Residual Reflux Research Articles

Laparoscopic and Robot-assisted Laparoscopic Reimplantation for Lower Ureter Pathology. A Multi-institutional Comparative Study in 1343 Patients

ObjectiveTo evaluate the outcomes of children with vesicoureteral reflux (VUR) and obstructive megaureter (OM) utilizing various laparoscopic and robot assisted approaches. Materials and methodsRetrospective review of all pediatric laparoscopic and robot assisted cases for lower ureter pathology was performed between 2016-2022 in 13 academic centers worldwide. Five surgical approaches were assessed: LEUR,LVCUR,LDECUR,RALUR and RADECUR. Results1343 patients (490 boys and 853 girls) with a median age of 30 month (IQR 12-63) were treated at 13 centers. 908 patients (68%) underwent reimplantation due to VUR (unilateral in 818 and bilateral in 90 patients). 435 (32%) had a surgery due to UVJ obstruction. Mean length of follow up was 14 month (IQR 8-33). Median operative time was 202 minutes (IQR 142-220) in the robotic arm compared to 240 minutes (IQR 160-267) in the laparoscopic (p=0.45). Intracorporeal excisional tapering was performed in 118 (8%) of the patients. 6 patients in the OM group required additional surgery due to progressive obstruction. In the VUR group, 84% underwent VCUG postoperatively. 5.6% showed residual reflux. Grade 1-2 Clavien-Dindo complications occurred in 10 patients (0.7%) and 6 (0.4%) in the laparoscopic and robotic arm respectively. Grade 3 complication occurred in 17 (1.2% and 8 (0.5%) in both arms respectively. Surgical success was achieved in 96% of patients. ConclusionLaparoscopic and robot assisted laparoscopic approaches are simple, safe, and effective for treating all grades of VUR and OM. Robot assisted approach is beneficial in terms of operative time, intracorporeal suturing and lower complications rate.

Clinical tolerance of untreated reflux after iliac vein stent placement

Background We have recently demonstrated in a large patient cohort that the prevalence and severity of reflux will improve in most limbs after stenting and that most limbs will not develop new-onset reflux. In the present report, we have focused on the long-term clinical outcomes associated with untreated reflux in the same patient cohort who had undergone iliofemoral venous stenting without correction of residual reflux.

Review on management of GERD

Gastroesophageal reflux disease (GERD) is a chronic disorder of the upper gastrointestinal tract with global distribution. The incidence is on the increase in different parts of the world. It is characterized by heartburn and/or regurgitation symptoms is one of the most common gastrointestinal disorders managed by gastroenterologists and primary care physicians. Optimization of therapy (improving compliance and timing of PPI doses), or increasing PPI dosage to twice daily in select circumstances, can reduce persistent symptoms. In patients with residual reflux, medications like H2 blockers, Prokinetics and baclofen may be used. In those with functional heartburn or reflux sensitivity neuro-modulators form an integral part of any therapeutic approach.

Clinical tolerance of untreated reflux after iliac vein stent placement

BackgroundWe have recently demonstrated in a large patient cohort that the prevalence and severity of reflux will improve in most limbs after stenting and that most limbs will not develop new-onset reflux. In the present report, we have focused on the long-term clinical outcomes associated with untreated reflux in the same patient cohort who had undergone iliofemoral venous stenting without correction of residual reflux. MethodsThe clinical outcomes data from 1379 limbs treated with only iliac vein stenting without correction of superficial or deep reflux from 1997 to 2018 were analyzed (23-year follow-up period). Of the 1379 limbs, 632 (46%) had had preexisting reflux before stenting and 747 (54%) had did not. The reflux data (reflux segmental score, air plethysmography, ambulatory venous pressure) for these patients have been previously reported in detail. The subsets were compared perioperatively with each other using the following variables: grade of swelling, visual analog scale for pain score, venous clinical severity score, venous stasis dermatitis, ulceration, and quality of life measures. ResultsBoth groups demonstrated improvements in the venous clinical severity score, grade of swelling, visual analog scale score, and quality of life. No differences were found in ulcer healing (5% vs 3% for limbs with and without prestent reflux, respectively) and resolution of dermatitis (6% vs 5% for limbs with and without prestent reflux, respectively) between the two groups. Of the 632 limbs with preexisting reflux, 218 (34%) had had axial reflux and 414 had had nonaxial reflux (66%). The clinical outcomes were similar between the two groups. Using a multisegment reflux score, the limbs with prestent reflux (n = 632) were divided into two groups. A segmental score of ≥3 indicated severe reflux and a score of <3 indicated moderate reflux. Of these 632 limbs, 161 (25%) had severe reflux and 471 (75%) had moderate reflux. The two groups demonstrated similar outcomes for most clinical parameters. The post-thrombotic limbs and nonthrombotic limbs also showed similar outcomes. ConclusionsThe long-term follow-up of patients after iliac vein stenting showed that uncorrected reflux is well tolerated by most patients across most clinical measures.

Long-term improvement of limb reflux prevalence and severity after iliac vein stent placement

BackgroundThe effect of iliac vein stenting on ipsilateral limb reflux is unknown and has remained a matter of speculation. It has been suggested that the propensity for reflux might worsen when proximal stenosis is corrected. This could allow for retrograde flow with coughing and the Valsalva maneuver, stressing the valve. We examined this hypothesis by an analysis of the long-term effects of iliac vein stenting on limb reflux using a single-center, retrospective analysis of prospectively collected data. MethodsReflux data from duplex ultrasound of 1387 limbs in 1228 patients who had undergone iliac vein stenting from 1997 to 2018 were analyzed. Of the 1387 limbs, 632 (46%) had had ipsilateral duplex ultrasound-determined valve reflux before stenting, and 747 limbs (54%) had not had reflux; data were missing for 8 limbs. Reflux status before and after stenting was available for seven individual segments for each limb in the database for analysis (total, 9653 segments). The stented patients were examined for reflux at least annually during the follow-up period (range, 1-26 years). Segmental reflux prevalence was detected using duplex ultrasound. We have referred to this as “duplex reflux” or simply “reflux.” Reflux severity was graded using (1) a reflux segmental score, assigning one point each for refluxing segments in the limb; (2) air plethysmography (venous filling index [VFI90]); and (3) ambulatory venous pressure (venous filling time [VFT]). ResultsPrestent duplex reflux was present in a combination of superficial, deep, and perforator segments. Reflux prevalence ranged from 7% of deep femoral segments to 51% at the popliteal segment. Post-stent reflux resolution varied from 21% at the femoral vein segment to 58% at the perforator segments. Reflux had completely resolved in 23% of the limbs. New-onset reflux was rare, with a median incidence of 7% for all segments at risk, with cumulative improvement (Kaplan-Meier curve) in reflux severity (segment score, VFI90, and VFT) for most limbs. These metrics were unimproved, with residual reflux in only 18%, 11%, and 6% (segment score, VFI90, and VFT, respectively) of the limbs at long-term follow-up. ConclusionsLong-term follow-up of limbs after iliac vein stenting has shown that the associated ipsilateral reflux prevalence and severity will improve in most limbs over time.

Fundoplication without esophagocrural sutures: Long-term follow-up of a randomized clinical trial

IntroductionWe previously conducted a randomized trial that showed a lack of need for esophagocrural (EC) sutures during fundoplication when no esophageal dissection was performed. There was no difference in wrap herniation or other complications in the group without EC sutures at a median 1.5 years of follow-up. In this follow-up study, we aim to evaluate long-term symptom control and complication profiles in these patients. Methods106 patients were randomized and participated in the original trial. We were primarily concerned with identification of late complications and persistence of symptoms. Presently, we conducted a retrospective chart review and a telephone follow-up survey at a minimum of 6.5 years after fundoplication. Results100 patients were alive at late follow-up and 70% of caregivers responded to the telephone survey. 53% of patients were male; 76% were Caucasian. Of these children, 39 (56%) received four EC sutures, while 31 (44%) did not. Follow-up was conducted at a median of 8.7 years [IQR 8.2,9.7] post-fundoplication.Late wrap herniation was not demonstrated radiographically on chart review or caregiver report in either group. The rate of residual reflux symptoms, post-operative hospitalizations for pneumonia, failure to thrive (FTT), and brief resolved unexplained event (BRUE) were also similar between groups. ConclusionLong-term follow-up in children who underwent fundoplication without esophagocrural sutures demonstrates no difference in symptom management or subsequent hospitalizations at a minimum of 6.5-year follow-up. Level of evidenceII (follow-up of a randomized controlled trial)

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.

Refractory Heartburn: A Challenging Problem in Clinical Practice.

Gastroesophageal reflux disease (GERD) is a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Heartburn and regurgitation are the typical symptoms of GERD. The treatment of GERD encompasses lifestyle modifications, pharmacological, endoscopic, and surgical therapy. The majority of the patients respond to 4-8weeks of proton-pump inhibitors therapy, but 20-42% will demonstrate partial or complete lack of response to treatment. While these patients have been considered as having refractory heartburn, a subset of them does not have GERD or have not been adequately treated.The main causes of refractory heartburn include: poor compliance; inadequate proton-pump inhibitors dosage; incorrect diagnosis; comorbidities; genotypic differences; residual gastroesophageal reflux; eosinophilic esophagitis and others. Treatment is commonly directed toward the underlying cause of patients' refractory heartburn.

Options and clinical evaluation of digestive tract reconstruction after distal gastrectomy for gastric cancer

Digestive tract reconstruction after distal gastrectomy for gastric cancer includes Billroth Ⅰ (BⅠ), Billroth Ⅱ (BⅡ), Roux-en-Y (RY), uncut-RY, RY-double tract (DT) and jejunal interposition (JI). BⅠreconstruction is the most common method, with an advantage of keeping normal duodenal pathway for food. The disadvantage of BⅡ reconstruction is that it could cause dumping syndrome-related syndroms compared with RY reconstruction. RY reconstruction was not superior to BⅠ reconstruction in terms of keeping body weight and improving nutritional status, although it could significantly decrease the incidences of reflux residual gastritis and reflux esophagitis. Uncut-RY reconstruction is better than Roux-en-Y reconstruction in the prevention of Roux stasis syndrome. DT reconstruction has not only the advantages of descending the incidences of reflux residual gastritis and reflux esophagitis but also kept the normal duodenal pathway for food. JI is feasible and safe with the advantages as mentioned above, however, it has complicated surgical process and time-consuming, and anastomotic ulcer may occur after the surgery. Key words: Gastric neoplasms; Distal gastrectomy; Digestive tract reconstruction

Randomised clinical trial: alginate (Gaviscon Advance) vs. placebo as add-on therapy in reflux patients with inadequate response to a once daily proton pump inhibitor.

Many reflux patients remain symptomatic on a standard dose of proton pump inhibitor (PPI). Alginates decrease the number of reflux events by forming a raft on top of the stomach content and thus offer a supplemental mechanism of action to acid suppression. To assess the efficacy of an alginate (Gaviscon Advance, Reckitt Benckiser, Slough, UK) on reflux symptoms in patients with persistent symptoms despite once daily PPI. This was a multicentre, randomised, placebo-controlled, 7-day double-blind trial preceded by a 7-day run-in period. Reflux symptoms were assessed using the Heartburn Reflux Dyspepsia Questionnaire (HRDQ). Based on symptom score during run-in, eligible patients were randomised to Gaviscon Advance 10mL four times a day or placebo in addition to a once daily PPI. The primary endpoint was change in HRDQ score post-treatment compared to baseline. One hundred and thirty-six patients were randomised. Change in HRDQ reflux score was significantly greater for Gaviscon Advance (mean: -5.0, s.d.: 4.7) than for placebo (mean: -3.5, s.d.: 5.5) with an LS mean difference of 1.6 [95% CI -3.1 to -0.1], P=0.03. A decrease in the mean (s.d.) number of nights with symptoms was observed from 3.6 (2.8) to 3.0 (3.0) in the placebo group and from 3.9 (2.8) to 2.2 (2.7) for the Gaviscon Advance group. This reduction was significantly greater in the Gaviscon Advance group than in the placebo group [LS mean difference=-0.9, 95% CI (-1.6 to -0.2), P<0.01]. In patients with residual reflux symptoms despite PPI treatment, adding an alginate offers additional decrease in the burden of reflux symptoms (EudraCT/IND Number: 2011-005486-21).

Hemodynamic classification of varicoceles in men: our experience

The aim of this work is to propose a new hemodynamic classification of male varicoceles that can improve the accuracy of staging and the quality of the examination report. We retrospectively analyzed data on outpatients referred to our vascular ultrasonography service by general practitioners or urologists for work-up of "varicoceles." Quantification and characterization of venous reflux is essential for selecting patients who require treatment and for evaluating the latter's effectiveness, as demonstrated by our experience in a subgroup of 58 patients referred for imaging after surgery on endovascular procedures. We performed scrotal Doppler sonography on 278 males seen during the period 2009-2011 for doubts raised during clinical assessment of varicoceles or for postoperative evaluation of residual reflux. The diagnosis of varicocele was confirmed on 193 subjects; in 32 patients who had undergone percutaneous or surgical treatment the examination demonstrated the presence of residual reflux, while in 85 cases the presence of pain or a scrotal mass was not associated with venous reflux. Standardized instrumental criteria have been developed for the diagnosis of varicoceles but not for their staging. The classification system we propose provides a simple, hemodynamically accurate method for qualitatively evaluating venous reflux, and it can be a useful tool for verifying the success of surgical and endovascular procedures for correcting varicoceles.

Endovenous management of venous leg ulcers.

Compression is the current "standard" in the treatment of venous leg ulcers, and corrective surgery is ancillary. The emergence of safe and effective minimally invasive corrective techniques prompts a reappraisal of this paradigm. Among 192 consecutive limbs with venous leg ulcers, 189 were treated by (1) endovenous laser ablation (n= 30), (2) iliac vein stent placement (n= 89), or (3) both (n= 69). Residual deep reflux was not treated. No specialized wound care was used, and 38% of patients did not use stockings. Outcome measures were time to heal the ulcer and cumulative long-term healing. Sixty percent of the limbs were post-thrombotic. The median reflux segment score was 3 (range, 0-7). Thirty-seven percent had deep axial reflux. Median intravascular ultrasound-detected stenosis was 70% (range, 0%-100%) in stented patients. Sensitivity of venography to iliac vein obstruction was 52%. Postprocedural mortality was 0%, and 2% had deep venous thrombosis (<30 days). By 14 weeks, 81% of the small ulcers approximately ≤1 inch in diameter had healed. Larger ulcers were slower in healing (P< .001). Post-thrombotic etiology, presence of uncorrected deep reflux, demographic factors, or stocking use had no bearing on healing time. Long-term cumulative healing at 5 years overall was 75%. Healing was better in nonthrombotic limbs compared with post-thrombotic limbs (87% vs 66% at 5 years; P< .02) but was similar among the various demographic subsets, procedures, and whether or not patients used compression. Quality-of-life measures improved significantly. Cumulative long-term healing was unaffected by residual axial reflux and was unrelated to hemodynamic severity (air plethysmography, ambulatory venous pressure). However, long-term ulcer healing was inferior in limbs with reflux segment score of ≥3 (P< .03). Post-thrombotic limbs with a reflux score of ≥3 had the lowest cumulative healing among cohorts, but even in this category, 60% of limbs had durable healing with very few recurrences. Most venous leg ulcers in this consecutive series achieved long-term healing with the described minimally invasive algorithm. Uncorrected residual reflux was not an impediment to ulcer healing. Ulcers sized ≤1 inch required no specialized or prolonged wound care. Compression was not necessary to achieve or maintain healing after interventional correction.

Risk factors for proton pump inhibitor refractoriness in Chinese patients with non-erosive reflux disease

To analyze risk factors for refractoriness to proton pump inhibitors (PPIs) in patients with non-erosive reflux disease (NERD). A total of 256 NERD patients treated with the PPI esomeprazole were enrolled. They were classified into symptom-free and residual symptoms groups according to Quality of Life in Reflux and Dyspepsia (QolRad) scale. All subjects completed questionnaires on psychological status (self-rating anxiety scale; self-rating depression scale) and quality of life scale (Short Form 36). Multivariate analysis was used to determine the predictive factors for PPI responses. According to QolRad, 97 patients were confirmed to have residual reflux symptoms, and the remaining 159 patients were considered symptom free. There were no significant differences between the two groups in lifestyle factors (smoking and alcohol consumption), age, Helicobacter pylori infection, and hiatal hernia. There were significant differences between the two groups in relation to sex, psychological distress including anxiety and depression, body mass index (BMI), and irritable bowel syndrome (IBS) (P < 0.05). Logistic regression analysis found that BMI < 23, comorbid IBS, anxiety, and depression were major risk factors for PPI resistance. Symptomatic patients had a lower quality of life compared with symptom-free patients. Some NERD patients are refractory to PPIs and have lower quality of life. Residual symptoms are associated with psychological distress, intestinal disorders, and low BMI.

PTU-167 The role of proton pump inhibitors in patients with Barrett's oesophagus following laparoscopic fundoplication can only be determined after the level of residual reflux has been quantified

IntroductionLaparoscopic fundoplication is carried out for pathological Gastro Oesophageal Reflux in patients with and without Barrett's oesophagus. It has been suggested that in patients with Barrett's, only those patients with...

Salvage Dextranomer-Hyaluronic Acid Copolymer for Persistent Reflux After Ureteral Reimplantation: Early Success Rates

Endoscopic injection of dextranomer-hyaluronic acid copolymer is an accepted initial procedure to correct vesicoureteral reflux. Less data are available on its role in treating failed ureteral reimplantation. We retrospectively reviewed the charts from 2002 to 2008 and identified 21 patients (26 ureteral units) with persistent reflux after reimplantation. Mean age was 7 years (range 2 to 13). Mean followup was 2 years (range 10 to 46 months). Of the 17 patients with a single system ureteral reimplantation was extravesical in 9 and intravesical in 8 with tapering performed in 5. Three patients underwent reimplantation of duplex systems and 1 underwent reimplantation due to ureterocele. Residual reflux grade was 1 to 4 in 3 (11%), 17 (65%), 3 (11%) and 3 ureteral units (11%), respectively. Dextranomer-hyaluronic acid copolymer was injected transurethrally. The mean volume injected was 1.2 ml (range 0.7 to 3). After 1 injection reflux resolved in 15 patients (71%) or a total of 20 ureteral units (77%), including 12 of 14 (86%) extravesically and 8 of 12 (66%) intravesically reimplanted units. The resolution rate improved to 84% after multiple injections. Two of the 6 patients with reflux after 1 injection had a single system, 2 had an obstructive megaureter with tapered reimplantation, 1 had a duplicated system and 1 had a ureterocele. Three of the 5 patients with persistent reflux underwent revision surgery. Ureteral abnormalities other than reflux and tapered reimplantation were associated with a statistically significant inferior success rate. Dextranomer-hyaluronic acid copolymer injection is an efficacious salvage procedure for persistent reflux after ureteral reimplantation. The success rate is inferior for ureteral abnormalities other than primary vesicoureteral reflux and after tapering.

Perspectives on gastroesophageal reflux disease in primary care: the REFLEX study of patient-physician agreement

BackgroundPhysicians may be unaware of the severity and extent of gastroesophageal reflux disease (GERD) in their patients. The aim of this study was to evaluate patient-physician agreement concerning proton pump inhibitor (PPI) treatment.Methods1818 French primary-care physicians and 5174 adult patients with GERD who were taking PPIs answered questions regarding symptoms and treatment satisfaction. Patient-physician agreement was scored using the Kappa (κ) method.ResultsThere was moderate patient-physician agreement for PPI treatment satisfaction (κ = 0.60), PPI prescription adherence (κ = 0.57) and use of over-the-counter gastrointestinal medications (κ = 0.44-0.51). Patient satisfaction with PPI therapy and PPI treatment adherence rates were both ~90%. There was poor patient-physician agreement concerning PPI therapy expectations (κ = 0.22-0.33). Residual reflux symptoms occurred in 61% of patients. Physicians underestimated residual symptom severity compared with their patients (κ = 0.43-0.47), though there was good agreement regarding the presence (κ = 0.62-0.78) and frequency (κ = 0.61-0.66) of these symptoms and their effect on patients' daily life (κ = 0.64).ConclusionsPatient-physician agreement regarding PPI therapy for GERD was moderate or good for the presence of residual symptoms and moderate for treatment satisfaction, but poor for treatment expectations. PPI treatment resulted in high satisfaction rates, but residual symptoms were fairly common and their severity was underestimated by physicians.

Pediatric Robotic Extravesical Ureteral Reimplantation: Comparison With Open Surgery

Robotic assisted laparoscopic extravesical ureteral reimplantation is becoming more widely used as an alternative to open reimplantation. To date, no direct comparison to the open approach in a similar cohort exists. We review a single surgeon experience and compare the outcomes of robotic assisted laparoscopic extravesical ureteral reimplantation and open ureteral reimplantation in children with vesicoureteral reflux. We retrospectively reviewed the charts of 25 pediatric patients (mean age 69 months, range 3 to 144) who underwent robotic assisted laparoscopic extravesical ureteral reimplantation for unilateral or bilateral vesicoureteral reflux between February 2006 and December 2009. A total of 25 patients undergoing open cross-trigonal ureteral reimplantation (mean age 50 months, range 8 to 110) during the same period were used for comparison. All cases were performed by a single surgeon. There were no conversions or intraoperative complications. There was no correlation between age or weight and operative time, length of stay or total analgesia used. Mean operative time was 12% longer in the robotic group vs controls (p <0.05). Mean length of stay (33 vs 53 hours) and pain medication usage were significantly less in the robotic group (p <0.001). Time to first oral intake was not significantly different. There were 3 episodes of transient urinary retention in the robotic group, all in patients undergoing bilateral reimplantation. The overall success rate, defined as no radiographic or clinical evidence of residual reflux, was 97% for robotic assisted laparoscopy after a mean followup of 16 months, compared to 100% for open reimplantation. Robotic assisted laparoscopic extravesical ureteral reimplantation appears to be a safe and efficacious option for repair of vesicoureteral reflux. This early series shows success rates similar to the open approach. We observed decreased length of stay and use of postoperative narcotics. These findings may serve to justify further exploration of this technology and to provide data for design of a prospective trial, although the relative value of specific reductions in morbidity will need to be defined.

Post-thrombotic syndrome: prevention is better than cure

Post-thrombotic syndrome (PTS) can be debilitating to patients and have a major economic impact on health-care services. It arises after deep venous thrombosis (DVT) due to residual venous obstruction or valvular reflux, leading to increased venous pressure in the microcirculation. While the inflammatory process at the time of DVT may aid thrombus resolution, it may also promote destruction of venous valves. The diagnosis of PTS is principally clinical and patients typically complain of leg heaviness, swelling, pain, itching, cramps, ulcer and signs of lipodermatosclerosis. Several clinical scales or classifications have been used but it is recommended that Villalta scale is the most suitable. Risk factors for PTS include a proximal DVT and recurrent thrombosis as well as obesity and prior varicose veins. Poor quality of anticoagulation control may also be a factor. Established PTS is usually managed along the same lines as chronic venous hypertension with compression therapy and leg elevation. Surgery has only a limited role but may benefit some patients. Further trials are desperately needed to define the role of acute thrombolysis and mechanical thrombectomy, which seem to be promising treatments in the studies to date. For patients who have had a DVT more attention should be given to prescribing and using compression hosiery.

Outcome following saphenopopliteal surgery: a prospective observational study

High recurrence rates following small saphenous varicose vein surgery have been reported. The aim of this study was to ascertain initial success rates following saphenopopliteal junction (SPJ) surgery using pre- and postoperative duplex scanning. A prospective study was performed on patients with ultrasound-proven SPJ reflux. Patients underwent preoperative duplex skin marking and a postoperative quality assurance scan. Ninety procedures were performed in 88 patients. The SPJ was successfully ligated in 87 (96.7%) cases. Reflux was completely abolished in 51 (56.7%) cases, but persisted solely in the small saphenous vein (SSV) in 32.2%. Subsequently, 10 consecutive patients underwent 11 SPJ ligations with stripping of the SSV. Follow-up ultrasound scan demonstrated successful ligation of the SPJ and elimination of superficial venous reflux. This study demonstrates that preoperative duplex SPJ marking results in a high percentage of successful ligation. Given that residual persistent reflux was avoided in patients who underwent stripping of the SSV, we propose that patients who require SPJ surgery undergo duplex marking along with specific consideration with regard to treatment of the residual SSV.

Management of gastroesophageal reflux disease that does not respond well to proton pump inhibitors

Patients with gastroesophageal reflux disease (GERD) who are not responding to proton pump inhibitors (PPIs) given once daily are very common. These therapy-resistant patients have become the new face of GERD in clinical practice in the last decade and presently pose a significant therapeutic challenge to the practicing physician. We reviewed newly accumulated information about the management of PPI failure that has been published over the past 2 years. There are diverse mechanisms that contribute to the failure of PPI treatment in GERD patients and they are not limited to residual reflux. Some of the causes of PPI failure may coincide in the same patient. Upper endoscopy appears to have limited diagnostic value. In contrast, esophageal impedance with pH testing on therapy appears to provide the most insightful information about the subsequent management of these patients. Commonly, doubling the PPI dose or switching to another PPI will be offered to patients who failed PPI once daily. Failure of such therapeutic strategies is commonly followed by assessment for residual reflux. There is growing information about the potential value of compounds that can reduce transient lower esophageal sphincter relaxations. Esophageal pain modulators are commonly offered to patients with functional heartburn, although supportive clinical studies are still missing. Management of refractory GERD patients remains an important clinical challenge. Recent studies have cemented the value of impedance-pH testing in pursuing proper treatment. Presently, the most promising therapeutic development for this patient population is transient lower esophageal sphincter relaxation reducers.