Severe Gastroesophageal Reflux Research Articles

Gastrointestinal dysmotility is associated with proton pump inhibitor refractory esophagitis in patients with systemic sclerosis.

Patients with systemic sclerosis present with severe gastroesophageal reflux disease, often refractory to proton-pump inhibitors (PPI) treatment. The aim of the present study was to identify factors associated with PPI-refractory esophagitis. We performed a cross-sectional study in a single-center cohort of patients diagnosed with systemic sclerosis. We included patients who underwent an esophagogastroduodenoscopy while on PPI treatment. Patients with PPI-refractory erosive esophagitis were compared with those with endoscopically normal esophageal mucosa. A total of 69 patients were included, from these, 23 patients (33%) had PPI-refractory esophagitis (Grade A, n = 11; Grade B, n = 7; Grade C, n = 2; Grade D, n = 3) and 46 (67%) had an endoscopically normal esophageal mucosa. On univariate analysis, patients with PPI-refractory esophagitis were more frequently diffuse SSc subset (43% vs 17%; p= 0.041). Evaluating gastrointestinal motility tests, neither absent esophageal contractility (39% vs 25%, p= 0.292) nor hypotensive lower esophageal sphincter (47% vs 44%, p= 0.980) were significantly associated with PPI-refractory esophagitis. Gastrointestinal dysmotility, defined as abnormal gastric emptying and/or small bowel dilated loops, was significantly associated with PPI-refractory esophagitis (66 vs 8%, p = <0.001). On a multivariate regression model to evaluate the association between motility test results adjusted for the diffuse subset, gastrointestinal dysmotility (β = 0.751, p= 0.010) was independently associated with PPI-refractory esophagitis, while absent esophageal contractility (β = 0.044, p= 0.886) or a hypotensive LES were not (β=-0.131, p= 0.663). Our findings suggest that gastric and small intestinal motor dysfunction may be an important contributor to the development of PPI-refractory esophagitis in patients with systemic sclerosis.

Abstract ID: 65 Outcomes of Modified Laparoscopic Sleeve Gastrectomy with Toupet Fundoplication in Patients with Severe Obesity and Gastroesophageal Reflux Disease

Abstract ID: 65 Outcomes of Modified Laparoscopic Sleeve Gastrectomy with Toupet Fundoplication in Patients with Severe Obesity and Gastroesophageal Reflux Disease

610. CROSS-BEDDED ANTI-REFLUX ANASTOMOSIS ACHIEVED LESS GASTROESOPHAGEAL REFLUX WITHOUT ADDITIONAL DYSPHAGIA COMPARED TO CONDITIONAL ANASTOMOSIS IN MCKEOWN ESOPHAGECTOMY

Abstract Background Most esophageal cancer patients undergoing Mckeown esophagectomy had severe postoperative gastroesophageal reflux and poor quality of life. A novel anastomosis technique was invented to improve this situation. We conducted this study to investigate the incidence of gastroesophageal reflux, dysphagia, and quality of life (QoL) among patients with esophageal cancer undergoing non-intussuscepted anastomosis and cross-bedded anti-reflux (CAR) anastomosis during Mckeown esophagectomy. Methods Data from patients who underwent Mckeown esophagectomy for esophageal cancer from March 2022 to December 2022 were retrospectively analyzed. The incidence of gastroesophageal reflux, dysphagia, and QoL were measured. We enrolled 218 patients, including 155 patients undergoing non-intussuscepted anastomosis and 63 patients undergoing CAR anastomosis. Propensity score matching was used to provide a balanced cohort consisting of 63 paired cases. Patients’ demographics and clinical data were compared between the two arms. Results Before propensity score matching, there were no significant differences between the two arms in terms of sex, age, body mass index, or comorbidities. Neoadjuvant therapy was the only unbalanced variable. After propensity matching, baseline characteristics were all comparable between them. Anastomotic leakage occurred in 1 (1.6%) patient in the CAR anastomosis arm and in 2 (3.2%) in the non-intussuscepted anastomosis arm. No significant difference was observed in dysphagia severity (P=0.267). 45 (71.4%) patients in the non-intussuscepted anastomosis arm and 60 (95.2%) in the CAR anastomosis arm slept in the supine position (P=0.001). Gastroesophageal reflux was milder in the CAR anastomosis arm (P&amp;lt;0.001). The CAR anastomosis arm was superior to the non-intussuscepted anastomosis arm in the social functioning domain (P=0.004) and financial difficulties domain (P=0.026) of QoL. Conclusions CAR anastomosis achieved sufficient control of gastroesophageal reflux without causing dysphagia. It also improved QoL compared with non-intussuscepted anastomosis. https://1drv.ms/v/s!AmCqlJJZqDPDjRcLYFEgRSPHrUDY?e=1bEAyy

Long-term efficacy of total versus posterior partial fundoplication in patients with gastro-oesophageal reflux disease: a systematic review and meta-analysis.

Laparoscopic fundoplication remains the standard treatment for patients with severe gastro-oesophageal reflux disease (GORD). Multiple randomised controlled trials (RCTs) have compared the two most commonly performed surgical techniques, total and posterior partial fundoplication (Nissen [NF] and Toupet [TF]), in terms of symptom control and treatment failure in patients without subsequent dysmotility disorders. We aimed to conduct a systematic review and meta-analysis of these two techniques with regard to the long-term effect on reflux control and associated dysphagia. The MEDLINE®, Embase®, PubMed® and Cochrane Library databases were searched, and all the relevant published RCTs were shortlisted according to the inclusion criteria. The summated outcomes of long-term results relating to the recurrence of GORD and dysphagia were evaluated in a meta-analysis using RevMan software. Eight studies (all RCTs) on 1,545 patients undergoing NF or TF were eligible for inclusion in this meta-analysis. There were 799 patients in the NF group and 746 in the TF group. In the random effects model analysis, the incidence of long-term recurrence of GORD was not statistically different between the NF and TF cohorts (odds ratio [OR]: 0.69, 95% confidence interval [CI]: 0.34-1.41, z=1.01, p=0.31). However, the incidence of long-term dysphagia was statistically lower in the TF group (OR: 2.92, 95% CI: 1.49-5.72, z=3.13, p=0.002) with low between-study heterogeneity (I2=0%). The findings of this systematic review and meta-analysis on symptomatic GORD appear to be in favour of partial posterior fundoplication (TF) as the optimal treatment. It provides equivalent outcomes in reflux symptom control with a lower risk of postoperative dysphagia compared with total fundoplication (NF).

Abstract ID: 51High-Resolution Manometry Features Can Segregate Non-Severe from Severe Gastro-Esophageal Reflux Disease

Abstract ID: 51High-Resolution Manometry Features Can Segregate Non-Severe from Severe Gastro-Esophageal Reflux Disease

A systematic review of Sandifer syndrome in children with severe gastroesophageal reflux

PurposeSandifer syndrome (SS), which combines gastroesophageal reflux (GER) and a neurological or psychiatric disorder, is an uncommon condition that often takes a long time to diagnosis. We aimed to systematically review available papers regarding SS.MethodsAfter presenting our two cases of SS, we systematically reviewed articles published in MEDILINE/PubMed, Cochrane Library, and Web of Science.ResultsThe meta-analysis included 54 reported cases and 2 of our own cases. Our results showed that all cases achieved symptom improvement with appropriate treatment for GER. Notably, 19 of the 56 cases exhibited anatomical anomalies, such as hiatal hernia and malrotation. Significantly more patients with than without anatomical anomalies required surgery (p < 0.001). However, 23 of the 29 patients without anatomical anomalies (79%) achieved symptom improvement without surgery. Patients who did not undergo surgery had a median (interquartile range) duration to symptom resolution of 1 (1–1) month.ConclusionThe primary care providers should keep SS in the differential diagnosis of patients presenting with abnormal posturing and no apparent neuromuscular disorders. Fundoplication may be effective especially for patients with anatomical anomalies or those whose symptoms do not improve after more than 1 month with nonsurgical treatment.

Efficacy and safety of one anastomosis gastric bypass versus Roux-en-Y gastric bypass at 5 years (YOMEGA): a prospective, open-label, non-inferiority, randomised extension study

The multicentre randomised trial YOMEGA (NCT02139813) comparing the one anastomosis gastric bypass (OAGB) with the Roux-en-Y gastric bypass (RYGB) confirmed the non-inferiority of OAGB on weight loss outcomes at 24 months. We aimed to report weight loss, metabolic, and safety outcomes at 5 years. YOMEGA is a prospective, open-label, non-inferiority, randomised trial conducted at nine centres in France. Inclusion criteria were BMI of 40 kg/m2 or more, or 35 kg/m2 or more with comorbidities. Key exclusion criteria were severe gastro-oesophageal reflux disease or Barrett's oesophagus and previous bariatric surgery. Patients were randomly assigned (1 :1) to OAGB (one gastrojejunal anastomosis with a 200 cm biliopancreatic limb) or RYGB (with a 150 cm alimentary limb and a 50 cm biliary limb), stratified by centre, with blocks of variable size. The primary endpoint of this extension study was percentage excess BMI loss and was analysed in the per-protocol population, including patients with data who were operated on with the technique randomly assigned to them and excluding patients with major deviations from the protocol during the follow-up (change of surgical technique, death, or withdrawal of consent). Non-inferiority was concluded for the primary endpoint if the upper bound of the CI was less than the non-inferiority limit (7 percentage points). YOMEGA is registered with ClinicalTrials.gov, NCT02139813, and the 5-year follow-up of YOMEGA is registered with ClinicalTrials.gov, NCT05549271. Between May 13, 2014, and March 2, 2016, 253 patients were randomly assigned to OAGB (n=129) or RYGB (n=124), and from these patients 114 in the OAGB group and 118 in the RYGB group were included in the per-protocol analysis. In the per-protocol population, at baseline, mean age was 43·0 years (SD 10·8), mean BMI was 44·0 kg/m2 (5·6), 54 (23%) patients were male and 178 (77%) were female; 55 (27%) of 207 patients had type 2 diabetes. After 5 years, mean percentage excess BMI loss was -75·6% (SD 28·1) in the OAGB group versus -71·4% (SD 29·8) in the RYGB group, confirming non-inferiority (mean difference -4·1% [90% CI -12·0 to 3·7], p=0·0099). Remission of type 2 diabetes was similar in both groups. Nutritional status did not differ; the most common adverse event was clinical gastro-oesophageal reflux disease, occurring in 27 (41%) of 66 patients in the OAGB group versus 14 (18%) of 76 patients in the RYGB group (p=0·0030). Among serious adverse events, ten (8%) of 127 patients converted from OAGB to RYGB. 171 (68%) of 253 patients were followed up. OAGB was not inferior to RYGB regarding percentage excess BMI loss at 5 years with similar metabolic outcomes. The high rate of clinical gastro-oesophageal reflux disease after OAGB raises questions about its long-term consequences, which need to be further investigated. Medtronic.

A commentary on 'Intraoperative endomanometric laparoscopic Nissen fundoplication improves postoperative outcomes in large sliding hiatus hernias with severe gastroesophageal reflux disease: a retrospective cohort study'.

A commentary on 'Intraoperative endomanometric laparoscopic Nissen fundoplication improves postoperative outcomes in large sliding hiatus hernias with severe gastroesophageal reflux disease: a retrospective cohort study'.

Stomach engineering: region-specific characterization of the decellularized porcine stomach

PurposePatients affected by microgastria, severe gastroesophageal reflux, or those who have undergone subtotal gastrectomy, have commonly described reporting dumping syndromes or other symptoms that seriously impair the quality of their life. Gastric tissue engineering may offer an alternative approach to treating these pathologies. Decellularization protocols have great potential to generate novel biomaterials for large gastric defect repair. There is an urgency to define more reliable protocols to foster clinical applications of tissue-engineered decellularized gastric grafts.MethodsIn this work, we investigated the biochemical and mechanical properties of decellularized porcine stomach tissue compared to its native counterpart. Histological and immunofluorescence analyses were performed to screen the quality of decellularized samples. Quantitative analysis was also performed to assess extracellular matrix composition. At last, we investigated the mechanical properties and cytocompatibility of the decellularized tissue compared to the native.ResultsThe optimized decellularization protocol produced efficient cell removal, highlighted in the absence of native cellular nuclei. Decellularized scaffolds preserved collagen and elastin contents, with partial loss of sulfated glycosaminoglycans. Decellularized gastric tissue revealed increased elastic modulus and strain at break during mechanical tensile tests, while ultimate tensile strength was significantly reduced. HepG2 cells were seeded on the ECM, revealing matrix cytocompatibility and the ability to support cell proliferation.ConclusionOur work reports the successful generation of acellular porcine gastric tissue able to support cell viability and proliferation of human cells.

Establishment of a nomogram prediction model using common preoperative indicators for early weight loss after laparoscopic sleeve gastrectomy

Objectives: To construct a nomogram prediction model using common preoperative indicators for early weight loss (EWL) 1 year after laparoscopic sleeve gastrectomy (LSG). Methods: Relevant data of obese patients who had undergone LSG from January 2015 to May 2022 in Fujian Medical University Union Hospital and Quanzhou First Hospital Affiliated Fujian Medical University were analyzed. Patients with a history of major abdominal surgery, severe gastroesophageal reflux disease, pregnancy within 1 year after surgery, or who were lost to follow-up were excluded, resulting in a total of 200 patients in the study (190 from Fujian Medical University Union Hospital and 10 from Quanzhou First Hospital Affiliated Fujian Medical University). The participants were 51 men and 149 women of a mean age 29.9±8.2 years and a body mass index (BMI) 38.7±6.5 kg/m2. All patients in this group underwent standardized LSG procedure. Achieving ideal weight (BMI≤25 kg/m2) 1 year after LSG was defined as goal of EWL. Logistic regression analyses were performed to identify factors that independently influenced EWL. These factors were incorporated into the nomogram model. Receiver operating characteristic (ROC) curves (the larger the area under the curve [AUC], the better the predictive ability and accuracy of the model), likelihood ratio test (higher likelihood ratio indicates greater model homogeneity), decision curve analysis (higher net benefit indicates a better model), Akaike information criterion (AIC; smaller AIC indicates a better model), and Bayesian information criterion (BIC; smaller BIC indicates a better model) were used to validate the predictive ability of the column line diagram model. Results: In this study of 200 obese patients who underwent LSG surgery, 136 achieved EWL goal, whereas the remaining 64 did not. The rate of EWL goal achievement of the entire group was 68.0%. Compared with patients who did not achieve EWL goal, those who did had lower BMI, alanine transaminase, aspartate transaminase, triglycerides, and higher cholesterol. Additionally, the proportion of female was higher and the proportions of patients with fatty liver and hypertension lower in those who achieved EWL goal (all P<0.05). Univariate and multivariate logistic regression analysis revealed that preoperative BMI (OR=0.852, 95%CI: 0.796-0.912, P<0.001), alanine transaminase (OR=0.992, 95%CI: 0.985-0.999, P=0.024), presence of fatty liver (OR=0.185, 95%CI: 0.038-0.887, P=0.035) and hypertension (OR=0.374, 95%CI: 0.144-0.969, P=0.043) were independently associated with failure to achieve EWL goal. Cholesterol (OR=1.428, 95%CI: 1.052-1.939, P=0.022) was independently associated with achieving EWL goal. We used the above variables to establish an EWL nomogram model. ROC analysis, the likelihood ratio test, decision curve analysis, and AIC all revealed that the predictive value of the model was better than that of BMI alone (nomogram model vs. BMI: area under the curve 0.840 vs. 0.798, P=0.047; likelihood ratio: 58.785 vs. 36.565, AIC: 193.066 vs. 207.063, BIC: 212.856 vs. 213.660). Conclusion: Our predictive model is more accurate in predicting EWL after LSG compared with using BMI.

A case series of pneumonia beyond usual infections in children

Pneumonia is the most common cause of mortality in under-five children worldwide. Largely, viral pneumonia is the most common cause of pneumonia in children across all age groups. We need to think outside the jukebox while dealing with cases of recurrent or persistent pneumonia. A few uncommon causes of persistent or recurrent pneumonia are primary or secondary immunodeficiencies, airway anomalies, infection with Mycobacterium tuberculosis complex, aspiration pneumonia, and severe gastroesophageal reflux. We present a few uncommon presentations of pneumonia in children, which can pose a significant diagnostic challenge in a resource-limited setting.

Endoscopic management of esophageal mucosal bridges in children with esophageal atresia

Background and study aimsEsophageal mucosal bridge (EMB) may be diagnosed at the anastomotic site in children operated on for esophageal atresia (EA) but so far only a few cases (n = 4) have been reported. This study aimed to characterize EMB in children with EA, risk factors, and treatment.Patients and methodsThis retrospective multicenter study recorded patient’s characteristics, EMB diagnosis circumstances, endoscopic management, follow-up, and EMB recurrence in children with EA aged less than 18 years, compared with paired EA patients without EMB.ResultsThirty patients were included (60% male, 90% EA/tracheoesophageal fistula, 43% associated malformations). Compared to 44 paired controls, EMB was associated with a history of nasogastric tube feeding (31% vs. 9.1%, p = 0.02) and severe gastroesophageal reflux disease (history of fundoplication: 41.4% vs. 13.6%, p < 0.01). 77% had symptoms (food impaction and/or dysphagia). Endoscopic management was performed in 53% of patients (83% electrocoagulation) with no technical difficulties or complications. 80% of the symptomatic patients with EMB improved after endoscopic treatment, independently of anastomotic stricture dilatation or not.ConclusionEMB endoscopic management by electrocoagulation is safe and often leads to symptom improvement.

O05 Management of acute desloughing of the oesophageal lining in patients with dystrophic epidermolysis bullosa: a case series of six paediatric patients

Abstract Dystrophic epidermolysis bullosa (DEB) is a subtype of inherited skin disorders characterized by skin and mucosal fragility due to collagen VII (COL7A1) gene mutations. Desloughing of the lining of the oesophagus has not been reported before. We retrospectively reviewed the hospital electronic patient records between 2008 and 2021 with regard to acute treatment and long-term management. Six patients with recessive DEB (RDEB) severe (n = 4), RDEB intermediate (n = 1) and dominant DEB (DDEB) were identified. The mean age at the time of the episode was 29.6 months. Most of the patients (n = 5) suffered from severe gastro-oesophageal reflux at the time of onset. Clinically, they presented with a coughing episode (n = 6), haematemesis (n = 6), vomiting (n = 6) and choking (n = 3) with a piece of mucosae coughed up. Four patients recovered with medical management including immediate hospitalization, no oral intake (nil by mouth, NBM), pain relief and optimization of the dose of proton-pump inhibitors. Due to severe persistent dysphagia, two patients required gastrostomy insertions for feeding; one also required a Nissen's fundoplication due to severe reflux. One patient had an aspiration pneumonia. Desloughing of varying lengths of segments of the oesophagus is an emergency. The lining coughed up needs to be cut at the mouth not pulled and the emergency services called immediately. On arrival, an urgent assessment and chest X-ray should be performed to rule out any signs of perforation. The patient should be kept NBM with intravenous fluids and pain relief. Expert multidisciplinary care is needed to manage this rare but extremely serious condition.

Changes in the properties of bulk-fill resins under conditions of gastroesophageal reflux and bulimia

Aim: Evaluate the roughness, microhardness and color change of different Bulk Fill resins when submitted to the condition of gastroesophageal reflux and bulimia. Methods: 60 specimens (n = 10) of Bulk-Fill composite resins were made: M1 – Filtek™; M2 – Tetric N-Ceram and M3 – OPUS, through a matrix 2x6 mm and light cured by the VALO light source. After polishing, initial analyzes (48 hours - T0) of surface roughness (Ra), microhardness (VHN) and color change (ΔE) were performed. To simulate the oral condition of severe gastroesophageal reflux and bulimia, the specimens were immersed in hydrochloric acid (S1) (pH 1.7) 4 minutes a day, for 7 days. Control group specimens were immersed in artificial saliva (S2). Subsequently to immersions, mechanical brushing was performed for 3 minutes, three times a day, simulating 7 days of brushing. And again, the analyzes of Ra, VHN and ΔE were performed (7 days - T1). Thus, hydrochloric acid immersion, mechanical brushing and Ra analysis were repeated at 14 days (T2) and 21 days (T3); and T2, T3 and T4 (3 years) for VHN and ΔE. Results: After Shapiro-Wilk statistical test, ANOVA and Tukey test with Bonferroni adjustment (p&gt;0.05), M3 showed the lowest Ra at all times compared to the other resins, while the highest Ra was at T0. M1 and T1 showed higher VHN. And M2 and T4 showed higher ΔE. Conclusion: Bulk Fill resins can be indicated for patients with Gastroesophageal Reflux and Bulimia, nonetheless, Tetric N-Ceram resin showed the worst results.

Radionuclide Diagnosis of Esophageal Dysmotility and Gastroesophageal Reflux in Patients with Systemic Sclerosis

Objective: to evaluate the possibilities of dynamic scintigraphy for the diagnosis of esophageal dysmotility (ED) and gastroesophageal reflux (GER) in patients with systemic sclerosis (SS).Material and methods. The study group included 77 patients with established SS of different disease duration (from several months to 30 years) who underwent Technephyt 99mTc dynamic esophageal scintigraphy using two-stage protocol. During the first stage, the esophageal transport function was evaluated; during the second stage, the presence and severity of GER were assessed. Scans were analyzed using visual assessment, quantitative estimation of time/activity curves, and a proposed three-point scale for evaluating ED and GER severity. The control group consisted of 19 practically healthy individuals who underwent a routine examination to exclude digestive system and gastrointestinal tract diseases, the algorithm of which included dynamic scintigraphy.Results. ED was found in 74 of 77 patients (96%). According to three-point scale, severe ED (3 points) was registrated in 41 (55%) patients, moderate ED (2 points) in 15 (21%), and mild ED in 18 (24%). GER was diagnosed in 35 of 77 cases (45%): mild GER in 13 (37%), moderate GER (2 points) in 22 (63%), and none of the patients was found to have severe GER (3 points). A significant relationship between the presence of GER and the severity of ED was not obtained, but a direct correlation was established between ED and GER severity.Conclusion. Most SS patients demonstrated ED of varying severity associated with mild and moderate GER in nearly 45% of the cases. The study results confirm the practical significance of dynamic scintigraphy for assessing the esophageal transport function and GER in SS patients.

Management of acute sloughing of the esophageal lining in patients with dystrophic epidermolysis bullosa-A series of six pediatric patients.

Dystrophic epidermolysis bullosa (DEB) is a subtype of an inherited skin disorder characterized by skin and mucosal fragility due to collagen VII (COL7A1) gene mutations. Esophageal strictures leading to chronic dysphagia and acute episodes are well recognized complications within this subtype. Sloughing of esophageal mucosa and the treatment of this emergency have heretofore received limited attention in the EB literature. We retrospectively reviewed the electronic medical records of the patients who had an acute episode of sloughing of the esophageal lining between 2008 and 2021 and extracted the information regarding their clinical presentation and management. Six patients out of 210 with recessive DEB severe (RDEB-S) (n = 4), RDEB intermediate (RDEB-I) (n = 1) and dominant DEB (DDEB) (n = 1) were identified. The mean age at the time of the episode was 2.7 years. All patients had early-onset severe gastroesophageal reflux. Clinically, they presented with a coughing episode (n = 6), hematemesis (n = 6), vomiting (n = 6), and choking (n = 3), followed by coughing up a string like tissue of variable length, part of the esophageal mucosal lining. Four patients recovered with medical management only, two patients required gastrostomy insertions for feeding due to severe persistent dysphagia and one also required a Nissen's fundoplication to manage severe reflux. One patient had aspiration pneumonia. Sloughing of varying lengths of segments of the esophagus is an emergency. The lining coughed up needs to be cut at the mouth not pulled and the emergency services called immediately for urgent assessment and management. Expert multidisciplinary care is needed to manage this rare but serious condition.

Challenges of transsphenoidal pituitary surgery in severe brachycephalic dogs.

Transsphenoidal hypophysectomy is the standard surgical technique for the excision of pituitary neoplasms. Anatomy may be more obscured in brachycephalic skull types due to the crowding of soft tissue and osseous structures. We describe the unique challenges to approach the sphenoid bone and localize the correct burr hole site in severe brachycephalic dogs. A single institution retrospective case series of brachycephalic dogs with pituitary-dependent hypercortisolism (PDH). Preoperative computed tomography enabled 3D-, and cross-sectional reconstruction to plan and dry-practice the position of the ideal burr hole in relation to the sella turcica, pterygoid hamular processes, and hard palate. Rostral burring of the caudal hard palate obscuring the direct sphenoid approach necessitated adaptations to the original transsphenoidal hypophysectomy procedure. Postoperative outcomes and complications with respect to those seen in mesocephalic dogs are described. Ten brachycephalic dogs including French Bulldogs (n = 9) and a single Dogue de Bordeaux were included. All dogs were diagnosed with PDH and had preoperative advanced imaging performed on the skull. All but one dog had an enlarged pituitary gland, with a median pituitary/brain value of 0.5 (range 0.21-0.9). A total of 11 transsphenoidal hypophysectomy procedures were performed in these 10 dogs. Rostral extension of the soft palate incision into the hard palate was performed to access the burr hole site on the sphenoid bone. Major complications included aspiration pneumonia (n = 1), severe gastroesophageal reflux (n = 1), and central nervous signs (=1). All dogs survived until discharge, with a median time to follow-up of 618 days (range 79-1,669 days). Seven dogs experienced long-term remission of PDH. Brachycephalic dogs undergoing transsphenoid al hypophysectomy benefit from meticulous presurgical planning and extension of the approach into the caudal hard palate. Advanced surgical skills can render a good outcome in a technically challenging environment.

The comparison of long-term oncological outcomes and complications after proximal gastrectomy with double tract reconstruction versus total gastrectomy for proximal gastric cancer

BackgroundConventional methods for treating patients with proximal gastric cancer (PGC) include proximal gastrectomy (PG) and total gastrectomy (TG) and such methods have become challenging due to double tract reconstruction (DTR). However, the clinical outcomes remain unclear. This study was performed with the aim of verifying that PG-DTR was beneficial in terms of reducing the incidence of postoperative complications and improving the prognosis.MethodsThe PGC patient cohort was retrospectively grouped into the PG-DTR and TG groups. Clinicopathological features, complications, and survival data were compared between the two groups.ResultsA total of 388 patients were included in the analyses. Patients who were subjected to TG tended to have more severe gastroesophageal reflux (GR) (P = 0.041), anemia (P = 0.007), and hypoalbuminemia (P < 0.001). Overall survival rates, regardless of clinical stage, were significantly different between the PG-DTR and TG groups (all P < 0.05). The multivariate Cox regression analysis confirmed that surgical procedure, tumor size, infiltration depth, lymph node metastasis, differentiation, and age were independent risk factors. The patients were likely to benefit from PG-DTR (all HR > 1 and P < 0.05). However, no significant differences were observed in the risks of GR, anemia, and hypoalbuminemia (all P > 0.05). Moreover, the nomogram derived from significant parameters showed great calibration and discrimination ability and significant clinical benefit.ConclusionsThe patients who underwent PG-DTR had a favorable prognosis. The risk of postoperative complications, such as severe GR, anemia, and hypoalbuminemia, was lower in PG-DTR than in TG. Thus, PG-DTR is more beneficial for patients with PGC and may be a valuable and promising surgical procedure.

Health-related Quality of Life of Children with Gastro-oesophageal Reflux Disease after Nissen Fundoplication and Gastrostomy Tube Insertion

Introduction: Severe gastro-oesophageal reflux disease (GERD) is associated with a poor health-related quality of life (HRQoL). Nissen fundoplication is the most common surgical procedure for patients with GERD. A feeding gastrostomy tube may be inserted at the same time in selected patients where there are unsafe swallowing and/or feeding difficulties. The goals of surgery are to eliminate symptoms, prevent reflux complications and ultimately improve the quality of life. The main objective of this study was to assess the HRQoL of children with GERD after Nissen fundoplication and gastrostomy tube insertion. Materials and Methods: This was an observational retrospective cohort study at two private, not-for-profit tertiary hospitals in Nairobi. The study population included children under 18 years of age with GERD who had Nissen fundoplication with or without gastrostomy tube insertion from January 2010 to December 2020. The quality of life was assessed from the caretakers using the Paediatric Quality of Life Inventory applied through a telephone call. Data analysis was done using SPSS version 26. The HRQoL was summarised using mean and standard deviation (SD) with a 95% confidence interval (CI) around the scores. Independent samples t-test was conducted to compare the means of HRQoL for gender, complications and comorbidities. Spearman’s correlation was done for HRQoL and age. Results: Eighty-two children were included in the study. Eighty-four per cent had comorbidities, with almost three-quarters of them having neurological impairment. Majority (91%) had open Nissen fundoplication, while 9% had laparoscopic Nissen fundoplication. One-third of these children reported complications post-procedure. Nissen fundoplication failure rate was 10%. Two-thirds had a concurrent gastrostomy tube insertion. The global mean HRQoL score was 75.8 (SD: 23.5, 95% CI: 70.4–81.2). Gastrostomy tube insertion had no impact on the quality of life. Children with neurological impairment had significantly lower quality of life than those without neurological impairment. Conclusion: The global score of the HRQoL following Nissen fundoplication in this cohort of children was 75.8. Further studies to reduce the proportion of children who experience complications postoperatively in this setting are required.

Effect of Remifentanil vs Neuromuscular Blockers During Rapid Sequence Intubation on Successful Intubation Without Major Complications Among Patients at Risk of Aspiration

It is uncertain whether a rapid-onset opioid is noninferior to a rapid-onset neuromuscular blocker during rapid sequence intubation when used in conjunction with a hypnotic agent. To determine whether remifentanil is noninferior to rapid-onset neuromuscular blockers for rapid sequence intubation. Multicenter, randomized, open-label, noninferiority trial among 1150 adults at risk of aspiration (fasting for <6 hours, bowel occlusion, recent trauma, or severe gastroesophageal reflux) who underwent tracheal intubation in the operating room at 15 hospitals in France from October 2019 to April 2021. Follow-up was completed on May 15, 2021. Patients were randomized to receive neuromuscular blockers (1 mg/kg of succinylcholine or rocuronium; n = 575) or remifentanil (3 to 4 μg/kg; n = 575) immediately after injection of a hypnotic. The primary outcome was assessed in all randomized patients (as-randomized population) and in all eligible patients who received assigned treatment (per-protocol population). The primary outcome was successful tracheal intubation on the first attempt without major complications, defined as lung aspiration of digestive content, oxygen desaturation, major hemodynamic instability, sustained arrhythmia, cardiac arrest, and severe anaphylactic reaction. The prespecified noninferiority margin was 7.0%. Among 1150 randomized patients (mean age, 50.7 [SD, 17.4] years; 573 [50%] women), 1130 (98.3%) completed the trial. In the as-randomized population, tracheal intubation on the first attempt without major complications occurred in 374 of 575 patients (66.1%) in the remifentanil group and 408 of 575 (71.6%) in the neuromuscular blocker group (between-group difference adjusted for randomization strata and center, -6.1%; 95% CI, -11.6% to -0.5%; P = .37 for noninferiority), demonstrating inferiority. In the per-protocol population, 374 of 565 patients (66.2%) in the remifentanil group and 403 of 565 (71.3%) in the neuromuscular blocker group had successful intubation without major complications (adjusted difference, -5.7%; 2-sided 95% CI, -11.3% to -0.1%; P = .32 for noninferiority). An adverse event of hemodynamic instability was recorded in 19 of 575 patients (3.3%) with remifentanil and 3 of 575 (0.5%) with neuromuscular blockers (adjusted difference, 2.8%; 95% CI, 1.2%-4.4%). Among adults at risk of aspiration during rapid sequence intubation in the operating room, remifentanil, compared with neuromuscular blockers, did not meet the criterion for noninferiority with regard to successful intubation on first attempt without major complications. Although remifentanil was statistically inferior to neuromuscular blockers, the wide confidence interval around the effect estimate remains compatible with noninferiority and limits conclusions about the clinical relevance of the difference. ClinicalTrials.gov Identifier: NCT03960801.