Regurgitation Scores Research Articles

Gastroesophageal reflux after per-oral endoscopic myotomy is frequently asymptomatic, but leads to more severe esophagitis: A case-control study.

Background and aimThe incidence of gastroesophageal reflux disease (GERD) is high after per‐oral endoscopic myotomy (POEM). GERD after POEM may be qualitatively different from GERD in patients without motility disorders. In this study, we aimed to analyze and compare different aspects of GERD between patients with post‐POEM GERD and nonachalasia GERD.MethodsThe data of patients with GERD after POEM (January 2018 to June 2019) were compared with that of a control group (nonachalasia GERD group), which included patients presenting with typical reflux symptoms without associated major motility disorders. Patients with lower esophageal sphincter pressure lower than 10 mmHg were excluded from the study. GERD was evaluated at 3 months after POEM. Esophageal acid exposure time higher than 4.2% was used to define GERD. The primary outcome of the study was comparison of GERD‐related quality of life and reflux symptom severity between the two groups. In addition, the severity of erosive esophagitis and reflux‐symptom association were also recorded in the two groups.ResultsA total of 100 patients were included in the study, with 50 patients in each group (post‐POEM GERD vs. controls). The baseline parameters were comparable between the two groups. Median interquartile range of GERD‐related quality of life score was significantly lower in the post‐POEM group (11 [0–23.3] versus 34 [24–44]; p < 0.001). The post‐POEM GERD group had significantly lower median heartburn (6.0 [0–16.3] versus 15.5 [7.5–24.8]; p = 0.001) and regurgitation scores (0 [0–6.0] versus 20.0 [12.3–25.0]; p < 0.001). Erosive esophagitis was more frequent in the post‐POEM group (28 [56%] versus 10 [20.4%], p = 0.001). Only three (6%) patients in the post‐POEM group had a positive reflux‐symptom association as compared with 28 (56%) patients in the control group (p < 0.001).ConclusionIn selected patients with pH positive GERD after POEM, the symptoms are milder and reflux‐symptom association is poor in spite of more severe esophagitis as compared with controls.

Long-term outcomes of transoral incisionless fundoplication for gastro-esophageal reflux disease: systematic-review and meta-analysis

Background and study aims Few reports exist about long-term outcomes of transoral incisionless fundoplication (TIF) for treating refractory gastro-esophageal reflux disease (GERD). Methods A literature search of four major scientific databases was performed up to May 2020 for studies reporting on more than 3-year outcomes of TIF. Data on atient satisfaction, proton pump inhibitor (PPI) daily consumption, PPI use reduction, GERD health-related quality-of-life (GERD-HRQL) score, and normalization of heartburn and regurgitation scores were pooled and summarized with forest plots. Publication bias and heterogeneity were explored. Results Overall, eight studies (418 patients, 232 men; 55.5 %) with a mean follow-up of 5.3 years (range: 3–10 years) were included. The pooled proportion of patient-reported satisfaction before and after TIF was 12.3 % (95 % CI:12.3–35.1 %, I 2 = 87.4 %) and 70.6 % (95 % CI:51.2–84.6, I 2 = 80 %), respectively, corresponding to an odds ratio of 21.4 (95 % CI:3.27–140.5). Pooled rates of patients completely off PPIs and on occasional PPIs were 53.8 % (95 %CI: 42.0 %-65.1 %) and 75.8 % (95 %CI: 67.6–82.6), respectively. The pooled estimated mean GERD-HRQL scores off PPI before and after TIF werey 26.1 (95 %CI: 21.5–30.7; range: 20.0–35.5) and 5.9, respectively (95 %CI:0.35.1–11.4; range: 5.3–9.8; P < 0.001). The overall pooled rates of heartburn and regurgitation scores normalization were 73.0 % (95 %CI: 0.62–0.82) and 86 %, respectively (95 %CI: 75.0–91.0 %). Conclusion Our study shows that TIF appears to offer a long-term safe therapeutic option for selected patients with GERD who refuse life-long medical therapy or surgery, are intolerant to PPIs, or are at increased surgical risk.

Transoral incisionless fundoplication demonstrates durability at up to 9 years.

Goals:To assess the long-term results of transoral incisionless fundoplication (TIF 2).Background:TIF with the EsophyX2 is an accepted procedure to treat gastroesophageal reflux disease (GERD). Long-term data have been limited. We report clinical outcomes of 151 patients followed up to 9 years.Study:A single institution prospective registry of patients undergoing TIF 2 between 11/2008 and 7/2015. Outcomes were assessed by complications, re-interventions, and a mixed effect model of clinical response over time.Results:A total of 151 patients (87 women), mean age 62 years (30–91), mean body mass index (BMI) 26.6 (20–36.1), 93% on daily proton pump inhibitor (PPI), underwent TIF 2 without hiatal hernia repair; 131 of the 151 patients (86%) were available for follow-up at a median of 4.92 years (0.7–9.7 years). Of 120 patients ⩾5 years post-TIF, 62 (51%) were followed for a median 6.8 years. Median GERD-health-related quality of life (HRQL) scores decreased from 21 (interquartile range (IQR) 9.5–30) off PPI and 14 (4–24) on PPI at baseline to 4 (2–8) at 4.92 years and remained at 5 (2–9) in the 62 patients 5–9 years post-TIF. Sixty-four per cent had successful (>50%) reductions in GERD-HRQL scores at 4.92 years and 68% of patients followed ⩾5 years. Median regurgitation decreased from 15 (8–20) off PPI and 11 (5–20) on PPI at baseline to 0 (0–4) at 4.92 years, remaining at 1 (0–3) in 62 patients 5–9 years post-TIF. Mixed model analyses confirmed significant and stable improvements in GERD-HRQL and regurgitation scores at all annual follow-up time points after TIF. Daily PPI use decreased from 93% to 32% at 4.92, and 22% at ⩾5 years post-TIF. Revision to laparoscopic fundoplication in 33(22%) showed comparable outcomes. Two patients recovered uneventfully after laparoscopic surgery for localized perforation.Conclusions:TIF 2 provides durable relief of GERD symptoms at up to 9 years with 69–80% of patients having a successful outcome by symptom response and PPI use.

Ameliorating Effects and Autonomic Mechanisms of Transcutaneous Electrical Acustimulation in Patients With Gastroesophageal Reflux Disease

Gastric dysmotility is one of pathophysiologies of gastroesophageal reflux disease (GERD). The aim of this study was to investigate the effects of transcutaneous electrical acustimulation (TEA) on gastric accommodation and gastric slow waves, and evaluate possible mechanisms in patients with GERD. Thirty patients were studied in two randomized sessions of sham-TEA and TEA with the measurements of esophageal high-resolution manometry (HRM), gastric accommodation assessed by a nutrient-drinking test, electrogastrogram (EGG), electrocardiogram (ECG), and postprandial dyspeptic symptoms. Compared with sham-TEA, TEA improved nutrient drinking-induced fullness (42.0 ± 3.3 vs. 31.0 ± 3.5, P = 0.003) at 10 min after the drink, and belching right after the drink (22.0 ± 4.6 vs. 11.7 ± 3.1, P = 0.012) and at 10 min (16.0 ± 3.8 vs. 3.0 ± 1.5, P = 0.002) after the drink. TEA also improved gastric accommodation (954 ± 37 mL vs. 857 ± 47 mL, P = 0.001) and normalized maximal drink-induced impairment in gastric slow waves. Concurrently, TEA enhanced vagal activity assessed from spectral analysis of heart rate variability in the postprandial state (0.42 ± 0.03 vs. 0.49 ± 0.04, P = 0.039). The vagal activity was positively correlated with the percentage of normal slow waves (r = 0.528; P = 0.003) and negatively correlated with the regurgitation score (r = -0.408, P = 0.025). Acute TEA increases gastric accommodation, improves gastric slow waves, and reduces postprandial fullness and belching, possibly mediated via the vagal mechanisms.

Predictors of Abnormal Functional Luminal Impedance Planimetry Findings in Non-mechanical Esophagogastric Junction Outflow Obstruction.

Esophagogastric junction outflow obstruction (EGJOO) is a common but nonspecific motility pattern identified by esophageal high-resolution manometry (HRM). Functional luminal impedance planimetry (FLIP) provides information regarding lower esophageal sphincter (LES) mechanics, which can identify achalasia spectrum disorders and is useful in evaluating EGJOO. However, the relationship between HRM and FLIP parameters in EGJOO is not clearly defined. To identify predictors of abnormal FLIP findings in patients with non-mechanical EGJOO. This is a retrospective cohort study of patients with non-mechanical EGJOO who underwent FLIP between 10/1/16 and 7/1/19. Demographic data including age and gender, examination indication, concomitant medications, HRM parameters, symptom burden, and FLIP metrics of diameter and distensibility index (DI) were collected. DI was categorized as not low (DI > 2.8), borderline low (DI 1.1-2.8), and definitely low (DI ≤ 1). Kruskal-Wallis and Fisher's exact tests were used to assess the relationship between HRM and FLIP parameters and to identify predictors of abnormal FLIP. Among the 44 patients studied, most were female (n = 33, 75%) and the median age was 63. The median IRP was 18.2, and 10 (23%) patients used chronic narcotics. Lower total heartburn and regurgitation scores, and LES diameter by FLIP are associated with definitely low DI. In patients with non-mechanical EGJOO, reflux burden scores and FLIP diameters can aid in predicting DI. These results may provide useful adjunctive data to help in differentiating which patients have meaningful outflow obstruction.

The effect of a low-nickel diet and nickel sensitization on gastroesophageal reflux disease: A pilot study.

Gastroesophageal reflux disease (GERD) is a common medical condition, frequently refractory to medical therapy. Nickel is a leading cause of allergic contact dermatitis. Although nickel is widely found in foods, the effect of nickel on GERD is unknown. This pilot study sought to evaluate the effect of a low-nickel diet on GERD and determine if epicutaneous patch testing to nickel could predict responsiveness to a low-nickel diet. This prospective, single-site pilot study recruited 20 refractory GERD patients as determined by GERD Health-Related Quality of Life (GERD-HRQL) scores. All patients had epicutaneous patch testing for nickel and were then instructed to follow a low-nickel diet for 8weeks regardless of patch test results. GERD-HRQL was recorded at baseline and following 8weeks of a low-nickel diet. Demographic and clinical data associated with GERD and nickel allergy were recorded. A Wilcoxon signed-rank test and nonparametric analysis of longitudinal data were run to determine statistical significance in pre-and post- GERD-HRQL scores in nickel patch test-positive and negative groups. Nearly all (19/20 [95%]) participants reported reduced GERD symptoms after 8weeks on a low-nickel diet. Mean total GERD-HRQL, regurgitation, and heartburn scores declined (27.05 ± 16.04, 11.45 ± 6.46, 10.85 ± 8.29). Participants with positive vs. negative patch testing to nickel responded equivalently to a low-nickel diet. A low-nickel diet improves GERD symptoms, but responsiveness to a low-nickel diet does not correlate with epicutaneous patch testing to nickel. ClinicalTrials.gov number: NCT03720756.

20 TREATMENT OPTIMIZATION AND PROGNOSTIC FACTORS IN ADVANCED ESOPHAGEAL CANCER

Abstract Esophageal cancer is a disease with high mortality due to advanced stage at the time of diagnosis in patients with poor general condition and/or multiple comorbidities which makes them unsuitable for radical treatment. The goal of this clinical trial is finding optimal treatment for this group of patients. Methods Hypothesis of this clinical trial is that sequential use of high dose rate intraluminal brachytherapy, external beam radiotherapy and chemotherapy decreases symptoms of disease, improves quality of life and prolongs overall survival in patients with esophageal cancer that are not candidates for radical treatment. We have included patients with esophageal cancer that are not candidates for radical treatment. Statistical analysis was done only for the patients that have completed planned treatment and not for the intent to treat population. Therefore, statistical analysis was done for 39 patients, 22 in control group and 17 in interventional group. Results In a survival analysis adapted for AJCC stage of the disease, addition of sequential chemotherapy improves overall survival statistically significant (P = 0.004). Sequential use of high dose rate intraluminal brachytherapy and external beam radiotherapy decreases the degree of: dysphagia (P = 0.001), odynophagia (P = 0.002) and regurgitation (P = 0.008) statistically significant. Decrease of a pain degree is statistically significant only with the use of sequential chemotherapy (P = 0.031). Sequential use of chemotherapy does not improve control over dysphagia (P = 0.872), odynophagia (P = 0.872) and regurgitation (P = 0.872) any further. Patients of female gender have greater improvement of regurgitation score (P = 0.068), pain score (P = 0.09) and quality of life (P = 0.019). Conclusion Sequential use of high dose rate intraluminal brachytherapy and external beam radiotherapy provides a safe use of high radiotherapy doses with minimal exposure of organs at risk, according to dose-volume histogram analysis. Sequential use of chemotherapy, after high dose rate intraluminal brachytherapy and external beam radiotherapy, improves overall survival in patients with esophageal cancer that are not candidates for radical treatment, in comparison to patients who do not receive chemotherapy (P = 0.09).

Long-term Outcomes of Laparoscopic Heller’s Cardiomyotomy in Achalasia Cardia With Megaesophagus

Megaesophagus secondary to achalasia cardia is conventionally treated with esophagectomy. With the advent of minimal invasive surgery, laparoscopic Heller's cardiomyotomy (LHCM) has been used in the management of megaesophagus. The authors hereby report our long-term results of 19 patients of megaesophagus managed with LHCM. Prospectively collected data of 19 patients with megaesophagus were reviewed for symptomatic outcome using defined symptom scores and achalasia disease-specific quality of life (A-DsQol) after LHCM with an antireflux procedure. Follow-up was done with clinical visits and telephonic calls. The mean age of the patients was 39.8 years with 7 female and 12 male individuals. The mean duration of symptoms was 105 months. Dysphagia was the predominant symptom followed by regurgitation and heartburn. A-DsQOL was poor with a mean of 58.6±8.11. Nine patients had extra respiratory symptoms. All patients underwent LHCM with an antireflux procedure with no conversion, intraoperative perforation, or mortality. At a median follow-up of 66 months (interquartile range, 24.5 to 80), there was a significant improvement of dysphagia, regurgitation, heartburn, and Eckardt scores from 2.26±1.14, 2.05±0.62, 1.0±0.67, and 7.21±2.22 to 0.21±0.53, 0.15±0.37, 0.42±0.61, and 0.57±2.06, respectively (P<0.001). One patient (5.2%) had a recurrence of dysphagia. Sixty-three percent of patients graded their satisfaction level as fully satisfied and 31% as better. A-DsQOL of life improved significantly (P<0.001) after surgery. The respiratory symptoms improved in all. LHCM provides durable relief of symptoms in patients with megaesophagus and may be considered as the first-line treatment option in such patients.

Anti-Heartburn Effects of Sugar Cane Flour: A Double-Blind, Randomized, Placebo-Controlled Study.

Gastroesophageal reflux disease (GERD) affects approximately 20% of Australians. Patients suffer a burning sensation known as heartburn due to the movement of acidic stomach content into the esophagus. There is anecdotal evidence of the effectiveness of prebiotic sugarcane flour in controlling symptoms of GERD. This pilot study aimed to investigate the effectiveness of a prebiotic sugarcane flour in alleviating symptoms in medically-diagnosed GERD patients. This pilot study was a single center, double-blinded, placebo-controlled randomized trial conducted on 43 eligible participants. The intervention group (n = 22) were randomized to receive 3 g of sugarcane flour per day, and the control group (n = 21) received 3 g of cellulose placebo per day. Symptoms of gastroesophageal reflux disease were assessed before and after three weeks treatment using the validated Gastroesophageal Reflux Disease-Health Related Quality of Life questionnaire (GERD-HRQL). After three weeks there were significant differences in symptoms for heartburn, regurgitation, and total symptoms scores (p < 0.05) between the sugarcane flour and placebo. Mean GERD-HRQL scores increased in the placebo group for regurgitation (mean increase 1.7; 95% CI 0.23 to 3.2; p = 0.015) and total symptom scores (2.9; 95% CI 0.26 to 5.7; p = 0.033). In contrast, there were significant reductions in heartburn (mean decrease −2.2; 95% CI −4.2 to −0.14; p = 0.037) and total symptom scores (−3.7; 95% CI −7.2 to −0.11; p = 0.044) in the intervention group. This pilot study has shown significant positive effects of sugarcane flour in the reduction of GERD symptoms, and a larger randomized controlled trial is warranted.

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Number of reflux episodes on pH-impedance monitoring associates with improved symptom outcome and treatment satisfaction in gastro-oesophageal reflux disease (GERD) patients with regurgitation

ObjectiveNumber of reflux episodes, an adjunctive metric on pH-impedance monitoring, is incompletely studied. We aimed to determine if number of reflux episodes associates with therapeutic outcome in regurgitation predominant gastro-oesophageal...

Transoral incisionless fundoplication with an ultrasonic surgical endostapler for the treatment of gastroesophageal reflux disease: 12-month outcomes.

Transoral incisionless fundoplication (TIF) with the Medigus ultrasonic surgical endostapler (MUSE) is a new intervention for the treatment of the gastroesophageal reflux disease (GERD). The aim of this study was to assess the 12-month clinical, functional, and endoscopic effects of TIF by MUSE. Patients undergoing MUSE completed the GERD-Health Related Quality of Life (GERD-HRQL) and Reflux Symptom Index (RSI) questionnaires, and underwent endoscopy, esophageal 24-hour pH-impedance recording, and high resolution manometry (HRM) before the TIF procedure and 12 months later, or after 6 months for HRM. Among the 37 patients treated, esophageal intubation was not possible in one and esophageal perforation occurred in another. Clinical and endoscopic follow-up at 12 months was completed in 20 patients, with significant improvements in GERD-HRQL, RSI, heartburn, regurgitation scores, and proton pump inhibitor (PPI) consumption observed. One patient required surgery for persisting symptoms. Functional follow-up was possible in 13 patients and showed no significant improvements in the analyzed parameters. TIF with MUSE significantly improved symptoms at 1-year follow-up, allowing the consumption of PPIs to be stopped or halved in 90 % of patients.

Predictors of dental erosions in patients evaluated with upper digestive endoscopy: a cross-sectional study.

The most studied medical condition related with dental erosions is gastroesophageal reflux disease (GERD). The aim of this study was to assess other predictors of dental erosions besides GERD in outpatients referred for upper digestive endoscopy. In a cross-sectional study, we prospectively evaluated 235 patients who underwent upper digestive endoscopy. Patients were interviewed and examined by a trained dentist before the endoscopies, addressing dental health as well as clinical information and food intake. Dental erosion was classified using Basic Erosive Wear Examination score. Potential predictors for dental erosions were: gender, age, chronic use of antidepressants and proton pump inhibitors (PPI), diabetes mellitus, body mass index, heartburn and acid regurgitation scores, chocolate intake, reflux esophagitis and hiatal hernia. Overall prevalence of dental erosions was 23.4%. The most parsimonious Poisson regression model for dental erosions considered age, chocolate intake and acid regurgitation as predictors. Dental erosions were associated with acid regurgitation in patients younger than 50years [adjusted prevalence ratio (PR) = 1.8 (95% CI 1.1-2.9)] and with chocolate intake in patients older than 50years [PR = 2.1 (95% CI 1.2-3.9]. The surfaces most eroded were palatine/lingual (n = 25) and occlusal (n = 25), followed by vestibular (n = 5). In outpatients evaluated with upper digestive endoscopy, the variables associated with dental erosions were age younger than 50years, acid regurgitation and chocolate intake. Referral for dental evaluation should be considered for young patients with GERD and frequent acid regurgitation.

Assessment of Health Related Quality of Life and Digestive Symptoms in Long-term, Disease Free Survivors After Esophagectomy.

The aim of this study was to investigate long-term HRQOL and symptom evolution in disease free patients up to 20 years after esophagectomy. Esophagectomy has been associated with decreased HRQOL and persistent gastrointestinal symptoms. The study cohort was identified from 2 high volume centers for the management of esophageal cancer. Patients completed HRQOL and symptom questionnaires, including: Digestive Symptom Questionnaire, EORTC QLQ-C30, EORTC QLQ-OG25 Euro QoL 5D, and SF36. Patients were assessed in 3 cohorts: <1 year; 1-5 years, and; >5 years after surgery. In total 171 of 222 patients who underwent esophagectomy between 1991 and 2017 who met inclusion criteria and were contactable, responded to the questionnaires, corresponding to a response rate of 77%. Median age was 66.2 years, and median time from operation to survey was 5.6 years (range 0.3-23.1). Early satiety was the most commonly reported symptom in all patients irrespective of timeframe (87.4%; range 82%-92%). Dysphagia was seen to decrease over time (58% at <2 years; 28% at 2-5 years; 20% at >5 years; P = 0.013). Weight loss scores demonstrated nonstatistical improvement over time. All other symptom scores including heartburn, regurgitation, respiratory symptoms, and pain scores remained constant over time. Average HRQOL did not improve from levels 1 year after surgery compared to patients up to 23 years after esophagectomy. With the exception of dysphagia, which improved over time, esophagectomy was associated with decreased HRQOL and lasting gastrointestinal symptoms up to 20 years after surgery. Pertinently however long-term survivors after oesophagectomy demonstrated comparable to improved HRQOL compared to the general population. The impact of esophagectomy on gastrointestinal symptoms and long-term HRQOL should be considered when counseling and caring for patients undergoing esophagectomy.

Efficacy of per-oral endoscopic myotomy for the treatment of non-achalasia esophageal motor disorders

Per-oral endoscopic myotomy (POEM) is effective in achalasia. The objective of this study was to evaluate the short-term clinical efficacy of POEM in non-achalasia esophageal motility disorders (NAEMD). Patients with NAEMD diagnosed by high-resolution manometry were included in a retrospective multicentric study. For each individual case, two controls paired on gender and age were matched: one with type I/II achalasia and one with type III achalasia. The clinical response, defined by an Eckardt score ≤ 3, was assessed at 3 and 6months. Ninety patients (mean age 66years, 57 men) were included, 30 patients with NAEMD (13 jackhammer esophagus, 6 spastic esophageal disorders, 4 nutcracker esophagus, and 7 esophagogastric junction obstruction), 30 patients with type I-II achalasia, and 30 patients with type III achalasia. The 3-month response rates were 80% (24/30), 90% (27/30), and 100% (30/30) in NAEMD, type I-II achalasia and type III achalasia, respectively (p < 0.01). Eckardt scores improved from preoperative baseline in all groups (median scores 2.0 after POEM vs. 6.5 before POEM, 1.3 vs. 7.2, and 0.5 vs. 6.1 in NAEMD, type I//I and Type III, respectively). No predictive factor of response was identified. In NAEMD patients, there was a significant improvement of dysphagia, regurgitation, and chest pain scores. The 6-month response rates were 63.2% (12/19), 95.5% (21/22), and 87.0% (20/23) in NAEMD, type I-II achalasia and type III achalasia, respectively (p = 0.03). Although less effective than in achalasia, POEM is an effective treatment for NAEMD. Long-term follow-up data are needed to further confirm that POEM may be a valid treatment of NAEMD.

P156 ASSESSMENT OF HEALTH RELATED QUALITY OF LIFE AND DIGESTIVE SYMPTOMS IN LONG-TERM, DISEASE FREE SURVIVORS AFTER ESOPHAGECTOMY

Abstract Background Esophagectomy has been associated with decreased health related quality of life (HRQOL) and persistent gastrointestinal symptoms. The aim of this study was to investigate HRQOL and symptom evolution in disease free patients up to 20 years following esophagectomy. Methods The study cohort was identified from prospective, IRB approved esophagectomy databases from two high volume centers for the management of esophageal cancer. Patients that were alive and without evidence of disease recurrence in April 2018 completed HRQOL and symptom questionnaires, including: Digestive Symptom Questionnaire, SF36, EORTC QLQ-C30, and EORTC QLQ-OG25. Patients were assessed in three cohorts: &lt;2 year; 2 to 5 years, and; &gt;5 years following surgery. Results In total 171 patients who underwent esophagectomy between 1995-2017, responded to the questionnaires, corresponding to a response rate of 81.3%. Median age was 66.2 years, and median time from operation to survey was 5.6 years (range 0.3-23.1). Early satiety was the most commonly reported symptom in all patients irrespective of timeframe (87.4%; range 82-92%). Dysphagia was seen to decrease over time (58% at &lt;2yrs; 28% at 2-5yrs; 20% at &gt;5 yrs. P=0.013). Weight loss scores demonstrated non-statistical improvement over time. All other symptom scores including heartburn, regurgitation, respiratory symptoms and pain scores remained constant over time. The average level of HRQOL did not improve from levels one year after surgery compared to patients up to 23 years following esophagectomy. Conclusion With the exception of dysphagia, which improved over time, esophagectomy was associated with decreased HRQOL and lasting gastrointestinal symptoms &gt;20 years after surgery. In additional to oncological outcomes, the impact of esophagectomy on long-term HRQOL and associated functional disorders should be considered by all members of the multidisciplinary team when counseling and caring for patients undergoing esophagectomy

397 Durability of Transoral Fundoplication (TIF 2): 154 Patients Followed Up to 9 Years

INTRODUCTION: Transoral Fundoplication (TIF 2.0) has become an accepted procedure to treat GERD. Long-term data on clinical success has been limited. We report results on 154 patients followed up to 9 years. METHODS: IRB approved retrospective study of prospective registry patients undergoing TIF 2.0 (without hernia repair) at single institution between 1/2008 and 7/2015. Perioperative complications, need for reintervention, and clinical response measured by GERD-HRQL and Regurgitation scores used in prior TIF studies, and changes in pH parameters were primary outcome measures. RESULTS: 154 patients with objectively documented GERD (88 F, mean age 54 (17-81), mean BMI 27 (19.6-38) underwent TIF 2.0 with the EsophyX-2 device. Using a combination of a caudal helical retractor, caudally-directed external advancement of the device to which the esophagus was adherent by suction, and a rotational movement of the tissue mold around one single helix engagement at 12 o’clock position, the fundus of the stomach was partially rotated around the distal esophagus and secured with multiple 6.5 mm H-shaped polypropylene fasteners. 131 (85%) patients were available for clinical follow-up at up to 9 years (0.7-9.7, Med 4.7, IQR 2-6.7); 75 (49%) were followed ≥ 5 years. 29 (19.3%) patients underwent laparoscopic fundoplication at median of 465 days after TIF (93-2643). QOL results were similar in this group (Figure 1). At a median of 4.7 years after TIF, GERD-HRQL and Regurgitation scores decreased by ≥50% in 70% and 78%. Figure 2 shows GERD-HRQL scores by year. Bloating by GERD-HRQL (score &gt;2) decreased from 46% (58/126) preop to 18% (23/127) of patients postop. 89% (137/154) presented with medically refractory GERD. 72% of patients not undergoing reoperation were not using PPIs and 2 (2%) prn PPI at follow-up. 101 patients had pH testing at a mean of 20 months [1-94 R] post-procedure. Worst day DeMeester score decreased from a median of 32.7 [IQR 23.5-50] to 19.7 [IQR 7.4-35], p&lt; 0.001, with 41/101 (41%) normalized. 3 complications required re-intervention: a GI bleed clipped endoscopically, an immediate laparoscopic repair of an esophageal leak, and an abscess at 5 days requiring laparoscopic drainage, repair, and fundoplication. CONCLUSION: Primary TIF 2.0 technique is durable with stable improvement in QOL and PPI use at up to 9 years, including 76/150 (51%) of patients followed ≥5 years. 72% non-reoperated TIF patients remained off PPI at up to 9 years of follow-up.

Transoral incisionless fundoplication with EsophyX for gastroesophageal reflux disease: clinical efficacy is maintained up to 10 years.

Background Transoral incisionless fundoplication with EsophyX is reported to be effective in patients with gastroesophageal reflux disease in short-medium term follow-up. Aim To examine clinical outcomes up to 10 years. Methods In total, 51 procedures were performed in 50 patients. All entered a yearly clinical follow-up schedule including gastroesophageal reflux disease health-related quality-of-life questionnaires, heartburn and regurgitation scores, and daily proton pump inhibitor consumption. Results The procedure was successfully performed in 49/50 patients. Severe complications occurred in 2/51 procedures. The remaining 49 patients were re-evaluated at 2 and 3 years, 41 after 5 years, 30 after 7 years, and 14 after 10 years. Eight patients were lost to follow-up between 3 and 5 years. Seven patients who were unresponsive to endoscopic fundoplication underwent surgical fundoplication. The mean scores at 2 years were significantly lower than before the procedure and did not change substantially during the follow-up. The rates of patients who had stopped or halved antisecretive therapy 2, 3, 5, 7, and 10 years after the procedure were 86.7 %, 84.4 %, 73.5 %, 83.3 %, and 91.7 %, respectively. Conclusions Transoral incisionless fundoplication with EsophyX is an effective therapeutic option for symptomatic gastroesophageal reflux disease patients, with Hill grades I – II or hiatal hernia < 2 cm, who refuse life-long medical therapy or surgery.

Poor myocardial blush grade accompanies to higher sudden death risk scores of hypertrophic cardiomyopathy

Aim: Hypertrophic cardiomyopathy (HCM) is predominantly inherited as an autosomal dominant disease. The aim of our study was to evaluate angiographic microvascular flow and predictors of poor MBG in patients with HCM.Material and Methods: Patients with poor MBG (MBG 0/1, n=43), and patients with normal MBG (MBG 2/3, n=15) were included retrospectively.Results: Family history and left ventricular end-diastolic diameter were significantly higher in the poor MBG group (p = 0.025, p=0.021). Left atrium diameter and moderate to severe mitral regurgitation (MR) were significantly higher in the normal MBG group (p=0.034, p=0.002). Percentage of SCD risk was significantly higher in patients with poor MBG (p=0.014). Moderate and severe mitral regurgitation (odds ratio =0.013, p=0.004) and HCM-SCD risk score (odds ratio = 0,398, p=0.009) were found to be independent parameters for predicting poor myocardial blush grade. The cut-off value of HCM-SCD risk score obtained by ROC curve analysis was 3.10 for the prediction of poor myocardial blush grade (sensitivity: 76.2%, specificity: 76.7%). The area under the curve (AUC) was 0.712 (p=0.016).Conclusions: Our study results demonstrated the increased risk of sudden cardiac death accompanies poor myocardial blush grade in patients with HCM. If confirmed by further studies, poor MBG may convey SCD-HCM risk of higher rates.Keywords: Hypertrophic cardiomyopathy; microvascular disease; sudden cardiac death risk score.

Effects of Ramadan Fasting on the Symptoms of Gastroesophageal Reflux Disease

Introduction: The effects of Ramadan fasting on gastroesophageal reflux disease (GERD) remains unknown, and few studies have been conducted in this regard. The nutritional, physiological, psychological, and behavioral changes in fasting individuals during Ramadan may affect the status of GERD. The present study aimed to evaluate the effects of these changes on the symptoms of GERD using a meticulous method. Methods: This study was conducted on patients with clinically diagnosed GERD by a gastroenterologist, who was followed-up for three consecutive months (from one month before to after Ramadan). Data were collected using GERD health-related quality of life (GERD-HRQL).For ethical considerations; antisecretory drugs were prescribed for all the patients. After data collection, the subjects were divided into two groups of fasting and non-fasting. Data analysis and comparison were performed in SPSS. Results: total, 69 patients with GERD completed the follow-up, including 33 fasting and 36 non-fasting subjects. No significant differences were observed in the changes of the Total, Heartburn and Regurgitation scores between the Fasting and Non-fasting groups from before Ramadan to Ramadan, Ramasdan to after Ramadan and also before to after Ramadan (P>0.05). Conclusion: According to the results, Ramadan fasting has no effects on the symptoms of GERD in the patients using antisecretory drugs during this month.