Refractory gastroesophageal reflux disease: advances and treatment

‘Refractory gastroesophageal reflux disease’ is one of the most common misnomers in the area of gastroesophageal reflux disease. The term implies reflux as the underlying etiology despite unresponsiveness to aggressive proton pump inhibitor therapy. The term should be replaced with ‘refractory symptoms.’ We must acknowledge that in many patients symptoms of reflux often overlap with non-GERD causes such as gastroparesis, dyspepsia, hypersensitive esophagus and functional disorders. Lack of response to aggressive acid suppressive therapy often leads to diagnostic testing. In majority of patients these tests are normal. The role of non-acid reflux in this group is uncertain and patients should not undergo surgical fundoplication based on this parameter. In patients unresponsive to acid suppressive therapy GERD is most commonly not causal and a search for non-GERD causes must ensue.     

Basal and residual lower esophageal pressures increase in old age in classic achalasia,but not vigorous achalasia

Background and Aim: The relationship between age and esophageal motility parameters (i.e. basal and residual pressure of the lower esophageal sphincter [LES]) remains to be established in achalasia patients, possibly because most previous studies did not distinguish between classic and vigorous achalasia patients. We investigated the relationship between age and esophageal motility parameters in both classic and vigorous achalasia patients. Methods: A retrospective review of esophageal manometry data in a single center was undertaken. Basal and residual pressure for LES was analyzed. A total of 103 achalasia patients were enrolled, comprising 84 classic and 19 vigorous types. They were subdivided into three different age groups as follows: 21–40 years old (group A), 41–60 years old (group B), and over 60 years old (group C). Results: In classic achalasia patients (M : F = 27:57, mean age = 44 ± 15 years old) the older age group showed a significantly higher basal LES pressure (49.62 ± 19.63 mmHg) than the younger age group (P < 0.0001). Moreover, the older age group also showed significantly high residual LES pressure (20.46 ± 8.61 mmHg) than the younger age group (P = 0.0006). In contrast, in vigorous achalasia patients (M : F = 12:7, mean age: 47 ± 15 years old) there were no difference between age and motility indices (all P > 0.05). Conclusion: In classic achalasia patients there appears to be a correlation between age and esophageal motility indices, especially basal and residual LES pressure. Such correlations do not appear to exist for vigorous achalasia patients.     

Prospective evaluation of the efficacy of peroral endoscopic myotomy in patients with achalasia

Peroral endoscopic myotomy (POEM) is an endoscopic alternative to surgical myotomy in patients with achalasia. This study aimed to evaluate the efficacy and clinical outcomes of POEM.A total of 20 patients with achalasia who underwent POEM between October 2016 and November 2017 were prospectively recruited. The intraoperative esophagogastric junction distensibility index (mm²/mm Hg) was measured pre- and post-myotomy using an endoluminal functional lumen imaging probe. Clinical response was defined as Eckardt score ≤3. Health-related quality of life was measured by the 36-item short-form health survey score.POEM was successfully completed in all cases. The median procedure time was 68.5 minutes (range 50.0–120.0), and the median myotomy length was 13 cm (range 11–18). Major adverse events were encountered in 2 cases. Overall, clinical responses were observed in all patients during a median follow-up of 11.9 months (range 1.2–26.2). Postoperative esophagogastric junction distensibility index was significantly higher than baseline (from 1.3 [range 0.8–6.9] to 6.3 [range 25–19.2], P < .001). The median Eckardt scores were decreased after POEM (5 [range 2–11] to 1 [range 0–3], P < .001), and the 36-item short-form health survey score was also improved significantly after POEM (67.5 [range 34.5–93.9] to 85.7 [range 53.4–93.3], P = .004).POEM is an effective treatment for achalasia, based on the improvement of both symptoms and objective measures.Clinicaltrial.gov {"type":"clinical-trial","attrs":{"text":"NCT 02989883","term_id":"NCT02989883"}}NCT 02989883     

Histology of esophageal mucosa from patients with achalasia

When achalasia becomes far advanced and leads to esophageal resection, inflammation of the esophageal mucosa is almost universal. The histology of the esophageal mucosa in less advanced cases of achalasia has not been firmly established. We have studied endoscopic biopsies obtained during evaluation of patients with achalasia. Two to four endoscopic biopsies from the lower esophagus of 26 patients with manometrically verified achalasia were mounted on mesh, serially sectioned, stained, coded and interpreted by two independent observers using recognized criteria. The histological findings were correlated with clinical data. Ten of 26 patients had at least one abnormal biopsy. Five of these 10 patients had a previous Heller myotomy; another patient had several pneumatic dilatations, and two other patients had endoscopically proven candida infections. Of the 16 patients with normal histology, four had prolonged stasis, five had heartburn and one patient had both heartburn and stasis. Unless the patient with achalasia has had a Heller myotomy, balloon dilatation, or a candida infection, the esophageal mucosa on biopsy appears to be within normal limits, even in patients with years of esophageal stasis or complaints of heartburn.     

Objective assessment of gastroesophageal reflux after extended Heller myotomy and total fundoplication for achalasia with the use of 24‐hour combined multichannel intraluminal impedance and pH monitoring (MII‐pH)

SUMMARY. This study aims to evaluate by the use of 24‐hour combined multichannel intraluminal impedance and pH monitoring (MII‐pH) the efficacy of the Nissen fundoplication in controlling both acid and nonacid gastroesophageal reflux (GER) in patients that underwent Heller myotomy for achalasia. It has been demonstrated that fundoplication prevents the pathologic acid GER after Heller myotomy, but no objective data exists on the efficacy of this antireflux surgery in controlling all types of reflux events. The study population consisted of 20 patients that underwent laparoscopic Heller myotomy and Nissen fundoplication for achalasia. All patients were investigated with manometry and MII‐pH. MII‐pH showed no evidence of postoperative pathologic GER. The overall number of GER episodes was normal in both the upright and recumbent position. This reduction was obtained because of the postoperative control of both the acid and nonacid reflux episodes. The Nissen fundoplication adequately controls both acid and nonacid GER after extended Heller myotomy. Further controls with MII‐pH are warranted to check at a longer follow‐up for the efficacy of this antireflux procedure in achalasic patients.     

Surgical risk for patients with Chagasic achalasia and its correlation with the degree of esophageal dilation

AIM: To analyze the risk of cardiovascular complications in patients with indication for surgical treatment of Chagasic esophageal achalasia and to correlate the surgical risks with the degree of esophageal dilation, thereby proposing a risk scale index. METHODS: One hundred and twenty-four patients with Chagasic esophageal achalasia, who received surgical treatment at the Hospital das Clinicas of the Federal University of Goias, were included in this study. The patients were mostly related to the postoperative complications due to the cardiovascular system. All the patients were submitted to: (1) clinical history to define the cardiac functional class (New York Heart Association); (2) conventional 12-lead electrocardiogram at rest; and (3) contrast imaging of the esophagus to determine esophageal dilatation according to Rezende's classification of Chagasic megaesophagus. RESULTS: An assessment of the functional classification (FC) of heart failure during the preoperative period determined that 67 patients (54.03%) were assigned functional class I (FC I), 46 patients (37.09%) were assigned functional class II (FC II), and 11 patients (8.87%) were assigned functional class III (FC III). None of the patients were assigned to functional class IV (FC IV). There was a positive correlation between the functional class and the postoperative complications (FC IXFC II: P<0.001; FC IXFC III: P<0.001). The ECG was normal in 44 patients (35.48%) and presented abnormalities in 80 patients (64.52%). There was a significant statistical correlation between abnormal ECG (arrhythmias and primary change in ventricular repolarization) and postoperative complications (P<0.001). With regard to the classification of the Chagasic esophageal achalasia, the following distribution was observed: group II, 53 patients (42.74%); group III, 37 patients (29.83%); and group IV, 34 patients (27.41%). There was a positive correlation between the degree of esophageal dilation and the increase in postoperative complications (grade IIXgrade III achalasia: P<0.001; grade IIXgrade IV achalasia: P<0.001; and grade IIIXgrade IV achalasia: P = 0.017). Analyzing these results and using a multivariate regression analysis associated with the probability decision analysis, a risk scale was proposed as follows: up to 21 points (mild risk); from 22 to 34 points (moderate risk); and more than 34 points (high risk). The scale had 82.4% accuracy for mild risk patients and up to 94.6% for the high risk cases. CONCLUSION: The preoperative evaluation of the cardiovascular system, through a careful anamnesis, an ECG and contrast imaging of the esophagus, makes possible to estimate the surgical risks for Chagas' disease patients who have to undergo surgical treatment for esophageal achalasia.     

The Outcomes and Quality of Life of Patients with Achalasia after Peroral Endoscopic Myotomy in the Short-Term

Purpose: To assess the short-term efficacy and quality of life (QOL) of patients with achalasia after peroral endoscopic myotomy (POEM).Methods: Thirty-five achalasia patients underwent POEM from May 2013 to December 2013. The data on clinical evaluation and QOL before therapy, at 1 month and 6 months postoperation were collected and analyzed.Results: All the thirty-five patients underwent POEM successfully. By comparing the data of the preoperative with that of 1 month and 6 months after POEM respectively, we found that: mean Eckardt score decreased (6.83 vs 0.51, 6.83 vs 0.46, all P <0.05), esophagus diameter reduced (47.97 mm vs 32.00 mm, 47.97 mm vs 28.50 mm, all P <0.05), and esophageal manometry declined (29.5 mmHg vs 11.5 mmHg, 29.5 mmHg vs 10.3 mmHg, all P <0.05). Complications occurred in 14.3% (5/35) of the cases, and no recurrence was observed. At each time point, postoperative QOL scores were higher than those of preoperative (P <0.05).Conclusions: POEM is safe and effective for treating achalasia in the short-term, it can relieve clinic symptoms as well as improve patients’ QOL.     

Clinical remission following endoscopic placement of retrievable,fully covered metal stents in patients with esophageal achalasia

Metal stents may represent an alternative therapy in the treatment of achalasia. We therefore evaluated the effectiveness of retrievable, fully covered metal stents in patients with achalasia. Fifty‐nine patients with achalasia were treated with retrievable, fully covered metal stents. Symptoms using a global symptom score (0–10), lower esophageal sphincter (LES) resting pressure, LES relaxation, and simultaneous contraction of the esophagus were analyzed before and 1 week and 1 month after intervention. Complications and treatment outcomes were followed up at 6, 12, 18, and 24 months postoperatively. Stent placement was successful, and clinical symptoms resolved (P < 0.01) in all patients. Regurgitation, dysphagia and chest pain improved significantly (all P < 0.01). Therapy improved LES resting pressure (51.4 ± 9.7 mmHg pretherapy vs. 20.9 ± 8.1 mmHg post‐therapy), LES relaxation (58.1 ± 17.1% pretherapy vs. 84.5 ± 18.9% post‐therapy), and simultaneous contraction of the esophagus (36.1 ± 8.6% pretherapy vs. 69.4 ± 23.1% post‐therapy) 1 month after stent placement (all P < 0.01). The cumulative clinical remission rates 6, 12, 18, 24, 30, and 36 months after stent removal were 90.9%, 81.8%, 76.4%, 69.1%, 65.5%, and 49.1%, respectively. All patients tolerated stent placement. Twelve patients (25.5%) complained of substernal pain and five (10.6%) had substernal burning. Stents migrated in four patients (8.5%). Insertion of retrievable, fully covered metal stents is an effective and safe treatment in patients with achalasia.     

Comparison of idiopathic achalasia and Chagas' disease esophagopathy at the light of high‐resolution manometry

The comparison between idiopathic achalasia (IA) and Chagas' disease esophagopathy (CDE) may evaluate if treatment options and their outcomes can be accepted universally. This study aims to compare IA and CDE at the light of high‐resolution manometry. We studied 86 patients with achalasia: 45 patients with CDE (54% females, mean age 55 years) and 41 patients with IA (58% females, mean age 49 years). All patients underwent high‐resolution manometry. Upper esophageal sphincter parameters were similar (basal pressure CDE = 72 ± 45 mmHg, IA = 82 ± 57 mmHg; residual pressure CDE = 9.9 ± 9.9 mmHg, IA = 9.8 ± 7.5 mmHg). In the body of the esophagus, the amplitude was higher in the IA group than the CDE group at 3 cm (CDE = 15 ± 14 mm Hg, IA = 42 ± 52 mmHg, P = 0.003) and 7 cm (CDE = 16 ± 15 mmHg, IA = 36 ± 57 mmHg, P = 0.04) above the lower esophageal sphincter (LES). The LES basal pressure (CDE = 17 ± 16 mmHg, IA = 40 ± 22 mmHg, P < 0.001) and residual pressure (CDE = 12 ± 11 mmHg, IA = 27 ± 13 mmHg, P < 0.001) were also higher in the IA group. Our results show that: (i) there is no difference in regards to the upper esophageal sphincter; (ii) higher pressures of the esophageal body are noticed in patients with IA; and (iii) basal and residual pressures of the LES are lower in patients with CDE. Our results did not show expressive manometric differences between IA and CDE. Some differences may be attributed to a more pronounced esophageal dilatation in patients with CDE.