution manometry. After informed consent, the patient preferred the option of laparoscopic MSA versus open laparotomy and Roux-en-Y conversion. Pneumoperitoneum was established with a Hasson trocar. After adhesiolysis, a hiatus hernia with retroesophageal lipoma was identified. The gastroesophageal junction was completely reduced in the abdominal cavity and a posterior crural repair was performed. A tunnel was made between the esophageal wall and the posterior vagus nerve and a no. 16 MSA (Linx®) device was applied. Results Results The postoperative course was uneventful and the patient was discharged home on postoperative day one. At 1- and 6-month follow-up visit the patient was off-medication, tolerated a free diet, and did not complain of any reflux symptom. The mean GERD-HRQL score decreased from 26 to 2 compared to baseline. A barium swallow confirmed the complete reduction of the hiatal hernia and the absence of reflux in the Trendelenburg position. Esophagitis was completely healed. Conclusion Conclusions To the best of our knowledge, this is the first case of MSA implant for refractory gastroesophageal reflux disease after Billroth II gastrectomy. This simple laparoscopic procedure allowed correction of both acid and biliary reflux. Disclosure All authors have declared no conflicts of interest.

Endoscopic techniques for treating gastroesophageal reflux

Nearly, a third of patients with medically refractory gastroesophageal reflux disease (GERD) will desire an additional nonsurgical treatment option. Recently, endoscopic therapy has been reintroduced as a minimally invasive antireflux barrier treatment, after addressing prior efficacy and safety concerns. Over the last two decades, additional experience and new technologies have resulted in devices and protocols with favorable short-term outcomes and safety profiles. The current literature in endoscopic antireflux therapies covers new devices, long-term follow-up data and further safety experience. This review discusses the endoscopic antireflux devices on the market and most recent studies in this area. Quality of life and reflux symptom score improvement is observed in 73-90% of patients through a 36-48 month follow-up period, with 41-77% remaining off all reflux medicines. Composite data from several thousand cases indicate a low rate (0.93-2.4%) of serious complications and no late adverse effects, including gas-bloat syndrome. In this review, we describe the four endoscopic antireflux devices on market and summarize the current data in the literature. The short and long-term data demonstrate durable symptom improvement and favorable safety profile. Endoscopic antireflux treatment should be considered in the management of GERD.

Review of emerging therapy in refractory GERD- an evidence based approach

Review of emerging therapy in refractory GERD- an evidence based approach

Modern achievements in the diagnosis and treatment of the refractory gastroesophageal reflux disease.

Purpose of the review to present up-to-date data on the causes, methods of diagnosis and treatment of the refractory form of gastroesophageal reflux disease (GERD). Refractory GERD is the preservation of typical symptoms of the disease and/or incomplete healing of the esophageal mucosa against the background of taking a standard dose of proton pump inhibitors (PPI) once a day for 8 weeks. The reasons for the lack of response to the treatment are divided into related to the patient, related to therapy, and not related to GERD. Diagnostic approaches include x-ray examination of the esophagus and stomach, endoscopy with biopsy, 24-hour Impedance-pH monitoring, esophageal manometry. Depending on the reasons for the lack of response to the therapy, treatment may include lifestyle changes, doubling the dose of PPI, replacing PPI with another, adding H2-receptor antagonists, prokinetics, antacids, alginates and adsorbents. If conservative treatment is ineffective, it is possible to consider alternative methods, such as surgical treatment. Refractory GERD is a serious clinical problem. The absence of an answer to 8-week therapy with PPI requires a thorough differential diagnosis using additional examination methods. The identification of the causes of refractory to the therapy allows to optimize the approaches to its overcoming and to choose the optimal treatment.

Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass.

A subset of patients undergoing laparoscopic sleeve gastrectomy (SG) require eventual conversion to Roux-en-Y gastric bypass (RYGB) due to complications from SG or to enhance weight loss. The aim of this study is to characterize the indications for conversion and perioperative outcomes in a large cohort of these patients at a single institution. Patients who underwent revisional surgery to convert SG to RYGB at our institution from January 2008 through January 2017 were retrospectively reviewed. Eighty-nine patients with previous SG underwent conversion to RYGB as part of a planned two-stage approach to gastric bypass (n = 36), for weight recidivism (n = 11), or for complications related to SG (n = 42). Complications from SG that warranted conversion included refractory GERD (40.5%), sleeve stenosis (31.0%), gastrocutaneous (16.7%), or gastropleural (7.1%) fistula, and gastric torsion (4.1%). The mean (SD) age was 47.2years (11.4years) and median BMI at the time of revision was 43.2kg/m2. A laparoscopic approach was successfully completed in 76 patients (85.4%), with an additional of four completed robotically (4.5%). The median length of stay was 3days. Twenty-eight patients (31.5%) had complications which included surgical site infection (20.2%), re-operation (6.7%), anastomotic stricture (3.4%), and one pulmonary embolism. There were no mortalities with a median follow-up of 15months. Conversion of SG to RYGB is safe and technically feasible when performed for complications of SG or to enhance weight loss. This operation can be successfully performed laparoscopically with a low rate of conversion and reasonable complication profile.

Diagnostic Efficacy of 24-hr Esophageal pH Monitoring in Patients with Refractory Gastroesophageal Reflux Disease.

BACKGROUND:Gastric reflux is one of the most important causes of the referral of patients to the internal clinic, which in some cases causes problems for patients due to resistance to common treatments. Therefore, timely diagnosis and treatment of this group of patients are very important.AIM:The purpose of the present study was to determine the off-proton pump inhibitor (off-PPI) 24 h pH-impedance analyses in patients with refractory gastroesophageal reflux disease (GERD) attending to Taleghani Hospital since 2009 to 2017.METHODS:In this observational descriptive-comparative off-PPI study, 572 patients with refractory GERD who were referred to Taleghani Hospital in Tehran from 2009 to 2017 were selected, and the results of 24 h pH Impedance analysis were then assessed.RESULTS:The results of 24h pH-impedance indicated that 7% of cases belonged to Pure Acid Reflux followed by weakly Acid (1%), non-acid (0.3%), mixed & gas (5.2%), functional (58.4%) and oesophagal hypersensitivity (28%). Furthermore, weakly acid plus acid was also found to be 8% and Weakly Acid + Acid + Non-Acid were determined as 8.3%.CONCLUSIONS:Our findings suggested that nearly more than half of the patients with refractory GERD would have a functional disorder in the 24h pH-impedance analysis.

Complications of Antireflux Surgery.

Antireflux surgery anatomically restores the antireflux barrier and is a therapeutic option for proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease or PPI intolerance. Laparoscopic fundoplication is the standard antireflux surgery, though its popularity has declined due to concerns regarding wrap durability and adverse events. As the esophagogastric junction is an anatomically complex and dynamic area subject to mechanical stress, wraps are susceptible to disruption, herniation or slippage. Additionally, recreating an antireflux barrier to balance bidirectional bolus flow is challenging, and wraps may be too tight or too loose. Given these complexities it is not surprising that post-fundoplication symptoms and complications are common. Perioperative mortality rates range from 0.1 to 0.2% and prolonged structural complications occur in up to 30% of cases. Upper gastrointestinal endoscopy with a comprehensive retroflexed examination of the fundoplication and barium esophagram are the primary tests to assess for structural complications. Management hinges on differentiating complications that can be managed with medical and lifestyle optimization versus those that require surgical revision. Reoperation is best reserved for severe structural abnormalities and troublesome symptoms despite medical and endoscopic therapy given its increased morbidity and mortality. Though further data are needed, magnetic sphincter augmentation may be a safer alternative to fundoplication.

528 ANTI-REFLUX ENDOSCOPIC SURGERY: ENDOSCOPIC CARDIOPLASTY USING ENDOSCOPIC MUCOSAL RESECTION MAY EFFECTIVELY TREAT REFRACTORY GASTROESOPHAGEAL REFLUX DISEASE

Anti-reflux endoscopic surgery (ARES) is a new efficacious treatment of option for gastroesophageal reflux disease. We propose to define “esophageal remodeling” as the functional restoration of the esophagogastric junction (EGJ) that involves increased lower esophageal sphincter (LES) pressure. ARES is a endoscopic fundoplication technique using endoscopic mucosal resection (EMR) to treat such refractory GERD patients. This study investigated the clinical outcomes of ARES for refractory GERD patients. ARES was performed in 106 patients with drug-refractory GERD from December 2015 to July 2017. We analyzed data from a prospectively collected database of ARES subjects, which included preprocedure and 6-month postprocedure of GERD-Q symptom scores, and results from esophageal high resolution manometry (HRM) and 24-h pH monitoring. Symptom control rates were compared according to clinical and surgical factors to identify predictive factors of successful surgical outcomes. ARES was performed for 106 patients (55% male; mean age 46.8 years) with PPI-refractory GERD. Mean PPI medication periods were 5.7 (1-30) years and median ARES procedure time was 32.6 (15-83) minutes. The GERD-Q score and 24hr pH monitoring were significantly improved after ARES. Mean post-treatment GERD-Q score was 7.54±2.6, compared to 10.87±2.7 pre-treatment (p<0.001). In impedance planimetry, the mean distensibility was 16.1±8.3 prior to and 9.1±5.7, respectively (p<0.001). No serious complications after ARES were occured. But 6 patients undergo post-treatment stricture, and were treated using balloon dilation and steroid injection. 3 patients suffered from minor post ARES bleeding, successfully treated with argon plasma coagulation. ARES is a very effective and safe treatment option for PPI-refractory GERD patients. ARES can be a good alternative treatment for refractory GERD.

Current and future perspectives in the management of gastroesophageal reflux disease.

Although the prevalence of gastroesophageal reflux disease (GERD) used to be lower in East Asia as compared to Western countries, it has recently been increasing, most likely due to the socioeconomic development in the East. The prevalence of both GERD and functional gastrointestinal disorders (FGIDs) ranges between 10% and 25% worldwide and there are distinct subgroups of patients with overlapping of GERD and FGIDs. However, the true prevalence of an overlap between GERD and FGIDs can be determined only when a formal pathophysiological evaluation has been performed. Nocturnal reflux symptoms have a significant impact on patients' sleep quality and quality of life. Although proton pump inhibitors (PPIs) can improve both reflux and sleep-related symptoms, the relationship between nocturnal reflux events and sleep disturbance is not fully understood. GERD plays an important role in the pathogenesis of lung fibrosis, and PPIs or fundoplication may decrease the likelihood of pulmonary exacerbation or even improve pulmonary function. Refractory reflux symptoms without esophagitis have become one of the most common presentations of GERD in gastroenterology clinics. There are several new medical therapies, and endoscopic as well as laparoscopic techniques that have been increasingly used in these patients. The selection of options should be tailored and individualized based on the pathophysiology of refractory GERD.