Prevalence of bile reflux in gastroesophageal reflux disease patients not responsive to proton pump inhibitors

AIM:To determine the prevalence and characteristics of bile reflux in gastroesophageal reflux disease(GERD) patients with persistent symptoms who are non-responsive to medical therapy.METHODS:Sixty-five patients(40 male,25 female;mean age,50 ± 7.8 years) who continued to report symptoms after 8 wk of high-dose proton pump inhibitor(PPI) therapy,as well as 18 patients with Barrett's esophagus,were studied.All patients filled out symptom questionnaires and underwent endoscopy,manometry and combined pH-metry and bilimetry.RESULTS:There were 4 groups of patients:22(26.5%) without esophagitis,24(28.9%) grade A-B esophagitis,19(22.8%) grade C-D and 18(21.6%) Barrett's esophagus.Heartburn was present in 71 patients(85.5%) and regurgitation in 55(66.2%),with 44(53%) reporting simultaneous heartburn and regurgitation.The prevalence of pathologic acid reflux in the groups without esophagitis and with grades A-B and C-D esophagitis was 45.4%,66.6% and 73.6%,respectively.The prevalence of pathologic bilirubin exposure in these 3 groups was 53.3%,75% and 78.9%,respectively.The overall prevalence of bile reflux in non-responsive patients was 68.7%.Pathologic acid and bile reflux was observed in 22.7% and 58.1% of non-esophagitic patients and esophagitic patients,respectively.CONCLUSION:The high percentage of patients poorly responsive to PPI therapy may result from poor control of duodenogastroesophageal reflux.Many patients without esophagitis have simultaneous acid and bile reflux,which increases with increasing esophagitis grade.

Laparoscopic calibrated total vs partial fundoplication following Heller myotomy for oesophageal achalasia

AIM:To compare the mid-term outcomes of laparoscopic calibrated Nissen-Rossetti fundoplication with Dor fundoplication performed after Heller myotomy for oesophageal achalasia.METHODS:Fifty-six patients(26 men,30 women;mean age 42.8±14.7 years)presenting for minimally invasive surgery for oesophageal achalasia,were enrolled.All patients underwent laparoscopic Heller myotomy followed by a 180°anterior partial fundoplication in 30 cases(group 1)and calibrated NissenRossetti fundoplication in 26(group 2).Intraoperative endoscopy and manometry were used to calibrate the myotomy and fundoplication.A 6-mo follow-up period with symptomatic evaluation and barium swallow was undertaken.One and two years after surgery,the patients underwent symptom questionnaires,endoscopy,oesophageal manometry and 24 h oesophago-gastric pH monitoring.RESULTS:At the 2-year follow-up,no significant difference in the median symptom score was observed between the 2 groups(P=0.66;Mann-WhitneyU-test).The median percentage time with oesophageal pH< 4 was significantly higher in the Dor group compared to the Nissen-Rossetti group(2;range 0.8-10 vs 0.35;range 0-2)(P<0.0001;Mann-WhitneyU-test).CONCLUSION:Laparoscopic Dor and calibrated Nissen-Rossetti fundoplication achieved similar results in the resolution of dysphagia.Nissen-Rossetti fundoplication seems to be more effective in suppressing oesophageal acid exposure.

Investigation of compensatory postures with videofluoromanometry in dysphagia patients

AIM: To investigate the effectiveness of head compensatory postures to ensure safe oropharyngeal transit. METHODS: A total of 321 dysphagia patients were enrolled and assessed with videofluoromanometry (VFM). The dysphagia patients were classified as follows: safe transit; penetration without aspiration; aspiration before, during or after swallowing; multiple aspirations and no transit. The patients with aspiration or no transit were tested with VFM to determine whether compensatory postures could correct their swallowing disorder. RESULTS: VFM revealed penetration without aspiration in 71 patients (22.1%); aspiration before swallowing in 17 patients (5.3%); aspiration during swallowing in 32 patients (10%); aspiration after swallowing in 21 patients (6.5%); multiple aspirations in six patients (1.9%); no transit in five patients (1.6%); and safe transit in 169 patients (52.6%). Compensatory postures guaranteed a safe transit in 66/75 (88%) patients with aspiration or no transit. A chin-down posture achieved a safe swallow in 42/75 (56%) patients, a head-turned posture in 19/75 (25.3%) and a hyperextended head posture in 5/75 (6.7%). The compensatory postures were not effective in 9/75 (12%) cases. CONCLUSION: VFM allows the speech-language therapist to choose the most effective compensatory posture without a trial-and-error process and check the effectiveness of the posture.