Can symptoms predict esophageal motor function or acid exposure in gastroesophageal reflux disease? A comparison of esophageal manometric and twenty-four-hour pH parameters in typical and extraesophageal gastroesophageal reflux disease

It has been suggested that patterns of esophageal motor function and acid exposure may differ between those patients with gastroesophageal reflux disease (GERD) with classic symptoms and those with extraesophageal manifestations. Our objective was to compare various parameters of esophageal motility and acid exposure between groups of patients who had presented with extraesophageal manifestations of GERD alone, a combination of classic and extraesophageal manifestations, or classic GERD symptoms alone. A retrospective review of consecutive patients undergoing esophageal manometry and 24-hour dual-channel esophageal pH testing was performed. Information on patient demographics, symptoms, and results of various manometric and pH testing parameters was examined. We evaluated 84 patients: 32 with extraesophageal symptoms alone, 24 with both classic and extraesophageal symptoms, and 28 with classic symptoms alone. Apart from a trend toward less supine acid exposure in those with extraesophageal symptoms alone, no significant differences were evident among the three patient groups in any of the other parameters of proximal or distal esophageal acid reflux. With respect to motility parameters, lower esophageal sphincter pressure was lower in those with combined symptoms; otherwise, manometric findings were similar in the three patient groups. Our data do not support the hypothesis that the nature of the clinical presentation of GERD, whether in the form of classic or extraesophageal manifestations, is related to differing patterns of esophageal motor function or esophageal acid exposure.     

Safety, tolerability, and efficacy of endoscopic low-pressure liquid nitrogen spray cryotherapy in the esophagus

Endoscopic cryotherapy is a new technique for ablation of esophageal dysplasia and neoplasia. Preliminary studies have shown it to be safe and effective for this indication. The objective of this study is to characterize safety, tolerability, and efficacy of low‐pressure liquid nitrogen endoscopic spray cryotherapy ablation in a large cohort across multiple study sites. Parallel prospective treatment studies at four tertiary care academic medical centers in the U.S. assessed spray cryotherapy in patients with Barrett's esophagus with or without dysplasia, early stage esophageal cancer, and severe squamous dysplasia who underwent cryotherapy ablation of the esophagus. All patients were contacted between 1 and 10 days after treatment to assess for side effects and complications of treatment. The main outcome measurement was the incidence of serious adverse events and side effects from treatment. Complete response for high‐grade dysplasia (HGD) (CR‐HGD), all dysplasia (CR‐D), intestinal metaplasia (CR‐IM) and cancer (CR‐C) were assessed in patients completing therapy during the study period. A total of 77 patients were treated for Barrett's high‐grade dysplasia (58.4%), intramucosal carcinoma (16.9%), invasive carcinoma (13%), Barrett's esophagus without dysplasia (9.1%), and severe squamous dysplasia (2.6%). Twenty‐two patients (28.6%) reported no side effects throughout treatment. In 323 procedures, the most common complaint was chest pain (17.6%) followed by dysphagia (13.3%), odynophagia (12.1%), and sore throat (9.6%). The mean duration of any symptoms was 3.6 days. No side effects were reported in 48% of the procedures (155/323). Symptoms did not correlate with age, gender, diagnosis, or to treatment early versus late in the patient's or site's experience. Logit analysis showed that symptoms were greater in those with a Barrett's segment of 6 cm or longer. Gastric perforation occurred in one patient with Marfan's syndrome. Esophageal stricture developed in three, all successfully treated with dilation. In 17 HGD patients, cryotherapy produced CR‐HGD, CR‐D, and CR‐IM of 94%, 88%, and 53%, respectively. Complete regression of cancer and HGD was seen in all seven patients with intramucosal carcinoma or stage I esophageal cancer. Endoscopic spray cryotherapy ablation using low‐pressure liquid nitrogen in the esophagus is safe, well‐tolerated, and efficacious.     

Short‐term and long‐term effect of diaphragm biofeedback training in gastroesophageal reflux disease: an open‐label,pilot, randomized trial

This study investigated the effectiveness of diaphragm biofeedback training (DBT) for patients with gastroesophageal reflux disease (GERD). A total of 40 patients with GERD treated at the Peking Union Medical College Hospital between September 2004 and July 2006 were randomized to receive DBT and rabeprazole proton pump inhibitor (PPI) or rabeprazole alone. The DBT + rabeprazole group received DBT during the 8‐week initial treatment; the rabeprazole group did not. During the 6‐month follow up, all patients took acid suppression according to their reflux symptoms, and the patients in the DBT + rabeprazole group were required to continue DBT. The primary outcome (used for power analysis) was the amount of acid suppression used at 6 months. Secondary outcomes were reflux symptoms, health‐related quality of life (HRQL), and esophageal motility differences after the 8‐week treatment compared with baseline. Acid suppression usage significantly decreased in the DBT + rabeprazole group compared with the rabeprazole group at 6 months (P < 0.05). At 8 weeks, reflux s ymptoms and GERD‐HRQL were significantly improved in both groups (P < 0.05), without difference between them. Crural diaphragm tension (CDT) and gastroesophageal junction pressure (GEJP) significantly increased in the DBT + rabeprazole group (P < 0.05), but without change in lower esophageal sphincter (LES) pressure. There was no significant change in CDT, GEJP, and LES pressure compared with baseline in the rabeprazole group. In conclusion, long‐term DBT could reduce acid suppression usage by enhancing the anti‐reflux barrier, providing a non‐pharmacological maintenance therapy and reducing medical costs for patients with GERD.     

Gastroesophageal reflux disease: Important considerations for the older patients

Gastroesophageal reflux disease (GERD) is the most common upper gastrointestinal disorder seen in the elderly. The worldwide incidence of GERD is increasing as the incidence of Helicobacter pylori is decreasing. Although elderly patients with GERD have fewer symptoms, their disease is more often severe. They have more esophageal and extraesophageal complications that may be potentially life threatening. Esophageal complications include erosive esophagitis, esophageal stricture, Barrett's esophagus and adenocarcinoma of the esophagus. Extraesophageal complications include atypical chest pain that can simulate angina pectoris; ear, nose, and throat manifestations such as globus sensation, laryngitis, and dental problems; pulmonary problems such as chronic cough, asthma, and pulmonary aspiration. A more aggressive approach may be warranted in the elderly patient, because of the higher incidence of severe complications. Although the evaluation and management of GERD are generally the same in elderly patients as for all adults, there are specific issues of causation, evaluation and treatment that must be considered when dealing with the elderly.     

Low levels of adherence with proton pump inhibitor therapy contribute to therapeutic failure in gastroesophageal reflux disease

To assess adherence to proton pump inhibitor (PPI) treatment and associated variables in patients with gastroesophageal reflux disease (GERD). Cross‐sectional and prospective comprising 240 consecutive adult patients, diagnosed with GERD for whom continuous use of standard or double dose of omeprazole had been prescribed. Patients were ranked as ne‐GERD (162: 67.5%) or e‐GERD classified according to the Los Angeles classification as A (48:20.0%), B (21:8.6%), C (1:0.5%), D (1:0.5%), and Barrett's esophagus (7:2.9%). The Morisky questionnaire was applied to assess adherence to therapy and a GERD questionnaire to assess symptoms and their impact. Adherence was correlated with demographics, cotherapies, comorbidities, treatment duration, symptoms scores, endoscopic findings, and patient awareness of their disease. 126 patients (52.5%) exhibited high level of adherence and 114 (47.5%) low level. Youngers (P= 0.002) or married (O.R. 2.41, P= 0.03 vs. widowers) patients had lower levels of adherence; symptomatic patients exhibited lower adherence (P= 0.02). All other variables studied had no influence on adherence. Patients with GERD attending a tertiary referral hospital in São Paulo exhibited a high rate of low adherence to the prescribed PPI therapy that may play a role in the therapy failure. Age <60 years, marital status and being symptomatic were risk factors for low adherence.     

Patients with gastroesophageal reflux disease and respiratory manifestations do not present lung function disorders during cardiopulmonary exercise test

Gastroesophageal reflux disease (GERD) has been associated with a variety of pulmonary manifestations, but it is unclear if gastroesophageal reflux causes any abnormality in pulmonary function. Cardiopulmonary exercise test (CPET) is a specialized method that is used to evaluate respiratory function during exercise. The aim of this study was to reveal any abnormality of pulmonary function in patients with GERD and respiratory symptoms. We evaluated 34 patients with GERD (24 men and 10 women, aged 21–63) and extraesophageal respiratory symptoms (wheezing and/or cough) before therapy and after a 12‐week treatment with double dose of omeprazole. No patient presented abnormal spirometry. CPET was performed in all the patients at baseline and after completion of the 12‐week treatment. CPET parameters including VO₂rest, VO₂max, VCO₂rest, VCO₂max, O₂–puls rest, O₂–puls max, HR (heart rate) rest, HRmax, PETCO₂rest, PETCO₂max, and VE/VCO₂ slope were recorded pretreatment and posttreatment. Twenty‐four patients (70.6%) had esophagitis (grade A–D), 16 patients had hiatal hernia (47.1%), and 13 patients (38.2%) tested positive for Helicobacter pylori. All of the patients completed the CPET. No one presented shortness of breath or respiratory symptoms. CPET parameters were within normal limits in all of the patients. Twenty‐eight patients were reevaluated. No improvement in any CPET parameter posttreatment was observed despite remission of esophageal and extraesophageal respiratory symptoms in all patients. No statistically significant difference was observed pretreatment and posttreatment between the patients older and younger than 40 years, smokers and nonsmokers, Hp(+) and Hp(–) patients, and those with and without hiatal hernia and esophagitis. The patients with GERD and respiratory manifestations and normal spirometry present no pulmonary dysfunction during CPET. No alterations in CPET values posttreatment or differences in CPET values according to age, smoking, Hp status, presence of esophagitis, or hiatal hernia were observed.     

Diagnosis and initial management of gastroesophageal complications

Chronic esophageal exposure to reflux of gastroduodenal contents can result in complications of GERD including esophageal stricture, Barrett's oesophagus or extraesophageal symptoms such as laryngitis, chronic cough or asthma. Endoscopy is the main diagnostic tool for patients with chronic reflux presenting with dysphagia to visualise esophageal mucosa and identify the underlying pathology. Barrett's oesophagus should be suspected in those with chronic reflux disease. Patients with Barrett's oesophagus should undergo surveillance endoscopy in order to risk stratify to dysplasia or adenocarcinoma. New endoscopic ablative therapies in patients with Barrett's oesophagus and high grade dysplasia are promising new treatment modality for those who may not be candidates for definitive intervention. Given poor sensitivity of diagnostic tests in extraesophageal reflux, empiric therapy with proton pump patients is the initial recommended approach. Diagnostic testing with esophagogastroduodenoscopy and ambulatory pH and impedance monitoring is usually reserved for those unresponsive to acid suppressive therapy. Many uncertainties remain in this group of patients including which patient subgroups might benefit from acid suppressive therapy. Future outcome studies are needed to assess the role of impedance/pH monitoring in this group of patients and to determine who might symptomatically benefit from medical or surgical intervention.     

From GERD to Barrett's esophagus: Is the pattern in Asia mirroring that in the West?

Gastroesophageal reflux disease (GERD) is a known predisposing factor for Barrett's esophagus. Amongst individuals with symptomatic GERD, the prevalence of Barrett esophagus is estimated to be more than 10%, and an individual with Barrett's esophagus is more likely than the general population to develop esophageal adenocarcinoma. In Western Europe and North America, incidence of esophageal adenocarcinoma had been on the upward trend for many decades. In comparison, although the prevalence of GERD and reflux esophagitis has increased several fold in some parts of Asia, the prevalence of esophageal adenocarcinoma and Barrett's esophagus remains generally low in the region. Rising incidence of esophageal adenocarcinoma has been observed in regions witnessing increasing prevalence of GERD. If the recent increase in prevalence of GERD in parts of urbanized Asia is any indication of the beginning of an upsurge in the incidence of Barrett's esophagus and associated adenocarcinoma, would we be witnessing a pattern of epidemiological shift mirroring that in the West? Given that more than 90% of Barrett's esophagus in Asian patients is of the short‐segment type, which is reported to have lesser propensity to develop to adenocarcinoma, could the ongoing epidemiologic transition take Asia on the same trail as that which the West has taken? This article will draw on relevant findings from various parts of Asia and take an in‐depth look at prevailing disease trends to see where Asia stands now in the changing epidemiology of GERD, Barrett's esophagus and associated adenocarcinoma.     

Nonsteroidal anti‐inflammatory drugs and esophageal inflammation – Barrett's esophagus – adenocarcinoma sequence: a meta‐analysis

The incidence of esophageal adenocarcinoma has markedly increased in the last few decades and Barrett's esophagus is regarded as the precursor lesion of this cancer. The aim of the study was to quantify the adenocarcinoma risk associated with nonsteroidal anti‐inflammatory drug use and to determine at which stage chemoprevention with this drug is the most effective in esophageal inflammation – Barrett's esophagus – adenocarcinoma sequence. A literature search was performed to identify studies published between 1998 and 2009 for relevant risk estimates. Fixed and random effect meta‐analytical techniques were conducted for aspirin, nonaspirin nonsteroidal anti‐inflammatory drugs, and all nonsteroidal anti‐inflammatory drugs. Four cohort and 10 case‐control studies were included. Use of aspirin and nonaspirin nonsteroidal anti‐inflammatory drugs in normal population was associated with a reduced risk of adenocarcinoma (odds ratio [OR]: 0.73, 95% confidence interval [CI]: 0.65–0.83; OR: 0.84, 95% CI: 0.72–0.98, respectively). The use of all nonsteroidal anti‐inflammatory drugs was associated with a reduced risk of adenocarcinoma (relative risk [RR]: 0.64, 95% CI: 0.42–0.96) in Barrett's esophagus patients. However, no obvious dose‐effect relationships were found. In addition, we discovered a reverse association between drugs use and adenocarcinoma risk in people without a history of upper gastrointestinal tract disorders (OR: 0.57, 95% CI: 0.43–0.77, P= 0.12). Our meta‐analyses suggest a protective effect of nonsteroidal anti‐inflammatory drugs on the risk of adenocarcinoma. Our results also suggest that the drugs might act after the formation of Barrett's epithelium in the esophageal inflammation – Barrett's esophagus – adenocarcinoma sequence.     

Utilization of wireless pH monitoring technologies: a summary of the proceedings from the Esophageal Diagnostic Working Group

Gastroesophageal reflux disease (GERD) can be difficult to diagnose – symptoms alone are often not enough, and thus, objective testing is often required. GERD is a manifestation of pathologic levels of reflux into the esophagus of acidic, nonacidic, and/or bilious gastric content. However, in our current evidence‐based knowledge approach, we only have reasonable outcome data in regards to acid reflux, as this particular type of refluxate predictably causes symptoms and mucosal damage, which improves with medical or surgical therapy. While there are data suggesting that nonacid reflux may be responsible for ongoing symptoms despite acid suppression in some patients, outcome data about this issue are limited. Therefore, this working group believes that it is essential to confirm the presence of acid reflux in patients with ‘refractory’ GERD symptoms or extraesophageal symptoms thought to be caused by gastroesophageal reflux before an escalation of antireflux therapy is considered. If patients do not have pathologic acid reflux off antisecretory therapy, they are unlikely to have clinically significant nonacid or bile reflux. Patients who do not have pathologic acid gastroesophageal reflux parameters on ambulatory pH monitoring then: (i) could attempt to discontinue antisecretory medications like proton pump inhibitors and H2‐receptor antagonists (which are expensive and which carry risks – i.e. C. diff, etc.); (ii) may undergo further evaluation for other causes of their esophageal symptoms (e.g. functional heartburn or chest pain, eosinophilic esophagitis, gastroparesis, achalasia, other esophageal motor disorders); and (iii) can be referred to an ear, nose, and throat/pulmonary/allergy physician for assessment of non‐GERD causes of their extraesophageal symptoms.     

Extraesophageal manifestations of GERD

The association between gastroesophageal reflux disease (GERD) and extraesophageal disease is often referred to as extraesophageal reflux (EER). This article reviews EER, discussing epidemiology, pathogenesis, diagnosis, and treatment with a focus on the most studied and convincing EER disorders-asthma, cough, and laryngitis. Although EER comprises a heterogeneous group of disorders, some general characterizations can be made, as follows. First, although GERD's association with extraesophageal diseases is well-established, definitive evidence of causation has been more elusive, rendering epidemiological data scarce. Secondly, regarding the pathogenesis of EER, 2 basic models have been proposed: direct injury to extraesophageal tissue by acid and pepsin exposure or injury mediated through an esophageal reflex mechanism. Third, because heartburn and regurgitation are often absent in patients with EER, GERD may not be suspected. Even when GERD is suspected, the diagnosis may be difficult to confirm. Although endoscopy and barium esophagram remain important tools for detecting esophageal complications, they may fail to establish the presence of GERD. Even when GERD is diagnosed by endoscopy or barium esophagram, causation between GERD and extraesophageal symptoms cannot be determined. Esophageal pH is the most sensitive tool for detecting GERD, and it plays an important role in EER. However, even pH testing cannot establish GERD's causative relationship to extraesophageal symptoms. In this regard, effective treatment of GERD resulting in significant improvement or remission of the extraesophageal symptoms provides the best evidence for GERD's pathogenic role. Finally, EER generally requires more prolonged and aggressive antisecretory therapy than typical GERD requires.     

Heterotopic gastric mucosa causing significant esophageal stricture in a 14‐year‐old child

Esophageal heterotopic gastric mucosa (HGM) is not uncommon and can be seen in up to 10% of the general population among numerous reports and epidemiologic studies which have been essentially performed in adult population. Pediatric data are still limited. Diagnosis requires clinician awareness of symptomatic cases who present with dysphagia or swallowing difficulties, and thorough endoscopic examination is crucial. Early detection of cases provides favorable clinical outcome and may prevent potential significant or serious long‐term consequences such as esophageal stricture or web, Barrett's esophagus or malignant transformation in pediatric population. We reported a 14‐year‐old male who presented with 1‐year history of gradually worsening dysphagia and was found to have two salmon‐colored patches, which resemble gastric mucosa, in the proximal esophagus causing significant esophageal stricture. Gastric cardiac‐type mucosa with acute and chronic inflammation was documented on biopsy. After several sessions of balloon dilation and endoscopic treatment, the HGM and esophageal stricture resolved and he became asymptomatic.     

Expression of the putative stem cell marker Musashi‐1 in Barrett's esophagus and esophageal adenocarcinoma

The cancer stem cell theory states that cancers contain tumor‐forming cells that have the ability to self‐renew as well as give rise to cells that differentiate. Cancer stem cells have been identified in several solid tumors, but stem cells in normal human esophagus or in Barrett's esophagus or adenocarcinoma have not been reported. Musashi‐1 is expressed by the crypt base columnar cells identified as intestinal stem cells. In other diseases of the gastrointestinal tract, local inflammation of the tunica mucosa may be an initiating factor of alteration of focal tissue ‘niches,’ where dormant stem cells locate. The present study investigated whether Musashi‐1 is expressed in the esophagus and its relation to immune inflammation of the mucosa in Barrett's esophagus and esophageal adenocarcinoma. A total of 41 esophageal tissue specimens from 41 patients were studied. Of these, 15 were esophageal adenocarcinoma, 17 were Barrett's esophagus (10 intestinal metaplasia and 7 dysplasia), and 9 were normal squamous esophagus tissue specimens from patients without esophageal pathology. Immunohistochemistry was performed using antibodies to Musashi‐1 and to a set of cell type‐specific markers. A multiplexed tandem polymerase chain reaction method was used to measure the relative mRNA expression levels of Musashi‐1 and the specific dendritic cell marker dendritic cell‐specific intercellular molecule‐3 (ICAM‐3)‐grabbing nonintegrin. Immunohistochemistry demonstrated the presence of small numbers of Musashi‐1+ cells scattered in the connective tissue stroma and within the epithelium in cardiac‐type glands in biopsies from patients without Barrett's esophagus. Musashi‐1 expression was present in Barrett's intestinal metaplasia and in dysplastic Barrett's in which the majority of epithelial cells in individual glands expressed this antigen. Expression of Musashi‐1 was highest in esophageal adenocarcinoma, where it was most intense in glands that displayed features of early stages of adenocarcinoma formation. In contrast, Musashi‐1 staining level was weaker in glands that displayed features of advanced adenocarcinoma. Double immunostaining with proliferating cell nuclear antigen showed low proliferation in the vast majority of Musashi‐1+ cells. Musashi‐1 mRNA expression levels were significantly higher in esophageal adenocarcinoma than in normal esophagus or Barrett's esophagus tissues. Dendritic cell‐specific intercellular molecule‐3 (ICAM‐3)‐grabbing nonintegrin (DC‐SIGN) mRNA expression levels were significantly increased in both Barrett's tissues and adenocarcinoma tissues. Expression of the putative stem cell marker Musashi‐1 is absent in normal squamous epithelium, weak in esophageal cardiac‐type glands and Barrett's esophagus, and markedly increased in adenocarcinoma, especially in glands displaying features of early cancer development. Musashi‐1 expressing cells may be significant in the etiology of Barrett's esophagus and adenocarcinoma, and perhaps even a cell of origin for this disease. We speculate that immune inflammation occurring in Barrett's esophagus alters the mucosal microenvironment in a manner which is favorable to the activation of dormant stem cells.     

Cost‐Effectiveness of Cardiac Resynchronization Therapy in the MADIT‐CRT Trial

Cost Effectiveness of MADIT‐CRT. Background: The Multicenter Automatic Defibrillator Implantation Trial‐Cardiac Resynchronization Therapy (MADIT‐CRT) trial demonstrated that cardiac resynchronization therapy (CRT) when added to the implantable cardiac defibrillator (ICD) reduces risk of heart failure or death in minimally symptomatic patients with reduced cardiac ejection fraction and wide QRS complex. Objectives: To evaluate 4‐year cost‐effectiveness of CRT‐ICD compared to ICD alone using MADIT‐CRT data. Research Design: Patients enrolled in the trial were randomized to implantation of either ICD or CRT‐ICD in a 2:3 ratio, with up to 4‐year follow‐up period. Cost‐effectiveness analyses were conducted, and sensitivity analyses by age, gender, and left bundle branch block (LBBB) conduction pattern were performed. Subjects: A total of 1,271 patients with ICD or CRT‐ICD (US centers only) who reported healthcare utilization and health‐related quality of life data. Measures: We used the EQ‐5D (US weights) to assess patient HRQOL and translated utilization data to costs using national Medicare reimbursement rates. Results: Average 4‐year healthcare expenditures in CRT‐ICD patients were higher than costs of ICD patients ($62,600 vs 57,050, P = 0.015), mainly due to the device and implant‐related costs. The incremental cost‐effectiveness ratio of CRT‐ICD compared to ICD was $58,330/quality‐adjusted life years (QALY) saved. The cost effectiveness improved with longer time horizon and for the LBBB subgroup ($7,320/QALY), with no cost‐effectiveness benefit being evident in the non‐LBBB group. Conclusions: In minimally symptomatic patients with low ejection fraction and LBBB, CRT‐ICD is cost effective within 4‐year horizon when compared to ICD‐only. (J Cardiovasc Electrophysiol, Vol. 24, pp. 66‐74, January 2013)     

Long‐gap esophageal atresia: traction‐growth and anastomosis – before and beyond

Long‐gap esophageal atresia (LGEA) is still a major surgical challenge. Options for esophageal reconstruction include the use of native esophagus or esophageal replacement with stomach, colon, or small intestine. Nonetheless, there is a consensus among most pediatric surgeons that the preservation of the native esophagus is associated with better postoperative outcomes. Thus, every effort should be made to conserve the native esophagus. The present study is aimed at critically reporting our experience focused on a standardized protocol based on the preoperative assessment of the gap in all cases and reviewing the present literature because no consensus is available regarding many aspects of LGEA (from definition to treatment). All newborn infants treated since 1995 for esophageal atresia (EA), regardless of type, were included in the present study. Identification of LGEA patients (gap ≥3 vertebral bodies) was performed based on preoperative esophageal gap measurement. The selected patients were grouped based on EA type (A/B vs. C/D) and whether they were referred from an outside institution or not. Postoperative outcome was compared. Statistical analysis was performed with the Fisher's exact test and Mann–Whitney test as appropriate, with P < 0.05 considered statistically significant. Two hundred and nineteen patients have been consecutively treated between 1995 and 2012 with the following EA subtypes: type: A 25 (11.4%); B 6 (2.7%); C 182 (83.1%); D 3 (1.4%); E 3 (1.4%). Fifty‐seven patients (26%) were classified as LGEA: type A‐B, 31 (54.4%); type C‐D, 26 (45.6%). Twenty seven (47%) of these patients were referred after at least one failed attempt at esophageal correction: type A‐B, 15 (55%); type C‐D, 12 (45%). Only one patient ultimately required esophageal substitution, with an overall survival rate of 94%. A standardized perioperative protocol enhances the possibility of preserving the native esophagus in cases of LGEA. Gap measurement can be accurately defined before surgery in all patients with EA. Esophageal anastomosis (either immediate or delayed repair) is almost always feasible; esophageal substitution should only be considered after a rigorous attempt at achieving end‐to‐end esophageal anastomosis.     

Ineffective esophageal motility: the most common motility abnormality in patients with GERD-associated respiratory symptoms

OBJECTIVE: The association of gastroesophageal reflux disease (GERD) and respiratory symptoms is well known. The coexistence of ineffective esophageal motility (IEM, low-amplitude [< 30 mm Hg] or nontransmitted contractions in > or = 30% of 10 wet swallows in the distal esophagus) in patients with GERD has recently been demonstrated. Our aim was to determine the prevalence of IEM in patients with GERD-associated respiratory symptoms. METHODS: Manometry and pH studies of 98 consecutive patients with respiratory symptoms and abnormal reflux shown by pH-metry were reviewed. Symptoms were chronic cough (n = 43), asthma (n = 13), and laryngitis (n = 42). Sixty-six patients with heartburn with no extraesophageal manifestations were used as a control group. Total esophageal acid clearance (EAC) time was calculated for each patient. RESULTS: IEM was the most common motility abnormality seen in all groups of GERD patients. It was seen significantly more often in patients with chronic cough (41%) (p = 0.003) or asthma (53%) (p = 0.01), and numerically more often in patients with laryngitis (31%) than in patients with heartburn (19%). Diffuse esophageal spasm and nutcracker esophagus were rarely seen. Incidence of hypertensive or hypotensive lower esophageal sphincter was similar across all groups. The total EAC time was longer (median: 1.51 min/episode) (p = 0.01) in patients with GERD-associated respiratory symptoms than in patients with heartburn (median: 0.72 min/episode). CONCLUSIONS: IEM is the most prevalent motility abnormality in patients with GERD-associated respiratory symptoms. Coexistence of IEM with GER may place patients at high risk for respiratory symptoms due to the associated delayed esophageal acid clearance seen with this motility abnormality.     

Intentional examination of esophagus by narrow‐band imaging endoscopy increases detection rate of cervical inlet patch

Foci of heterotopic gastric mucosa have been identified at different sites in the human body and the most common location is the proximal esophagus which is referred to as cervical inlet patch (CIP). The true prevalence of CIP varies and it is usually incidental findings during endoscopy. Because CIP is always asymptomatic, it was believed to be of little clinical relevance. However, emerging studies have described the acid‐secreting characteristics of heterotopic gastric mucosa and associations of CIP with gastroesophageal reflux disease (GERD). In addition, complications such as stricture, fistula, infection, mucosal hyperplasia, and malignant transformation have been reported. In this study, we investigated the prevalence of CIP, its associations with clinical manifestations, and the effect of intentional screening upper esophagus by magnifying endoscopy‐narrow‐band imaging (ME‐NBI) system. Consecutive healthy adults who underwent panendoscopy were separated into two groups. Patients in group I (n = 471) were examined by an endoscopist who intended to find CIPs by ME‐NBI. Patients in group II (n = 428) were examined by two endoscopists who were unaware of the study and performed white‐light imaging endoscopy. Participants provided questionnaires on GERD‐related symptoms. Higher CIP prevalence (11.7% vs. 1.9%, P < 0.0001) and longer duration of esophageal examination (mean ± standard deviation, 17.50 ± 12.40 vs. 15.24 ± 10.78 seconds, P = 0.004) were noted in group I than in group II. Analyzing group I patients revealed the higher prevalences of reflux symptoms (32.7% vs. 18.3%, P = 0.013) and erosive esophagitis (43.6% vs. 25.5%, P = 0.005) in patients with CIP than in those without. CIP was not associated with globus or dysphagia symptoms. More small CIPs (<5 mm) were detected by ME‐NBI than by white‐light imaging (85.3% vs. 41.4%, P = 0.001). In conclusion, CIP prevalence was not low under intentional ME‐NBI examination of the upper esophagus. The clinical relevance of CIP and its association with GERD require further investigation.     

Enfermedades esofágicas: enfermedad por reflujo grastroesofágico y esófago de Barrett

Digestive Disease Week always offers interesting advances. Among the notable advances concerning gastroesophageal reflux disease (GERD) in the 2012 meeting were studies on its association with functional dyspepsia. Furthermore, novel data suggest that undetected reflux plays a role in certain extraesophageal diseases. We also discuss the potential utility of impedanciometry of the esophageal mucosa in the diagnosis of GERD and review the management and implications of lack of response to proton pump inhibitors. We also review promising new techniques for screening for esophageal adenocarcinoma in Barrett's esophagus and new data on the efficacy and durability of radiofrequency ablation as the treatment of choice in cases associated with dysplasia or neoplasia in situ.     

Medium‐term outcome of fundoplication after lung transplantation

Gastroesophageal reflux disease (GERD) in lung transplant recipients has gained increasing attention as a factor in allograft failure. There are few data on the impact of fundoplication on survival or lung function, and less on its effect on symptoms or quality of life. Patients undergoing fundoplication following lung transplantation from 1999 to 2005 were included in the study. Patient satisfaction, changes in GERD symptoms, and the presence of known side effects were assessed. The effect on lung function, body mass index, and rate of progression to the bronchiolitis obliterans syndrome (BOS) were recorded. Twenty‐one patients (13 males), in whom reflux was confirmed on objective criteria, were included, with a mean age of 43 years (range 20–68). Time between transplantation and fundoplication was 768 days (range 145–1524). The indication for fundoplication was suspected microaspiration in 13 and symptoms of GERD in 8. There was one perioperative death, at day 17. There were three other late deaths. Fundoplication did not appear to affect progression to BOS stage 1, although it may have slowed progression to stage 2 and 3. Forced expiratory volume‐1% predicted was 72.9 (20.9), 6 months prior to fundoplication and 70.4 (26.8), six months post‐fundoplication, P= 0.33. Body mass index decreased significantly in the 6 months following fundoplication (23 kg/m² vs. 21 kg/m², P= 0.05). Patients were satisfied with the outcome of the fundoplication (mean satisfaction score 8.8 out of 10). Prevalence of GERD symptoms decreased significantly following surgery (11 of 14 vs. 4 of 17, P= 0.002). Fundoplication does not reverse any decline in lung function when performed at a late stage post‐lung transplantation in patients with objectively confirmed GERD. It may, however, slow progression to the more advanced stages of BOS. Reflux symptoms are well controlled and patients are highly satisfied. Whether performing fundoplication early post‐lung transplant in selected patients can prevent BOS and improve long‐term outcomes requires formal evaluation.     

Symptom priority ranking in the care of gastroesophageal reflux: a review of 1,850 cases

BACKGROUND: Clinical history remains an important part of the medical evaluation of patients with gastroesophageal reflux disease (GERD). Heartburn, regurgitation, and dysphagia are considered typical symptoms of GERD. Priority rankings of these symptoms can be determined with a standardized questionnaire. OBJECTIVE: To determine whether symptom priority ranking and symptom severity grading can provide useful information in the evaluation of patients with GERD. METHODS: From 1,850 patients that were analyzed retrospectively, patients with dysphagia unrelated to GERD were excluded. A standardized questionnaire was applied before each patient underwent any esophageal diagnostic study. Priority of symptoms was determined to be primary, secondary, tertiary, or none based on the patient response to the questionnaire. Presence of a stricture was determined either by endoscopy, esophagraphy, or both studies. Stationary esophageal manometry and 24-hour pH monitoring were performed on all patients. Through bivariate and multivariate analysis, the relationships among typical GERD symptoms, esophageal reflux-related stenosis, lower esophageal sphincter pressure, and composite score were established. RESULTS: High priority ranking of the symptom dysphagia is predictive of the presence of an esophageal stricture, but has a negative association with abnormal manometric and pH studies. In contrast, high priority ranking of the symptom heartburn and regurgitation are positively associated with abnormal manometric and pH results. CONCLUSIONS: Priority ranking can be a valuable adjunct to objective testing in the evaluation of GERD. In certain clinical situations it can obviate the need for 24-hour pH monitoring.