Magnetic Sphincter Augmentation Outcomes in Severe Gastroesophageal Reflux Disease

Introduction: Outcomes of laparoscopic procedures for gastroesophageal reflux disease (GERD) are variable depending on surgical expertise and/or patient-related factors. Some procedures may be inadequate in patients with severe disease. Effectiveness of laparoscopic magnetic sphincter augmentation (MSA) has not been extensively tested in patients with severe disease.Methods: A prospectively collected database was analyzed to identify patients who underwent MSA at a single institution. Individuals who had previous esophago-gastric surgery were excluded. Severe GERD was defined as lower esophageal sphincter pressure <5 mmHg, distal esophageal amplitude <30 mmHg, Barrett's metaplasia, stricture or grade C-D esophagitis, and/or DeMeester score >50. Clinical characteristics and outcomes of patients with severe GERD were compared with those of patients with mild to moderate GERD who served as control group.Results: Over the study period, a total of 336 patients met the inclusion criteria, and 102 (30.4%) had severe GERD. The median follow-up was 24 months (IQR = 75) in severe GERD patients and 32 months (IQR = 84) in those with non-severe GERD. Patients with severe GERD had a higher rate of dysphagia and higher GERD-HRQL scores. After the MSA procedure, symptoms, health-related quality of life scores, and proton-pump inhibitors consumption significantly decreased in both groups (p < 0.05). No difference between groups was found in the prevalence of severe post-operative dysphagia, the need for endoscopic dilation or device removal, and the DeMeester score.Conclusion: Laparoscopic MSA is safe and effective in reducing symptoms, PPI use, and esophageal acid exposure also in patients with severe GERD.

Outcome of Pneumatic Balloon Dilatation in Achalasia Cardia

Background: Achalasia Cardia is a rare esophageal motility disorder. Among various treatment options, Pneumatic Dilatation (PD) is the most widely used and cost effective modality till date. This is the first observational study aiming to evaluate the short term response and complications of PD for Achalasia Cardia in Nepal. Methods: This prospective observational study was conducted between 28th Jan 2020 to 27th Jan 2021. It included 39 patients with Achalasia Cardia diagnosed by clinical presentation, esophagoscopy, barium esophagogram and high resolution manometry. Two patients of Type III achalasia were excluded from study. Thirty seven patients underwent pneumatic dilatation with 30 mm Rigiflex balloon (Boston Scientific, USA) for a duration of 1 minute. Response was assessed by Eckardts score at 3 and 6 months. Result: Among 39 cases (mean age= 39.03±15.017 years, 59% men), commonest was Type II Achalasia (71.8%) followed by Type I (23.1%) and Type III (5.1%). Dysphagia was present in all patients (100%), followed by weight loss (84.6%), regurgitation (79.5%) and chest pain (35.9%). Mean basal Eckardts score and Lower Esophageal Sphincter pressure of the study population was 7.81±1.24 and 24.40±6.83 respectively. Response to pneumatic dilatation was 89.2%. Eckardts score changed significantly from7.81±1.24 to 1.03±1.82 at 6 months (p<0.001). None of the patients had major complications. Younger age (23±6.377 years) had poor response to treatment, while predilatation Lower Esophageal Sphincter pressure, gender and type of achalasia did not affect the treatment outcome. Conclusion: PD is safe and effective treatment modality for Achalasia. Younger patients have poor response to treatment with Pneumatic Dilatation.

Clinical outcomes of peroral endoscopic myotomy for achalasia in children: a systematic review and meta-analysis

Peroral endoscopic myotomy (POEM) is a novel minimally invasive intervention, which has shown to be effective and safe for treating achalasia in adults. Presently, POEM was also reported to be effective for achalasia in children. So we conducted this study to explore the clinical outcomes of POEM for pediatric achalasia. A systematic literature search in PubMed, Embase, and Cochrane databases was performed, which covered the period from January 2009 to June 2020. Selecting studies and collecting data was independently by two reviewers according to predefined criteria. The statistical analysis was carried out using Comprehensive Meta-Analysis software version 2 and Review Manager 5.3. A total of 11 studies with 389 children were identified in the final analysis. Pooled technical success of POEM treatment achalasia was achieved in 385 children (97.4%; 95% confidence interval [CI], 94.7%–98.7%), and the pooled clinical success was achieved in 348 children (92.4%; 95% CI, 89.0%–94.8%). After POEM, the Eckardt score was significantly decreased by 6.76 points (95% CI, 6.18–7.34, P &lt; 0.00001), and the lower esophageal sphincter pressure was significantly reduced by 19.38 mmHg (95% CI, 17.54–21.22, P &lt; 0.00001). The pooled major adverse events rate related to POEM was 12.8% (95% CI, 4.5%–31.5%) and the gastroesophageal reflux rate was 17.8% (95% CI, 14.2%–22.0%). Our current study demonstrated that the POEM was an effective and safe technique for treating achalasia in children. Further randomized comparative studies of POEM and other therapeutic methods are warranted to determine the most effective treatment modality for achalasia in children.

Experimental Study of the Effect of Helicobacter pylori Infection on Barrett Esophagus and Its Correlation with Immune Function

Background: Helicobacter pylori is an important pathogen in the upper digestive tract. It is of great significance to properly understand the risk factors for the transformation of Barrett esophagus into esophageal carcinoma. However, the relationship between H. pylori and gastroesophageal reflux disease (GERD) and Barrett esophagus remains controversial, and the correlation with immune function has been rarely reported. Objectives: This study investigated the effect of H. pylori infection on Barrett esophagus and its correlation with immune function. Methods: We recruited 40 patients with Barrett esophagus (Barrett esophagus group) and 40 patients with GERD (GERD group). In addition, 40 healthy controls were selected for the control group. Esophageal function and its correlation with immune function were measured in each group. Results: The positivity rate of H. pylori (P < 0.05) and sphincter pressure were lower in both Barrett esophagus and GERD groups than in the control group, while the levels of PGI, PGII, PGI/II, and G-17 were higher (P < 0.05). The levels of CD3+, CD4+, and CD4+/CD8+ were lower in the Barrett esophagus group than in the GERD group, but they were negatively correlated (P < 0.05) with H. pylori infection. The level of CD8+ was higher in the Barrett esophagus group, and it was positively correlated (P < 0.05) with H. pylori infection. Conclusions: Helicobacter pylori infection may protect against Barrett esophagus by reducing gastric acid secretion and increasing lower esophageal sphincter pressure. Besides, it has a certain correlation with immune function.

Clinical Symptom Presentation of Hypercontractile Peristalsis in the Era of High-Resolution Manometry: A Single-Center Experience

Background: Hypercontractile motility of the esophagus is occasionally noted on high-resolution manometry (HRM), but its clinical correlations are unclear. We compared symptom severity and clinical presentation of patients with hypercontractile motility of the esophagus. Methods: This was a retrospective cohort study. We queried a prospectively maintained database for patients who underwent esophageal function testing from October 1, 2016, to October 30, 2018. We included patients with jackhammer esophagus (JE; ≥2 swallows with distal contractile integral [DCI] ≥8,000 mm Hg∙cm∙s), nutcracker esophagus (NE; mean DCI 5,000–8,000 mm Hg∙cm∙s without meeting JE criteria), or esophagogastric junction outflow obstruction ([EGJOO]: abnormal median integrated relaxation pressure (>15 mm Hg) without meeting achalasia criteria, with JE [EGJOO-h], or normal motility [EGJOO-n]). HRM, endoscopy, barium esophagram, ambulatory pH studies, and symptom questionnaires were reevaluated for further analysis. Clinical parameters were analyzed using Spearman Rho correlation. Categorical variables were assessed with Fisher exact or chi-square test. Results: Altogether, 85 patients met inclusion criteria. They were divided into 4 subgroups: 28 with JE, 18 with NE, 15 with EGJOO-h, and 24 with EGJOO-n. Patients with EGJOO-h were the most symptomatic overall. No correlation was seen between symptoms and mean DCI (p ≥ 0.05 all groups) or number of hypercontractile swallows (≥8,000 mm Hg∙cm∙s, p ≥ 0.05). A significant correlation was noted between dysphagia and lower esophageal sphincter pressure (LESP) and LESP integral (p ≤ 0.05). Conclusion: The number of hypercontractile swallows and mean DCI were not associated with patient-reported symptoms. Elevated LESP may be a more relevant contributor to dysphagia.

ENDOSCOPIC EVALUATION OF MANOMETRIC PROFILE OF GASTRO ESOPHAGEAL REFLUX DISEASE

Background: Gastro esophageal reflux disease leads to poor quality of life to patients because of pain and discomfort. Some studies also reported that incidence of adenocarcinoma of esophagus and Barrett's esophagus among patients with reflux disease. The abnormal esophageal motility act as a major risk factors and also reported with severity and prognosis of the disease. Material & Methods: In present study 50 patients of heart burn or acid regurgitation (GERD) for at least more than 3 months were enrolled from outdoor and from ward by simple random sampling. Clearance from Institutional Ethics Committee was taken before start of study. Written informed consent was taken from each study participant. Results: 15 (30%) had non-erosive reflux disease and 35 (70%) had erosive reflux disease. Among the patients of non-erosive reflux disease, 13 (26%) had normal lower esophageal sphincter pressure and 2 (4%) had Low Lower esophageal sphincter pressure. Among the patients of erosive reflux disease, 32 (64%) had normal lower esophageal sphincter pressure and 3 (6%) had Low Lower esophageal sphincter pressure (P value >0.05). Among the patients of non-erosive reflux disease, 10 (20%) had normal esophageal motility and 5 (10%) had Ineffective esophageal motility. Among the patients of erosive reflux disease, 25 (50%) had normal esophageal motility and 10 (20%) had Ineffective esophageal motility (P value >0.05). Conclusion: Low Lower esophageal sphincter and Ineffective or abnormal esophageal motility pressure was non-significantly associated with non-erosive and erosive reflux disease. Ineffective esophageal motility and Low LES pressure was the main cause for gastro esophageal reflux disease Keywords: GERD, High Resolution Manometry, Ineffective peristalsis.