Significant Reflux Research Articles

Is less more? Laparoscopic versus open Ladd's procedure in children with malrotation

BackgroundWith the advent of minimally invasive techniques, laparoscopic Ladd's procedure is increasingly used to treat children with malrotation, yet evidence regarding its safety and efficacy is lacking. We hypothesize that operative and postoperative outcomes with the open technique are superior to the laparoscopic Ladd's procedure. MethodsWe conducted a 5-y retrospective chart review of all patients who underwent Ladd's procedure at our institution from 2010-2015. Exclusion of patients included those with concomitant conditions, such as poor gut perfusion, significant reflux, tracheoesophageal fistula, failure to thrive requiring concomitant gastrostomy, and biliary atresia. Kruskal–Wallis and Mann–Whitney tests were used where appropriate. ResultsBetween 2010 and 2015, of 130 patients who underwent Ladd's procedure, 77 met inclusion criteria. Sixty-two patients underwent initial open surgery, 15 patients underwent laparoscopy, seven of which were converted to open. Patients undergoing open surgery were younger compared to the laparoscopic groups. Thirty-three of the 77 malrotation patients (43%) presented with volvulus, 27 underwent open surgery, four had laparoscopic converted to open procedures, and two patients underwent laparoscopic Ladd's without incident. Laparoscopy resulted in increased operative time and clinic visits. Patients undergoing laparoscopic to open surgery had longer operative times, time to resume diet, and length of hospital stay. No difference was noted in complications among the groups. ConclusionsAlthough minimally invasive approaches are becoming increasingly used, no evidence supports laparoscopic superiority over open Ladd's procedure. We found that open surgery was associated with shorter operating times and fewer clinic visits. Furthermore, laparotomy remains the favored procedure for patients presenting with volvulus.

Reflux Finding Score (RFS) a Quantitative Guide for Diagnosis and Treatment of Laryngopharyngeal Reflux.

The study was under taken to know the prevalence of reflux signs in an individuals with throat complaints on the basis of reflux finding score (RFS) and quantitatively assess the effect of treatment. A cross-sectional study was done to evaluate the presence of laryngo-pharyngeal reflux signs in patients visiting ENT clinic with throat or voice problems in central India. There were 80 patients included in the study from 2017 to 2018 individuals. They were questioned regarding their symptoms. Their pharyngeal findings on rigid 70° laryngoscopy were viewed and RFS was made. The patients were reviewed at monthly intervals. Laryngopharyngeal reflux changes were seen in 36 of the 80 patients (45%). The reflux was graded as per the reflux finding score. The score ranged from 7 to maximum of 17 out of 26 in the patients with LPRD. Majority of the patients the score decreased with lifestyle changes and pantaprazole twice daily. There was poor response in 5% (4) patients, who were then advised to undergo upper gastro intestinal endoscopy for further assessment. Laryngopharyngeal reflux has become a very common entity in urban lifestyle. On careful examination the signs can be picked and assessed with the RFS, which is a very useful tool to grade and reassess patient on subsequent follow up.

The Role of Reflux in Childhood Otorhinolaryngological Disorders

This article seeks to review the current literature on the role of laryngopharyngeal reflux in the development of various disorders of the ear, nose and throat in infants and children including otitis media, chronic rhinosinusitis and airway disorders. The aim is to guide the otolaryngology clinician in investigation and management of reflux and to identify priorities for future research in this area. Many otolaryngological disorders coexist with reflux more often than might be expected by chance, but evidence of causality is weak. Although many otolaryngologists are convinced that treatment of reflux can make a significant difference to the clinical course of many upper airway disorders, the evidence to support this is lacking. In part, this is due to inadequate tools for describing the symptoms and endoscopic signs of laryngopharyngeal reflux and the lack of a sensitive, specific and reliable objective test. Further research demonstrating simple associations between otolaryngological diseases and reflux is unlikely to be of much value. Instead, researchers should concentrate their efforts on studies to develop and validate better means of recording symptoms and signs of laryngopharyngeal reflux and investigating the clinical utility of salivary pepsin, oropharyngeal pH monitoring and multichannel intraluminal impedance.

AB002. Tracheal surgery

AB002. Tracheal surgery

Falcotentorial Location of Dural Arteriovenous Fistulas Derived from theNeural Crest as aRisk Factor for Aggressive Clinical Course.

The topographical distribution of dural arteriovenous fistulas (DAVFs) was analyzed based on the embryological anatomy of the dural membrane. Sixty-six consecutive cases of intracranial and spinal DAVFs were analyzed based on the angiography, and each shunt point was identified according to the embryological bony structures. The area of dural membranes was categorized into three different groups: a ventral group located on the endochondral bone (VE group), a dorsal group on the membranous bone (DM group), and a falcotentorial group (FT group) in the falx cerebri, tentorium cerebelli, falx cerebelli, and diaphragma sellae. The FT group was derived from the neural crest and designated when the dural membrane was formed only with the dura propria (meningeal layer of the dura mater) and not from the endosteal dura. Olfactory groove, falx, tent of the cerebellum, and nerve sleeve of spinal cord were categorized in the FT group, which presented later in life and which had a male predominance, more aggressive clinical presentations, and significant cortical and spinal venous reflux. The FT group was formed only with the dura propria that was considered as an independent risk factor for aggressive clinical course and hemorrhage of DAVFs.

Correlation of obesity & comorbid conditions with chronic venous insufficiency: Results of a single-centre study.

Background & objectives:Chronic venous insufficiency (CVI) is a common clinical problem among obese patients. This study was conducted to evaluate the impact of body mass index (BMI) and associated morbidities such as diabetes, hypertension and hypothyroidism on venous disease clinical scores as per Clinical, Etiological, Anatomical, Pathological (CEAP) classification.Methods:In this study, adult patients with BMI more than 30 kg/m2 with signs of CVI were evaluated clinically and by using Duplex ultrasonography of venous system. The patients with C0, C1, C2, C3 and C4, C5, C6 clinical scores in CEAP classification were grouped as lower and higher clinical scores of CVI, respectively.Results:Of the 200 enrolled patients, 147 (73.5%) were males and were associated with higher grades of clinical scores (P=0.051). Superficial venous system was involved in 96 per cent patients and 91 per cent patients had reflux in the sapheno-femoral junction. A negative association was observed between hypertension and male gender (P=0.001). Higher BMI was associated with higher clinical scoring (P=0.053). BMI >40 kg/m2 was associated with primary aetiology (P=0.007) of CVI. There was no correlation between superficial, deep or perforator incompetence with BMI (P=0.506). Duplex-confirmed significant reflux was observed in patients with higher BMI (P=0.006). Age and BMI were positively correlated with clinical score (r=0.176; P=0.013 & r=0.140; P=0.049), respectively.Interpretation & conclusions:Our findings indicated that elderly male patients with high BMI seemed to be at a higher risk of advanced clinical grades of CVI. The impact of comorbid conditions such as diabetes, hypertension and hypothyroidism on CVI could not reach at significance in the present study.

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.

A Large Spontaneous Esophageal Perforation Treated With Endoscopic Stent Placement

Esophageal perforations are extremely rare, with an incidence of 3.1 per 1,000,000 annually. About 15% are spontaneous, usually referred to as Boerhaave's syndrome, which occurs due to increased intraluminal pressure with inability of upper esophageal sphincter to relax during retching. However, a spontaneous perforation without such an inciting event is even more infrequent. An 88 year-old male with no prior medical history presented with chest pain, dyspnea and worsening acid reflux. Preliminary workup was concerning for a cardiac event, for which he underwent a cardiac catherization with stent placement. However, he continued to have chest pain, thus a CTA chest/abdomen/pelvis was performed, and revealed a likely hiatal hernia with significant reflux, however otherwise normal. Three days later a CXR showed a left pleural effusion, and eventually a CT chest revealed oral contrast in the left thorax with significant pneumomediastinum, suspicious for an esophageal perforation. He was transferred to the surgical ICU, kept NPO, started on empiric antibiotic, antifungal, and acid suppression therapy. The cardiothoracic surgical team placed two chest tubes. He then had an esophagram, showing a large esophageal defect with free extravasation of contrast into the mediastinum. Given that he was deemed a poor surgical candidate, he was taken to the OR for endoscopic stent placement. EGD revealed a large, 5cm perforation in the distal esophagus. No esophagitis or tumor was seen. Successful placement of two fully covered metal stents achieved adequate closure of the defect. Taking into account the lack of typical symptoms, typical inciting events, and overall patient tolerance of such a large perforation, this is a highly unusual case and suggests a possibly chronic underlying defect. Diagnosis of spontaneous esophageal perforation is often delayed as the classic triad of vomiting, chest pain and subcutaneous or mediastinal air, is only described in 50% of cases. Esophageal stents are an alternative to surgical treatment of perforations. Although esophageal stent placement successfully sealed the majority of our patients' perforation, a defect of this size will likely require surgical repair. This case emphasizes the importance of prompt recognition of a suspected esophageal perforation, the importance and diagnostic accuracy of CT scan with PO contrast and the potential role of fully covered metal stents as a therapeutic alternative to emergent surgery. Watch the video: https://goo.gl/fhkDGTFigure: CT chest/abdomen with IV and PO contrast demonstrating pneumomediastinum and oral contrast in the mediastinum.Figure: Fluoroscopic images from gastrograffin esophagram revealing large area of extravasation into the left mediastinum.

Ultrasound changes of the varicose veins of the lower extremities against connective tissue dysplasia

Background. The article presents the data of sonographic study of patients with varicose veins of the lower extremities in order to determine the typical ultrasound manifestations of connective tissue dysplasia. Revealed changes in these patients indicate a widespread and combined lesion of the lower extremity venous system almost on all the levels, which explains the pathogenic role of connective tissue weakness of veins framework and has a great diagnostic value in the planning stages of surgical treatment and selecting the volume of full and adequate surgical intervention. The purpose was to identify typical preoperative sonographic changes of the venous system in patients with varicose veins of the lower extremities with connective tissue dysplasia. Materials and methods. One-hundred and four patients with varicose veins of the lower extremities were preoperatively examined for typical clinical, phenotypic and biochemical markers of undifferentiated connective tissue dysplasia and divided into two groups according to the presence or absence of connective tissue dysplasia manifestations. Then, during preoperative preparation sonographic features were identified by ultrasound scanning using standard protocol for examination. Results. The form of varicose veins was determined in all patients. In patients with dysplasia symptoms mixed form dominated (23 (67.65 %) patients). During measuring main venous trunks the patients of this group had mainly thinning of vein walls, with significantly expanded diameters, reduced contractility, increased rigidity. In some places the walls of veins were significantly thinned. Valve unit worked poorly with signs of failure, which manifested by hemodynamic significant vertical and horizontal reflux. Reflux was mainly decompensated with retrograde blood flow over 1.5–3 seconds. Valve failure was observed in the superficial and deep veins. The patients often had abnormalities of sapheno-femoral junction: aneurysm extensions (7 (20.59 %)); tortuous great saphenous vein looking like a cluster of grape (4 (11.76 %)); real doubling the main trunk of the thigh (7 (20.59 %)) and shin (3 (8.82 %)). Also in this group of patients (23 (67.65 %)) widespread and combined varicose process of the main trunk in thighs and shins predominated. In addition, multiple perforating veins failure was observed, mainly in shins with hemodynamic significant reflux at these levels. Conclusions. Restructuring of the connective tissue in patients with symptoms of connective tissue dysplasia significantly affect the state of the venous system of the lower extremities, namely its functionality, which can be efficiently evaluate today with ultrasound scanning. In these patients sapheno-femoral junction valve failure with pronounced vertical reflux along a significant segment of the limb prevails. Perforating veins of shin and foot manifested with horizontal refluxes at their levels. In 2/3 patients mixed form of varicose vein of the low extremities was diagnosed that confirms the prevalence of venous system lesions with more severe varicose of the main venous structures. More often different configurations of vein aneurysm are determined, both in the area of junctions and along the venous trunk.

Substernal goiter and laryngopharyngeal reflux.

This study aims to compare the prevalence of laryngopharyngeal reflux signs between two groups of patients undergoing thyroidectomy for voluminous goiter: substernal goiters and voluminous cervical goiter without thoracic extension. A retrospective case-control study was performed with data retrieved of the charts of the patients submitted to thyroidectomies occurred at a tertiary care center (Head and Neck Surgery Department, University of São Paulo Medical School) between 2010 and 2014. The selected thyroidectomies were allocated in two groups for study: patients with substernal goiters and patients with voluminous cervical goiter without thoracic extension. Cervical goiters were selected by ultrasonography mensuration. Clinical criterion was used to define substernal goiter. The average thyroid volume in patients with substernal goiter was significantly greater than the average volume in patients with only cervical goiter (p < 0.001). The prevalence of signs of reflux laryngitis at laryngoscopy was significantly greater in substernal goiter patients (p = 0.036). Moreover, substernal goiter was considered as the unique independent variable for high reflux laryngitis signs at laryngoscopy (OR = 2.75; CI95%: 1.05-7.20; p = 0.039) when compared to only cervical goiter patients. This study shows a significant association between substernal goiters and signs of laryngopharyngeal reflux at preoperative laryngoscopy. Therefore, when compared with voluminous cervical goiters, the substernal goiters increase the chance of reflux laryngitis signs in patients.

Three Cases of Esophageal Squamous Papilloma: A Rare and Poorly Understood Lesion

Squamous papilloma is a rare lesion of the esophagus. The estimated prevalence is between 0.07% and 0.45% on endoscopy. The pathogenesis remains uncertain, however underlying inflammation from reflux, as well as chronic mechanical/chemical irritation have been implicated. Further, human papilloma virus has been proposed as a risk factor. Although currently considered a benign lesion, the malignant potential of esophageal squamous papilloma in causing squamous cell carcinoma is controversial.Figure 1Figure 2Figure 3We present three cases of esophageal squamous papilloma. In the first, a 51 year old asymptomatic African American female with multiple sclerosis on dimethyl fumarate underwent esophagogastroduodenoscopy (EGD) for workup of iron deficiency anemia. On exam, the Z-line appeared irregular and a single 2mm white-pink wart like projection was seen in the middle esophagus. Excisional biopsy was performed. Pathology revealed squamous papilloma with biopsies of the distal esophagus showing chronic inflammation. Of note, a recent pap smear was negative for HPV. In the second case, a 28 year old Hispanic male with 2 months of epigastric abdominal pain, and hematemesis was seen for further evaluation. An EGD revealed a single 5mm nonbleeding exophytic projection 33cm from the incisors. Excisional biopsy showed squamous papilloma. In the final case, a 42 year old female underwent evaluation for abdominal pain and melena. EGD demonstrated a single 5mm exophytic nodule in the middle esophagus and diffuse inflammation in the stomach. The lesion was excised and showed a squamous papilloma. The present cases demonstrate the heterogeneity in gender, age, esophageal location, and risk factors of squamous papilloma. Prior reports from Western countries demonstrate a male predominance, average 48 years of age and location in the lower esophagus, thought to be related to reflux disease. However, in the present series two of the three patients were female and had lesions in the middle esophagus. One patient was 28 years of age without any signs of reflux. Moreover, the present series reports the first case of esophageal squamous papilloma in a patient taking dimethyl fumarate, an agent known to increase papillomas and squamous cell carcinomas of the forestomach in mice and rat models. Further studies are needed to understand pathogenesis and risk factors of esophageal papilloma to identify at-risk patients since the natural history and malignant potential remain poorly understood.

Acute Pulmonary Embolism Masquerading as Acute Liver Failure

Introduction: A clinical presentation of acute liver failure (ALF) due to pulmonary embolism (PE) is rare with only one prior report to our knowledge. Case Presentation: 32 year-old Caucasian female presented with nausea, vomiting, and somnolence. She had Crohn's disease with recent adjustment of therapy for poorly controlled disease. She was on multiple home medications, recently completed amoxicillin for a tooth abscess, and did no excess acetaminophen use. She was afebrile with a heart rate of 109 beats per minute, blood pressure of 167/80 mmHg, and oxygen saturation of 82%. She was anicteric, without abdominal distention, and without notable lower extremity edema. She was not fully oriented and had asterixis. Her laboratory values revealed an elevated AST of 9616 IU/L, ALT of 2350 IU/L, and INR of 2.29. She had a leukocytosis of 13.7 K/uL, platelet count of 94 K/uL, and creatinine of 1.67 mg/dL. Viral and autoimmune labs were unrevealing. An ultrasound demonstrated increased liver echogenicity with patent vasculature. A chest x-ray showed a right upper lobe pneumonia and CT head did not show cerebral edema. Her findings were consistent with ALF with initial concern for possible drug induced liver injury (DILI). Initial management consisted of neurologic and hemodynamic monitoring, N-acetylcysteine, and antibiotics for pneumonia. Transplant evaluation was initiated which included a transthoracic echocardiogram (TTE) on the second day of admission. It revealed a severely enlarged right ventricle with reduced systolic function. A follow-up CT pulmonary angiogram revealed multiple large bilateral PE with significant clot burden and reflux of contrast into the hepatic veins. Anticoagulation was initiated with heparin. Her liver studies improved and normalized, her mental status changes resolved, and she did not require transplantation. Discussion: The patient's initial clinical presentation led to work-up for more common ALF etiologies with concern for DILI due to multiple medications along with recent amoxicillin. PE may pose a diagnostic challenge as her tachycardia and hypoxia were initially attributed to pneumonia. Her TTE as part of a transplant evaluation was the initial clue to a PE diagnosis. Of mention, the patient did have IBD which is a known risk for venous thromboembolism. Although rare, an extensive PE leading to a presentation of ALF should be considered in the differential particularly for those with risk factors.Figure 1Figure 2Figure 3

A randomized trial comparing reflux symptoms in sleeve gastrectomy patients with or without hiatal hernia repair

BackgroundThe effect of laparoscopic sleeve gastrectomy (SG) on reflux symptoms is unclear. Many surgeons offer SG only to patients with minor or no reflux symptoms, fearing that patients with severe reflux symptoms will experience worsening of their condition after SG. Many also advocate crural repair at the time of SG to prevent de novo or worsening reflux symptoms. These decisions are made without suitable data to form such conclusions. ObjectiveTo determine the effect of SG with or without hiatal hernia repair on reflux symptoms. SettingUniversity of Texas Health Sciences Center in Houston. MethodsThe Gastrointestinal Symptom Rating Scale (GSRS) was administered to 100 consecutive, preoperative SG patients who were then randomly assigned into a crural repair group or nonrepair group in a parallel design. The patients were subsequently followed-up every 3 months for 1 year. We compared reflux symptoms of the 2 groups on the basis of demographic characteristics, body mass index, weight loss, presence and size of hiatal hernia, and GSRS for 12 months. ResultsAt 1 year, with 78% follow-up, the data demonstrated a significant decrease in the GSRS for both groups (P<.001); however, there was no difference between the groups (P = .35). Age, starting body mass index, percent excessive weight loss, and hiatal hernia size did not correlate with change in the GSRS score. The only variable that affected outcome was the preoperative GSRS. At 12 months, 38% of patients with a preoperative GSRS score less than the median score of the study population experienced worsening of their symptoms compared with only 2% of patients who had a preoperative GSRS score greater than the median. Overall, 19% experienced worsening reflux (5% de novo), 14% had no change, and 66% reported an improvement in symptoms. ConclusionThese data suggest that a crural repair at the time of SG does not significantly reduce reflux symptoms compared with SG alone. Preoperative patients with significant reflux symptoms experienced a more significant improvement in symptoms after surgery compared with those who did not report significant reflux symptoms before surgery. The high incidence of reflux after SG observed in the current literature may be a result of a specific patient subpopulation who undergoes SG because of surgeon bias rather than an inherent property of SG itself or the presence of a hiatal hernia.

Esophageal stent fixation with endoscopic suturing device improves clinical outcomes and reduces complications in patients with locally advanced esophageal cancer prior to neoadjuvant therapy: a large multicenter experience.

Endoscopic placement of fully covered self-expanding metal stents (FCSEMS) to treat malignant dysphagia in patients with esophageal cancer significantly improves dysphagia; however, these stents have a high migration rate. To determine whether FCSEMS fixation using an endoscopic suturing device treated malignant dysphagia and prevented stent migration in patients with locally advanced esophageal cancer receiving neoadjuvant therapy when compared to patients with FCSEMS placement alone. A review of patients with locally advanced esophageal cancer who underwent FCSEMS placement at 3 centers was performed. Patients were divided into two groups: Group A (n=26) was composed of patients who underwent FCSEMS placement with suture placement, and Group B (n=67) was composed of patients with FCSEMS placement alone. There were no significant differences between Groups A and B in demographics, and tumor characteristics. The technical success rate for stent placement was 100%. There was no difference between Groups A and B in the median stent diameter and stent lengths. Mean dysphagia score obtained at 1week after stent placement had improved significantly from baseline (2.4 and 1, respectively, p<0.001). Patients had a median follow-up of 4months. Immediate adverse events were mild chest discomfort in 4 patients in Group A and 2 patients in Group B (p=0.05), and significant acid reflux in 3 patient in Group A compared to 2 patients in Group B (p=0.1). The stent migration rate was significantly lower in Group A compared to compared to Group B (7.7 vs 26.9%, respectively, p=0.004). There was a delayed perforation in 1 patient and 1 death due to aspiration pneumonia in Group B. Fixation of esophageal FCSEMSs by using an endoscopic suturing device in patients receiving neoadjuvant therapy was shown to be feasible, safe, and relatively effective at preventing stent migration compared to those who had stent placed alone.

Long-term results of transjugular coil embolisation for pelvic vein reflux - Results of the abolition of venous reflux at 6-8 years.

Pelvic venous reflux is known to be associated with lower limb varicose veins in 20% of women with a history of at least one previous vaginal delivery. Pelvic vein embolisation with coils has been shown to be a successful treatment in the short term. The objective of this study was to ascertain the long-term outcomes of pelvic vein embolisation for pelvic venous reflux. Patients who had undergone pelvic vein embolisation in 2005-2007 were invited back to a specialist vein unit for transvaginal duplex ultrasonography in the summer of 2013. A total of 110 women were contacted. Pre-embolisation transvaginal duplex ultrasonography results were compared to those obtained six weeks post-procedure and at long-term follow-up. Twenty-eight female patients aged 40 to 75 years (mean 53.5) attended (response rate 25.5%), with parity prior to embolisation ranging from 1-5 children (mean 2.8). Mean follow-up time was 7.5 years. Six weeks post-procedure, 25 women had complete or virtual elimination of all reflux, and three had persistent reflux in at least one vein. At long-term follow-up, 11 women had complete elimination of all reflux, seven had elimination of all truncal reflux but minor reflux in vulval veins, six had minor reflux in one truncal vein, and four had significant reflux in one or more truncal veins (one of these gave birth one-year post-pelvic vein embolisation and another had coils removed during gynaecological surgery). Transjugular pelvic vein embolisation is a durable technique for the abolition of reflux in the pelvic veins and is particularly adept at treating reflux in the ovarian veins.

Laparoscopic Gastrostomy Is Superior to Percutaneous Endoscopic Gastrostomy Tube Placement in Children Less Than 5 years of Age.

Minimally invasive procedures for enteral access in children have evolved over the years, resulting in various techniques of gastrostomy tube placement. The two most common techniques are laparoscopic gastrostomy (LG) and percutaneous endoscopic gastrostomy (PEG). Our study compares the outcomes of both procedures exclusively in children under the age of five. All procedures relating to enteral access in children <5 years of age were reviewed retrospectively from July 2009 to July of 2014 as approved by our Institutional Review Board. Demographics, techniques, and complications were collected and analyzed. Of 293 patients in our study, 150 patients underwent PEG, 75 LG, and 68 LG with Nissen fundoplication (LNG). The most common indication for enteral tube placement was failure to thrive and feeding intolerance. Operative time was less in the PEG group than in the other two groups (P = .001). Overall complication rate was 60% for LG and LNG and 58% for PEG (P = NS). The major complication rate was 3.3% in the PEG group and 0.7% for the LG and LNG groups. There were two deaths in the PEG group. Sixty-eight patients (45.3%) from the PEG group underwent tube changes under anesthesia, requiring additional trip to the operating room with general anesthesia compared with LG and LNG groups (2%) (P = .001). From the PEG group, 134 patients (89%) required many fluoroscopic interventions for tube dislodgments and conversion to gastrojejunostomy tubes for significant reflux and inability to use the gastrostomy (P = .001). PEG tubes had a higher major complication rate than LG tubes with or without fundoplication in children <5 years of age. Despite longer operative time, LG seems to be the procedure of choice for children of this age for enteral access. Elimination of unnecessary tube changes under anesthesia and the fluoroscopic interventions after the PEG would be beneficial.

A Ruby Anniversary.

On July 16, 1975, at 26 years of age, after almost 6 months of observing a left epididymal mass slowly enlarge, with work up for epididymal tuberculosis, I finally underwent a left inguinal orchiectomy and resection of what proved to be a pure seminoma. A subsequent lymphangiogram was reported to be normal, and I proceeded to prophylactic abdominal irradiation. All would be fine, I was reassured by my surgeon and radiation oncologist; no, there was no need to undergo sperm banking, and the radiation therapy would surely cure this most irradiationsensitive of cancers. As a young pediatric resident, who was I to question my consultants? I rapidly learned the consequences of poor communication between physicians and their patients. There I was, hospitalized on the openmale cancer ward of a large university teaching hospital, about 12 beds lined up on either side of a very long central corridor, and a great television room with armchairs at the end. It was there that those of us allowed out of bed would convene in the evenings, and when my roommates learned I was a doctor, out poured all the questions they had not dared ask of their physicians, and their physicians had not addressed with them in anticipation of their concerns. One assumed he would die of a completely resected indolent thyroid cancer, because no one had told him otherwise. Others had no idea that they even had cancer. So many colleagues and friends were supportive, from my fiancee and a few of my closest friends to the professor of surgery, who stopped by my bed and joked that because they had spent so muchmoney training me, I needed to get better fast and “earn my keep.” Other colleagues and friends found it hard to visit or even speak about my cancer. I understood their discomfort, which I, too, would most likely have shared previously; it was my cancer, and I had to deal with it, not them. I took 4 weeks off residency for my radiotherapy, helped my dearest friends with their home reconstruction, and cooked meals for us all in the evenings (they somehow knew that distracting me with mundane tasks was good medicine), and I managed to maintain my weight with a little support from metoclopramide. And then I got onwithmy pediatric residency training. Alas, my cancer had not read the textbooks. By March 1976, while undertaking a senior residency in pediatric oncology, I was experiencing significant reflux esophagitis, inordinate belching, and, after a negative work up for gall bladder disease, underwent a barium swallow. My radiology colleague supervising the study looked pale as he informed me that there were mediastinal masses squashing my esophagus and, oh yes, there appeared to be a solitary, left-lung parenchymal metastasis. Now the conversation took on a different tone. I met with a senior radiation oncologist who tried to reassure me that he did, indeed, have one long-term survivor of recurrent metastatic seminoma over the course of his long career, a bassoonist from a prominent professional orchestra, who, alas, was unable to play the bassoon any longer after they finished irradiating his lungs. With this level of reassurance, I embarked upon mediastinal irradiation and focal left-lung boost to around 30 Gy, planned my bachelor party with a circle of friends in Paris before my departure for my marriage in the United States in June, and continued to work daily as a senior resident on the pediatric oncology ward. I remember distinctly, one day during irradiation, meeting with a senior radiation oncologist who sat me down and stunned me with crucial and unexpected questions: Did I realize that I might die of this? (Of course, I had not!) Who were the sources of my emotional support? (I had not even informed my elderly parents of any of this, relying onmywonderful older sister to help me through.) I realized these were the kinds of questions I should be asking the parents of the little children for whom I was currently caring on the pediatric cancer ward, especially the 9-year-old boy with pulmonary metastatic Wilms tumor, who thought it so cool that he was receiving radiation therapy at the same time as his doc. He did not survive the experience. I made it to my bachelor party in Paris, despite an unmeasurably low platelet count and exhaustion for much of the 3 days, made it to my wedding, and returned to England on honeymoon, where I felt a lump in my right testis. Sure

Optimal timing of saliva collection to detect pepsin in patients with laryngopharyngeal reflux.

To determine salivary pepsin levels as a function of collection time. A prospective, case-control study. We selected 57 patients with clinical symptoms and signs of laryngopharyngeal reflux who underwent 24-hour multichannel intraluminal impedance-pH (24h MII-pH) monitoring tests, and 12 control subjects without clinical symptoms and signs of laryngopharyngeal reflux. All subjects were instructed to collect saliva samples upon waking, 1 hour after each meal (3 times per day), and upon any occurrence of laryngopharyngeal reflux (LPR) symptoms. The pepsin levels in saliva were measured by using enzyme-linked immunosorbent assay. The Reflux Symptom Index survey was also administered. A total of 50 patients in whom LPR was diagnosed based on results of 24h MII-pH monitoring test were enrolled in the study. The average pepsin level upon waking was 17.2 ng/mL, which was significantly higher than that measured in samples collected at any other time (P < .005). Pepsin levels were higher in patients with LPR than those in controls. The Reflux Symptom Index scores were statistically different between these groups of subjects. The levels of total pepsin in saliva collected upon waking were significantly higher in the group of patients presenting with LPR symptoms and who demonstrated at least one episode of proximal esophageal reflux during 24h MII-pH monitoring. Furthermore, the average pepsin level upon waking was higher than that measured at any other time. Measuring pepsin levels in the saliva upon waking may be a useful method in the diagnosis of LPR. 3b Laryngoscope, 126:2770-2773, 2016.

Reliability of the reflux finding score for infants in flexible versus rigid laryngoscopy

ObjectivesThe Reflux Finding Score for Infants (RFS-I) was developed to assess signs of laryngopharyngeal reflux (LPR) in infants. With flexible laryngoscopy, moderate inter- and highly variable intraobserver reliability was found. We hypothesized that the use of rigid laryngoscopy would increase reliability and therefore evaluated the reliability of the RFS-I for flexible versus rigid laryngoscopy in infants. MethodsWe established a set of videos of consecutively performed flexible and rigid laryngoscopies in infants. The RFS-I was scored twice by 4 otorhinolaryngologists, 2 otorhinolaryngology fellows, and 2 inexperienced observers. Cohen's and Fleiss' kappas (k) were calculated for categorical data and the intraclass correlation coefficient (ICC) was calculated for ordinal data. ResultsThe study set consisted of laryngoscopic videos of 30 infants (median age 7.5 (0–19.8) months). Overall interobserver reliability of the RFS-I was moderate for both flexible (ICC = 0.60, 95% CI 0.44–0.76) and rigid (ICC = 0.42, 95% CI 0.26–0.62) laryngoscopy. There were no significant differences in reliability of overall RFS-I scores and individual RFS-I items for flexible versus rigid laryngoscopy. Intraobserver reliability of the total RFS-I score ranged from fair to excellent for both flexible (ICC = 0.33–0.93) and rigid (ICC = 0.39–0.86) laryngoscopies. Comparing RFS-I results for flexible versus rigid laryngoscopy per observer, reliability ranged from no to substantial (k = −0.16–0.63, mean k = 0.22), with an observed agreement of 0.08–0.35. ConclusionReliability of the RFS-I was moderate and did not differ between flexible and rigid laryngoscopies. The RFS-I is not suitable to detect signs or to guide treatment of LPR in infants, neither with flexible nor with rigid laryngoscopy.

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.