Use Of Antireflux Medications Research Articles

Intrathoracic Sleeve Migration Following Sleeve Gastrectomy: Incidence and Outcomes.

With laparoscopic sleeve gastrectomy (LSG) taking its place as the primary metabolic bariatric procedure in the past decade, de novo or persistent gastroesophageal reflux disease (GERD) has come into the spotlight as one of the most debilitating postoperative complications. Among the causes of GERD, intrathoracic migration (ITM) of the sleeve has become an understated yet significant phenomenon. This study aims to analyze the actual incidence of spontaneous ITM at our center, as well as its relationship to the baseline characteristics of patients and perioperative outcomes. A retrospective chart review of 206 patients who had undergone LSG at our center from July 2019 to December 2022 was done. At 1-year follow-up, a non-enhanced abdominopelvic computed tomography (CT) scan and esophagogastroduodenoscopy (EGD) were performed, and these exams were repeated annually. Baseline characteristics and perioperative outcomes including the clinical disease course of GERD were compared. The incidence of ITM was 14% (n = 29). There was a significant correlation between ITM and postoperative reflux symptoms (p = 0.001). The mean duration of anti-reflux medication use was also significantly longer in the ITM group than in the no ITM group at 17 and 11months, respectively (p = 0.004). A significantly higher number of patients in the ITM group were diagnosed with esophagitis on postoperative EGD than in the no ITM group (p = 0.002). The incidence of ITM using non-enhanced CT was 14%. ITM was significantly correlated to clinical reflux and EGD-confirmed esophagitis.

Prevalence of Gastroesophageal Reflux Disease in Congenital Diaphragmatic Hernia Survivors From Infancy to Adulthood

BackgroundGastroesophageal reflux disease (GERD) is a common comorbidity associated with congenital diaphragmatic hernia (CDH), with reported cases of Barrett's esophagus (BE) and esophageal adenocarcinoma before the age of 25. The prevalence and natural course of GERD in CDH survivors remain uncertain due to variations in diagnostic methods. We aimed to analyse the GERD prevalence from infancy through young adulthood. MethodsWe retrospectively analyzed pH-impedance measurements and endoscopic findings in 96 CDH survivors evaluated as routine care using well established clinical protocols.GERD was defined as an abnormal acid exposure time for pH-MII measurements and as presence of reflux esophagitis or BE at upper endoscopy. Clinical data including symptoms at time of follow-up and use of antireflux medication were collected. ResultsGERD prevalence remained consistently low (≤10%) across all age groups, yet many patients experienced GER symptoms. Histological abnormalities were observed in 80% of adolescents and young adults, including microscopic esophagitis in 50%. BE was diagnosed in 7% before the age of 18, all had GER symptoms. CDH severity, anatomy at the time of CDH correction, alcohol usage, and smoking did not emerge as significant risk factors for GERD. ConclusionsGiven the low GERD prevalence in CDH survivors, a symptom-driven approach to diagnosis and follow-up is warranted. We advise long-term follow-up for all adult patients due to the early onset of BE and the limited evidence available. The longitudinal course and impact of GERD on other long-term CDH-related comorbidities should be explored in larger cohorts. Level of EvidenceNot applicable

Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: impact on reflux and weight loss

BackgroundSleeve gastrectomy (SG) is the most commonly performed weight loss operation, and its 2 most common complications are postoperative reflux and weight recurrence. There is limited evidence to guide decision-making in treating these conditions. ObjectivesTo determine the efficacy of conversion of SG to Roux-en-Y gastric bypass (RYGB) for GERD management and weight loss. SettingForty-one hospitals in Michigan. MethodsWe conducted a retrospective cohort study examining patients who underwent conversion of SG to RYGB from 2014 to 2022. The primary outcomes were changes in GERD-HRQL scores, anti-reflux medication use, and weight from baseline to 1 year after conversion. Secondary outcomes included 30-day postoperative complications and resource utilization. ResultsAmong 2133 patients undergoing conversion, 279 (13%) patients had baseline and 1-year GERD-HRQL survey data and anti-reflux medication data. GERD-HRQL scores decreased significantly from 24.6 to 6.6 (P < .01). Among these, 207 patients (74%) required anti-reflux medication at baseline, with only 76 patients (27%) requiring anti-reflux medication at 1 year postoperatively (P < .01). Of the 380 patients (18%) with weight loss data, mean weight decreased by 68.4lbs, with a 24.3% decline in total body weight and 51.5% decline in excess body weight. In terms of 30-day complications, 308 (14%) patients experienced any complication and 89 (4%) experienced a serious complication, but there were no leaks, perforations, or deaths. Three-hundred and fifty-five (17%) patients presented to the emergency department and 64 (3%) patients underwent reoperation. ConclusionsThis study represents the largest reported experience with conversion from SG to RYGB. We found that conversion to RYGB is associated with significant improvement in GERD symptoms, reduction in anti-reflux medication use, and significant weight loss and is therefore an effective treatment for GERD and weight regain after SG. However, the risks and benefits of conversion surgery should be carefully considered, especially in patients with significant comorbidity burden.

Long-term impact of gastropexy on use of acid-reducing medication, second operations for gastroesophageal reflux and subjective reflux symptoms after sleeve gastrectomy.

We investigated whether adding gastropexy to sleeve gastrectomy (SG) reduced gastroesophageal reflux disease (GERD) in patients operated for severe obesity, assessed mainly by use of anti-reflux medication (ARM) and second operations due to GERD worsening. In a prospective non-randomized study, patients undergoing SG at two Norwegian hospitals were included from 2011 to 2015 and followed for 7 years. GERD was defined by regular use of ARM, and epigastric pain and heartburn were measured by the Rome II questionnaire. Gastropexy was done by suturing the gastrocolic ligament to the staple line. Patients undergoing SG only, mainly before gastropexia was introduced in 2013, were compared to those with additional gastropexy from 2013 onwards. Of 376 included patients (75% females, mean age 42.6 years and BMI 42.9 kg/m2 ), 350 (93%) and 232 (62%) were available for evaluation after 1 and 7 years, respectively. Baseline characteristics in the no-gastropexy (n = 235) and gastropexy groups (n = 141) were similar. In patients without ARM use before surgery, the use increased and in those that used ARM at baseline, the proportion decreased, with no difference in the no-gastropexy and gastropexy groups. With a combined endpoint of ARM use and/or second operation for GERD, there was no difference during follow-up between the two groups. With time, adding gastropexy did not reduce symptoms of GERD significantly. In this population, adding gastropexy to SG did not reduce use of ARM and/or second operation for uncontrolled GERD, epigastric pain or heartburn during the first 7 postoperative years.

Corrosive Esophageal Strictures: Alarming News for Gastroenterologists

Dysphagia is a common yet alarming symptom reported by patients during routine visits to outpatient clinics of gastroenterology. Most of them have a chronic history gastroesophageal reflux disease and use of proton pump inhibitors or anti reflux medications for years. The agonising part is that they are not referred by the physicians in the general practice. One of the major reasons behind this is persistent reluctance of patients to go for invasive investigations Gastroesophgeal reflus disease, achalasia ,hiatal hernia,benign esophgeal strictures, barrets esophagus and esophageal carcinoma are common causes of dysphagia. One of the causes which has been quite prevalent in our country is use of corrosives especially young girls and boys who are emotionaland depressed. They do something very outrageous in a moment which becomes a reason for regret for a long time .Corrosive esophgeal strictures isn’t that difficult got gastroenterology experts in normal circumstances but the cases can get complicated rarely including the risk of perforation in early stages of injury. Endoscopic dilatation either by Savory or TTS Balloon has been the cardinal line of management of corrosive strictures. They are done after necessary workup and investigations including barium swallow . The real dilemma is that patent develop complications like tracheoesophageal fistula after repeated dilatations. The length of follow up session are also difficult to determine with some centres opting for one weekly and others for two weekly sessions .Weekly sessions have been reported to ease off symptoms like dyphagia but causes higher risk of complications while in case of two weekly follow up there is enhanced risk of recurrence of symptoms and lesser complications.

Redo fundoplication vs. Roux-en-Y gastric bypass conversion for failed anti-reflux surgery: which is better?

Different techniques have been proposed for reoperation after failed anti-reflux surgery. However, there is no consensus on which should be preferred. We aim to report and compare the outcomes of different revisional techniques for failed anti-reflux surgery. We performed a retrospective analysis of patients who underwent redo fundoplication (RF) or Roux-en-Y gastric bypass (RYGB) conversion after a failed fundoplication at our institution between 2016 and 2021. The primary outcome was long-term presence of reflux or dysphagia following revisional surgery. Secondary outcomes included 30-day perioperative complications as well as long-term use of anti-reflux medication and radiographic recurrence of hiatal hernia (HH). A total of 165 (median age 63years, 73.9% female) patients were included. RF was performed in 120 (73 Toupet and 47 Nissen), RYGB in 38, and 7 patients had fundoplication takedown alone. The RYGB group had a significantly higher BMI, and more prior revisional surgeries compared to the other groups. Median operative time and length of stay were longer for RYGB. Twenty (12.1%) patients experienced postoperative complications, with the highest incidence in the RYGB group. Reflux and dysphagia improved significantly for the whole cohort, with the greatest improvement noted with reflux in the RYGB group (89.5% with preoperative reflux vs. 10.5% with postoperative reflux, p = < .001). On multivariable regression we found that prior re-operative surgery was associated with persistent reflux and dysphagia, whereas RYGB conversion was protective against reflux. Conversion to RYGB may offer superior resolution of reflux than RF, especially for obese patients.

Clinical and financial outcomes of per-oral endoscopic myotomy compared to laparoscopic heller myotomy for treatment of achalasia.

Previous studies analyzing short-term outcomes for per-oral endoscopic myotomy (POEM) have shown excellent clinical response rates and shorter operative times compared to laparoscopic Heller myotomy (LHM). Despite this, many payors have been slow to recognize POEM as a valid treatment option. Furthermore, comparative studies analyzing long-term outcomes are limited. This study compares perioperative and long-term outcomes, cost-effectiveness, and reimbursement for POEM and LHM at a single institution. Adult patients who underwent POEM or LHM between 2014 and 2021 and had complete preoperative data with at least one complete follow up, were retrospectively analyzed. Demographic data, success rate, operative time, myotomy length, length of stay, pre- and postoperative symptom scores, anti-reflux medication use, cost and reimbursement were compared. 58 patients met inclusion with 25 undergoing LHM and 33 undergoing POEM. There were no significant differences in preoperative characteristics. Treatment success (Eckardt ≤ 3) for POEM and LHM was achieved by 88% and 76% of patients, respectively (p = 0.302). POEM patients had a shorter median operative time (106min. vs. 145min., p = 0.003) and longer median myotomy length (11cm vs. 8cm, p < 0.001). All LHM patients had a length of stay (LOS) ≥ 1day vs. 51.5% for POEM patients (p < 0.001). Both groups showed improvements in dysphagia, heartburn, regurgitation, Eckardt score, GERD HRQL, RSI, and anti-reflux medication use. The improvement in dysphagia score was greater in patients undergoing POEM (2.30 vs 1.12, p = 0.003). Median hospital reimbursement was dramatically less for POEM ($3,658 vs. $14,152, p = 0.002), despite median hospital costs being significantly lower compared to LHM ($2,420 vs. $3,132, p = 0.029). POEM is associated with a shorter operative time and LOS, longer myotomy length, and greater resolution of dysphagia compared to LHM. POEM costs are significantly less than LHM but is poorly reimbursed.

Laryngopharyngeal reflux in children- a current Otolaryngologists perspective

Gastroesophageal reflux disease (GERD) is diagnosed when the reflux of the stomach contents causes complications or troublesome symptoms. This disease can present with esophageal or extraesophageal symptoms. Laryngopharyngeal reflux (LPR) occurs when gastric contents reflux beyond the oesophagus to laryngopharynx, oropharynx or nasopharynx and it can cause symptoms such as: globus, hoarseness, chronic cough, regurgitations, vomiting or failure to thrive in infants. LPR can influence clinical course of many diseases i.a laryngomalacia, subglottic stenosis, chronic hoarseness and/or recurrent respiratory papillomatosis. LPR is also believed to be a factor leading to formation of laryngeal granulomas, ulcerations, Reinkes edema, functional voice disorders, sinusitis, otitis media or even life threatening events in neonates. The main diagnostic methods currently used are laryngoscopy, 24-hours pH-metry and esophageal multichannel intraluminal impedance testing. Treatment consist of lifestyle changes and pharmacologic treatment.The use of antireflux medications is not recommended in patients with extraesophageal symptoms in absence of typical GERD symptoms. Surgical treatment can be considered in children with severe LPR symptoms refractory to pharmacological treatment. Controversies regarding diagnosis and treatment of LPR still exists. Further investigations are needed to establish guidelines for the diagnosis and management of LPR.

Long-term comparative effectiveness of gastric bypass and sleeve gastrectomy on use of antireflux medication: a difference-in-differences analysis.

Gastroesophageal reflux (GERD) is common among patients with obesity who undergo bariatric surgery. Although gastric bypass and sleeve gastrectomy are the most common bariatric operations performed in the United States, their long-term comparative effectiveness on GERD medication use is unknown. To compare the long-term effectiveness of gastric bypass and sleeve gastrectomy on use of antireflux medication. National cohort undergoing inpatient bariatric surgery. This is a retrospective study of Medicare beneficiaries undergoing gastric bypass and sleeve gastrectomy between January 1, 2012, and December 31, 2017. A difference-in-differences analysis was conducted to evaluate the differential change in antireflux medication use between groups before and after surgery. A total of 16,640 patients underwent gastric bypass, and 26,724 patients underwent sleeve gastrectomy. Before surgery, GERD medication use was higher among patients who underwent gastric bypass (62.4%; 95% confidence interval [CI]: 62.0%-63.7%) compared with patients who underwent sleeve gastrectomy (60.1%; 95% CI: 59.3%-60.9%). Five years after surgery, GERD medication use was lower in patients who underwent gastric bypass (47.8%; 95% CI: 46.3%-49.3%) compared with patients who underwent sleeve gastrectomy (53.7%; 95% CI: 50.5%-56.9%). The differential decrease from baseline GERD medication use was greater for patients who underwent gastric bypass at 2 years (-4.1 percentage points [pp]; 95% CI: -1.7 to -6.5 pp), 3 years (-4.3 pp; 95% CI: -1.6 to -7.0 pp), 4 years (-6.9 pp; 95% CI: -4.1 to -9.6 pp), and 5 years (-8.3 pp; 95% CI: -3.7 to 12.8 pp) after surgery. Though use of antireflux medication decreased following both procedures, gastric bypass was associated with a greater reduction in antireflux medication use 5 years after surgery compared with sleeve gastrectomy. Understanding the long-term comparative effectiveness of these common bariatric operations may better inform treatment decisions among patients and surgeons.

Laparoscopic revision paraesophageal hernia repair: a 16-year experience at a single institution.

Laparoscopic paraesophageal hernia repair (PEHr) is a safe and effective procedure for relieving foregut symptoms associated with paraesophageal hernias (PEH). Nonetheless, it is estimated that about 30-50% of patients will have symptomatic recurrence requiring additional surgical intervention. Revision surgery is technically demanding and may be associated with a higher rate of morbidity and poor patient-reported outcomes. We present the largest study of perioperative and quality-of-life outcomes among patients who underwent laparoscopic revision PEHr. A retrospective review of all patients who underwent laparoscopic revision paraesophageal hernia repair between February 2003 and October 2019, at a single institution was conducted. All revisions of Type I hiatal hernias were excluded. The following validated surveys were used to evaluate quality-of-life outcomes: Reflux Symptom Index (RSI) and Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL). Patient demographic, perioperative, and quality-of-life (QOL) data wereanalyzed using univariate analysis. One hundred ninety patients were included in the final analysis (63.2% female, 90.5% single revision, 9.5% multiple revisions) with a mean age, BMI, and age-adjusted Charlson score of 56.6 ± 14.7years, 29.7 ± 5.7kg/m2, and 2.04 ± 1.9, respectively. The study cohort consisted of type II (49.5%), III (46.3%), and IV hiatal hernia (4.2%), respectively. Most patients underwent either a complete (68.7%) or partial (27.7%) fundoplication. A Collis gastroplasty was performed in 14.7% of patients. The median follow-up was 17.6months. The overall morbidity and mortality rate were 15.8% and 1.1%, respectively. The 30-day readmission rate was 9.5%. Additionally, at latest follow-up 47.9% remained on antireflux medication. At latest follow-up, there was significant improvement in mean RSI score (46.4%, p < 0.001) from baseline within the study population. Furthermore, there was no significant difference in QOL between patients who had a history of an initial repair only or history of revision surgery at latest review. The overall recurrence rate was 16.3% with 6.3% requiring a surgical revision. Laparoscopic revision PEHr is associated with a low rate of morbidity and mortality. Revision surgery may provide improvement in QOL outcomes, despite the high rate of long-term antireflux medication use. The rate of recurrent paraesophageal hernia remains low with few patients requiring a second revision. However, longer follow-up is needed to better characterize the long-term recurrence rate and symptomatic improvements.

Anti-reflux medication use in preterm infants

BackgroundCurrent recommendations do not support the use of anti-reflux medications to treat gastro-oesophageal reflux disease (GORD) among preterm infants.ObjectiveTo describe the prevalence of GORD and the use of anti-reflux medications amongst very preterm infants (<32 weeks’ gestational age (GA)) in neonatal units in England and Wales.DesignRetrospective cohort study using the National Neonatal Research Database.ResultsAmong 58,108 infants [median GA (IQR) 29 (27–30) weeks], 15.8% (n = 9191) had a diagnosis of GORD and 36.9% (n = 12,446) received anti-reflux medications. Those who received anti-reflux medications were more preterm [GA, median (IQR): medications, 28 (26–30) vs. no medications, 30 (28–31); p < 0.001] and had lower birth weight [mean (SD): medications, 1124 g (354) vs. no medications, 1265 g (384); p < 0.001]. Most (57%, n = 12,224) received Gaviscon, or Histamine-2 Receptor Antagonist (H2RA) (56%, n = 11,959). Over time, prokinetic use has declined substantially, the use of H2RAs and Gaviscon has reduced although they continue to be used frequently, whilst the use of PPIs has increased.ConclusionsAnti-reflux medications are frequently prescribed in very preterm infants, despite evidence to suggest that they are not effective and may be harmful. Clear guidelines for diagnosing GORD and the use of anti-reflux medications are required to rationalise the pharmacological management of GORD in preterm infants.ImpactAnti-reflux medications are frequently prescribed, often without a diagnosis of gastro-oesophageal reflux disease, to very preterm infants while in the neonatal unit and at discharge.Half of the infants born at <28 weeks’ gestational age receive anti-reflux medications in hospital and a quarter are discharged home on them.Although the use of prokinetics declined following alerts of adverse events, histamine2-receptor antagonists and alginates such as Gaviscon continue to be used and the use of proton-pump inhibitors has increased more than 2-fold.

Effect of anti-reflux therapy on pulmonary function in idiopathic pulmonary fibrosis: a systematic review and meta-analysis.

BackgroundCurrent guideline conditionally recommends regular use of anti-reflux medication in idiopathic pulmonary fibrosis (IPF). However, the effect of anti-reflux therapy in this group remains controversial. We systematically reviewed literatures to evaluate whether anti-reflux therapy could ameliorate pulmonary function in IPF.MethodsWe performed electronic search in PubMed, Embase and CENTRAL (Cochrane Central Register of Controlled Trials) to identify original articles published in English language. We included randomized controlled trials (RCTs) and observational studies regarding anti-reflux therapy on pulmonary function in IPF. Qualitative and quantitative analyses were conducted. In quantitative analysis, the inverse-variance method with fixed-effect model was used to analyze pooled data.ResultsFifteen studies (2 RCTs and 13 observational studies) including 3,891 patients with IPF were included. Pooled analysis suggested that anti-reflux therapy did not improve forced vital capacity (FVC)% predicted [mean difference (MD) =0.88, 95% confidence interval (CI): −0.22 to 1.98, P=0.12, I2 =0%, 8 studies, n=3,076], diffusing capacity of the lung for carbon monoxide (DLCO) % predicted (MD =0.75, 95% CI: −0.13 to 1.62, P=0.10, I2 =0%, 8 studies, n=3,073), and FVC decline (MD =0.02, 95% CI: −0.01 to 0.04, P=0.29, I2 =17%, 5 studies, n=1,586) in IPF.DiscussionAnti-reflux therapy may not ameliorate pulmonary function in IPF. However, adequately powered studies are warranted to validate the present findings.

Decreasing Inappropriate Use of Antireflux Medications by Standardizing Gastroesophageal Reflux Disease Management in NICU.

A multidisciplinary team developed evidence-based clinical practice guidelines (CPG) for GERD management. Process improvement included developing a GERD management algorithm, electronic order sets, and education for all providers. Multiple plan-do-study-act cycles done. Implementation of standardized GERD management guideline, decreased the overall use of antireflux medications from baseline, 15.1%-6.8% [χ2 (1, N = 1259) = 12.98, P < 0.001]. There was elimination of GERD medication use in preterm from baseline of 19.3% [χ2 (1, N = 220) = 12.18, P < 0.001]. The most frequently used GERD medication was lansoprazole, with an incorrect initial dosing rate of 55.0% that deceased to zero [χ2 (1, N = 33) = 10.73, P = 0.001]. Appropriate testing with PH probe with 24-hour multichannel impedance was observed (17.1%-28.0%) identifying patients with correct GERD diagnosis [χ2 (1, N = 101) = 1.41, P = 0.236]. Length of stay for GERD patient's improved from a median of 89-53 days. Standardizing clinical management leads to best practices for GERD management with appropriate diagnostic testing, eliminating incorrect medication dosing, and improved patient safety with value-based outcomes.

Gastroesophageal Reflux Disease in Neonates: Facts and Figures.

* Abbreviations: AAP: : American Academy of Pediatrics BPD: : bronchopulmonary dysplasia CMPA: : cow milk protein allergy GEJ: : gastroesophageal junction GER: : gastroesophageal reflux GERD: : gastroesophageal reflux disease H2RA: : histamine 2 receptor antagonist LES: : lower esophageal sphincter NASPGHAN: : North American Society of Pediatric Gastroenterology, Hepatology and Nutrition pH-MII: : multichannel intraluminal pH impedance PPI: : proton pump inhibitor SLESR: : swallow-associated lower esophageal sphincter relaxation SSI: : symptom sensitivity index TLESR: : transient lower esophageal sphincter relaxation VLBW: : very low-birthweight Clinicians caring for premature infants need to recognize the natural history and pathophysiology of gastroesophageal reflux (GER) and GER disease. Clinicians also need to make the most out of the diagnostic tools available in their clinical settings and offer the most appropriate therapy for these conditions, which constitute a significant burden to patients and to our health care system. After completing this article, readers should be able to: 1. Explain the terminology, mechanisms, and controversies surrounding gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) in neonates. 2. Describe the epidemiology, pathophysiology, and risk factors of GER and GERD in neonates. 3. Explain the approach to evaluate, diagnose, and manage GERD in neonates. Gastroesophageal reflux (GER) is a normal physiologic process that occurs in all age groups. In healthy preterm infants, an average of 2 to 3 reflux events occur per hour, as has been reported using 24-hour pH impedance monitoring. (1) GER has historically been associated with a wide variety of behaviors commonly attributed to “GERD-like” symptoms in infants. (2) However, the association between a specific symptom and GER needs supporting data. (3) In the NICU infant, many of these symptoms may have multisystemic etiologies related to prematurity, chronic lung disease, and neuropathology, among others, rather than solely GER. Over the years, GER has remained a controversial topic for clinicians because of the challenges that entail its accurate diagnosis, as well as the uncertainty of treatment efficacy in symptomatic neonates. Furthermore, various studies have shown that histamine 2 receptor antagonists (H2RAs), proton pump inhibitors (PPIs), and prokinetics therapy may be associated with serious adverse outcomes in preterm infants. (4)(5)(6)(7) In addition, the American Academy of Pediatrics (AAP) through the “Choosing Wisely in Newborn Medicine” initiative highlighted routine use of antireflux medications in symptomatic GER in preterm infants …

The Natural Course of Gastroesophageal Reflux Disease: A Critical Appraisal of the Literature.

Interpreting natural course studies have been very difficult due to their retrospective design, lack of standardization, reliability of reported mucosal findings, liberal use of antireflux medications and accuracy of chart documentation. Studies provided a wide range of progression rates of patients from nonerosive reflux disease (NERD) to erosive esophagitis (EE). However, direct progression from NERD to Barrett's esophagus appears to be an uncommon phenomenon. Importantly, progression of NERD patients was commonly reported to low grades of EE, which are currently considered inconclusive of gastroesophageal reflux disease. Reports of progression rates from low grades to high grades EE also vary considerably. Progression of patients with EE, without metaplastic epithelium underneath the inflammation, to Barrett's esophagus is relatively uncommon. Recently, it was also recognized that regression from high grades to low grades EE and from EE to NERD is a common phenomenon affecting up to 25% of the patients from each group.

Use of anti-reflux medications in infants under 1 year of age: a retrospective drug utilization study using national prescription reimbursement data

Non-specific symptoms such as irritability, vomiting, and back arching during the infant period are often attributed to gastroesophageal reflux. While numerous studies have shown no significant benefit to the use of acid suppressant medications in this population, these medications are frequently prescribed in response to these symptoms. Our goals were to understand how often children were being prescribed this medication. To do this, data was extracted from a national database for reimbursement of prescribed medications through the General Medical Services scheme (GMS). Infants aged less than 1 year and eligible for reimbursement under GMS were included for analysis. A total of 450 infants per 10,000 eligible population received an anti-reflux preparation from the following drug classes (H2 antagonists, proton pump inhibitors, or alginate preparations) in 2018. This is compared with that in 2009 where only 137 per 10,000 eligible infants received these medications. This increase was predominantly attributable to an increase in ranitidine prescriptions.Conclusion: Despite a change in clinical guidelines, anti-reflux preparations are increasingly being prescribed to infants aged less than 1 year. The reasons behind the increase in prescriptions containing these medications cannot be ascertained from this data. This may suggest a proportion of these prescriptions may be unwarranted in this population. What is Known: • The prescription of PPIs in infants has increased in a number of countries. • Use of anti-reflux medications has a very poor evidence base in infancy. What is New: • This data focuses only on an infant age group in a "well" cohort. • Ranitidine may contribute to increased acid-suppressant use in infancy.

Long-term Symptom Control After Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia

Achalasia is a primary esophageal motility disorder in which there is incomplete relaxation of the lower esophageal sphincter and absence of peristalsis in the lower two thirds of the esophagus. A favored treatment is laparoscopic modified Heller myotomy with Dor fundoplication (LHMDor) with more than 90% immediate beneficial effect. The short-term outcomes of LHMDor are well documented, but stability and durability of postoperative symptom control over time is less understood. Between 2004 and 2016, 54 patients with achalasia underwent LHMDor (single center). Using validated questionnaires, patients rated their symptoms in five domains: pain, gastroesophageal reflux disease (GERD), dysphagia, regurgitation, and quality of life. Symptom ratings were done preoperatively, 4 weeks postoperatively, 6 months postoperatively, and yearly after the operation. As expected, patients reported marked improvement in dysphagia, odynophagia, regurgitation, GERD, and quality of life after the operation (P < .001). From then on, the symptom control remained durable with respect to absence of pain, regurgitation, and odynophagia; however, we observed a recurrence of GERD symptoms beginning 3 to 5 years postoperatively (P= .001 and P= .04, respectively), with associated increased antireflux medication use. After initial LHMDor, 5 patients required endoscopic dilatation an average of 1.5 years postoperatively, and no patient required reoperation. Patients reported preserved improved quality of life to 11 years after the operation (P= .001). These results demonstrate the durability of LHMDor in the definitive management of achalasia, offering consistent symptomatic relief and significant improvement in quality of life over the decade after surgery, despite some increase in GERD symptoms and antireflux medication use.

Treatment of newly-diagnosed gastroesophageal reflux disease: a nationwide register-based cohort study

Objective: The aim of this study was to describe short-term treatment of gastroesophageal reflux disease (GERD) in patients registered with a GERD-diagnosis as part of evaluation with endoscopy using national Danish registers.Methods: The study population included all adults undergoing upper gastrointestinal endoscopy in Denmark from 1 January 2000 to 31 December 2015, who within 90 days received a diagnosis of GERD. We obtained nationwide data from The National Patient Registry on procedures (endoscopy and anti-reflux surgery) and diagnosis (GERD diagnosis and comorbidity), The Danish National Prescription Registry on the use of anti-reflux medication and ulcerogenic drugs, and The National Civil Registry on death and civil status. The primary outcome was a type of treatment of GERD within two years of primary endoscopy defined as either no treatment, medical treatment alone, surgical treatment alone or both medical and surgical treatment.Results: A total of 36,292 patients were included in the study. Endoscopies were performed without biopsies in 67.5% (n = 24,479) of cases. The majority (66.3%, n = 24,077) was registered as GERD with esophagitis. After initial endoscopy, 10.6% (n = 3862) received no pharmacological or surgical treatment for GERD within two years of follow-up, 87.5% (n = 31,761) received only pharmacological treatment, 0.1% (n = 50) received only surgical treatment and 1.7% (n = 619) received a combination of pharmacological and surgical treatment.Conclusion: Patients referred to investigation with endoscopy and diagnosed with GERD in Denmark are primarily treated with pharmacological anti-reflux treatment within the first two years with PPI being the primary agent. Only a small fraction of patients is treated surgically.

Partial fundoplication may be an effective therapy for gastroesophageal reflux disease for patients with severe esophageal dysmotility

We appreciate Dr. Herbella’s thorough review on our article. Indeed, the updated classification on esophageal dysmotility based on high-resolution manometry brings a new perspective for the treatment of patients with gastroesophageal reflux disease (GERD). Due to the high prevalence of GERD, and its commonly related esophageal conditions, is it crucial to understand not only the benefits of surgical treatment for this disease, but also which surgical technique is most appropriate in this scenario. This is particularly important for patients with severe esophageal dysmotility, who often present with dysphagia after fundoplication, requiring additional postoperative dilations and continuous use of anti-reflux medication (1).

Prenatal use of medications for gastroesophageal reflux disease and early childhood fracture risk.

Gastroesophageal reflux disease is a common condition in pregnancy and is often managed with medications. Specific medications have been linked to osteoporosis and fragility fracture in older adults. This study assessed whether maternal use of antireflux medications is associated with early childhood fracture. TRICARE beneficiaries during pregnancy were retrospectively identified using the Military Health System Data Repository and pharmacy data. Mother and infant data were linked; children with continuous enrollment for the first 5years of life were included. Differences in the children's fracture risk were analyzed through multivariate analysis, adjusting for region, rank, and military branch of service. A total of 378150 patients comprised the final cohort with 3.3% (n=12479) prescribed antireflux medications during pregnancy. A significant decrease in fracture rate was found among children of women who were prescribed antireflux medications during pregnancy compared with those who were not (0.8% vs 1.2%, RR=0.70, 95% CI 0.58-0.85). There was no difference in fracture risk between histamine type 2 receptor antagonists and proton pump inhibitors. A significantly increased fracture incidence was seen in pregnancies with multiple gestations (RR=1.38, 95% CI 1.04-1.85). There was no identified difference in fracture risk for women with gestational diabetes, preeclampsia, preterm or low birthweight, chronic hypertension, induction, or breech presentation when compared to women without these conditions. We found no increase in early childhood fracture risk with maternal antireflux medication use. This suggests that prenatal exposure to antireflux medications does not affect fetal bones to a clinically significant extent.