Significant Gastroesophageal Reflux Research Articles

Laparoscopic Paraesophageal Hernia (PEH) Repair, Roux-en-Y Gastric Bypass, and Per Oral Endoscopic Myotomy (POEM) in a Patient with Achalasia After Sleeve Gastrectomy.

GERD and Achalasia are two known complications after sleeve gastrectomy. Treatment towards each of these complications varies and requires a tailored approach. We present a 55-year-old female with class II obesity and a previous history of sleeve gastrectomy who developed significant gastroesophageal reflux disease refractory to medical management. After a covid infection in fall of 2020, she began to report new symptoms of dysphagia that progressed from solids to liquids. She underwent extensive workup including upper endoscopy, upper GI barium swallow, manometry, pH impedence, and EndoFlip leading to a diagnosis of Achalasia type II as well as a paraesophageal hernia. Given these findings, she underwent a combined paraesophageal hernia repair with conversion of sleeve gastrectomy to Roux-en-Y gastric diversion and an intra-operative peroral endoscopic myotomy. Intraoperatively, she was noted to have significant lower abdominal adhesions leading to performing the Roux-en-Y reconstruction through a supramesocolic defect in a retrocolic fashion. While the development of heartburn and achalasia after sleeve gastrectomy is rare, it requires interventions dedicated towards each etiology. This case demonstrates treatment of both these symptoms is feasible in a single operation.

Anastomotic Stricture in End-to-End Anastomosis-Risk Factors in a Series of 261 Patients with Esophageal Atresia.

To assess the risk factors for anastomotic stricture (AS) in end-to-end anastomosis (EEA) in patients with esophageal atresia (EA). With ethical consent, hospital records of 341 EA patients from 1980 to 2020 were reviewed. Patients with less than 3 months survival (n = 30) with Gross type E EA (n = 24) and with primary reconstruction (n = 21) were excluded. Outcome measures were revisional surgery for anastomotic stricture (RSAS) and number of dilatations required for anastomotic patency without RSAS. The factors that were tested for risk of RSAS or dilatations were distal tracheoesophageal fistula (TEF) at the carina in C-type EA (congenital TEF [CTEF]), type A/B EA, antireflux surgery (ARS), anastomotic leakage, recurrent TEF, and Spitz group and congenital heart disease. A total of 266 patients, Gross type A (n = 17), B (n = 3), C (n = 237), or D (n = 9) underwent EEA (early n = 240, delayed n = 26). Early anastomotic breakdown required secondary reconstruction in five patients. Of the remaining 261 patients, 17 (6.1%) had RSAS, whereas 244 patients with intact end to end required a median of five (interquartile range: 2-8) dilatations for anastomotic patency. Main risk factors for RSAS or (> 8) dilatations were CTEF, type A/B, ARS, and anastomotic leakage that increased the risk of RSAS or dilatations from 4.6- to 11-fold. The risk of severe AS is associated with long-gap EA, significant gastroesophageal reflux, and anastomotic leakage.

Prevalence of Barrett's Esophagus in Female Patients With Scleroderma.

Systemic sclerosis or scleroderma (SSc) is a chronic autoimmune disease that renders the esophagus prone to significant gastroesophageal reflux due to impaired esophageal clearance and reduced lower esophageal sphincter pressure. The reported prevalence of Barrett's esophagus (BE) in women with SSc varies from 2% to 37% and is derived from older studies with small sample sizes. We aimed to assess the prevalence of BE in a large cohort of women with SSc. Women with SSc referred from the Mayo Clinic Arizona Rheumatology Clinic who completed esophagogastroduodenoscopy between 2002 and 2020 were included. Demographic and high-resolution manometry data were evaluated. The diagnosis of scleroderma was confirmed by an expert rheumatologist. The BE diagnosis was confirmed by an expert gastrointestinal pathologist. There were 235 women with SSc who underwent EGD. High-resolution manometry (HRM) was completed in 172 patients. Women with SSc with BE were significantly more likely to have scleroderma esophagus (absent contractility with hypotensive lower esophageal sphincter) on HRM than women with SSc without BE (P = 0.018). There were 30 patients with SSc (12.8%) with histologically proven BE. Dysplasia was found in 13 (43.3%): 4 with indefinite, 7 with low grade, and 2 with adenocarcinoma. The incidence of any dysplasia was 5.3% per year (0.9% per year for adenocarcinoma). This the largest study on prevalence of BE in women with SSc, yielding a prevalence of 12.8%. Women with SSc with BE were significantly more likely to have absent contractility with hypotensive lower esophageal sphincter findings on HRM. The high prevalence and incidence of dysplasia found suggest that women with SSc should be included in the screening recommendations for BE.

S0383 Prevalence of Barrett’s Esophagus in Female Scleroderma Patients

INTRODUCTION: Scleroderma renders the esophagus prone to significant gastroesophageal reflux due to impairment in esophageal clearance (aperistalsis in the lower third of the esophagus) and reduced lower esophageal sphincter (LES) pressure. Scleroderma mainly affects women, whereas Barrett’s esophagus (BE) predominantly affects men. The reported prevalence of BE in women with scleroderma varies widely from 6% to 37%, and is mainly derived from older small studies. We aimed to assess the true prevalence of BE in a large cohort of women with scleroderma. METHODS: Clinical data were collected from two prospectively maintained databases at a single academic tertiary referral center. One database consisted of scleroderma patients referred for high-resolution esophageal manometry (HREM). The other database consists of all patients with BE and associated clinical and endoscopic data. The diagnosis of scleroderma was confirmed by a rheumatologist with expertise in scleroderma according to the 2013 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) criteria for systemic sclerosis/scleroderma. Inclusion criteria included female sex, confirmed scleroderma, and a diagnosis of Barrett’s esophagus confirmed by an expert gastrointestinal pathologist. Prevalence data were tabulated for each database and in aggregate. RESULTS: There were 286 women with scleroderma who underwent HREM (Table 1). There were 17 patients with histologically proven Barrett’s esophagus, representing 5.9% of the group. Of these Barrett’s patients, 11 had non-dysplastic Barrett’s esophagus, 2 had indefinite dysplasia, 3 had low grade dysplasia (LGD), and 1 had esophageal adenocarcinoma (EAC) (Table 2). Of 616 women with Barrett’s esophagus, 33 had scleroderma (5 diffuse, 25 limited and 3 unclassified). CONCLUSION: In this large cohort of female patients, the prevalence of BE in patients with scleroderma presenting for esophageal evaluation was 5.9% and the prevalence of scleroderma in women with Barrett’s esophagus was 5.4%. Although uncommon, both LGD and EAC were found in this population. BE is a prevalent complication of scleroderma and screening for its presence should be considered.Table 1

School Nurses on the Front Lines of Healthcare: Children With Medical Devices—A “BOLUS” of Information About Gastrostomy Tube Malfunctions and Infections

An important subgroup of children with special healthcare needs are children with medical complexities that require long-term, intensive healthcare interventions and treatments. As medical technology continues to advance and children with complex medical needs survive the neonatal period and progress into school-age, it is essential for school nurses to be able to recognize and acutely manage complications and malfunctions of devices in children requiring assistance from medical devices. An example of a common medical device includes gastrostomy tubes (aka G-tubes or GJ-tubes), ensuring nutrition in children with failure to thrive, significant developmental delay, swallowing dysfunction, or severe gastroesophageal reflux. These devices put children at serious medical or surgical risk when they malfunction, so it is important for healthcare providers, especially school nurses who are the first responders in schools, to recognize malfunctions and initiate appropriate care management.

Application of magnetic compression anastomosis technique in pediatric surgery

Malformation of digestive tract is common in neonates. Esophageal atresia (EA) comprises a group of congenital abnormalities defined by discontinuity of the esophagus. EA with communication with the trachea is known as tracheoesophageal fistula (TEF). For the repair of EA, it is needed to establish an anastomosis between two structures that may be significantly spaced apart, such as in long-gap EA (with a gap >3 cm). The repair across a long-gap can induce tension on the anastomosis, leading to dehiscence, anastomotic leak, or procedure failure. In neonatal patients with long-gap EA with TEF, the complications of significant gastroesophageal reflux, or anastomotic leaks and severe refractory esophageal stricture after surgery are common, which remains challenging for pediatric surgery. There are multiple options for lengthening and approximating the ends in long-gap EA such as myotomies, Gough flap, or the Foker technique. The treatment of long gap EA usually requires thoracotomy or thoracoscopy to place traction sutures on each esophageal in multiple stage operations, the treatment period of which is long. Esophageal stricture is the most common complication following EA repair. Refractory esophageal anastomotic stricture after repair of EA in infants is a challenging surgical problem. In general, these strictures can be successfully managed using endoscopic techniques including bougie and balloon dilation, stenting, and chemotherapeutic agents. If these techniques are unsuccessful, treatment options are limited to surgical resection of the strictured segment and reanastomosis, or esophageal replacement. Magnetic compression anastomosis (MCA) has been introduced for several decades. Recently, rare-earth magnets have been employed to create solid anastomosis for long-gap EA and refractory esophageal stricture in children. In MCA, a sutureless anastomosis of the gastrointestinal tract can be formed using two magnetic Harrison rings. Magnetic compress has been shown to be effective for the treatment of long-gap EA in children. MCA can be conducted during the same stage surgery of ligating the TEF with customized magnetic rings. Under the magnetic force, the two magnetic rings pull along the gastric tube to achieve anastomosis. Once the postoperative permanent suction of these two pouches is instituted, spontaneous growth can be awaited. MCA has been shown to be effective in anastomosis of stomach, small bowel and colon in both experimental and clinical cases. The magnets are most commonly made of neodymium-boron or samarium-cobalt, which can display strengths significantly greater than those of ferrite. Magnetic compression has been used to treat biliary strictures in adult patients who have undergone liver transplantation, as magnetic connectors for coronary surgery, and for the functional undiversion of ileostomy in pediatric patients. Reports also describe the use of magnetic compression in restoring patency of anastomotic strictures of the alimentary tract in patients who have undergone surgery for esophageal, gastric, and rectal cancer. Yamanouchi and colleagues have published many papers on their experience with Samarium cobalt magnets. They even used them to treat recurrent anastomotic strictures after initial MCA. It has been reported that in conditions such as congenital oesophageal atresia or rectal atresia in children, and also is a safe, minimally invasive way to gradually refunctionalize the excluded distal bowel after previous diverting ostomy. MCA using mated magnets with their interposed compressed tissue may result in serosa-to-serosa apposition. At present, MCA for the treatment of EA patients is restricted to gross type A (without TEF) and anastomotic stenosis without thoracotomy. Magnamosis offers a minimally invasive technique for repair of this congenital anomaly. This is particularly helpful in those patients who cannot undergo initial or repeat thoracotomy or thoracoscopy due to anatomic considerations or overall severity of illness. Translumenal digestive tract anastomosis using the constant magnetic field is reliable and feasible as a minimally invasive technique to treat congenital esophageal and anorectal abnormalities. Magnamosis is technically feasible for esophago-esophageal anastomoses. In anorectal malformations with favorable anatomy, this procedure may avoid an operative repair such as posterior sagittal reconstruction. We propose that magnamosis can be considered as an alternative for the treatment of rectal atresia in certain children.

Gastroesophageal reflux in children: an updated review.

BackgroundGastroesophageal reflux is a common disorder in pediatrics. Clinicians should be familiar with the proper evaluation and management of this condition.ObjectiveTo provide an update on the current understanding, evaluation, and management of gastroesophageal reflux in children.MethodsA PubMed search was performed with Clinical Queries using the key term ‘gastroesophageal reflux’. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to the English literature and the pediatric age group.ResultsRegurgitation is the most frequent symptom of gastroesophageal reflux and is present in nearly all cases. Gastroesophageal reflux occurs normally in infants, is often physiological, peaks at 4 months of age, and tends to resolve with time. Gastroesophageal reflux disease occurs when gastric contents reflux into the esophagus or oropharynx and produce troublesome symptom(s) and/or complication(s). A thorough clinical history and a thorough physical examination are usually adequate for diagnosis. When the diagnosis is ambiguous, diagnostic studies may be warranted. A combined esophageal pH monitoring and multichannel intraluminal esophageal electrical impedance device is the gold standard for the diagnosis of gastroesophageal reflux disease if the diagnosis is in doubt. In the majority of cases, no treatment is necessary for gastroesophageal reflux apart from reassurance of the benign nature of the condition. Treatment options for gastroesophageal reflux disease are discussed.ConclusionIn most cases, no treatment is necessary for gastroesophageal reflux apart from reassurance because the condition is benign and self-limiting. Thickened feedings, postural therapy, and lifestyle changes should be considered if the regurgitation is frequent and problematic. Pharmacotherapy should be considered in the treatment of more severe gastroesophageal reflux disease for patients who do not respond to conservative measures. Proton pump inhibitors are favored over H2-receptor antagonists because of their superior efficacy. Antireflux surgery is indicated for patients with significant gastroesophageal reflux disease who are resistant to medical therapy.

Two-stage treatment of Barrett's esophagus

To evaluate the results of treatment of Barrett's esophagus using laparoscopic 270° Toupet fundoplication or radiofrequency ablation (RFA) and their combination. We have analyzed data for the period 2011-2018. Antireflux surgery was performed in the first group, RFA - in the second group, both procedures were done in the third group. The majority of patients with hiatal hernia underwent cruroraphy, laparoscopic 270° Toupet fundoplication, endoscopic treatment as the second stage was performed in some of them. Patients without hiatal hernia and no signs of reflux underwent RFA without antireflux surgery. Control endoscopic examination was carried out after 3, 6 and 12 months and then annually. There were 84 patients with Barrett's esophagus. We performed 51 RFA procedures in 47 patients and fundoplication in 71 patients. Antireflux surgery as the first stage was preferred in patients with hiatal hernia (n=60), subsequent radiofrequency ablation (RFA) was performed in 28 of them. Seven patients without hiatal hernia, but with significant gastroesophageal reflux underwent antireflux surgery too. Other 12 patients without hiatal hernia underwent RFA alone. Need for delayed antireflux surgery after endoscopic treatment occurred in 23.5% of patients. Complete regression of metaplasia was noted in 95.2% after 1 procedure and in 100% after 2 procedures. Recurrent metaplasia was registered in 4.3% of patients. Progression to dysplasia was not detected. Two-stage surgical approach including antireflux surgery and radiofrequency ablation in combination with drug therapy is optimal. Endoscopic therapy is recommended for all types and length of metaplasia.

Evaluation of technetium-99m metastable nanocolloid as an imaging agent for performing milk scans.

ObjectiveThe aim of this study was to determine whether technetium-99m (99mTc) nanocolloid was a suitable alternative tracer for carrying out milk scan studies in pediatric patients.Participants and methodsTwenty-seven milk scans performed with 99mTc nanocolloid were retrospectively assessed for identification of significant esophageal hold-up, gastroesophageal reflux, pulmonary aspiration, and gastric emptying (GE). Scans were also assessed for liver, spleen, and bone marrow uptake. GE results were compared with those of 27 randomly selected normal GE studies carried out using 99mTc tin colloid.ResultsNone of the studies had liver, spleen, or bone marrow uptake, and all studies were interpretable. Significant esophageal hold-up and gastroesophageal reflux was observed in 11 and 48% of the patients, respectively. Only one patient had evidence of pulmonary aspiration, and all patients had normal GE at 2 h after radiolabeled milk ingestion. The average rate of GE at 2 h was faster in the 99mTc nanocolloid group compared with the 99mTc tin colloid group (8.85% retained±8.96% vs. 15.48% retained±10.52%, P=0.016).ConclusionOur findings show that 99mTc nanocolloid is technically a suitable alternative to 99mTc sulfur colloid for performing milk scans. However, we could not conclude with certainty on the comparison of the GE rates of 99mTc nanocolloid and 99mTc tin colloid. This was because of the variability in the two population groups as well as the fact that the milk that was used in each patient was individualized to the patient and was not standardized.

AB002. Tracheal surgery

AB002. Tracheal surgery

Longitudinal study of gastroesophageal reflux and erosive tooth wear

BackgroundApproximately 60% of patients presenting to dentists with erosive tooth wear have significant gastroesophageal reflux (GERD), despite minor reflux symptoms. No longitudinal studies of reflux-associated erosive tooth wear and of reflux characteristics have been reported to date.The aim of this study was to characterize the longitudinal course of GERD and of associated erosive tooth wear, as well as factors predictive of its progression, in a large group of patients.MethodsSeventy-two patients presenting to dentists with clinically significant erosive tooth wear and increased esophageal acid exposure by 24-h multichannel intraluminal pH-impedance measurement (MII-pH) were re-assessed clinically and by MII-pH after 1 year treatment with esomeprazole 20 mg twice-daily. Predictive factors for erosive tooth wear were assessed by logistic regression.ResultsAt follow-up, no further progression in erosive tooth wear was observed in 53 (74%) of patients. The percentage of time with a pH < 4, the number of acid reflux episodes and the percentage of proximal esophageal reflux off-PPI did not change significantly after one year, but the number of weakly acidic reflux episodes decreased significantly in the large subgroup without progression. None of the baseline demographic, clinical, endoscopic or esophageal acid exposure characteristics were significantly associated with progression of erosive tooth wear at follow-up.ConclusionsIn this longitudinal study in patients with erosive tooth wear and oligosymptomatic GERD receiving esomeprazole for one year, erosive tooth wear did not progress further in the majority of patients. Background acidic esophageal reflux exposure appeared stable over time, whereas weakly acidic exposure decreased significantly in patients without erosion progression. MII-pH measurements on-PPI and with healthy controls will be useful in the further elucidation of the causal role of reflux in erosive tooth wear.Trial registrationClinicalTrials.gov, retrospectively registered: NCT02087345.

The Effect of Acute Stress on Esophageal Motility and Gastroesophageal Reflux in Healthy Humans.

Background/AimsLittle research has been done to evaluate the effect of stress in exacerbating the symptoms associated with gastroesophageal reflux (GER). We aimed to investigate the effect of acute stress on esophageal motility and GER parameters in healthy volunteers.MethodsA total of 10 (M:F = 8:2, median age 34 years-old) healthy volunteers without any recurrent gastrointestinal symptoms participated in this study. They underwent esophageal high-resolution manometry with 10 wet swallows (Experiment I) and esophageal impedance-pH monitoring (Experiment II) in the basal period and in the stress period. In the stress period, either real stress or sham stress was given in a randomized cross-over design. The stress scores, symptom severity, and pulse rates were measured.ResultsThe stress scores and the severity of nausea were significantly greater under real stress, compared with sham stress. The percentages of weak, failed, rapid, premature, and hyper-contractile contractions were not significantly altered during real stress and during sham stress, compared with the basal period. The median resting pressure of the lower esophageal sphincter and distal contractile integral of esophageal contractions did not differ in the stress period, compared with the basal period. Contractile front velocity and distal latency of esophageal peristaltic contractions were significantly changed during real stress, which was not observed during sham stress. GER parameters were not significantly altered during real stress and during sham stress.ConclusionAlthough acute auditory and visual stress seems to affect esophageal body motility, it does not induce significant motor abnormalities or increase GER in healthy humans.

High Frecuency of Gastroesophageal Reflux Disease in Symptomatic Preterm Infants

Introduction: Gastroesophageal reflux (GER) occurs commonly in newborn infants and mostly among preterm infants. Gastroesophageal reflux disease (GERD) is clinically significant GER that causes morbidity, such as frequent vomiting, aspiration pneumonia, irritability, and can influence growth, length of hospital stay, and respiratory outcome. Esophageal 24-hours pH monitoring is the most widely employed diagnostic test for GER in preterm infants. Methods: We included 58 consecutive symptomatic neonates (≤1 month old) who underwent esophageal 24- hours pH monitoring from January 2014 to March 2016 in a tertiary refereal center. Each patient had previously fulfilled 3 basic clinical findings supporting GERD diagnosis, including frequent vomiting, failure to thrive and exacerbation of respiratory symptoms. The diagnosis of GERD was made by Boix-Ochoa Score ≥16.6. Frequencies were expressed as percentages. Statistical comparison between groups was performed using X2 and Student's T test. Results: A total of 20 studies were positive for GERD (34.48%). The mean age of the population without GERD was 38.33 weeks of gestation (WOG). Most of the neonates with GERD were male 70% (N=14). The mean age of the population with GERD was 33.92 ± 2.65 weeks of gestation WOG and the mean value of Boix-Ochoa Score was 67.77 ± 65. Most of the reflux events occur in the postprandial period 85% (N=17), and in supine position 70% (N=14). The Symptom Index was positive in 38.9% (N=7) and Symptom Association Probability (SAP) was positive in 55.6% (N=10). There was a significant association between female gender and a positive Symptom Index and between WOG and the presence of GERD p < 0.005. Conclusion: There is an association between prematurity and the diagnosis of GERD. The SAP could be more sensitive to GERD diagnosis in this population.

A case of advanced systemic sclerosis with severe GERD successfully treated with acotiamide

The majority of systemic sclerosis (SSc) patients have gastrointestinal tract involvement, but therapies of prokinetic agents are usually unsatisfactory. Patients are often compromised by the use of steroid; therefore, a surgical indication including fundoplication has been controversial. There is no report that advanced SSc with severe gastroesophageal reflux disease (GERD) is successfully treated with acotiamide, which is the acetylcholinesterase (AChE) inhibitor designed for functional dyspepsia (FD). We report a 44-year-old woman of SSc with severe GERD successfully treated with acotiamide. She had received medical treatment in our hospital since 2003. She had been aware of the significant gastroesophageal reflux symptoms (e.g., heartburn, chest pain, and dysphagia) due to the development of esophageal hardening associated with SSc since 2014. As a result of upper gastrointestinal series, upper gastrointestinal endoscopy, and 24-h pH monitoring and frequency scale for the symptoms of the GERD (FSSG) scoring, she has been diagnosed with GERD associated with SSc. First of all, she started to take prokinetic agents Rikkunshito and mosapride and proton pump inhibitor; there was no change in reflux symptoms. So, we started to prescribe her the acotiamide.After oral administration started, reflux symptoms have been improved. Five months after oral administration, FSSG score, a questionnaire for evaluation of the symptoms of GERD, was improved. Since its introduction of acotiamide, the patient has kept free from symptoms for 6 months.

The feasibility and efficacy of multi-channel intraluminal impedance monitoring in children.

The diagnosis of gastro-oesophageal reflux is currently based on clinical presentation and oesophageal pH monitoring. In recent years, the use of multi-channel intraluminal impedance (MII) monitoring has gained increasing attention in the adult population. However, its use in the paediatric population is still in the developing stage with only limited number of publications. This study aims to review our early experience of MII application in children. A retrospective study of all patients who underwent MII monitoring between 2011 and 2014 at a tertiary referral centre was performed. Patients' medical records were reviewed with demographic data extracted. Number of reflux episodes and other MII parameters were analysed. In total, 34 patients were identified during the study period, with 20 males and 14 females. Indication for study included previous aspiration pneumonia (n=13), persistent reflux or vomiting symptom (n=10) and as part of routine assessment before gastrostomy (n=11). At the time of study the average age was 69months (range 9-216months). 28 patients showed significant gastro-oesophageal reflux. On average patient has 36.1 acidic and 22.3 non-acidic reflux episodes during the 24h monitoring period. Non-acidic reflux accounts for 38.1% of the overall reflux episodes. The sensitivity of MII monitoring to detect reflux was higher compared to conventional pH study (73 vs 50%, p=0.1). MII monitoring is safe and feasible in children. Non-acid reflux should not be underestimated in paediatric population. MII appears to be more sensitive than conventional pH monitoring in our study, but its true significance is yet to be confirmed by larger study in the future.

Efficacy of enteral ticagrelor in hypothermic patients after out-of-hospital cardiac arrest.

IntroductionDelivery of crushed ticagrelor via a nasogastric tube is a widely spread off-label use in unconscious patients following out-of-hospital cardiac arrest (OHCA). Notwithstanding the importance of a potent dual antiplatelet therapy in these patients, the efficacy of crushed ticagrelor after OHCA has not been established yet.MethodsIn a prospective, single-center, observational trial, 38 consecutive MI patients after OHCA were included. 27 patients (71.1 %) underwent mild induced hypothermia. The primary outcome was platelet inhibition at 24h measured by impedance aggregometry.ResultsThere was sufficient platelet inhibition in most patients after OHCA. In all hypothermic patients, there was an adequate platelet inhibition by ticagrelor at 24 h (p < 0.001). 15 patients (39.5 %) had significant gastroesophageal reflux and one patient with significant reflux had inadequate platelet inhibition at 24 h. There were no stent thrombosis or recurrent atherothrombotic events in these patients.ConclusionAdministration of crushed ticagrelor via a nasogastric tube reliably inhibited platelet function in vitro and in vivo regardless of the presence of hypothermia in MI patients. Thus, platelet inhibition can be reliably achieved in MI patients during neuroprotective hypothermia following OHCA.

Radiofrequency Catheter Ablation for Atrial Fibrillation Elicited "Jackhammer Esophagus": A New Complication Due to Vagal Nerve Stimulation?

Radiofrequency catheter ablation (RFCA) is a potentially curative method for treatment of highly symptomatic and drug-refractory atrial fibrillation (AF). However, this technique can provoke esophageal and nerve lesion, due to thermal injury. To our knowledge, there have been no reported cases of a newly described motor disorder, the Jackhammer esophagus (JE) after RFCA, independently of GERD. We report a case of JE diagnosed by high-resolution manometry (HRM), in whom esophageal symptoms developed 2 weeks after RFCA, in absence of objective evidence of GERD. A 65-year-old male with highly symptomatic, drug-refractory paroxysmal AF was candidate to complete electrical pulmonary vein isolation with RFCA. Prior the procedure, the patient underwent HRM and impedance-pH to rule out GERD or hiatal hernia presence. All HRM parameters, according to Chicago classification, were within normal limits. No significant gastroesophageal reflux was documented at impedance pH monitoring. Patient underwent RFCA with electrical disconnection of pulmonary vein. After two weeks, patient started to complain of dysphagia for solids, with acute chest-pain. The patient repeated HRM and impedance-pH monitoring 8 weeks after RFCA. HRM showed in all liquid swallows the typical spastic hypercontractile contractions consistent with the diagnosis of JE, whereas impedance-pH monitoring resulted again negative for GERD. Esophageal dysmotility can represent a possible complication of RFCA for AF, probably due to a vagal nerve injury, and dysphagia appearance after this procedure must be timely investigated by HRM.

PWE-428 Oesophageal ph/manometry – the trainees’ perspective

<h3>Introduction</h3> Oesophageal disorders are among the commonest medical conditions.¹ Management of these conditions is a core competence in the curriculum of gastroenterology trainees.²British Society of Gastroenterology (BSG) guidelines outline the uses of oesophageal pH/manometry assessment in establishing oesophageal diagnoses and targeting relevant treatments.¹ <h3>Method</h3> We aimed to assess the trainees’ knowledge and experience of oesophageal pH/manometry as per JRCPTB guidelines.² An anonymous survey of gastroenterology trainees in Kent Surrey and Sussex and North East London deaneries was carried out. A questionnaire was sent out twice over a one month period (November 2014) and responses were assessed. <h3>Results</h3> 23/70 (33%) completed the survey. 5/23 were in their 1^styear of training, 4/23 in their 2^nd, 6/23 in their 3^rd, 6/23 in their 4^thand 2/23 in their 5^th. Training: 22 of trainees replied. No trainee had done research in the field. 13/22 (59%) trainees had teaching on oesophageal physiology at a regional training day at some point during their training and four of these had also attended lectures on this field at a national/international meeting. 1/22 (4.5%) had only attended lectures at a national/international meeting and 8/22 (36%) trainees had no training or education at all. 16/23 (70%) had read all or part of any BSG guidelines and 8/23 (35%) had read the BSG guidelines on oesophageal/pH manometry. Only 4/23 (17%) felt that their training in this area was satisfactory. Understanding: 16/23 (70%) trainees listed at least one indication for oesophageal pH assessment. Only 3/23 (13%) were able to list more than two indications. 15/23 (65%) would request manometry studies for suspected oesophageal motility disorders. 7/23 (30%) knew of its use as a pre-assessment prior to fundoplication. 15/23 (65%) knew that an oesophageal pH below 4 is indicative of significant gastro-oesophageal reflux disease and 5/23 (22%) were familiar with the DeMeester score. Technical ability: 17/23 (74%) had worked in hospitals with oesophageal pH/manometry facilities. No trainee had “hands-on” experience and only 4/23 (17%) had seen it performed at all. 21/23 (91%) said that they would like to further their knowledge and expertise in the area. 18/23 (78%) felt that it might improve job prospects. <h3>Conclusion</h3> Education and training in oesophageal pH/manometry is deficient despite this area being recognised in the gastroenterology curriculum and available in hospitals in the South-East. There is scope for improvements in both areas. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> British Society of Gastroenterology: Guidelines for oesophageal manometry and pH monitoring (Nov 2006)-K. Bodger and N. Trudgill Joint Royal College of Physicians Training Board (2010) – Higher Medical Training Curriculum for Gastroenterology

Rates of reflux before and after laparoscopic sleeve gastrectomy for severe obesity.

A current management dilemma in laparoscopic sleeve gastrectomy (LSG) patients is the development of significant gastroesophageal reflux symptoms after surgery. Treatment is typically directed towards reducing acid reflux despite the surgical removal of parietal cell mass. In contrast, laparoscopic Roux-en-Y gastric bypass (LRYGB) has been known to reduce or resolve preoperative reflux symptoms. The objective of this study was to determine the incidence of preoperative and postoperative reflux of LSG and LRYGB patients, and review reflux treatment type and response. A retrospective chart review was performed for patients undergoing either LSG or LRYGB between January 2010 and December 2012 as part of the Weight Wise program, Royal Alexandra Hospital, Edmonton, Canada. A total of 387 cases were included in our review. We observed a significant reduction in BMI postoperatively for both LSG and LRYGB groups (p < 0.001). Between surgical groups, preoperative proton-pump inhibitor (PPI) use was not significantly different; however, at 1 month (p < 0.05) to 1-2 years (p < 0.001), there was significantly increased PPI use in patients after LSG in comparison to LRYGB. Of the LSG patients that continued their PPI treatment after surgery, 58% increased, 42% continued the same, and 0% decreased their dose 1 year after surgery. Reflux symptoms are significantly increased after LSG in comparison to LRYGB patients. In addition, LSG patients more frequently require initiation of reflux treatment after surgery than that of LRYGB patients. Patients reported postoperative reflux symptom relief with acid-suppressant therapies.

Tu1854 Patients With Dental Erosions Have Significant Silent Gastroesophageal Reflux As Quantified by Multichannel Intraluminal Impedance and pH-Monitoring

G A A b st ra ct s parameters were dichotomized, IPF was associated with increased abnormal distal nonacid reflux (57.9% vs. 26.3%, p=0.03). Trends in increased abnormal proximal bolus reflux (21.1% vs. 5.3%) and abnormal distal bolus reflux (31.6% vs. 15.8%) in IPF compared to NF were also observed but did not reach statistical significance. Conclusion: Increased reflux parameters on pre-lung transplant MII-pH were observed in IPF patients compared to NF patients with similar pulmonary function. IPF patients also had significantly more abnormal nonacid reflux compared to NF subjects. Our results suggest that microaspiration likely plays a role in chronic inflammation and fibrosis in IPF patients. The majority of IPF patients had abnormal nonacid reflux, which may explain the inconsistent response to acid suppression. Anti-reflux therapy such as fundoplication may provide more clinical benefit compared to anti-secretory medications in these patients.