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1.
Background
The appearance and incidence of gastroesophageal reflux after sleeve gastrectomy is not yet resolved, and there is an important controversy in the literature. No publications regarding the appearance of Barrett’s esophagus after sleeve gastrectomy are present in the current literature.Purpose
The purpose of this paper was to report the incidence of Barrett’s esophagus in patients submitted to sleeve.Material and Methods
Two hundred thirty-one patients are included in this study who were submitted to sleeve gastrectomy for morbid obesity. None had Barrett’s esophagus. Postoperative upper endoscopy control was routinely performed 1 month after surgery and 1 year after the operation, all completed the follow-up in the first year, 188 in the second year, 123 in the third year, 108 in the fifth year, and 66 patients over 5 years after surgery.Results
Among 231 patients operated on and followed clinically, reflux symptoms were detected in 57 (23.2 %). Erosive esophagitis was found in 38 patients (15.5 %), and histological examination confirmed Barrett’s esophagus in 3/231 cases (1.2 %) with presence of intestinal metaplasia.Conclusion
Bariatric surgeons should be aware of the association of gastroesophageal reflux (GER) disease and obesity. Appropriate bariatric surgery should be indicated in order to prevent the occurrence of esophagitis and Barrett’s esophagus.2.
Introduction
Gastroesophageal reflux disease (GERD) may present with heartburn, regurgitation, dysphagia, chronic cough, laryngitis, or even asthma. The clinical presentation of GERD is therefore varied and poses certain challenges to the physician, especially given the limitations of the diagnostic testing.Discussion
The evaluation of patients with suspected GERD might be challenging. It is based on the evaluation of clinical features, objective evidence of reflux on diagnostic testing, correlation of symptoms with episodes of reflux, evaluation of anatomical abnormalities, and excluding other causes that might account for the presence of the patient’s symptoms.Conclusions
The diagnostic evaluation should include multiple tests, in addition to a thorough clinical examination.3.
Background
Gastroesophageal reflux disease (GERD) affects an estimated 20% of the population in the USA, and its prevalence is increasing worldwide. About 10–15% of patients with GERD will develop Barrett’s esophagus (BE).Aims
The aims of this study were to review the available evidence of the pathophysiology of BE and the role of anti-reflux surgery in the treatment of this disease.Results
The transformation of the squamous epithelium into columnar epithelium with goblet cells is due to the chronic injury produced by repeated reflux episodes. It involves genetic mutations that in some patients may lead to high-grade dysplasia and cancer. There is no strong evidence that anti-reflux surgery is associated with resolution or improvement in BE, and its indications should be the same as for other GERD patients without BE.Conclusions
Patients with BE without dysplasia require endoscopic surveillance, while those with low- or high-grade dysplasia should have consideration of endoscopic eradication therapy followed by surveillance. New endoscopic treatment modalities are being developed, which hold the promise to improve the management of patients with BE.4.
Background
Gastroesophageal reflux disease (GERD) affects an estimated 20% of the population in the USA, and its prevalence is increasing worldwide. Lifestyle modifications and proton pump inhibitors (PPI) therapy are effective in the majority of patients and remain the mainstay of treatment of GERD. However, some patients will need surgical intervention because they have partial control of symptoms, do not want to be on long-term medical treatment, or suffer complications related to PPI therapy.Aims
The aim of this study was to review the available evidence that supports laparoscopic antireflux surgery, and to study the effect of surgical therapy on the natural history of GERD.Results
The key elements for the success of antireflux surgery are proper patient selection, careful analysis of the indications for surgery, complete pre-operative work-up, and proper execution of the surgical technique.Conclusions
When the key elements are respected, antireflux surgery is very effective in controlling GERD, and it is associated to minimal morbidity and mortality.5.
Background
Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease of unknown origin that affects about 40,000 new patients every year in the USA. Albeit the disease is labelled as idiopathic, it is thought that pathologic reflux, often silent, plays a role in its pathogenesis through a process of microaspiration of gastric contents.Aims
The aim of this study was to review the available evidence linking reflux to IPF, and to study the effect of medical and surgical therapy on the natural history of this disease.Results
Medical therapy with acid-reducing medications controls the production of acid and has some benefit. However, reflux and aspiraion of weakly acidic or alkaline gastric contents can still occur. Better results have been reported after laparoscopic anti-reflux surgery, as this form of therapy re-establishes the competence of the lower esophageal sphincter, therefore stopping any type of reflux.Conclusions
A phase II NIH study in currently in progress in the USA to determine the role of antireflux surgery in patients with GERD and IPF. The hope is that this simple operations might alter the natural history of IPF, avoiding progression and the need for lung transplantation.6.
7.
Leonardo M. Del Grande Fernando A. M. Herbella Amilcar M. Bigatao Jose R. Jardim Marco G. Patti 《Journal of gastrointestinal surgery》2016,20(10):1679-1682
Background
Chronic obstructive pulmonary disease (COPD) patients have a high incidence of gastroesophageal reflux disease (GERD) whose pathophysiology seems to be linked to an increased trans-diaphragmatic pressure gradient and not to a defective esophagogastric barrier. Inhaled beta agonist bronchodilators are a common therapy used by patients with COPD. This drug knowingly not only leads to a decrease in the lower esophageal sphincter (LES) resting pressure, favoring GERD, but also may improve ventilatory parameters, therefore preventing GERD.Aims
This study aims to evaluate the effect of inhaled beta agonist bronchodilators on the trans-diaphragmatic pressure gradient and the esophagogastric barrier.Methods
We studied 21 patients (mean age 67 years, 57 % males) with COPD and GERD. All patients underwent high-resolution manometry and esophageal pH monitoring. Abdominal and thoracic pressure, trans-diaphragmatic pressure gradient (abdominal–thoracic pressure), and the LES retention pressure (LES basal pressure–transdiaphragmatic gradient) were measured before and 5 min after inhaling beta agonist bronchodilators.Results
The administration of inhaled beta agonist bronchodilators leads to the following: (a) a simultaneous increase in abdominal and thoracic pressure not affecting the trans-diaphragmatic pressure gradient and (b) a decrease in the LES resting pressure with a reduction of the LES retention pressure.Conclusion
In conclusion, inhaled beta agonist bronchodilators not only increase the thoracic pressure but also lead to an increased abdominal pressure favoring GERD by affecting the esophagogastric barrier.8.
Nesreen Khidir Luigi Angrisani Jowhara Al-Qahtani Sheraz Abayazeed Moataz Bashah 《Obesity surgery》2018,28(10):3125-3130
Background
Gastroesophageal reflux disease (GERD) occurs de novo or intensifies after sleeve gastrectomy (LSG). Endoscopic radiofrequency (Stretta) is a minimally invasive, effective tool to treat GERD. However, Stretta safety and efficacy are unknown in patients with GERD after LSG. To evaluate the safety and efficacy of Stretta treatment post-LSG GERD, quality of life, and PPI dose up to 6 months.Methods
A retrospective review of all patients’ data who underwent Stretta procedure in our center. Demographics, pre-Stretta lower esophageal manometry, 24-h pH monitoring, endoscopic and radiological findings, GERD symptoms using Quality of Life (HR-QoL) questionnaire, and PPI doses at 0, 3, and 6 months were reviewed.Results
Fifteen patients had an initial BMI of 44.4?±?9 kg/m2. Pre-Stretta BMI was 29.7?±?6.3 kg/m2 with an EWL% of 44?±?21.4%. Pre-Stretta endoscopic reflux esophagitis was found in 26.7%, and barium imaging showed severe reflux in 40%. The mean DeMeester score was 27.9?±?6.7. Hypotensive LES pressure occurred in 93.3% of patients. Patients’ mean HR-QoL scores were 42.7?±?8.9 pre-Stretta and 41.8?±?11 at 6 months (P?=?0.8). One case (6.7%) was complicated by hematemesis. At 6 months, 66.7% of patients were not satisfied, though the PPI medications were ceased in 20%. Two patients (13.3%) underwent Roux-en-Y gastric bypass at 8 months post-Stretta to relieve symptoms.Conclusions
Stretta did not improve GERD symptoms in patients post-LSG at short-term follow-up, and about 6.7% complication rate was reported. Patients were not satisfied despite the decrease in PPI dose.9.
J. Straub M. Apfelbeck A. Karl W. Khoder K. Lellig S. Tritschler C. Stief M. Riccabona 《Der Urologe. Ausg. A》2016,55(1):27-34
Background
Vesico-ureteral reflux (VUR) is one of the most common urologic diseases in childhood. About every third child that presents with a urinary tract infection (UTI) has urinary reflux to the ureter or kidney. Demonstration of a backflow of urine into the ureters or kidneys proves vesicoureteral reflux. In unclear cases, a positioned instillation of contrast agent (PIC) cystogram might be performed and is able to prove vesico-ureteral reflux.Objectives
Since low-grade VUR has a high probability of maturation and self-limitation, infants with VUR should be given prophylactic antibiotics during their first year of life, reevaluating the status of VUR after 12 months. The aim of any treatment is to prevent renal damage.Therapy
The individual risk of renal scarring is decisive for the choice of adequate therapy. This risk is mainly dependent on reflux grade, age, and gender of the child as well as parental therapy adherence. In principle, therapeutic options include conservative as well as endoscopic or open surgical antireflux therapies.Conclusion
Decisions on treatment should be made individually with parents taking into account all the findings available.10.
Steven R. DeMeester 《Journal of gastrointestinal surgery》2010,14(1):94-100
Introduction
Adenocarcinoma of the esophagus is the fastest increasing cancer in the USA, and an increasing number of patients are identified with early-stage disease. The evaluation and treatment of these superficial cancers differs from local and regionally advanced lesions.Methods
This paper is a review of the current methods to diagnose, stage, and treat superficial esophageal adenocarcinoma.Results
Intramucosal adenocarcinoma can be effectively treated with endoscopic resection techniques and with less morbid surgical options including a vagal-sparing esophagectomy. However, submucosal lesions are associated with a significant risk for lymph node metastases and are best treated with esophagectomy and lymphadenectomy.Discussion
There has been a major shift in the treatment for Barrett’s high-grade dysplasia and superficial esophageal adenocarcinoma in the past 10 years. New therapies minimize the morbidity and mortality of traditional forms of esophagectomy and in some cases allow esophageal preservation. Individualization of therapy will allow maximization of successful outcome and quality of life with minimization of complications and recurrence of Barrett’s or cancer.11.
Background
Transoral intraluminal surgery is less painful. However, endoscopic antireflux procedures have been unsuccessful, endoscopic foregut mucosal excision procedures are often difficult to perform, and endoscopic intra-luminal suturing is both imprecise and too shallow. We have endeavored to correct these deficiencies and report here new devices for GERD, obesity, and Barrett’s mucosal excision.Method
A retrospective review of ex vivo and in vivo animal experiments using sharp blade mucosal excision for esophageal and gastric mucosa and a suturing device with transverse needles designed to full thickness penetrate the gastric wall were completed. A total of 338 excisions were performed in 134 ex vivo tissue experiments and in 119 in vivo attempts. Suture needle testing was performed in ex vivo human stomachs and porcine stomachs and in in vivo canine and baboon stomachs.Results
One excision perforation (0.9%) occurred in a live animal. Satisfactory mucosal excision depth for the Barrett’s device was reproducible. Progressive suture actuation reliability improved from 83% during ex vivo testing to 96.7% in in vivo experiments.Conclusion
The results demonstrate feasibility, reliability, and safety for gastric and esophageal mucosal excision. Suturing reliability improved and further studies will be performed to finalize the instrument designs, the operative techniques, and the other device applications.12.
Background
Gastroesophageal reflux disease (GERD) is commonly associated with obesity, and its surgical management is debatable.Objective
The objective of this study was to prove the safety and feasibility of laparoscopic Nissen’s fundoplication (LNF) combined with mid-gastric plication (MGP) for treatment of obese patients with GERD.Methods
LNF combined with MGP was done for 18 patients. All interventions were performed under general anesthesia. The follow-up protocol included body mass index (BMI), percentage of excess weight loss (%EWL), percentage of excess BMI loss (%EBMIL), and clinical assessment using the Gastro-esophageal Reflux Health-Related Quality-of-Life (GERD-HRQOL) scale at 6 and 12 months.Results
The period of follow-up ranged from 12 to 33 months with a mean of 17.74 ± 3.73 months. The operation time was 1.40 ± 0.27 h. No serious procedure-related complications occurred. GERD-related symptoms resolved in all patients (p < 0.001). There was a significant improvment in endoscopic findings at 6 months compared to properatively (p = 0.001). There was a significant patient satisfaction score using GERD-HRQOL at 6 and 12 months (p = 0.000). The 1-year follow-up excess weight was significantly less than the baseline excess weight (p < 0.001). The average BMI decreased from 37.59 ± 1.89 kg/m2 at baseline to 30.61 ± 1.57 kg/m2 at 1 year (p < 0.001).Conclusions
LNF combined with MGP for treatment of obese patients with GERD is technically safe, feasible, and promising with no serious procedure-related complications. The technique is effective in terms of weight loss and cure of GERD. However, future larger studies are required to demonstrate the safety, effectiveness, and long-term durability of the procedure.13.
Joachim H. Schneider Markus A. Küper Alfred Königsrainer Björn L. D. M. Brücher 《Journal of gastrointestinal surgery》2010,14(1):17-23
Background
Diagnosing gastroesophageal reflux disease is challenging in the older population, as comorbid conditions can obscure the disease.Methods
This prospective study included 97 participants: 25 healthy controls (group 1), 46 reflux patients aged 26–64 (group 2), and 26 patients over 65 (group 3). Esophageal motility was assessed using conventional esophageal manometry, and 24-h pH-metry and non-acid reflux episodes were assessed using multichannel intraluminal impedance.Results
Among the older patients (group 3), 34% had reflux disease. The rate of lower esophageal sphincter insufficiency in group 3 was comparable with that in group 2 and significantly different from group 1. Gastric 24-h pH-metry showed no significant differences between the groups. Esophageal pH-metry results for groups 1 and 3 differed significantly from those in group 2. Impedance assessment showed that older patients have non-acid reflux episodes in the recumbent position significantly more often in comparison with controls and reflux patients. Reflux patients and older patients had proximal reflux episodes significantly more often than healthy volunteers.Conclusions
Patients aged over 65 have non-acid reflux, particularly in the recumbent position, significantly more often than normal individuals and patients with reflux disease. Non-acid reflux may mimic a negative DeMeester score in older patients with severe reflux disease.14.
Summary
Gastroesophageal reflux disease (GERD) with proton pump inhibitor (PPI) use is associated with an increased risk of osteoporosis. The risk of hip fracture is not increased in GERD patients with PPI use.Introduction
The relationship between GERD with PPI treatment and the risk of osteoporosis is unclear. We aimed to determine the risk of developing osteoporosis in patients diagnosed with GERD.Methods
Patients diagnosed with GERD and received PPI treatment between 2000 and 2010 were identified from the Longitudinal Health Insurance Database as the study cohort (n?=?10,620), which was frequency matched with the comparison cohort (n?=?20,738) sampled from the general population according to age, sex, index year, and comorbidities. Both cohorts were followed until the end of 2011. The risk of osteoporosis was evaluated in both groups by using Cox proportional hazards regression models.Results
The GERD patients with PPI treatment had a greater incidence (31.4 vs 20.7 per 1000 person-year; crude hazard ratio [cHR] 1.51; 95 % confidence interval [CI] 1.40–1.63) and a higher risk (adjusted HR [aHR] 1.50; 95 % CI 1.39–1.62) of osteoporosis than that of the comparison cohort. However, the overall incidence of hip fracture was not different between the GERD with PPI use and the control cohorts (aHR 0.79; 95 % CI 0.53–1.18).Conclusion
GERD with PPI use is associated with an increased risk of osteoporosis. The findings of our study do not support an increased risk of hip fracture in GERD patients treated with a PPI.15.
Heather F. Warren Jessica L. Reynolds John C. Lipham Joerg Zehetner Nikolai A. Bildzukewicz Paul A. Taiganides Jody Mickley Ralph W. Aye Alexander S. Farivar Brian E. Louie 《Surgical endoscopy》2016,30(8):3289-3296
Background
Magnetic sphincter augmentation (MSA) has emerged as an alternative surgical treatment of gastroesophageal reflux disease (GERD). The safety and efficacy of MSA has been previously demonstrated, although adequate comparison to Nissen fundoplication (NF) is lacking, and required to validate the role of MSA in GERD management.Methods
A multi-institutional retrospective cohort study of patients with GERD undergoing either MSA or NF. Comparisons were made at 1 year for the overall group and for a propensity-matched group.Results
A total of 415 patients (201 MSA and 214 NF) underwent surgery. The groups were similar in age, gender, and GERD-HRQL scores but significantly different in preoperative obesity (32 vs. 40 %), dysphagia (27 vs. 39 %), DeMeester scores (34 vs. 39), presence of microscopic Barrett’s (18 vs. 31 %) and hiatal hernia (55 vs. 69 %). At a minimum of 1-year follow-up, 354 patients (169 MSA and 185 NF) had significant improvement in GERD-HRQL scores (pre to post: 21–3 and 19–4). MSA patients had greater ability to belch (96 vs. 69 %) and vomit (95 vs. 43 %) with less gas bloat (47 vs. 59 %). Propensity-matched cases showed similar GERD-HRQL scores and the differences in ability to belch or vomit, and gas bloat persisted in favor of MSA. Mild dysphagia was higher for MSA (44 vs. 32 %). Resumption of daily PPIs was higher for MSA (24 vs. 12, p = 0.02) with similar patient-reported satisfaction rates.Conclusions
MSA for uncomplicated GERD achieves similar improvements in quality of life and symptomatic relief, with fewer side effects, but lower PPI elimination rates when compared to propensity-matched NF cases. In appropriate candidates, MSA is a valid alternative surgical treatment for GERD management.16.
Background
The emergence of novel endoscopic modalities has challenged the role of surgery for patients with Barrett’s esophagus (BE) and high-grade dysplasia (HGD) or early esophageal adenocarcinoma.Aim
The aim of this study was to review the available evidence of the endoscopic treatment of HGD and early esopahgeal adenocarcinoma.Results
For most patients with BE and HGD, endoscopic ablative therapy is the preferred treatment strategy. Patients with intramucosal adenocarcinoma (T1a) should be treated with endoscopic mucosal resection (EMR) followed by ablative therapy, in order to eradicate the remaining intestinal metaplasia. The best approach to treatment of adenocarcinoma with submucosal invasion (T1b) remains elusive. Endoscopic resection may be suitable for low-risk T1b tumors (well differentiated, without lymphovascular invasion and with superficial submucosal invasion); however, further data are necessary to better risk stratify this group. Careful endoscopic surveillance is recommended following complete eradication of intestinal metaplasia to detect recurrent disease.Conclusion
Patients with BE and HGD should undergo endoscopic ablative therapy. Patients with T1a adenocarcinoma should be treated with EMR and subsequent ablation of the entire BE segment. Low-risk T1b tumors may be suitable for endoscopic resection.17.
John P. Kuckelman Cody J. Phillips Michael J. Derickson Byron J. Faler Matthew J. Martin 《Obesity surgery》2018,28(10):3080-3086
Background
We sought to evaluate the safety and effectiveness of magnetic sphincter augmentation (MSA) in patients with GERD after bariatric surgery.Methods
Pre- and post-operative GERD quality of life (G-QOL) surveys were conducted. Standard indications (SI) group or the post-bariatric group (PB) created. Outcomes were compared between groups.Results
Twenty-eight patients analyzed with no losses to follow-up. All patients had preoperative testing confirming normal motility and presence of GERD. No patients were lost to follow-up. The PB group (N?=?10) were mostly prior sleeve gastrectomies (N?=?8) with two previous gastric bypasses. PB patients required larger MSA device size (16 beads) compared to the SI group (14 beads, p?<?0.001). Outcomes were no different with percent improvement between pre- and post-operative G-QOL survey scores with 70% improvement for PB and 84% for SI (p?=?0.13). Medication cessation was possible in 90% for PB versus 94% for SI (p?=?0.99). Rates of post-operative dysphagia were similar between the two groups.Conclusions
Although larger prospective randomized studies are needed, there is an exciting potential for the role of MSA, providing surgeons a new and much needed tool in their armamentarium against refractory or de novo GERD after bariatric procedures.18.
Introduction
Management of gastroesophageal reflux disease (GERD) is based on the concept that gastric contents, principally acid and pepsin, are responsible for symptoms of reflux and esophageal injury. Pharmacologic treatment is based on the principle that controlling intragastric pH will affect esophageal healing and subsequently symptom relief.Results and Discussion
Control of pH can be accomplished with antisecretory agents, principally proton pump inhibitors (PPIs). The majority of patients respond to a single daily dose of a PPI; however, some will require higher doses, and a small percentage are “refractory” to twice daily dosing of these drugs. The success of these agents, and in fact the reasons for “failure,” is elucidated by understanding the mechanism of action of PPIs and the effect of dose timing and meals on their efficacy.Conclusion
Awareness of new concerns regarding potential side effects of PPIs when used long-term require careful thought as GERD is a chronic disease with most needing some form of medical treatment over time. This article reviews the pharmacologic properties of PPIs and the impact on the treatment of GERD.19.
Saad Althuwaini Fahad Bamehriz Abdullah Aldohayan Waleed Alshammari Saleh Alhaidar Mazen Alotaibi Abdullah Alanazi Hossam Alsahabi Majid Abdularahman Almadi 《Obesity surgery》2018,28(4):916-922
Background and Aims
Laparoscopic sleeve gastrectomy (LSG) might be associated with a new onset or worsening of gastroesophageal reflux disease (GERD). We aim to evaluate the prevalence of post-LSG GERD symptoms and its predictors.Methods
We included patients who underwent primary LSG at a university hospital from 2009 to 2015. We used the GERD-Health-Related Quality of Life (GERD-HRQL) questionnaire and included questions regarding regurgitation to evaluate symptoms before and after LSG; each item was scored from 1 to 5 based on the symptom severity.Results
A total of 213 patients (mean age, 36.08 ± 10.22 years; 48.36% were men) were included. The mean preoperative body mass index (BMI) was 47.84 kg/m2, mean percent total weight loss was 37.99% (95% CI, 36.64 to 39.34), mean percent excess weight loss was 84.14% (95% CI, 80.91 to 87.36), and the mean percent excess BMI loss was 84.17% (95% CI, 80.94 to 87.41). The mean heartburn score while standing increased (0.71 vs. 1.09, p < 0.01) as well as the score of heartburn requiring a diet change (0.67 vs. 1.16, p < 0.01) post-LSG. The scores for dysphagia, odynophagia, and regurgitation increased. New-onset heartburn was reported in 47.06% of our cohort. Those with high preoperative BMIs were less likely to develop new-onset or worsening symptoms of GERD (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95–0.99). More severe heartburn symptoms while standing were associated with higher risks of developing or worsening GERD symptoms (OR, 1.22; 95% CI, 1.01–1.47). None of the other variables could predict the development or worsening of the GERD symptoms.Conclusion
Symptoms of heartburn and regurgitation are common after LSG; however, none of the variables preoperatively could strongly predict patients who would develop new onset or experience worsening of symptoms postoperatively.20.