Comparison of 180° anti-reflux mucosectomy versus 270° anti-reflux mucosectomy for treatment of refractory gastroesophageal reflux disease: a retrospective study

Background Anti-reflux mucosectomy (ARMS) is a novel endoscopic treatment for refractory gastroesophageal reflux disease (rGERD). Several studies have validated its safety and effectiveness, but postoperative dysphagia remains in concern. Since the influence of different resection ranges on efficacy and complications of ARMS has rarely been studied, this study aimed to compare outcomes of 180°ARMS and 270°ARMS in treatment of rGERD. Methods This study was conducted from August 2017 to September 2020. 39 eligible patients underwent either 180° ARMS or 270° ARMS and followed up at 6 months postoperation. Primary outcome measure was assessed by Gastroesophageal Reflux Disease Questionnaire (GERD-Q). Secondary outcomes included quality of life, PPI use, gastroesophageal flap valve grade, presence of reflux esophagitis, acid exposure time (AET), distal contractile integral (DCI), and integrated relaxation pressure (IRP) measured by high-resolution manometry (HRM) and complication rate. Per-protocol analysis was performed. Results Among 39 patients, 18 underwent 180° ARMS, while 21 underwent 270° ARMS. At postoperative 6 months follow-up period, primary outcome showed no significant difference between two groups (p = 0.34). Similarly, no significant difference was demonstrated between groups regarding most secondary outcomes except for fewer complaints of newly dysphagia in 180° ARMS group. No other serious complications were observed in both groups. Conclusion Although 180° ARMS and 270° ARMS could be equally effective for treatment of rGERD, 180° ARMS might be more recommended due to lower incidence of newly post-procedural dysphagia.

Phenotyping patients with borderline elevated esophageal acid exposure

Summary Acid exposure time (AET) <4% on ambulatory reflux monitoring definitively rules out pathologic gastroesophageal acid reflux, while AET >6% indicates pathologic reflux per the Lyon Consensus, leaving AET of 4–6% as borderline. We aimed to elucidate the borderline AET population and identify metrics that could help differentiate this group. A total of 50 subjects in each group, AET <4, 4–6, and >6% on pH-impedance monitoring between 2015 and 2019, were retrospectively reviewed. In addition to demographic and clinical information, the extracted data included mean nocturnal baseline impedance (MNBI) on reflux study and high-resolution manometry (HRM) parameters and diagnosis. After excluding patients with prior foregut surgery, major esophageal motility disorder, or unreliable impedance testing, a total of 89 subjects were included in the analysis (25 with normal AET < 4%, 38 with borderline 4–6%, 26 with abnormal >6%). MNBI in borderline AET patients was significantly lower compared to normal AET (1607.7 vs. 2524.0 ohms, P < 0.01), and higher than abnormal AET (951.5 ohms, P < 0.01). Borderline subjects had a greater frequency of ineffective esophageal motility (IEM) diagnosis per Chicago classification v3.0 (42.1 vs. 8.0%, P = 0.01), but did not demonstrate any differences compared to abnormal subjects (34.6%, P = 0.56). Patients with borderline AET had an average MNBI that was in between normal AET and abnormal AET. Borderline AET patients also commonly demonstrate IEM on HRM, similar to those with abnormal AET. Our findings can be potentially useful in assigning higher clinical significance for patients found to have borderline AET with concomitant low MNBI and IEM on manometry.

800 ASSOCIATION OF MULTIPLE RAPID SWALLOW PARAMETERS WITH SYMPTOMS IN PATIENTS WITH INEFFECTIVE AND NORMAL ESOPHAGEAL MOTILITY

Multiple rapid swallows (MRS) is a provocative test to assess inhibitory swallowing mechanisms and esophageal peristaltic reserve. MRS response has been purposed to predict post-fundoplication dysphagia and has been associated with increased acid exposure time. Recently it was added to the Chicago classification v 4.0 protocol as an adjunctive test. This study aimed to understand the association of MRS parameters with symptoms in patients within ineffective (IEM) or normal esophageal motility (NEM). Methods After IRB approval, a prospectively maintained esophageal motility database was retrospectively reviewed to identify patients with IEM and NEM who also had an MRS evaluation. Patients with previous gastroesophageal surgery, manometric hiatal hernia, or a diagnosed motility disorder (except IEM) were excluded. Patient-reported symptoms (0–4) (heartburn, regurgitation, dysphagia, and chest pain) were grouped by score: 0, 1–2, or 3–4. We compared the prevalence of normal or abnormal MRS and individual MRS parameters (distal contractile integral [DCI], integrated relaxation pressure, distal latency, adequate inhibition, and post-MRS DCI/mean single swallow DCI ratio) with patient-reported symptoms. Results From 2019–2020, a total of 531 patients (254 = IEM, 277 = NEM) met the inclusion criteria and formed the study cohort. The presence of normal or abnormal MRS results was not associated with any patient-reported symptom in either the NEM or IEM group. Furthermore, patient-reported symptoms were not associated with individual MRS parameters in either group. Conclusion In patients with IEM and NEM, adjunct assessment with MRS does not correlate with patient-reported symptoms. Further studies are needed to assess the role of MRS as an adjunctive test during routine manometry.

719 REDUCED MEAN NOCTURNAL BASELINE IMPEDANCE AIDS DIAGNOSIS OF GASTRO-ESOPHAGEAL REFLUX DISEASE AND LARYNGOPHARYNGEAL REFLUX DISEASE

Laryngopharyngeal reflux disease (LPR) and gastro-esophageal reflux disease (GERD) occur due to acidic gastric refluxate causing symptoms. Baseline esophageal impedance has been shown to be reduced with prolonged acid exposure. Mean nocturnal baseline impedance (MNBI) is a novel measure that has shown promise in GERD but has not been evaluated in LPR. This study aimed to assess the role of MNBI in LPR and GERD patients. Methods Off-therapy impedance-pH tracings were blindly reviewed for 187 patients previously prospectively allocated clinical diagnoses of LPR (n = 105) or GERD (n = 82). Conventional impedance-pH measures and MNBI were analysed for the two groups. Results MNBI was significantly lower in the distal esophagus in GERD patients compared with LPR (1679 ± 914 vs. 2109 ± 863; p = 0.001). Similarly, in the proximal esophagus, MNBI was lower in GERD than LPR (2289 ± 579 vs. 2541 ± 471; p = 0.001). In the pharynx, MNBI was similar between the two groups (2116 ± 699 vs. 2133 ± 770; p = 0.878). Distal acid exposure time (AET) and the number of distal acid reflux episodes negatively correlated with distal esophageal MNBI (r = −0.195; p = 0.007) and (r = −0.330; p < 0.001) respectively. Conclusion Baseline impedance was reduced in both LPR and GERD at both distal and proximal esophageal measurements, and more severely reduced in GERD. Baseline impedance is strongly and inversely related to acid exposure in the esophagus. Pharyngeal MNBI was not reduced or different between groups. Distal and proximal esophageal MNBI may be useful in diagnosis of LPR as well as GERD.

Response of Laryngopharyngeal Symptoms to Transoral Incisionless Fundoplication in Patients with Refractory Proven Gastroesophageal Reflux

Objective: Patients with laryngopharyngeal reflux (LPR) symptoms may not respond to proton pump inhibitors (PPI) if they have an alternative laryngeal diagnosis or high-volume reflux. Transoral incisionless fundoplication (TIF) or TIF with concomitant hiatal hernia repair (cTIF) are effective in decreasing symptoms of gastroesophageal reflux disease (GERD) but are not well studied in patients with LPR symptoms. This prospective multicenter study assessed the patient-reported and clinical outcomes after TIF/cTIF in patients with LPR symptoms and proven GERD. Methods: Patients with refractory LPR symptoms (reflux symptom index [RSI] > 13) and with erosive esophagitis, Barrett’s esophagus, and/or pathologic acid reflux by distal esophageal pH testing were evaluated before and after a minimum of 6 months after TIF/cTIF. The primary outcome was normalization of RSI. Secondary outcomes were >50% improvement in GERD-Health-Related Quality of Life (GERD-HRQL), normalization of esophageal acid exposure time, discontinuation of PPI, and patient satisfaction. Results: Forty-nine patients had TIF (n = 26) or cTIF (n = 23) with at least 6 months follow-up. Mean pre- and post TIF/cTIF RSI were 23.6 and 5.9 (mean difference: 17.7, P < .001). Post TIF/cTIF, 90% of patients had improved GERD-HQRL score, 85% normalized RSI, 75% normalized esophageal acid exposure time, and 80% discontinued PPI. No serious procedure-related adverse events occurred. Patient satisfaction was 4% prior to TIF/cTIF and 73% after TIF/cTIF ( P < .001). Conclusion: In patients with objective evidence of GERD, TIF, or cTIF are safe and effective in controlling LPR symptoms as measured by normalization of RSI and improvement in patient satisfaction after TIF/cTIF. Level of Evidence Level 4

Application of Lyon Consensus criteria for GORD diagnosis: evaluation of conventional and new impedance-pH parameters

ObjectiveTo validate Lyon Consensus criteria for diagnosing gastro-oesophageal reflux disease (GORD) by reflux monitoring.DesignManual review of impedance-pH tracings from patients with proton pump inhibitor (PPI)-dependent heartburn, evaluated off PPI. Acid exposure time (AET) thresholds defined by the Lyon Consensus and impedance parameters were investigated, namely, total refluxes (TRs), postreflux swallow-induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI).ResultsThe study included 488 patients, 178 (36%) with normal (<4%) AET, 89 (18%) with inconclusive (4%–6%) AET and 221 (45%) with abnormal (>6%) AET, alongside with 70 healthy controls. At receiver operating characteristic analysis, area under curve was 0.89, 0.95 and 0.89 for TRs, PSPW index and MNBI, respectively, and threshold values were 40, 50% and 2000 Ω; the 4% physiological AET threshold defined by the Lyon Consensus showed 100% specificity but 63% sensitivity. The thresholds defined for impedance parameters were validated against AET by means of ordered logistic regression, being in concordance with the 4% AET threshold (OR 2.5 for TRs, 18.9 for PSPW index and 5.7 for MNBI). TRs positivity and concordant PSPW index/MNBI positivity were found in 80%–90% of patients in the abnormal AET group, in 73%–74% of cases in the inconclusive AET group and in 28%–40% of cases in the group with normal AET.ConclusionsOur results show the overall validity of the Lyon Consensus approach to GORD diagnosis. Adding evaluation of impedance parameters, namely, TRs, PSPW index and MNBI to AET appraisal, substantially improves the diagnostic yield of reflux monitoring.

Esophageal Physiologic Testing of Obese Subjects as a Part of Bariatric Surgery Planning

Background: Choice of bariatric procedure may be impacted by esophageal motor disorders and reflux disease, which are not routinely evaluated in obese subjects. Methods: Clinical characteristics on validated questionnaires and esophageal physiologic test findings were collected in 110 consecutive obese subjects (median age 48.5 years, 82% F, median BMI 46.9 kg/m2) evaluated for bariatric surgery. High resolution manometry (HRM) metrics included intragastric pressure (IGP), basal lower esophageal sphincter pressures (LESP), end-expiratory LESP, EGJ contractile integral (EGJ-CI), integrated relaxation pressure (IRP), distal contractile integral (DCI), and Chicago classification (CC) v4.0 diagnoses; acid exposure time (AET, normal if <4%) was obtained from ambulatory reflux monitoring. Comparative analyses determined differences between obese subjects and 15 institutional normal controls (median age 24.7 years, 53% F, median BMI 24.7 kg/m2) and if symptoms predicted abnormal tests. Results: Basal LESP and EGJ-CI were higher in obese subjects ( P = .03) compared to controls, while end-expiratory LESP was similar ( P = .97). IGP was also higher in obese subjects ( P < .0001), which modestly correlated with BMI. The most common CC 4.0 diagnosis was ineffective esophageal motility (IEM, 11.8%). EGJ outflow obstruction was seen in 9.1% and achalasia in 0.9%. Hiatus hernia (type 2 or 3 EGJ morphology) was found in 28%. Of 34 patients completing ambulatory reflux monitoring, 15 (44%) had elevated AET, without symptom or motor predictors. Conclusions: Achalasia, esophageal outflow obstruction, and reflux were encountered in higher than expected proportions without specific symptoms in pre-bariatric surgery patients. Thus, esophageal physiologic testing may be of value prior to bariatric surgery.

Nutrients Consumption Affect the Number of Gastroesophageal Refluxes and Oesophageal Acidity in Children

Objectives To evaluate the correlation between types and number of gastroesophageal refluxes and nutrients consumption in children and adolescents. Methods The study was approved by IEC. The data of examination of 219 children (7–17 y.o.), 147 with GERD and 72 controls served as a source for the study. The amount and types of GER were determined using 24-hours esophageal pH-impedansometry (Ohmega, MMS, The Netherlands). Food frequency questionnaire was used to evaluate level of nutrients consumption. To make possible comparison of data obtained in different age and sex groups of children, direct levels of nutrients consumption were converted to a percentage deviation from the recommended daily allowance rates. Spearman rank correlation analysis was performed with the use of Statistica 10 (StatSoft Inc., USA) to reveal association between usual nutrition and number of gastroesophageal reflux episodes, their acidity and duration in children. Results Statistically significant (p &lt; .05) correlation of Acid exposure time was found with amounts of PUFA (Spearman R = −0.334), ω-3 (R = −0.33), ω-6 (R = −0.3); retinols (R = −0.34), niacin (R = −0.28) and ascorbic acid (R = −0.37) consumption. The number of acid refluxes correlated with energy values of the ration (R = 0.269), amount of total protein (R = 0.279), total fat (R = 0.272), total carbohydrates (R = 0.152), and added sugar (R = 0.157) consumption. The number of weak-acid refluxes was not correlated with any of the parameters of actual nutrition. We found significant correlation between the number of non-acid refluxes and amount of PUFAs (R = 0.19), ω-6 (R = 0.151), ω-3 (R = 0.19); sodium (R = 0.158), phosphorus (R = 0.166), vitamin B1 (R = 0.17), niacin (R = 0.19), and ascorbic acid (0.23). Conclusions We found that types and number of gastroesophageal refluxes, as well as acidification of the lower part of oesophagus may be associated with diet in children. Our results may mean that different nutrients have different impact on esophageal motility in children. The results may have practical outcome for planning non-pharmacological intervention in children with GERD Funding Sources Ministry of Science and Hiigher Education of Russia, research project #0529–2019-0055.

Is transoral incisionless fundoplication (TIF) an answer to post-peroral endoscopic myotomy gastroesophageal reflux? A multicenter retrospective study

Background: The use of peroral endoscopic myotomy (POEM) for achalasia has a high incidence of post-procedural gastroesophageal reflux (GER). Transoral incisionless fundoplication (TIF) may be an ideal endoscopic treatment. We report our experience with the use of post-POEM TIF. Methods: In this multicenter retrospective study, post-POEM patients with GER who underwent TIF were included. The study end points were: (i) technical success; (ii) safety; (iii) effectiveness (changes in symptoms, scores, proton pump inhibitor [PPI] use, pH studies). Results: 12 patients underwent TIF after POEM, nine of whom had daily symptoms, with 91.7% requiring twice daily (BID) PPIs. Technical success was achieved in all patients. Two adverse events occurred. There were significant decreases in the percentage of patients on BID PPIs (P = 0.03), frequency of daily symptoms (P = 0.03), Reflux Severity Index questionnaire, and GERD Health-related Quality of Life scores (P = 0.03 and P = 0.003; n = 6). pH studies performed in seven of the patients showed a significant reduction in the mean DeMeester score (P = 0.05) and mean percentage acid exposure time (P = 0.04). Conclusion: Our experience suggests that TIF may be effective and safe in treating GER after POEM. Larger prospective trials are needed.

Validation of the Lyon classification for GORD diagnosis: acid exposure time assessed by prolonged wireless pH monitoring in healthy controls and patients with erosive oesophagitis

ObjectiveAcid exposure time (AET) from ambulatory pH studies and reflux oesophagitis are independent measurements used by the Lyon classification to diagnose GORD. This study aimed to validate AET reference ranges and diagnostic thresholds by analysis of 96-hour wireless pH studies from healthy, asymptomatic controls (HCs) and patients with and without oesophagitis.DesignHC and consecutive patients referred for wireless pH studies (off acid suppressants for >7 days) underwent 96-hour pH studies at two tertiary referral centres. Erosive oesophagitis was categorised by the Los Angeles (LA) classification. Linear regression and receiver operating curve (ROC) analysis were performed to define optimal diagnostic cut-offs.ResultsProlonged, 96-hour pH studies were completed in 39 HCs (age 28 (18–53) years, 72% female) and 944 patients (age 46 (16–85) years, 65% female), of whom 136 (14.5%) had reflux oesophagitis. Median AET in HC was 1.3% (upper 95th percentile 4.6%) for any study day and 2.6% (upper 95th percentile 6.9%) for the worst day (24-hour period) during the study. ROC analysis for average AET differentiated HC from patients with moderate-to-severe oesophagitis (LA BCD; sensitivity 87%, specificity 95%, positive predictive value (PPV) 59%, negative predictive value 99% for a cut-off AET of 4.3%; area under the receiver operating curve 0.95). Specificity was higher, but PPV was substantially lower for severe oesophagitis (LA CD). ‘Worst-day’ analysis provided similar results; however, day-to-day variability was high.ConclusionDiagnostic thresholds for average AET were identified that accurately discriminate between HCs and patients with erosive oesophagitis. The findings provide conditional support for diagnostic criteria for GORD proposed by the Lyon Consensus.