EP.TH.267Gastroesophageal Reflux Disease after sleeve gastrectomy

Aim A prominent complication of a sleeve gastrectomy is gastroesophageal disease (GERD). Symptoms include chest pain, dysphagia, heartburn, regurgitation, chronic cough, and laryngitis. With the rise in obesity, and the already high prevalence of GERD in these populations, this is a significant cause of morbidity in western populations and is likely set to worsen. Method The literature search was carried out using Ovid MEDLINE and PubMed databases to search for keywords and MeSH terms including “bariatric surgery”, “sleeve gastrectomy”, “complications”, “gastroesophageal reflux disease”, “GERD”, “GORD”, and “obesity”. Result Approximately 20% of patients who undergo SG will develop de-novo GERD whilst 19% will have an increase in reflux symptoms. The exact mechanism of GERD in both obesity and post-operatively following SG is unclear. However, it can involve several different mechanisms. This includes poor surgical technique, disruption to physiological anatomy, increase in gastric pressure, increased risk of hiatus hernia, and disruption to normal hormonal balance. An effective approach to treat GERD includes the Stretta procedure with studies showing 72% of patients being symptom-free after 10 years. If this fails, conversion of SG to Roux-en-Y is effective but there is an increased risk of gastro-jejunal anastomotic leak (3% vs 1%). Alternatively, addition of hiatoplasty and 180° cardioplication can also be effective. Conclusion More evidence and international collaborations would help determine which patient groups require counselling and will benefit from novel management to minimise complications.

Gastric and urinary bladder pressures correlate with intra-abdominal pressure in patients with morbid obesity

Intra-abdominal pressure (IAP) affects cardio-respiratory and hemodynamic parameters and can be measured directly or indirectly by measuring gastric or urinary bladder pressure. The aim of this study was to investigate the correlation between IAP, gastric pressure and urinary bladder pressure in patients with morbid obesity, at normal and elevated levels of IAP in two positions. As well, to examine the effects of increasing IAP and patient's position on hemodynamic and respiratory parameters. Twelve patients undergoing laparoscopic bariatric surgery were included. IAP, gastric pressure, and urinary bladder pressure were measured while patients were in the supine position and after 45° anti-Trendelenburg tilt. Mean inspiratory pressure, peak inspiratory pressure, and tidal volume were recorded and assessed. In supine position; directly measured IAP was 9.1 ± 1.8 mmHg, compared to 10 ± 3.6 and 8.9 ± 2.9 mmHg in the stomach and bladder, respectively. Increasing IAP to 15 mmHg resulted in an increased gastric pressure of 17 ± 3.8 mmHg, and urinary bladder pressure of 14.8 ± 3.9 mmHg. Gastric and urinary bladder pressures strongly correlated with IAP (R = 0.875 and 0.847, respectively). With 45° anti-Trendelenburg tilt; directly measured IAP was 9.4 ± 2.2 mmHg, and pressures of 10.8 ± 3.8 mmHg and 9.2 ± 3.8 mmHg were measured in the stomach and the bladder, respectively. Increasing IAP to 15 mmHg resulted in elevating gastric and bladder pressures to 16.6 ± 5.3 and 13.3 ± 4 mmHg, respectively. Gastric and urinary bladder pressures had good correlation with IAP (R = 0.843 and 0.819, respectively). Changing patient position from supine to 45° anti-Trendelenburg position resulted in decreased mean and peak inspiratory pressures, and increased tidal volume. Basal IAP is high in patients with morbid obesity. IAP shows positive correlation to gastric and urinary bladder pressures at both normal and elevated levels of IAP. Anti-Trendelenburg tilt of mechanically ventilated morbidly obese patients resulted in favorable effects on respiratory parameters.Trial Registration: The study was retrospectively registered in the NIH registry. Registration number is pending.

Continuous intra-gastral monitoring of intra-abdominal pressure in critically ill children: a validation study

Background In critically ill children, detection of intra-abdominal hypertension (IAH > 10 mmHg) and abdominal compartment syndrome (ACS = IAH + organ dysfunction) is paramount and usually monitored through intra-vesical pressures (IVP) as current standard. IVP, however, carries important disadvantages, being time-consuming, discontinuous, with infection risk through observer-dependent manipulation, and ill-defined for catheter sizes. Therefore, we sought to validate air-capsule-based measurement of intra-gastric pressure (ACM-IGP). Methods We prospectively compared ACM-IGP with IVP both in vivo and in vitro (water column), according to Abdominal-Compartment-Society validation criteria. We controlled for patient age, admission diagnosis, gastric filling/propulsive medication, respiratory status, sedation levels and transurethral catheters, all influencing intra-abdominal pressure (IAP). Results In tertiary care PICU setting, finally, n = 97 children were enrolled (median age, 1.3 years [range 0 days–17 years], LOS-PICU 8.0 [1–332] days, PRISM-III-Score 13 [0–35]). In n = 2.770 measurements pairs, median IAP was 6.7 [0.9–23.0] mmHg, n = 38 (39%) children suffered from IAH > 10 mmHg, n = 4 from ACS. In vitro against water column, ACM-IGP correlated perfectly (r2 0.99, mean bias − 0.1 ± 0.5 mmHg, limits of agreement (LOA) − 1.1/+ 0.9, percentage error [PE] 12%) as compared with IVP (r2 0.98, bias + 0.7 ± 0.6 mmHg, LOA − 0.5/+ 1.9, PE 15%). With larger IVP catheters at higher pressure levels, IVP underestimated pressures against water column. In vivo, agreement between either technique was strong (r2 0.95, bias 0.3 ± 0.8 mmHg, LOA − 1.3/+ 1.9 mmHg, PE 23%). No impact of predefined control variables on measurement agreement was observed. Conclusions In a large PICU population with high IAH prevalence, ACM-IGP agreed favourably with IVP. More widespread usage of ACM-IGP may improve detection rates of ACS in critically ill children. Trial registration WHO-ICTRP-No. DRKS00006556 (German Clinical Trial Register). Registered 12th September 2014, URL: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00006556

The cardiovascular consequences of fatiguing expiratory muscle work in otherwise resting healthy humans

In 11 healthy adults (25 ± 4 years; 2 females), we investigated the effect of expiratory resisted loaded breathing [65% maximal expiratory mouth pressure (MEP), 15 breaths·min−1, duty cycle 0.5; ERLPm] on mean arterial pressure (MAP), leg vascular resistance (LVR), and leg blood flow (Q̇L). On a separate day, a subset of 5 males performed ERL targeting 65% of maximal expiratory gastric pressure (ERLPga). ERL-induced expiratory muscle fatigue was confirmed by a 17 ± 5% reduction in MEP (P < 0.05) and a 16 ± 12% reduction in the gastric twitch pressure response to magnetic nerve stimulation (P = 0.09) from before to after ERLPm and ERLPga, respectively. From rest to task failure in ERLPm and ERLPga, MAP increased (ERLPm = 31 ± 10 mmHg, ERLPga = 18 ± 9 mmHg, both P < 0.05), but group mean LVR and Q̇L were unchanged (ERLPm: LVR = 0.78 ± 0.21 vs. 0.97 ± 0.36 mmHg·ml−1·min−1, Q̇L = 133 ± 34 vs. 152 ± 74 ml·min−1; ERLPga: LVR = 0.70 ± 0.21 vs. 0.84 ± 0.33 mmHg·ml−1·min−1, Q̇L = 160 ± 48 vs. 179 ± 110 ml·min−1) (all P ≥ 0.05). Interestingly, Q̇L during ERLPga oscillated within each breath, increasing (~66%) and decreasing (~50%) relative to resting values during resisted expirations and un-resisted inspirations, respectively. In conclusion, fatiguing expiratory muscle work did not affect group mean LVR or Q̇L in otherwise resting humans. We speculate that any sympathetically-mediated peripheral vasoconstriction was counteracted by transient mechanical effects of high intra-abdominal pressures during ERL.

Continuous Intra-Gastral Monitoring of Intra-Abdominal Pressure in Critically ill Children – A Validation Study

Background: In critically ill children, detection of intra-abdominal hypertension (IAH, >10mmHg) and abdominal compartment syndrome (ACS, =IAH + organ dysfunction) is paramount and usually monitored through intra-vesical pressures (IVP) as current standard. IVP however carries important disadvantages, being time-consuming, discontinuous, with infection risk through observer-dependent manipulation, and ill-defined for catheter sizes. Therefore, we sought to validate air-capsule-based measurement of intra-gastric pressure (ACM-IGP).Methods: We prospectively compared ACM-IGP with IVP both in-vivo and in-vitro (water-column), according to Abdominal-Compartment-Society validation criteria. We controlled for patient age, admission diagnosis, gastric filling/propulsive medication, respiratory status, sedation levels and transurethral catheters, all influencing intra-abdominal pressure (IAP).Results: In tertiary care PICU setting, finally, n=97 children were enrolled (median age, 1.3 years [range, 0 days -17 years], LOS-PICU 8.0 [1-332] days, PRISM-III-Score 13 [0-35]). In n=2.770 measurements pairs, median IAP was 6.7 [0.9 -23.0] mmHg. n=38 (39%) children suffered from IAH>10mmHg, n=4 from ACS. In-vitro against water-column, ACM-IGP correlated perfectly (r² 0.99, mean bias -0.1±0.5 mmHg, limits-of-agreement (LOA) -1.1/+0.9, percentage error [PE] 12%) as compared with IVP (r² 0.98, bias +0.7±0.6 mmHg, LOA -0.5/+1.9, PE 15%). With larger IVP catheters at higher pressure levels, IVP underestimated pressures against water-column. In-vivo, agreement between either technique was strong (r² 0.95, bias 0.3±0.8 mmHg, LOA -1.3/+1.9mmHg, PE 23%). No impact of predefined control variables on measurement agreement was observed. Conclusions: In a large PICU population with high IAH prevalence, ACM-IGP agreed favourably with IVP. More wide-spread usage of ACM-IGP may improve detection rates of ACS in critically ill children. Trial registration: WHO-ICTRP-No. DRKS00006556 (German Clinical Trial Register). Registeres 12th September 2014, URL: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00006556

Comparison of intra-gastric pressure between endotracheal tube and supraglottic airway devices in laparoscopic hepatectomy:A randomised, controlled, non-inferiority study

Background Supraglottic airway (SGA) devices do not definitively protect the airway from regurgitation of gastric contents. Increased gastric pressure and long operation time are associated with development of complications such as aspiration pneumonia. The aim of this study was to compare intra-gastric pressure between second-generation SGA and endotracheal tube (ETT) devices during long-duration laparoscopic hepatectomy.Methods A total of 66 patients was randomly assigned to two groups; 33 patients each in the ETT and SGA groups. Intra-gastric pressure was continuously measured via a gastric drainage tube with a three-way stopcock connected to the pressure monitoring device. Normal saline was added to the end of the gastric drainage tube at each operation time point.Results Intra-gastric pressure during pneumoperitoneum was no different between the two groups (p = 0.146) or over time (p = 0.094). The mean (SD) pH of the SGA tip measured after operation was 6.7 (0.4), and a pH less than 4 was not observed. Relative risk of postoperative complications was significantly higher in the ETT group relative to the SGA group (sore throat, 5.5; cough,13.0).Conclusions Use of SGA devices does not further increase intra-gastric pressure, even during prolonged upper abdominal laparoscopic surgery. Also, the frequency of postoperative sore throat and cough was significantly lower when the second-generation SGA device was used.Clinical trial registration of Korea (https://cris.nih.go.kr/cris/index.jsp): KCT0003512 Principle investigator: G S K; date of registration February 15, 2019, https://cris.nih.go.kr/cris).

Gastric and Urinary Bladder Pressures Correlate with Intra-abdominal Pressure in Patients with Morbid Obesity

Background Intra-abdominal pressure (IAP) affects cardio-respiratory and hemodynamic parameters and can be measured directly or indirectly by measuring gastric or urinary bladder pressure. The aim of this study was to investigate the correlation between IAP, gastric pressure and urinary bladder pressure in patients with morbid obesity, at normal and elevated levels of IAP in two positions. As well, to examine the effects of increasing IAP and patient's position on hemodynamic and respiratory parameters. Methods Twelve patients undergoing bariatric surgery were included. IAP, gastric pressure, and urinary bladder pressure were measured while patients were in the supine position and after 45o anti-Trendelenburg tilt. Mean inspiratory pressure, peak inspiratory pressure, and tidal volume were recorded and assessed. Results In supine position; directly measured IAP was 9.1 ± 1.8 mmHg, compared to 10 ± 3.6 and 8.9 ± 2.9 mmHg in the stomach and bladder, respectively. Increasing IAP to 15 mmHg resulted in an increased gastric pressure of 17 ± 3.8 mmHg, and urinary bladder pressure of 14.8 ± 3.9 mmHg. Gastric and urinary bladder pressures strongly correlated with IAP (R = 0.875 and 0.847, respectively). With 45o anti-Trendelenburg tilt; directly measured IAP was 9.4 ± 2.2 mmHg, and pressures of 10.8 ± 3.8 mmHg and 9.2 ± 3.8 mmHg were measured in the stomach and the bladder, respectively. Increasing IAP to 15 mmHg resulted in elevating gastric and bladder pressures to 16.6 ± 5.3 and 13.3 ± 4 mmHg, respectively. Gastric and urinary bladder pressures had good correlation with IAP (R = 0.843 and 0.819, respectively). Changing patient position from supine to 45o anti-Trendelenburg position resulted in decreased mean and peak inspiratory pressures, and increased tidal volume. Conclusions Basal IAP is high in patients with morbid obesity. IAP shows positive correlation to gastric and urinary bladder pressures at both normal and elevated levels of IAP. Anti-Trendelenburg tilt of mechanically ventilated morbidly obese patients resulted in favorable effects on respiratory parameters.