Small Hiatal Hernia Research Articles

Transoral incisionless fundoplication: current status.

Purpose of reviewTransoral incisionless fundoplication (TIF) performed with the EsophyX device (Redmond, Washington, USA) is a totally endoscopic procedure with the objectives to mechanically repair a defective gastroesophageal valve and to reduce small hiatal hernias. The recent publication of randomized controlled trials and long-term follow-up data offers the opportunity to reevaluate this treatment modality and its role in the management of patients with chronic gastroesophageal reflux disease (GERD).Recent findingsRandomized controlled trials have confirmed the ability of TIF to eliminate troublesome GERD symptoms, heal esophagitis, and improve distal esophageal acid exposure in appropriately selected patient populations. These studies establish TIF's superiority to conventional medical therapy, especially in clinical scenarios where proton-pump inhibitors fail to provide complete symptom relief across the spectrum of classic and atypical GERD manifestations, including regurgitation and laryngopharyngeal reflux. Long-term data indicate sustained positive outcomes and durability up to 6 years after procedure. These results were achieved with a low rate of serious adverse events and usually without introducing troublesome dysphagia, gas bloat, or flatulence.SummaryBased on the most recent data, TIF appears to be a valuable treatment alternative for the management of appropriately selected patients with moderate to severe chronic GERD symptoms.

Technique of Hill's Gastropexy Combined with Sleeve Gastrectomy for Patients with Morbid Obesity and Gastroesophageal Reflux Disease or Hiatal Hernia.

Observational studies based on quality-of-life and endoscopy relate sleeve gastrectomy (SG) to gastroesophageal reflux disease (GERD), while some functional studies have demonstrated a decrease in esophageal exposure to gastric acid after SG. Currently, it is recommended to treat hiatal hernia along with the SG. However, as the sleeve gastrectomy involves the resection of the fundus, it is not possible to add a traditional fundoplication to the closure of the hiatus. Based on the classic works of Hill et al., and more recent studies by Swänstrom and Aye, our group has incorporated a modified Hill's gastropexy to the sleeve gastrectomy for patients with pathologic GERD and/or huge hiatal hernia submitted to weight loss surgery. A 28-year-old male patient, 43kg/m(2) BMI, with a small hiatal hernia and pathologic GERD was scheduled for sleeve gastrectomy. After complete fundus and left crus dissection, the phrenoesophageal membrane was opened and the distal esophagus dissected. The hiatus was closed with interrupted sutures. The sleeve was completed over a 42-French bougie. The preaortic fascia was dissected at the root of the crura and three interrupted sutures placed approximating the gastroesophageal junction to the aforementioned fascia. At 6months from the operation, weight loss has been satisfactory and the patient does not complaint GERD. Barium swallow demonstrates absence of gastroesophageal reflux, pHmetry and manometry have normalized, and endoscopy shows no esophagitis. Gastropexy to the preaortic fascia is a possible antireflux technique to combine with SG.

Surgical Technique for Laparoscopic Removal of a Magnetic Lower Esophageal Sphincter Augmentation Device

Nissen fundoplication is the current gold standard for surgical management of gastroesophageal reflux disease; however, a magnetic antireflux device is now an alternative surgical procedure. The early literature shows good reflux control with minimal complications, and therefore placement of these devices is growing in popularity. As more of these devices are placed, there will be cases in which they will need to be removed. A laparoscopic method for removing the device is presented here. We present a case of a 42-year-old female with history of gastroesophageal reflux who underwent a laparoscopic placement of a magnetic lower esophageal sphincter augmentation device and repair of a small hiatal hernia. She had a complicated postoperative course before presenting to our institution with a 2-year history of persistent dysphagia and requesting the device be removed. Laparoscopic removal of the device was performed. After laparoscopic removal of the patient's magnetic lower esophageal sphincter augmentation device, she had subjective improvement in her dysphagia but is now being medically managed for gastroesophageal reflux and for delayed gastric emptying. Laparoscopic removal of magnetic lower esophageal sphincter augmentation devices will sometimes be necessary and may be challenging if the surgeon encounters significant scar tissue around the gastroesophageal junction. Postoperative complications are similar to those encountered with foregut surgeries and include postoperative delayed gastric emptying.

Do Hiatal Hernias Influence GERD in Patients on PPI Therapy?

Introduction: 24-hour Multichannel intraluminal impedance and pH (MII-pH) esophageal monitoring allows detection of Gastro-esophageal reflux (GER). MII-PH allows identification of acid and non-acid reflux. Hiatal hernia (HH) is more common in Western countries. Complications of HH are frequent and are usually related to reflux. Aim: To evaluate the effect of the presence and size of HH on the GER characteristics assessed by MIIpH. Methods: Retrospective review of 119 consecutive adult patients on proton pump inhibitor (PPI) therapy who underwent an upper endoscopy and MII-pH studies (81 Females, mean age =52 years) between 2009 and 2014. Presence and size of HH was identified endoscopically. The group was divided based on the presence of HH and then subdivided based on the size of HH: small HH =2-3cm, medium HH=4-5cm and large HH ≥6cm. MII-pH reports were reviewed to assess GER characteristics. Results: 63/119 (52%) patients had HH. There was no statistically significant difference between the presence and size of HH and GER characteristics (tables). Conclusion: In patients on PPI therapy, HH does not seem to increase GERD as measured by MII-pH.Table 1: HH vs. no HHTable 2: Size of HH vs. no HH

Impact of Hiatal Hernia on Pediatric Gastroesophageal Reflux Disease

Objectives: To identify the frequency of hiatal hernia (HH) and the impact of HH size in children with gastroesophageal reflux disease (GERD). Methods: Outpatient records were retrospectively reviewed in children ages 0-17 years old, diagnosed clinically with GERD. HH was diagnosed based on an upper gastrointestinal (UGI) series and HH body was characterized as either small ( 5yr) with a large HH. Children with large HH were more frequently found to fail medications and require Nissen fundoplication than those with a small HH (p=0.032). Conclusions: Children with GERD had high frequency of HH based on UGI. Children with large HH required significantly more anti-reflux surgery than those with small HH. A larger scale longitudinal prospective study is needed to further investigate the impact of HH on GERD complications and the effects of therapy.

Transoral Fundoplication Provides Better GERD Symptom Control Than PPIs in Patients With Troublesome Regurgitation: A Multicenter Sham-Controlled Randomized Clinical Trial

Introduction: Transoral esophagogastric fundoplication (TF) can decrease or eliminate gastroesophageal reflux disease (GERD) symptoms in selected patients with persistent symptoms on proton pump inhibitors (PPIs). We aimed to determine if TF provided better control of troublesome regurgitation than PPIs in patients with well-documented GERD. Methods: The Randomized Esophyx vs Sham, PlacEbo-Controlled Transoral fundoplication (RESPECT) trial was carried out at eight academic and community medical centers across the United States and was approved by the Institutional Review Board of each site. Six hundred ninety-six patients with troublesome regurgitation, despite daily PPI of at least 40 mg/day, were screened with 3 validated GERD-specific symptom scales. Scores were obtained on and off PPIs. Those with at least ‘troublesome’ regurgitation (Montreal definition) on PPIs underwent barium swallow, esophagogastroduodenoscopy (EGD), 48-hr esophageal pH monitoring, and high-resolution esophageal manometry. One hundred twenty-nine patients with well-proven GERD and hiatal hernia (HH) ≤2 cm were randomized 2:1 to either TF and six months of placebo, or sham surgery and 6 months of daily or twice daily PPI (40 mg omeprazole). Patients were blinded to therapy during follow-up and were reassessed at 2, 12, and 26 weeks. At final analysis (6 months), patients were reassessed symptomatically and underwent testing with 48-hr esophageal pH monitoring and EGD. The primary study endpoint was the elimination of troublesome regurgitation, using the regurgitation fields of the RDQ at 6 month follow-up. Results: Six months following operation, 54 of 80 (68%) of patients in the TF/placebo arm reported the elimination of troublesome regurgitation, compared to 17 of 37 patients (46%) of patients in the sham/PPI arm (p=0.041). TF was associated with significant decrease in intraesophageal acid exposure in all parameters measured (p<.001). In sham patients, no improvement in pH control was detected. With the exception of postoperative epigastric pain, complications and adverse effects were no different between TF and sham groups. Early treatment failure was more common in those randomized to sham surgery and PPI than in those randomized to TF and placebo. Dysphagia and bloating were improved in both groups. Conclusion: TF plus bid placebo was more effective than a sham procedure plus PPI (qd or bid) in eliminating troublesome regurgitation for GERD patients enrolled with persistent troublesome regurgitation despite PPI therapy. We believe TF has a role in treating GERD patients with small or absent hiatal hernia who suffer from troublesome regurgitation, despite PPI therapy. Disclosure: Dr Kahrilas has served as a consultant for Reckitt Benckiser, AstraZeneca, and Pfizer. Dr. Hungness received an honorarium as part of faculty for a surgical training course for Baxter. Dr. Hunter is a consultant for EndoGastric Solutions. Dr. Bell is a consultant for EndoGastric Solutions. Dr. Trad is a consultant for and has received a research grant from EndoGastric Solutions. Dr. Wilson received a research grant from EndoGastric Solutions, Apollo Endosurgery, Reshape Medical; and is a consultant for Apollo Endosurgery, Gore Medical and Ethicon. Dr Oelschlager is a consultant for EndoGastric Solutions and has received research support from EndoGastric Solutions. Dr. Reavis is a consultant for EndoGastric Solutions. Drs. Melvin, Burch, Snyder, Perry, Soper and Turgeon do not have any relevant financial relationships to disclose. This research was supported by an industry grant from EndoGastric Solutions (EGS).

Testicular Acute Hepatitis B-Related Polyarteritis Nodosa

Introduction: Polyarteritis nodosa (PAN) is a necrotizing focal segmental vasculitis that affects medium-sized muscular arteries. Less than 1% of patients with hepatitis B virus (HBV) develop PAN. Survival rate at 1 year is worse in HBV-related PAN due to lethal GI complications. We describe a case of acute hepatitis B-associated PAN presenting with testicular pain. A 35-year-old African American male presented to the emergency department with a chief complaint of testicular pain for 2 months. He was previously treated for suspected epididymitis as an outpatient with a course of doxycycline. On physical examination, the patient was found to be afebrile, with a blood pressure of 169/104 mmHg and a heart rate of 94 bpm. He was anicteric, with a benign abdominal exam and right testicular pain elicited on palpation. On admission, labs showed: white blood cell count 14.7 thou/mm3, hemoglobin 11.4 g/dl, MCV 66.7, Cr 1.74 mg/dl, AST 202, ALT 188, alkaline phosphatasel, total bilirubin 0.9, urinalysis: protein 50. Testicular ultrasound with Doppler was ordered, showing a 0.3-cm x 0.4 cm x 0.4 cm ill-defined heterogeneous irregular mixed hypoechoic focus on the medial aspect of the right testicle, with a target/bull’s eye appearance, exquisitely tender to sonographic examination. Doppler images demonstrated increased vascularity. Urology was consulted for evaluation of testicular pain and abnormal testicular ultrasound. Pt tested negative for gonorrhea and Chlamydia; he was started on IV Ceftriaxone for empiric coverage; scrotal support/elevation was provided. The patient was admitted to medicine for workup of transaminitis and acute kidney injury concerning for possible vasculitis. Gastroenterology was consulted for evaluation of anemia and transaminitis. The patient tested positive for hepatitis B surface antigen and hepatitis B core antibody IgM, positive HBe antigen, and a HBV DNA viral load of 113,392.000 IU/mL. He had EGD and colonoscopy for work-up of anemia that showed a small hiatal hernia, gastric erosion, and erythema in fundus and body; 2-mm rectal polyp. Pathology revealed mild chronic gastritis. Urology performed right testicular biopsy, revealing vasculitis with associated thrombosis involving medium-sized muscular arteries most consistent with polyarteritis nodosa located on the superior medial region of the right testicle. The patient was then started on treatment for hepatitis B with tenofovir adjusted to his creatinine clearance. Rheumatology was consulted and recommended IV steroids, and later the patient was started on cyclophosphamide. After few days of treatment, there was a significant improvement on the patients liver enzymes. The patient will be followed in GI clinic to confirm viral suppression and conversion of HBeAg.

Patient Symptoms Correlate Poorly with Objective Measures among Patients with Gastroesophageal Reflux Disease

Presentation of gastroesophageal reflux disease (GERD) varies among patients. To attempt to understand the patient's perception of the severity of their reflux symptoms, we developed a questionnaire on which patients rated symptom severity at each office visit. After receiving Institutional Review Board approval, we retrospectively reviewed patient charts of all patients seen by one surgeon for GERD symptoms and/or presence of hiatal hernia (HH) from September 2012 to April 2013. Data from patient questionnaires combined with objective findings from subsequent or prior workup and eventual operative information were recorded. A total of 144 questionnaires were reviewed from 108 patients. Frequencies were calculated for categorical variables. Patients were divided into four categories based on size of the HH on the endoscopic report; 10 patients had no HH, 15 had small HH, 20 had medium HH, and 31 patients had large HH. Size of HH was not available for three patients. Pre- and postoperative questionnaire responses were obtained for 15 patients. A combined reflux score was calculated using the median for each symptom. Patient perception of severity of symptoms does not necessarily predict presence of pathological reflux or HH nor is there a perfect combination of symptoms to predict the presence of pathological reflux or HH based on our sample. The workup of this pathology must be comprehensive, and the confirmation of reflux is imperative when the diagnosis is unclear.

Is the severity of gastroesophageal reflux dependent on hiatus hernia size?

To determine if the severity of gastroesophageal reflux disease is dependent on the size of a hiatus hernia. Seventy-five patients with either a small (n = 25), medium (n = 25) or large (n = 25) hiatus hernia (assessed by high resolution esophageal manometry) were investigated using 24-h esophageal monitoring and a self-assessed symptom questionnaire. The questionnaire comprised the following items, each graded from 0 to 3 according to severity: heartburn; pharyngeal burning sensation; acid regurgitation; and chest pain. The percentage total reflux time was significantly longer in the group with hernia of 5 cm or more compared with the group with a hernia of < 3 cm (P < 0.002), and the group with a hernia of 3 to < 5 cm (P < 0.04). Pharyngeal burning sensation, heartburn and acid regurgitation were more common with large hernias than small hernias, but the frequency of chest pain was similar in all three hernia groups. Patients with a large hiatus hernia are more prone to have pathological gastroesophageal reflux and to have more acid symptoms than patients with a small hiatus hernia. However, it is unlikely that patients with an absence of acid symptoms will have pathological reflux regardless of hernia size.

Small Bowel Volvulus Following Upper Gastrointestinal Barium Radiography

Introduction: Small bowel volvulus is extremely rare in adults. Barium has been associated with obstructive symptoms related to baroliths, but these take several days to weeks to form. Small bowel volvulus has never been reported immediately following a barium study. Case: The patient is a 49-year-old man who presented with persistent gastroesophageal reflux despite treatment with dexlansoprazole. An upper GI series was performed to evaluate for hiatal hernia. The study revealed mid-esophageal reflux with small hiatal hernia and one area of nonspecific proximal small bowel prominence. One hour after the study, he ate lunch, and fifteen minutes later developed nausea, vomiting and diffuse abdominal pain. The pain progressed and his vomiting persisted requiring hospital admission. His past medical history includes bipolar disorder, hypertension and obstructive sleep apnea. He had no prior abdominal surgeries. His medications include depakote, trileptal, seroquel, lisinopril and dexlansoprazole. Exam revealed hypoactive bowel sounds and tenderness in the epigastrium and bilateral upper quadrants. Laboratories were notable for only mild neutrophilia. Abdominal computed topography (CT) scan showed small bowel volvulus and closed loop obstruction without free air. Contrast from the prior day was present in dilated proximal small bowel loops. Nasogastric tube was placed. Repeat abdominal x-ray showed persistent obstruction without any contrast in the colon. Given lack of improvement, laparoscopy was pursued. It revealed torsion of the jejunal mesentery that was corrected. No ischemic changes were noted. His symptoms resolved and he was discharged home without any further issues. Five months later, CT enterography with gastrograffin showed no evidence of intraluminal lesion or mesenteric pathology. Discussion: Small bowel volvulus is generally described in neonates with embryologic malrotation of the midgut. The etiology in this patient is a mystery. Contributing factors may have been slowing of colonic transit as side effect of bipolar medications as evidenced by excessive stool on CT. A large bolus of barium in setting of mild ileus may have caused the jejunal volvulus.

Pseudomelanosis Duodeni: A Rare Endoscopic Finding

Introduction: Pseudomelanosis duodeni is a benign condition characterized by dark speckled appearance of the duodenum. It is a rare endoscopic finding whose etiology and significance is unknown. We present a case of pseudomelanosis duodenii that was found on endoscopy done for chronic gastroesophageal reflux. Case presentation: A 80-year-old male with history of hypertension, diabetes, gastroesophageal reflux disease (GERD), and diverticulosis was referred for esophagogastroduodenoscopy (EGD) due to persistent GERD symptoms and abdominal pain. His medications included valsartan, lasix, ferrous sulphate, doxazosin, minoxidil, metoprolol, aspirin and lansoprazole. EGD showed a small hiatus hernia, moderate antral gastritis and speckled black pigmentation in the bulb and second portion of the duodenum. Biopsies revealed small intestinal mucosa with multiple areas of pigmentation in lamina propria, especially at villous tips which stained positive for both iron and Periodic acid schiff stain (PAS) suggestive of pseudomelanosis coli. Discussion: Pseudomelanosis duodeni (PMD) was first reported in 1976. It is characterized by collection of pigment-laden macrophages in the tips of duodenal villi. PMD manifests endoscopically as brown-black spots or speckled black pigmentation in the duodenal mucosa. It should be differentiated from melanosis coli which is more commonly seen with long term laxative use. In a recent case series, most patients with PMD were hypertensive, had upper gastrointestinal bleeding, chronic renal failure, or diabetes. Histology shows numerous pigment-laden macrophages in the lamina propria of mucosal villi. Several pigments may result in the endoscopic appearance, including lipomelanin, ceroid, iron sulfide, and hemosiderin. However, the consensus is that PMD is mostly composed of iron sulfide which may get converted to iron oxide. Iron oxide does not turn positive with the usual iron stains thereby giving histological negative but endoscopic positive pigmentation. The source of iron is thought to be prior gastro intestinal bleeds or from iron supplements. There is increased incidence in patients with hypertension and it is proposed that the sulfur is derived from medications containing the sulfur moiety such as furosemide and thiazides. However, several patients with PMD are on medications that do not contain sulfur moieties. Conclusion: Pseudomelanosis duodenii is a benign condition whose etiology and significance is currently unknown. It does not produce any symptoms. The composition of the pigment is ferrous sulfide. There are no current guidelines regarding the need for repeat endoscopy if patient is found to have pseudomelanosis duodeni on routine endoscopy.

Progressive Dysphagia and Cough

An otherwise healthy 54-year-old male with no significant past medical history presented with a 6-month history of food sticking in his throat and night awakenings secondary to coughing, choking, and difficulty managing his secretions. He reported occasional regurgitation of food and/or liquids with his cough. He denied any weight loss or recent history of pulmonary infection. He was on montelukast for a cat allergy and atorvastatin for hypercholesterolemia. He reported consuming approximately one glass of wine per day and denied tobacco use. As a component of his previous workup, he had undergone manometry, visualization of the esophagus, and 48-h BRAVO pH monitoring and presented to his initial appointment with results from these evaluations. Briefly, manometric findings were unremarkable. Esophagogastroduodenoscopy revealed thickened mucosa, esophageal trachealization or ‘‘ringed esophagus,’’ and a small hiatal hernia. A biopsy of the proximal, medial, and distal esophagus was significant for eosinophils (15–18 per high power field), and pH monitoring revealed substantial reflux only when in the supine position [% time pH \ 4 averaged 13 (normal \1.2)]. Based on these findings, he was placed on twice daily esomeprazole and ranitidine before bed. A pH impedance study to assess treatment efficacy while on reflux therapy was unremarkable. What additional test is needed and what is the likely diagnosis? (refer the answer in the next page)

Duodenal lipomatosis

A 54-year-old man with a history of tonsillar cancer had a follow-up CT scan, which showed incidental duodenal lipomatosis (A). Two years later, upper endoscopy was performed to evaluate acid reflux. A small hiatus hernia was observed. Starting at the distal end of the bulb and leading to the third part of the duodenum were 10 submucosal lesions 0.5 to 2.0 cm in diameter (B). Probing with the forceps resulted in a shallow pillow sign, and biopsies of three nodules resulted in exposure of underlying fat (C). Pathologic examination revealed typical findings of a submucosal lipoma.

Hiatal hernia repair with biologic mesh reinforcement reduces recurrence rate in small hiatal hernias

The utility of mesh reinforcement for small hiatal hernia found especially during antireflux surgery is unknown. Initial reports for the use of biological mesh for crural reinforcement during repair for defects greater than 5 cm have been shown to decrease recurrence rates. This study compares patients with small hiatal hernias who underwent onlay biologic mesh buttress repair versus those with suture cruroplasty alone. This is a single-institution retrospective review of all patients undergoing repair of hiatal hernia measuring 1-5 cm between 2002 and 2009. The patients were evaluated based on surgical repair: one group undergoing crural reinforcement with onlay biologic mesh and other group with suture cruroplasty only. Seventy patients with hiatal hernia measuring 1-5 cm were identified. Thirty-eight patients had hernia repair with biologic mesh, and 32 patients had repair with suture cruroplasty only. Recurrence rate at 1 year was 16% (5/32) in patients who had suture cruroplasty only and 0% (0/38) in the group with crural reinforcement with absorbable mesh (statistically significant, P = 0.017). Suture cruroplasty alone appears to be inadequate for hiatal hernias measuring 1-5 cm with significant recurrence rate and failure of antireflux surgery. Crural reinforcement with absorbable mesh may reduce hiatal hernia recurrence rate in small hiatal hernias.

A Case of Video Capsule Retention in a Rare Epiphrenic Diverticulum

Purpose: Video capsule endoscopy (VCE) is a minimally invasive method of visualizing the small bowel. Capsule retention is the most common complication of VCE. While VCE retention has been described in various anatomical locations, there are no known reports of retention in an epiphrenic esophageal diverticulum. A 73-year old African-American female, with a long history of iron deficiency anemia, presented for evaluation of obscure gastrointestinal bleeding with VCE. She denied melena, hematochezia, abdominal pain, or dizziness. Her physical exam was unremarkable, with a negative in-office fecal occult blood test. On presentation to our clinic the patient was noted to have hemoglobin and hematocrit values of 9.9g/dL and 29.9%, respectively. VCE was performed using a PillCam SB (Given Imaging, Yoqneam, Israel). After 8 hours of recording, the capsule was noted to be halted in the esophagus. Further evaluation with an esophagram showed a large epiphenic esophageal diverticulum and diffuse esophageal spasms with poor peristalsis. The retained capsule was not observed in this study. The patient remained completely asymptomatic during this time. She underwent a second VCE study, this time with endoscopic deployment of the video capsule. The EGD confirmed a large epiphrenic diverticulum just above the gastroesophageal (GE) junction and a small hiatal hernia. The initial retained capsule, however, was not seen during the EGD and was presumed to have spontaneously passed. To our knowledge, this is the first case of video capsule retention in an epiphrenic esophageal diverticulum, likely due to their rarity. Our case suggests that esophageal diverticula may be a relative contraindication for VCE. In patients with hyper or hypomotility disorders, which are commonly associated with other anatomical problems within the GI tract, endoscopic deployment of the VCE beyond the diverticulum is a much safer alternative. Moreover, symptomatic patients may benefit from diagnostic work-up of esophageal and other GI tract diverticula as a preventative measure of capsule retention.Figure: Esophagram showing distal esophageal diverticulum (epiphrenic diverticulum).

Endoscopic fundoplication for the treatment of gastroesophageal reflux disease: Initial experience

Transoral incisionless fundoplication (TIF) is a promising approach for gastroesophageal reflux disease (GERD) that may decrease morbidity compared with conventional antireflux procedures. We report our initial experience with this minimally invasive approach. Over a 24-month period, 46 patients (mean age, 49 years; 50% female) underwent 48 TIF procedures. All procedures were performed under general anesthesia. Two surgeons participated in all cases; one served as the endoscopist, and the other performed the partial fundoplication. Heartburn severity was measured using the GERD health-related quality of life (GERD-HRQL) instrument (best score=0, worst score=45), which includes an additional question assessing overall satisfaction. Preoperatively, 33 (72%) of 46 patients had small (<3 cm) hiatal hernias, and none had undergone any previous antireflux procedures. Preoperative workup included manometry and barium esophagogram, with pH testing reserved for patients with atypical symptoms or typical symptoms and a lack of response to proton-pump inhibitors. The mean procedure time was 83 minutes (range, 36-180 minutes). The mean procedure time decreased after the first 5 cases from 122 to 78 minutes (P=.001). Mean length of stay was 1.3 days. One patient was readmitted with aspiration pneumonia. Three patients had minor complications (1 had minor bleeding from a suture site and 2 had urinary retention). There were no perioperative deaths. Mean follow-up was 140 days. The mean GERD-HRQL scores improved significantly (23 vs 7; P<.001). There were 22 patients with follow-up greater than 90 days (mean follow-up, 240 days). GERD-HRQL scores remained significantly improved for these patients (23 vs 8; P=.001). Four patients from the entire group (8.6%) had no improvement, in 3 instances due to breakdown of the wrap. Two patients were treated with repeat endoscopic fundoplication and 1 was treated with laparoscopic Nissen fundoplication, and all had a significant improvement in symptoms after reoperation. TIF is effective at short-term follow-up and safe for patients with GERD. However, long-term follow-up and randomized trials are required to assess the efficacy and durability of this approach compared with conventional surgical repair.

Comprehensive evaluation of endoscopic fundoplication using the EsophyXTM device

There are limited studies that evaluate the efficacy of endoscopic fundoplication (EF) for gastroesophageal reflux disease (GERD) with the EsophyX™ device, especially with the most recent procedural iteration (TIF-2). This study was a prospective evaluation of our early experience with this device and procedure. Data were collected prospectively on 23 consecutive patients undergoing EF (March 2009 to August 2010). All patients completed a symptom questionnaire assessing frequency and severity of gastrointestinal and respiratory symptoms, 24-h pH, and manometry studies preoperatively and were encouraged to repeat these at 6 months. All patients had abnormal pH studies and were on proton-pump inhibitor (PPI) therapy prior to EF. Median age was 47 years (19-62 years), and six (23%) were male. Nine (41%) patients had Body Mass Index (BMI) ≥ 30 kg/m(2), and three (14%) had a small hiatal hernia (≤ 2 cm). The procedure was aborted in two patients for retained food. Three patients underwent subsequent laparoscopic Nissen fundoplication for persistent or recurrent symptoms. Median hospitalization was 1 day, and there were no major perioperative complications. At 6 month follow-up, 19 (86%) patients completed a symptom questionnaire, and 14 (64%) and 11 (50%) patients underwent pH and manometry studies, respectively. There was a significant reduction in heartburn (P = 0.02), total percentage acid contact time (P = 0.002), DeMeester score (P = 0.002), and PPI use (P = 0.003). Overall, 8 out of 14 (57%) patients had abnormal pH studies and 11 out of 19 (58%) remained on PPI therapy at 6 months. EF with EsophyX™ is associated with significant reduction in heartburn and abnormal acid exposure at 6 months, although the majority of patients did not experience normalization of their pH studies and remained on PPI therapy. The procedure has an acceptable safety profile, but the question remains as to whether it is effective enough to warrant a place in the armamentarium for the treatment of GERD.

Can Yoga Be Used to Treat Gastroesophageal Reflux Disease (GERD)?

Purpose: Case: A 62 year old male presented with several years history of heartburn which led to dysphagia with solid food. Endoscopy was performed. Based on the findings of severe esophagitis, he was started on high dose Proton Pump Inhibitor (PPI) therapy with dietary modification. A second Endoscopy with ambulatory pH monitoring test (BRAVO) was performed 7 months later, following this, in addition to the previous treatment, a regimen of specific Yoga exercises was initiated. The two Yoga exercises performed by the patient were Agnisar Kriya and Kapal Bhati (videos available on www.youtube.com). Agnisar Kriya can be done by sitting on chair with back straight or by sitting cross-legged on the floor. Following complete exhalation, the abdominal area is moved back and forth while holding the breath out. Kapal Bhati i.e., breathing exercise with forced exhalation. It is better to perform the Agnisar kriya after Kapal Bhati. Both Yoga exercises were performed by the patient for 10 minutes each every morning with an empty stomach. After 7 months of continuous treatment with PPI and yoga, the third endoscopy was performed. One month later, the patient was asked to discontinue the PPI for 10 days and fourth endoscopy was performed in addition to the BRAVO study. Results: The 1st endoscopy results showed a Grade D esophagitis, hiatal hernia with a non-obstructing stricture. The 2nd endoscopy revealed LA Grade C esophagitis, hiatal hernia with a non-obstructing stricture. A simultaneous BRAVO showed a Demeester score (normal < 14.7) of 81 on day 1 and 35 on day 2. The 3rd endoscopy showed a LA Grade A esophagitis, and a small hiatal hernia with non-obstructive stricture. The 4th endoscopy revealed LA Grade B esophagitis, and a large sliding hiatal hernia. A simultaneous BRAVO study was repeated and observed a Demeester score of 12 on day 1 and 17.2 on day 2. Conclusion: The patient used both yoga exercises and PPI that alleviated the symptoms of GERD but did not reduce the hiatal hernia. PPI treatment demonstrated a reduction in the LA grading of esophagitis. On the other hand, the Yoga exercises may have contributed towards a reduction of reflux as seen by an improvement of the Demeester score. One of the possible mechanisms resulting in reduction of the reflux may be that Yoga causes a decrease in the frequency of Transient Lower Esophageal Sphincter Relaxations (TLESR). In essence, the patient's regularity in performing yoga with the right technique has helped relieve his symptoms and can be used as an adjunct to PPI and lifestyle modification in the treatment of GERD.Since this is only a single patient experience, further investigation is warranted into the role of Yoga in the treatment of GERD.

Squamous Papilloma: An Unusual Esophageal Entity

Purpose: We describe a case series of two patients who underwent EGD for different indications. The first case is of a 61 yr old male who presented with symptoms of intermittent dysphagia to solids for 2 months. Medical history included diabetes mellitus and CAD. He had quit smoking tobacco 40 years ago and denied alcohol use. He underwent EGD which showed a 1.5 cm exophytic mass in the distal esophagus. The lesion was removed with jumbo biopsy forceps. Pathology was consistent with squamous cell papilloma of the esophagus. Special stain did not detect Human papilloma virus DNA in the lesion. A follow up EGD was performed after 3 months which showed normal appearing mucosa. He improved symptomatically with no further complaints of dysphagia. The second case is of a 56 yr old male with hepatitis C who was referred for an EGD for symptoms of abdominal pain, nausea and weight loss. He denied dysphagia or any other esophageal symptoms. He had past history of tobacco and alcohol use.EGD showed a nodular lesion at 30 cm from incisors which was removed with jumbo biopsy forceps. Pathology was consistent with squamous papilloma without dysplasia. Squamous papilloma of the esophagus is a rare benign lesion of the esophagus. The prevalence ranges from 0.01% to 0.45%. It is usually asymptomatic and rarely causes dysphagia. The underlying etiology is unclear but chronic reflux disease, mucosal trauma and HPV infection have been implicated although most lesions are found to be HPV negative. Both patients described here had small hiatal hernia noted on EGD and chronic reflux could have played a role in papilloma formation. This entity presents as a ‘wart' like lesion most commonly in middle and distal esophagus and can be removed endoscopically. Histologically there are three different forms of squamous papilloma. The most common form has a branching core of lamina propria producing fronds that are covered by squamous epithelium. Occasionally the squamous epithelium has “koilocytotic changes with crinkled nuclei surrounded by clear cytoplasmic halos resembling the squamous cells of condylomas.” Malignant potential of the lesion is unknown and no guidelines exist regarding follow up of these lesions. Long term follow up studies have suggested removing the lesion endoscopically. Recurrence is uncommon.Figure: No Caption available.

Does imaging the oesophagus, stomach and duodenum with the ESO 2 pillcam compare favourably with conventional video-endoscopy in patients with dyspepsia?

IntroductionOesophageal capsule endoscopy (ESO 2) has been developed to image the oesophageal mucosa and compares with endoscopy (OGD).1 With a battery life of 30 min, the capsule transmits gastric and...