Impact of Laparoscopic Sleeve Gastrectomy on Esophageal Physiology

Introduction: Laparoscopic sleeve gastrectomy (LSG) is a popular weight loss surgery technique, but the impact on esophageal physiology and esophagogastric junction is still debatable. The aim of our study was to evaluate the manometric changes of the lower esophageal sphincter (LES) after LSG in order to indicate LES manometry pre- procedure. Methods: In a prospective study we evaluated clinically, with upper gastrointestinal endoscopy, and high-resolution esophageal manometry 45 morbidly obese patients before, and 6-12 months after LSG. Results: The BMI (body mass index) decreased from 46.28±5.79 kg/m2 to 32.28±4.65 kg/m2 postoperatively (p <0.01), with a reduction of ~14 kg/m2 of BMI, 39.9 (±11.9) kg body weight and 29.9 (± 6.2)% of the TWL (Total Weight Loss index), in a median interval of 7.9 months. Gastroesophageal reflux disease (GERD) prevalence increased from 17.8% to 31.1% postoperatively, with new GERD onset in 22.2%, but mild symptomatology (the median GERDHRQL score increased from 1.56 to 2.84 points). Postoperatory reflux was associated with lower esophageal sphincter (LES) hypotonia, shortening of LES length and IIGP (increased intragastric pressure). Hiatal hernia repair rate was 17.8%, and proton pump inhibitor consumption 20%. After weight loss, the 10 cases of esophagitis discovered preoperatively cured, but 3 patients were diagnosed with de novo esophagitis. The prevalence of manometric dysmotility after LSG was 28.9%, lower than before surgery (44.4%). Conclusion: Even if GERD remains the main limitation of LSG, the high-resolution esophageal manometry has proved useful and should be implemented in morbidly obese evaluation protocol, to better select the bariatric procedure.

Comparison of Objective Intermediate-Term Outcomes Between per-Oral Endoscopic Myotomy and Laparoscopic Heller Myotomy Show Equivalence

Introduction. The surgical gold standard for esophageal motility disorders is laparoscopic Heller myotomy (LHM). Per-oral endoscopic myotomy (POEM) is a less invasive flexible endoscopic alternative. We compare their intermediate-term outcomes. Methods. Data were collected on consecutive LHM and POEM patients treated for esophageal motility disorders from January 2015 to December 2019. All patients were invited for a comprehensive workup between 6 and 12 months post-myotomy including symptom evaluation, pH testing off medications, manometry, and esophagogastroduodenoscopy (EGD). Primary outcomes include swallowing function and development of postoperative gastroesophageal reflux disease (GERD). Results. There were 100 patients (46 LHM and 54 POEM). Patient demographics and presenting symptoms were comparable. Follow-up data were obtained from 49% of patients. Average length of follow-up for all patients was 10 months. Mean Eckardt scores for LHM decreased from 6.6 to 2.4 ( P < .05) and from 7.06 to 2.2 for POEM ( P < .05). Mean integrated relaxation pressure decreased from 22.8 preoperatively to 11 postoperatively in LHM patients and from 24.6 to 11.5 in POEM patients. POEM patients had a lower incidence of objective postoperative GERD with lower average DeMeester scores (20 vs 29.4) and a higher percentage of patients with a normal DeMeester score (47% vs 31%) compared to LHM patients. However, postoperative GERD health related quality of life scores (11.7 vs 14.1), the percent of patients on proton pump inhibitors (PPIs) (40% vs 53%), and frequency of grade C/D esophagitis (4.3% vs 5.6%) were lower in LHM patients. Conclusions. Intermediate-term symptom resolution and esophageal physiology are improved equally with both procedures. The development of postoperative GERD is equivalent.

PS01.073: HIATAL HERNIA—DIAGNOSIS AND RELEVANCE—THE CONUNDRUM CONTINUES….

Background Upper GI endoscopy and barium swallow are the commonly used diagnostic modalities and Oesophageal manometry of late has contributed to the diagnosis of hiatal hernias. It is known that there exist considerable limitations within each modality in the diagnosis of this seemingly common condition. Aims To assess the correlation between the commonly used investigations of Upper GI Endoscopy and Barium studies and selective use of Esophageal physiology studies in the diagnosis of hiatal hernias. Methods 92 patients who had both an Upper GI endoscopy and Barium swallow in a University hospital formed the study population. There was a subgroup of 29 patients who also underwent a manometry and pH study as a part of their workup. A mix of endoscopists (Physicians, GPs, Surgeons, Supervised trainees and Nurses) performed the upper GI endoscopies. The barium studies were performed by specialist radiographers based on a standard protocol. GI physiology studies were performed by a single GI physiologist with over 25 years of experience. Correlation was performed in varied combinations based on the presence/absence and the size of hernias on different investigations. Results 74% (68) of patients were diagnosed to have a hiatal hernia on endoscopy whereas only 55% of the same group had a hiatal hernia on Barium studies. Of the 29 patients who had all the 3 investigations a hiatal hernia was diagnosed in 82% on endoscopy, 34% on Barium swallow and 48% on High resolution manometry. Only 21% of patients had correlation between all 3 studies. 62 percent had correlation between any 2 modalities and 17% did not have any correlation between any of the diagnostic modalities. The correlation in-between studies was greater for the moderate to large hernias and least for the small/absent hernias. Conclusion There exists considerable variation between the commonly performed procedures for this relatively presumed common condition. There is a greater observed tendency to diagnose a hiatal hernias on endoscopies and less on barium swallows based on the above study. The gold standard for the diagnosis is debatable, considering known limitations based on criteria for diagnosis, dynamic of the Oesophagogastric junction and operator variability. Disclosure All authors have declared no conflicts of interest.

PS01.054: GASTROESOPHAGEAL REFLUX DISEASE PHENOTYPES IN THE MODERN ERA: CLINICAL, ENDOSCOPIC, MANOMETRIC AND PH TESTING PROPERTIES

Background Reflux phenotypes have classically been divided into supine, upright, and bipositional predominant reflux. Recent data on clinical, endoscopic, and manometric features in these patient groups are scant and most prior reports occurred prior to the advent of high resolution impedance manometry and prolonged wireless pH monitoring. We aimed to evaluate the distribution, demographic, manometric, and endoscopic characteristics of the reflux phenotypes in this modern era of testing. Methods Patients who had esophageal physiology testing at a single tertiary care center over a one year period were retrospectively reviewed for demographic, clinical, endoscopic, manometric and pH impedance data. We included consecutive patients who had undergone pH-impedance or wireless pH testing with an EGD within 6 months. Results 139 patients were included and 91 (65.5%) patients were women was mean age of 51.9 + /- 15.2 years and mean BMI of 29.1 + /- 6.4. The most common reflux pattern was bipositional (46% of patients), followed by supine (25%). Baseline characteristics, endoscopic and manometric data across groups are included in Table 1. Barrett's esophagus was most common in the non-acid group. Endoscopically, esophagitis was most common in the supine and bipositional groups. Manometric findings were similar across groups. Conclusion The epidemiology of GERD patients appears to be changing as evidenced by a higher mean BMI than in the largest prior study from 1999. Despite demographic changes in GERD and more widespread use of advanced esophageal physiology testing, the manometric and endoscopic characteristics of GERD phenotypes remains fairly similar. Disclosure All authors have declared no conflicts of interest.