Reflux Symptoms Research Articles

BN SO25 - Laparoscopic Management of Achalasia and Iatrogenic Mucosal Perforation in a Patient with Severe Reflux Following Multiple Therapeutic Dilatations

Abstract Background Laparoscopic Heller's cardiomyotomy (LHC) is the gold standard intervention for achalasia. Owing to its well-established complications of reflux symptoms, some surgeons perform an additional fundoplication surgery, although the consensus regarding the clinical benefits of this approach remains unclear.1 A meta-analysis showed that posterior fundoplication has proven to be superior to anterior fundoplication in controlling reflux symptoms.2 Method A gentleman in his 60s reported ongoing severe reflux symptoms following multiple Rigiflex ballon dilatations for achalasia, on manometry and pH studies showed features of pathological acid reflux, incomplete lower oesophageal sphincter relaxation and defective peristalsis. As shown in the video, type 1 sliding hiatus hernia, submucosal fibrosis and peri-oesophagitis were seen intraoperatively. A short cardiomyotomy was performed, which was complicated by iatrogenic oesophageal perforation. Anterior fundoplication with mucosal closure was performed. Results Following the surgery, no leak was observed on the swallow test and the patient reported a massive improvement in reflux symptoms. The addition of fundoplication to LHC in patients with achalasia and reflux symptoms has improved clinical outcomes. Conclusion Concomitant LHC and anti-reflux surgery should be considered in patients presenting with achalasia and gastro-oesophageal reflux symptoms.

Vagus Nerve Preservation for Early Distal Gastric Cancer With Monitoring and Indocyanine Green Labeling

ImportanceRadical gastric cancer surgery can cause functional and physiological disorders due to the resection of perigastric vagus nerves. Few studies have used intraoperative neurophysiological monitoring and indocyanine green (ICG) labeling to preserve the perigastric vagus nerve and to evaluate the corresponding effects.ObjectiveTo assess the feasibility and effects of vagus nerve preservation using neurophysiologic monitoring and ICG labeling during laparoscopic distal gastrectomy in patients with early distal gastric cancer.Design, Setting, and ParticipantsThis open-label, prospective randomized clinical trial initially enrolled 285 patients with clinical stage cT1N0M0 distal gastric cancer from May 2022 to May 2023. This trial was conducted at Qilu Hospital of Shandong University in Jinan, China, and enrolled patients aged 18 to 80 years with histologically proven gastric adenocarcinoma scheduled for distal gastrectomy. The final follow-up examination was performed May 1, 2024.InterventionsEligible participants were randomly assigned 1:1 to vagus nerve preservation distal gastrectomy (VPG) or vagus nerve resection distal gastrectomy (VRG).Main Outcomes and MeasuresThe primary outcome was the incidence of postsurgical gastroparesis. Secondary outcomes included postoperative gallstone formation, quality of life, morbidity, mortality, overall survival, and disease-free survival up to 12 months postoperatively. All analyses were based on both intention-to-treat and per-protocol analyses.ResultsOf 264 patients included in the intention-to-treat analysis, the median (IQR) patient age was 58.0 (52.0-67.0) years, and 67 patients (25.4%) were female. Both the VPG and VRG groups included 132 patients. Postoperative gastroparesis occurred in 1 patient (0.8%) in the VPG group and in 10 patients (7.6%) in the VRG group. Gallstones developed in 0 patients in the VPG group and in 9 patients (6.8%) in the VRG group. As assessed by mean (SD) score on the 30-item European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, the VRG group experienced more nausea and vomiting at 6 months postsurgery (19.38 [7.62]) than the VPG group (17.15 [9.21]) (P = .03) and had significantly higher rates of persistent appetite loss, reflux symptoms, and eating difficulties at both 6 months and 12 months than the VPG group. Differences in postoperative complications and metastasis were not significant.Conclusions and RelevanceNeurophysiologic monitoring and ICG labeling during distal laparoscopic gastrectomy for vagus nerve preservation in patients with early distal gastric cancer are safe and feasible. Preserving the perigastric vagus nerve may retain the function of the remnant stomach and improve quality of life.Trial RegistrationChictr.org.cn Identifier: ChiCTR2200059489

BS SO15 - Outcomes of Braun procedure for reflux after OAGB- Audit from a single center

Abstract Background Braun procedure is a procedure used for management of reflux in gastric bypass patients. It is a simple procedure offering a jejuno-jejunal anastomosis to bypass bile away from stomach to prevent symptoms of reflux. It has been used in cancer patients needing bypass surgery. This has also been used in One anastomosis gastric bypass patients presenting with reflux. Method We would like to present the steps of Braun procedure. At the same time, we would like to take this opportunity to present the results of our audit of patients presenting with bile reflux needing surgical management of symptoms. We analysed our operation sheets from December 2016- Jan 2024 and retrospectively looked into the patients who needed surgical management of bile reflux. Results Total number of OAGB procedures done –1024, out of these 30 patients presented with bile reflux needing surgical management. 26 of these 30 patients underwent Braun procedure and 4 underwent RYGB. 6 patients out of the 26 patients who underwent Braun procedure needed conversion to RYGB because of non-resolution of symptoms. Since we looked at operation sheets, we have not analysed the total number of patients who have reflux post OAGB. Conclusion Conversion to RYGB is the gold standard procedure for managing bile reflux after OAGB. Braun’s procedure is a simpler procedure which can be done as day case and suffices in 86 % of patients. Patients should be offered both the procedures.

BN SO28 - Dual Mesh Technique in Revisional Complex Laparoscopic Repair of Recurrent Paraesophageal Hernia (PEH)

Abstract Background Mesh Augmentation in laparoscopic repair of complex PEH has been an ongoing debate with regards to its risk profile and success rate in reducing hernia recurrence.1 There have been concerns regarding the deployment of non-absorbable mesh around the hiatus resulting in erosion and stricture, which may lead to oesophagectomy or gastrectomy.2 Absorbable mesh has been introduced with appealing advantages of lower mesh-related morbidities, however its high cost and unclear long-term durability remains questionable for its role as an ideal mesh.2 Method This is the case of a 65-year-old patient with chronic reflux symptoms undergoing revisional complex laparoscopic repair of recurrent type 4 PEH. The focus of this video is using a dual mesh technique involving fixation of a non-absorbable synthetic mesh at least 15mm from the oesophageal wall, reinforced with placement of an absorbable biosynthetic mesh which is in contact with the hiatus boundary. Results With regards to position of the permanent synthetic mesh, direct contact with the oesophagogastric wall should be avoided due to complications secondary to erosions and strictures. The deployment of a second mesh of absorbable material is preferred in this patient for hiatal reinforcement to reduce risk of recurrence due to friability of adjacent tissues. Conclusion The dual mesh technique aims to overcome the limitations of both types of mesh materials while preserving their individual benefits, expectantly reducing recurrence.

BN SO47 - Can Peroral Endoscopic Myotomy (POEM) be the new gold standard for Achalasia? – as it is safe and effective

Abstract Background Laparoscopic Heller’s cardiomyotomy is the gold standard for treatment of achalasia. POEM has emerged as a revolutionary minimal invasive procedure in the management of achalasia and related oesophageal motility disorders. POEM effectively utilises an endoscopic approach by creating a submucosal tunnel to perform a myotomy at the lower oesophageal sphincter (LES) , achieving symptomatic relief. Being firstly introduced in 2008, POEM offers an excellent alternative option to surgical intervention and conservative approaches. The aim of this study is to evaluate the clinical efficacy and safety of POEM since its introduction in our unit. Method POEM procedures performed in adult patients are recruited prospectively from May 2020 to January 2024 and data are collected using electronic trust records. Eckardt score (a commonly used scoring system to characterise severity of achalasia) is recorded before and after the procedure. A total of 46 patients are identified however three patients are excluded in this study due to unavailable clinical information. This study presents a cohort of patients with median age of 60 and an equal gender distribution. Results Out of 43 patients, 69.8% were treatment naïve and 30.2% had previous treatments. Mean Eckardt score pre-procedure was 8.2. The average length of hospital stay was 1.7 days and immediate post treatment complications were 6.9% (2.3% mucosotomy, 2.3% oesophageal leak, 2.3% infection). No mortality was recorded within 30 days post-procedure. A 93% clinical success rate (Eckardt score ≤3) was achieved in the initial follow-up period (three to six months) with a mean Eckardt score of 1.1. 41.9% of patients experienced reflux symptoms which require proton pump inhibitor use within four weeks post-procedure. 18.4% of patients had recurrent achalasia symptoms over their follow-up period. Conclusion The clinical success rate (Eckardt score ≤3) and recurrence rate post POEM in this study are comparable with the international cohort quoted in literature. Post POEM reflux rate is prevalent, which is a well-known complication. The substantial improvement in clinical outcomes, evidenced by the Eckardt score reduction and the low incidence of post-operative complications, underscores the procedure’s efficacy and safety. Overall, POEM represents a significant advancement in the treatment of oesophageal motility disorders, especially achalasia. This study presents POEM as a safer and less invasive treatment alternative compared to Heller’s cardiomyotomy.

BN SO60 - Oesophageal physiology studies: Conversion to surgery

Abstract Background This study aims to assess the proportion of patients that proceed to have hiatal surgery after oesophageal physiology studies. The results allow better planning in service development and workforce provision. Approximately 25% of the adult population suffer reflux symptoms (1), however not all patients benefit from surgical intervention. UK data show 1693 anti-reflux operations and 740 hiatal hernia repairs took place 2022-2023 (2). Oesophageal physiology studies, i.e. high resolution pH manometry and 24-hour pH monitoring, are the gold standard investigation in such patients to determine diagnosis and guide management. Method All patients who underwent oesophageal physiology studies between January 2021 and December 2023 were assessed by case note analysis. All patients considered for surgery were discussed in our hiatal MDT. Whilst achalasia is relatively rare, these patients also pass through oesophageal physiology and so are also considered here. Patients with previous hiatal surgery were excluded (20 patients). Results 182 patients attended; 137 underwent the tests, 22 tolerated manometry only, 5 underwent BRAVO. 78 were diagnosed with symptomatic/volume reflux, 3 with hiatus hernia. Mean DeMeester score was 47.63 (range 1.87-228.58) c.f. 20.2 (range 0.2-192.96) in the non-operative group. Ten patients had achalasia; two were referred for POEM, one Botox and one awaits further investigation. Six underwent Heller’s cardiomyotomy and Dor fundoplication. 76 patients were offered surgical intervention for reflux and/or hiatus hernia; 10 of whom declined. 3 patients underwent surgery privately. To date 39 procedures have been completed. 16 patients await further tests. Conclusion 42% of patients undergoing oesophageal studies were offered surgical intervention across a two-year period in our benign unit. A further 9% are awaiting outcome. The data suggest that when planning surgical services, finances and workforce we should anticipate approximately 40% of these patients will go on to require surgery.

Characteristics and Management of Laryngopharyngeal Reflux in The Elderly : A Case Report

Laryngopharyngeal reflux is a condition resulting from the retrograde flow of stomach acid through the distal esophagus into the laryngopharyngeal area. The prevalence of laryngo-pharyngeal reflux in the elderly population remains uncertain. Therefore, the symptoms, findings, and therapy for laryngopharyngeal reflux in the elderly require further investigation. To analyze the characteristics and management of laryngopharyngeal reflux in the elderly. A case of laryngopharyngeal reflux in a 70-year-old woman who frequently experiences sudden choking sensations is presented in this report. Other symptoms include hoarseness, a sensation of throat obstruction, and chest burning. We explored literature on laryngopharyngeal reflux in the elderly through PubMed, PMC, and Google Scholar databases to discuss the case. Laryngopharyngeal reflux in the elderly has a lower reflux symptoms index but a higher reflux finding score. Mental health factors significantly influence laryngopharyngeal reflux incidence in the elderly. Therefore, besides pharmaco-logical therapy, additional non-pharmacological therapies need to be considered to ensure effective laryngopharyngeal reflux treatment. Elderly patients diagnosed with laryngopharyngeal reflux have different presentations and management of the disease compared with younger patients.

Mesocolic schwannoma mimicking gastrointestinal stromal tumor: A case report and review of literature

Rationale: Schwannomas are common peripheral nerve tumors originating from Schwann cells, primarily occurring in the head and neck, limbs, and trunk. Schwannomas occurring in the mesocolon are rare and often have no specific manifestations. Abdominal schwannomas need to be differentiated from common abdominal tumors such as gastrointestinal stromal tumors. Patient concerns: We report a case of a mesocolic schwannoma in a 59-year-old female presenting with gastrointestinal symptoms of acid reflux. At an outside hospital, gastroscopy, colonoscopy, and abdominal computed tomography scans revealed a soft tissue mass adjacent to the greater curvature of the stomach, leading to a suspicion of a gastric mesenchymal tumor. Diagnoses: Mesocolic schwannoma. Interventions: Laparoscopy was performed at our hospital. Intraoperatively, the tumor was found to be closely related to the transverse colon and was initially diagnosed as a mass originating from the transverse colon. Consequently, a resection of the mass along with the adherent portion of the transverse colon was performed. Postoperative pathology and immunohistochemistry confirmed that the tumor was a schwannoma of the mesentery and did not originate from the transverse colon. Outcomes and lessons: Schwannomas can be distinguished from gastrointestinal stromal tumors by immunohistochemical staining, and surgical treatment is effective for benign schwannomas.

Per-oral endoscopic myotomy: a multi-centre New Zealand experience.

Per-oral endoscopic myotomy (POEM) is an established treatment for achalasia. We aim to review outcomes of all POEM cases performed in New Zealand for achalasia. A retrospective review of all POEM procedures performed in the five hospitals offering POEM between November 2015 and December 2022 was undertaken. The primary outcome was clinical success, defined as Eckardt score ≤3. Secondary outcomes included procedural complications. One hundred and sixty-six index and four redo POEM procedures were performed by seven clinicians. Ninety-six (58%) were male and mean age was 49.6 years (standard deviation [SD] 19.2 years). Eighty-three (50%) had a previous achalasia intervention. Median length of hospital stay was 1 day (interquartile range [IQR] 1-2 days). Median pre-POEM Eckardt score was 8 (IQR 6-9) and improved to 0 (IQR 0-2) at 6 months (p<0.001). Technical success was achieved in 164 (99%). Clinical success was achieved in 124 (93%) at 6 months and sustained to 12 months in 37/42 (88%) of these patients with follow-up data. Clinical success was achieved in 92% who underwent any prior intervention. There were five reported complications: tunnel leak (three), significant pain (one) and pneumothorax (one). One tunnel leak required thoracotomy for empyema debridement, all other complications were managed conservatively. Forty-seven (31%) reported symptomatic reflux after POEM. This first review of all POEM procedures performed in New Zealand for achalasia demonstrates high 6-month clinical success and safety for the management of achalasia.

Robotic versus laparoscopic revision to Toupet fundoplication for failed Nissen fundoplication: a single-center experience.

Nissen fundoplication (NF) is a common surgical procedure to treat gastroesophageal reflux disease; however, a subset of patients may continue to experience symptoms or develop symptom recurrence despite a successful procedure. This study aims to compare laparoscopic and robotic approaches for treating failed NF and evaluate the outcomes after converting to Toupet fundoplication (TF). We conducted a retrospective analysis of patients who underwent robotic or laparoscopic revision to TF for failed NF between 2016 and 2023. The data collected included demographics, pre-operative workup, and peri- and post-operative outcomes. Symptom analysis and anti-reflux medication usage were collected using a patient questionnaire. Failed fundoplication was defined as the need for an additional operation due to unresolved GERD symptoms or the emergence of a new issue. Eighty-eight patients (56 laparoscopic, 32 robotic) were included. Mean operative time was 148.71 ± 53.64min for the total cohort and was significantly longer in the robotic group (RG) 167.43min vs 138.01min in the Laparoscopic group (LG) (p value = 0.012). The LG had a length of hospital stay of 2.16 ± 1.69days vs RG 2.21 ± 1.28days (p value = 0.867). The LG had a higher number of early readmissions (5.4%, p value = 0.629) and both the LG and the RG had 1 patient that required an early reintervention. Symptoms of dysphagia and reflux decreased in both groups at last follow-up, but the reduction in PPI use was not significant. Surgical revision to TF for failed NF provides significant symptom improvement with low rates of complications and recurrences. Our study shows that both approaches are safe and feasible and have comparable surgical and symptom outcomes.

Association between laryngopharyngeal reflux clinical scores and esophageal multichannel intraluminal impedance pH monitoring interpretation according to Lyon Consensus 2.0.

Laryngopharyngeal reflux remains a diagnostic challenge due to the lack of a definitive diagnostic tool. Esophageal multichannel intraluminal impedance (MII) pH monitoring has been proven reliable for detecting gastric reflux. This study aims to evaluate the association between clinical scores and MII/pH monitoring according to the Lyon Consensus 2.0. Patients with laryngo-pharyngeal symptoms (LPS) who had a reflux symptom index (RSI) ≥13 or reflux finding score (RFS) ≥7 underwent MII/pH monitoring. The findings were analyzed in comparison with clinical scores. A total of 100 patients meeting the inclusion criteria were recruited for this study. MII/pH monitoring revealed a median acid exposure time (AET) of 1.9% (interquartile range [IQR] = 0.2, 4.9), with 22% of patients recording an AET above 6%. The median number of reflux episodes was 29.5 episodes per day (IQR = 19.0, 43.8), with 7% experiencing more than 80 episodes per day. Gas reflux was identified as the most prevalent type. Based on the Lyon Consensus 2.0, 25 patients exhibited conclusive pathological reflux, while 75 patients showed no conclusive evidence of pathological reflux. No significant differences were found in RSI and RFS between these groups. Only gas reflux episodes showed a significant correlation with RSI (r = 0.255, P = 0.011). RSI and RFS among patients with LPS showed no statistically significant differences in identifying pathological reflux or no conclusive evidence of pathological reflux. This finding suggests that the pathophysiology underlying LPS may not be solely attributable to reflux.

Transoral Incisionless Fundoplication Leads to Esophageal Mucosa Healing in Responder Patients Followed up to 2 Years, as Documented by Esophageal Mean Nocturnal Baseline Impedance.

Decrease of esophageal mean nocturnal baseline impedance reflects loss of mucosal integrity. It can predict response to anti-reflux therapy. Mean nocturnal baseline impedance after transoral incisionless fundoplication for gastroesophageal reflux disease has never been assessed. The aim of the study is to investigate mean nocturnal baseline impedance and conventional pathophysiological parameters following transoral incisionless fundoplication. Patients prospectively treated by transoral incisionless fundoplication in a single center were retrospectively reviewed regarding 1- and 2-year 24-hour pH-metry and multichannel intraluminal impedance with calculation of mean nocturnal baseline impedance, gastroesophageal reflux disease-health related quality of life and reflux symptom index scores. Thirty-eight and 17/38 patients with 1- and 2-year 24-hour pH-multichannel intraluminal impedance assessment and mean nocturnal baseline impedance's calculation after transoral incisionless fundoplication, respectively, were identified. Mean nocturnal baseline impedance significantly increased up to 2-year follow-up (P = 0.033), along with significant decrease in % of acid exposure time (P = 0.003), gastroesophageal reflux disease-health related quality of life score (P < 0.001), and reflux symptom index (P = 0.008), compared with baseline. The longest orthostatic reflux decreased too, approaching statistical significance (P = 0.054). These significant changes occurred in patients experiencing ≥ 50% reduction of symptom questionnaires' scores ("responders"). Conversely, mean nocturnal baseline impedance worsened and no significant changes of 24-hour pH-multichannel intraluminal impedance metrics were observed in "non-responder" patients (symptom questionnaires' scores decrease < 50%).ConclusionIn patients who responded a significant improvement of mean nocturnal baseline impedance and % acid exposure time was observed up to 2-year follow-up, suggesting that transoral incisionless fundoplication achieves an effective esophageal mucosa healing besides symptom improvement.

Surgical treatment strategies for gastroesophageal reflux after laparoscopic sleeve gastrectomy

Bariatric surgery has emerged as an effective therapeutic approach for combating obesity. As the most commonly performed bariatric surgery, laparoscopic sleeve gastrectomy (LSG) has a long-term and effective outcome in weight reduction. However, studies have reported an increased incidence of gastroesophageal reflux disease (GERD) among patients after LSG. For those who fail to respond to conventional oral acid-suppressing medication, surgical intervention comes into consideration. The most commonly performed revisional surgery for sleeve gastrectomy is the Roux-en-Y gastric bypass, which can effectively alleviate the symptoms of reflux in patients and also continues to promote weight loss in patients who have not achieved satisfactory results or have experienced weight regain. In addition to this established procedure, innovative techniques such as laparoscopic magnetic sphincter augmentation (MSA) are being explored. MSA is less invasive, has good reflux treatment outcomes, and its safety and efficacy are supported by the literature, making it a promising tool for the future treatment of gastroesophageal reflux. This article also explores the role of endoscopic interventions for GERD treatment of post-sleeve gastrectomy patients. Although these methods have shown some therapeutic effect, their efficacy still requires further study due to a lack of support from more clinical data. For patients with preoperative hiatal hernia or gastroesophageal reflux symptoms, some experts now consider performing LSG combined with hiatal hernia repair or fundoplication to alleviate or prevent postoperative reflux symptoms. Both of these surgical approaches have demonstrated favorable outcomes; however, the addition of fundoplication requires further investigation regarding its long-term effects and potential postoperative complications. This article gathers and examines the current laparoscopic and endoscopic treatments for refractory gastroesophageal reflux following LSG, as well as the concurrent treatment of LSG in patients with preoperative gastroesophageal reflux or hiatal hernia.

Multidisciplinary management of gastroesophageal reflux disease: an italian retrospective study

Abstract Background Millions of individuals are affected by gastroesophageal reflux disease (GERD) that causes significant discomfort negatively affecting patients’ overall quality of life. For a collaborative approach of continuous improvement in public health we wanted to know the real-world perspectives in the multidisciplinary and multimodal management pathway. Methods We aimed to interview a sample of gastroenterologists (GE), primary care physicians (GP), and otolaryngologists (ENT) to investigate the management of the intake and treatment of patients reporting symptoms of GERD. Symptoms were divided into typical and extraesophageal, and their severity and impact on quality of life was explored with the GERD Impact Scale (GSI) and Reflux Symptom Index (RSI). Results A total of 6211 patients were analyzed of whom with typical symptoms were 53.5%, while those with extraesophageal symptoms were 46.5%. The latter were more frequently reported by ENT patients (53.6%, p &amp;lt; 0.0001). GSI was highest in patients followed by GE (9 points) and GP (9 points) than ENT specialists (8 points), while the RSI was higher in the ENT group (14.3 ± 6.93) than in the groups of GP and GE, respectively (10.36 ± 6.36 and 10.81 ± 7.30, p &amp;lt; 0.0001). Chest pain had the greatest negative impact on quality of life (p &amp;lt; 0.0001). Of the 3,025 patients who used (proton pump inhibitors) PPIs, non-responders had a lower GSI when treated with a combination of adjunctive drug treatments and bioadhesive compounds, compared with single-component drugs. Conclusions The multidisciplinary and multimodal approach to the management pathway of GERD patients reveals variations in patient profiles by physician specialty, directing toward more appropriate and targeted treatments. In addition, the combination of adjunctive drug treatments and bioadhesive compounds appears to be effective in the management of patients refractory to PPIs. Key messages • The presentation of GERD symptoms is different in accordance with the physician’s speciality: the patients with GERD referred to a gastroenterologist had more severe disease and poorer quality of life. • The combination of adjunctive pharmacological treatments and bioadhesive compounds seems to be effective in the management of PPI refractory patients.

Bolus exposure as a novel predictor of postoperative symptom resolution after laparoscopic nissen fundoplication: A two-institutional retrospective cohort study.

Even in the absence of definite evidence of pathological acid reflux, antireflux surgery (ARS) can still effectively improve gastroesophageal reflux symptoms. Nonetheless, predicting postoperative reflux symptom improvement has been primarily dependent on acid-based parameters. No objective index reflecting both acid and non-acid reflux was identified to select ARS candidates. Prospectively collected data of 121 patients with gastroesophageal reflux disease (GERD), who underwent laparoscopic Nissen fundoplication from two institutions, were retrospectively reviewed. The patients reported preoperative and postoperative GERD symptoms using the Korean version of the GERD questionnaire, along with the gastroesophageal reflux disease-health-related quality of life (GERD-HRQL). The patients assessed for reflux symptoms using bolus exposure, acid exposure time (AET), and DeMeester score (DMS) as measurements were selected. For each reflux parameter, its association, correlation, and predictive capacity of the degree of postoperative symptom resolution were analyzed using chi-squared tests, point-biserial correlations, logistic regression analyses, and receiver operating characteristic curve analyses. 72 patients were eligible for this study. Bolus exposure was superior to the other parameters in terms of the degree of association and correlation with resolution of typical symptoms. Bolus exposure also showed a higher diagnostic accuracy in predicting the resolution of epigastric pain (area under the curve [AUC]=0.723, P=0.013) and regurgitation (AUC=0.981, P<0.001). Secondary analyses were performed in patients without pathological reflux, defined as the DMS-negative (DMS<14.7) or AET-negative (AET<6%) groups. In the secondary analyses, bolus exposure showed considerable diagnostic accuracy with statistical significance for all typical symptoms in both in the DMS-negative (heartburn: AUC=0.717, P=0.025; epigastric pain: AUC=0.717, P=0.025; regurgitation: AUC=0.975, P<0.001) and AET-negative (heartburn: AUC=0.681, P=0.045; epigastric pain: AUC=0.749, P=0.009; regurgitation: AUC=0.975, P<0.001) groups. Bolus exposure, a parameter of total reflux, was superior to AET or DMS in defining candidates for ARS. Further studies investigating the surgical indications for ARS in patients with non-acid reflux using bolus exposure are required.

Evaluation and Management of Urological Complications Following Pediatric Kidney Transplantation: Experience from a Single Tertiary Center

Background/Objectives: Kidney transplantation is the treatment of choice for children with end-stage renal disease (ESRD), but its outcome can be affected by urological complications, with incidence rates of 2.5–25%. The aim of this study was to evaluate the occurrence of urological complications and their management in a cohort of pediatric kidney transplant recipients. Materials and Methods: A retrospective analysis on 178 patients who received a renal transplant at our Pediatric Kidney Transplant Center between 2011 and 2023 was conducted. Demographic and clinical data were analyzed. Urological complications were categorized as early, intermediate, or late based on their onset time. Results: Out of 178 patients, 28 (15.7%) experienced urological complications. Most patients (61%) had a pre-existing uropathy. Early complications (7–30 days) were all obstructive, namely, ureterovesical junction obstruction and perirenal collections. Intermediate complications (1–3 months) comprised ureteral stenosis, symptomatic vesicoureteral reflux (VUR), and obstructive lymphocele. Late complications (&gt;3 months) included symptomatic VUR and ureteral stenosis, with one case leading to ureteral rupture. Early complications were often detected due to acute graft dysfunction, while late ones were mainly identified during routine clinical, laboratory, or ultrasound follow-up. Urological complications requiring surgical or endoscopic therapy were 13.4%. Most ureteral stenoses were treated with initial endoscopic stents, followed by definitive surgery. VUR was treated with endoscopic correction with a high success rate (75%), while open surgery was reserved for cases where initial treatments failed or complications recurred. No clear correlations were found between patient characteristics and risk of urological complication. Urological complications required multiple diagnostic procedures and therapeutic interventions (+2.5 admissions in mean and approximately +EUR 24,000) compared to an uncomplicated post-transplant course. However, they did not significantly impact transplant outcomes, with a graft survival rate comparable to that of the control group. Conclusions: Regular post-transplant follow-up is crucial, especially for patients with known risk factors, to allow for timely detection and treatment of urological complications, avoiding detrimental effects on graft function and improving transplantation outcomes.

Development and validation of a novel nomogram to predict worsening of gastroesophageal reflux symptoms after laparoscopic sleeve gastrectomy using Lasso-logistic regression

Background Gastroesophageal reflux disease (GERD) is among the most common complications of bariatric surgery. This study aimed to analyse the risk factors affecting the worsening of GERD symptoms after laparoscopic sleeve gastrectomy (LSG), and to establish and validate a related nomogram model. Methods The study recruited 236 participants and randomly divided them into training and validation sets in a ratio of 7:3. LASSO regression technique was used to select the optimal predictive features, and multivariate logistic regression was used to construct the column line graphs. The performance of the nomogram was evaluated and validated by analyzing the area under the receiver operating characteristic (ROC) curve, calibration curve, and decision curve. Results In this study, Lasso-logistic regression was applied to select 5 predictors from the relevant variables, which were body mass index (BMI), diabetes, hiatal hernia, GERD, and triglyceride levels. These 5 predictor variables constructed a model with moderate predictive power, with an area under the ROC curve of 0.779 for the training set and 0.796 for the validation set. Decision curve analysis showed that in external validation, if the risk thresholds were between 4 and 98% and 14–95%, then the nomogram can be applied to the clinic. Conclusions We have developed and validated a nomogram that effectively predicts the risk of worsening gastroesophageal reflux symptoms following LSG.

Analysis of long-term efficacy of CO2 laser partial excision of vocal folds for 599 cases in the treatment of vocal cord leukoplakia

Objective: To analyze long-term prognosis and influencing factors of recurrence in vocal fold leukoplakia treated by endoscopic cordectomy with CO2 laser. Methods: A retrospective review was conducted on 599 patients with vocal fold leukoplakia [566 males and 33 females, aged 17-84 years (median age 55 years)], undergoing endoscopic cordectomy by CO2 laser under general anesthesia at the Department of Otorhinolaryngology Head and Neck Surgery of Beijing Tongren Hospital, Capital Medical University, from January 2000 to December 2023. The study analyzed the clinical features, pathological grade, surgical methods, postoperative voice function, recurrence, malignant changes and analyzed the long-term efficacy and and its influencing factors. The patients were followed up for a duration of 6-249 months postoperatively, with a median follow-up time of 48 months. SPSS 20.0 software was used for statistical analysis. Results: Among the 599 patients, the histopathological grades included simple squamous cell hyperplasia in (n=264, 44.08%), mild dysplasia (n=96, 16.03%), moderate dysplasia (n=74, 12.35%), severe dysplasia(n=43, 7.81%), carcinoma in situ(n=35, 5.84%), and carcinoma in situ with microinvasion(n=87, 14.52%). The 3-year and 5-year overall recurrence rates were 12.91% and 16.00%, respectively. In patients with precancerous lesion, 3.91% of recurrences presented with an upgraded pathologic grade and 2.34% evolved into carcinoma. The risk of recurrence was higher in lesions involving the anterior commissure, larger lesions, significant reduction/absence of mucosal waves, neovascularization/suspected neovascularization, and pathology of dysplasia/carcinoma in situ/carcinoma in situ with microinvasion(F=44.76,21.54,11.55,8.78,23.20,respectively,P<0.05). Additionally, patients with recurrent disease exhibited higher reflux symptom index scores compared to those without recurrence. Exophytic lesion characteristics and the inability to cease smoking postoperatively were identified as independent risk factors for recurrence with an upgraded pathological grade, with odds ratios of 8.675 and 11.380 times greater than those with non-exophytic lesions and successful smoking cessation, respectively. At the 6-months postoperative assessment, patients who underwent subepithelial cordectomy (typeⅠ) demonstrated a statistically significant increase in fundamental frequency (t=-3.38, P<0.05), and while other voice acoustic parameters were not significantly different.Conversely, those who underwent transmuscular cordectomy (TypeⅢ) exhibited significant alterations in multiple voice acoustic parameters when compared to preoperative values (P<0.05). Furthermore, postoperative vocal fold adhesions developed in 84 patients with 13 of these individuals requiring surgical intervention for adhesion release. Conclusions: Lesions involving the anterior commissure, larger lesions, pathology of dysplasia/carcinoma in situ/carcinoma in situ with microinfiltration, significant reduction/absence of vocal fold mucosal waves, and neovascularization visible under NBI are indicative of an increased risk of recurrence, whereas exophytic lesions and the inability to cease smoking postoperatively significantly increase the risk of recurrence with elevated pathologic grade. Recovery of postoperative voice quality is procedure-dependent, underscoring the importance of surgical approach selection in the management of vocal fold leukoplakia.

Gastrointestinal effects of caffeine in preterm infants: a systematic review and Bayesian meta-analysis

ObjectiveCaffeine is widely used in preterm infants to prevent or treat apnoea of prematurity. Adverse gastrointestinal effects of caffeine have not been thoroughly researched in preterm infants. With this systematic...

Efficacy of ursodeoxycholic acid for bile reflux after distal gastrectomy in patients with gastric cancer: A secondary analysis of the PEGASUS-D randomized clinical trial.

Few studies have been conducted on the prevention of bile reflux in gastric cancer patients who have undergone gastrectomy. The aim of this study was to evaluate the efficacy and safety of ursodeoxycholic acid (UDCA) in preventing bile reflux after gastrectomy in patients with gastric cancer. This study was a secondary analysis of the PEGASUS-D trial, a randomized, double-blind, placebo-controlled clinical trial. Adults with a diagnosis of gastric cancer who underwent gastrectomy were enrolled. Eligible participants were randomly assigned to receive 300mg of UDCA, 600mg of UDCA, or placebo at a ratio of 1:1:1. UDCA and placebo were administered daily for 52 weeks. The primary outcomes included bile reflux symptoms at each time point, percentage of participants with bile reflux, and the grade of gastritis. Among 521 participants who underwent randomization, 151, 164, and 150 participants were analyzed from the 300 mg UDCA, 600mg UDCA, and placebo groups, respectively. The difference in symptoms between the three groups was not significant. Bile reflux was less evident in the UDCA group than in the placebo group; however, this difference was significant only in the 300-mg group at 12 months post-operation (odds ratio, 0.44; P = 0.0076). A significant reduction in gastritis was also observed in the 300-mg group at 12 months post-operation (odds ratio, 0.50; P = 0.0368) compared to the placebo group. This study showed that UDCA administration significantly reduced bile reflux and gastritis by approximately 50% at the 12 months-postoperative follow-up in patients who underwent gastrectomy for gastric cancer.