Rabeprazole vs esomeprazole in non-erosive gastro-esophageal reflux disease: A randomized, double-blind study in urban Asia

AIM：Gastro-esophageal reflux disease (GERD) is becoming increasingly common in Asia. Data on the efficacy of proton pump inhibitors in patients with non-erosive GERD (NERD)in Asia is lacking. This double-blind study compared the efficacy and safety of rabeprazole with esomeprazole in relief of symptoms in patients with NERD.METHODS: One hundred and thirty-four patients with reflux symptoms of NERD and normal endoscopy were randomized to receive rabeprazole 10 mg or esomeprazole 20 mg once daily for 4 wk. Symptoms were recorded in a diary and changes in severity of symptoms noted.RESULTS: At 4 wk of treatment, rabeprazole 10 mg and esomeprazole 20 mg were comparable with regards to the primary endpoint of time to achieve 24-h symptomfree interval for heartburn 8.5 d vs9 d and regurgitation 6 d vs 7.5 d. Rabeprazole and esomeprazole were also similarly efficacious in term of patient's global evaluation with 96% of patients on rabeprazole and 87.9% of patients on esomeprazole, reporting that symptoms improved(P=NS). Satisfactory relief of day- and night-time symptoms was achieved in 98% of patients receiving rabeprazole and 81.4% of patients receiving esomeprazole. Adverse events were comparable in both groups (P = NS).CONCLUSION: Rabeprazole 10 mg has a similar efficacy and safety profile in Asians with NERD as esomeprazole 20 mg. Further study is necessary to investigate whether the small differences between the two drugs seen in this study are related to the improved pharmacodynamicpro perties of rabeprazole. Both drugs were well tolerated.

Inverse correlation between gastroesophageal reflux disease and atrophic gastritis assessed by endoscopy and serology

BACKGROUND Helicobacter pylori(H.pylori)infection is known to prevent the occurrence of gastroesophageal reflux disease(GERD)by inducing gastric mucosal atrophy.However,little is known about the relationship between atrophic gastritis(AG)and GERD.AIM To confirm the inverse correlation between AG and the occurrence and severity of GERD.METHODS Individuals receiving health checkups who underwent upper gastrointestinal endoscopy at Seoul National University Healthcare System Gangnam Center were included.The grade of reflux esophagitis was evaluated according to the Los Angeles classification.Endoscopic AG(EAG)was categorized into six grades.Serologic AG(SAG)was defined as pepsinogen I≤70 ng/m L and pepsinogen I/II ratio≤3.0.The association between the extent of EAG and SAG and the occurrence and severity of GERD was evaluated using multivariate logistic regression analysis.RESULTS In total,4684 individuals with GERD were compared with 21901 healthy controls.In multivariate logistic regression analysis,advanced age,male sex,body mass index>23 kg/m2,presence of metabolic syndrome,current smoking,and alcohol consumption were associated with an increased risk of GERD.Seropositivity for H.pylori immunoglobulin G antibodies was associated with a decreased risk of GERD.There was an inverse correlation between the extent of EAG and occurrence of GERD:Odds ratio(OR),1.01[95%confidence interval(CI):0.90-1.14]in C1,0.87(0.78-0.97)in C2,0.71(0.62-0.80)in C3,0.52(0.44-0.61)in O1,0.37(0.29-0.48)in O2,and 0.28(0.18-0.43)in O3.Additionally,the extent of EAG showed an inverse correlation with the severity of GERD.The presence of SAG was correlated with a reduced risk of GERD(OR=0.49,95%CI:0.28-0.87,P=0.014).CONCLUSION The extent of EAG and SAG exhibited strong inverse relationships with the occurrence and severity of GERD.AG followed by H.pylori infection may be independently protect against GERD.

Effects of refluxate pH values on duodenogastroesophageal reflux-induced esophageal adenocarcinoma

AIM： To determine the effects of duodenogastric juice pH on the development of esophageal adenocarcinoma （EAC）. METHODS： An animal model of duodenogastroesophageal reflux was established using Sprague-Dawley （SD） rats undergoing esophagoduodenostomy （ED）. The development of EAC was investigated in rats exposed to duodenogastric juice of different pH. The rats were di- vided into three groups： Iow-pH group （group A）, high- pH group （group B） and a sham-operated group as a control （group C） （n = 30 rats in each group）. The inci- dence of esophagitis, Barrett＇s esophagus （BE）, intestinal metaplasia with dysplasia and EAC was observed 40 wk after the treatment. RESULTS： The incidence rate of esophagitis, BE, intestinal metaplasia with dysplasia and EAC was higher in groups A and B compared with the control group after 40 wk （P 〈 0.01）, being 96% and 100% （P 〉 0.05）, 88% and 82.4% （P 〉 0.05）, 20% and 52.1% （P 〈 0.05）, and 8% and 39% （P 〈 0.05）, respectively. CONCLUSION： Non-acidic refluxate increases the occurrence of intestinal metaplasia with dysplasia and EAC while the Iow-pH gastric juice exerts a protective effect in the presence of duodenal juice. The non-acid reflux is particularly important in the progression from BE to cancer. Therefore, control of duodenal reflux may be an important prophylaxis for EAC.

Esophageal epithelial surface in patients with gastroesophageal reflux disease:An electron microscopic study

A/M： To investigate the intercellular spaces between the most superficially located esophageal epithelial cells in patients with gastroesophageal reflux disease （GERD）. METHODS： Eighteen patients with erosive esophagitis, 10 patients with non-erosive reflux disease （NERD）, and 18 normal asymptomatic volunteers were enrolled. Biopsy specimens were obtained from the lower esophageal mucosa without ulcer or erosion. Scanning electron microscopy was employed to investigate the tightness of the superficial cellular attachment. RESULTS： The intercellular space between the most superficially located epithelial cells in patients with erosive esophagitis or NERD was not different from that in asymptomatic healthy individuals. CONCLUSION： Widened luminal intercellular spaces of esophageal superficial epithelium are not responsible for the induction of reflux symptoms in patients with GERD.

Gastroesophageal reflux disease in pediatric esophageal atresia:Assessment of clinical symptoms and pH-impedance data

BACKGROUND Esophageal atresia(EA)is the most common congenital anomaly of the gastrointestinal tract.Gastroesophageal reflux disease(GERD)is a frequent and lifelong problem in these patients.GERD can be asymptomatic and the incidence of esophageal gastric and intestinal metaplasia(Barrett’s esophagus)is increased in adults with EA compared with the general population.Timely and accurate diagnosis of GERD is important to reduce long-term problems and this may be achieved by pH-impedance testing.AIM To assess symptoms and pH-impedance data in children after EA,in order to identify their specific features of GERD.METHODS This study was conducted from November 2017 to February 2020 and involved 37 children who had undergone EA via open surgical repair(51.35%boys,48.65%girls;age range:1-14 years,median:4.99 years).GERD diagnosis was made based on multichannel intraluminal impedance/pH study and two groups were established:EA without GERD,n=17;EA with GERD,n=20.A control group was established with 66 children with proven GERD(68.18%boys,31.82%girls;median age:7.21 years),composed of a nonerosive reflux disease(referred to as NERD)group(n=41)and a reflux esophagitis group(n=25).Upper gastrointestinal endoscopy with a mucosal esophageal biopsy was performed on all patients.RESULTS The most frequently observed symptom in EA patients with GERD and without GERD was cough(70%and 76.5%respectively).The number of patients with positive symptom association probability in the EA groups was significantly larger in the EA without GERD group(P=0.03).In the control reflux esophagitis group,prevalence of gastrointestinal symptoms was significantly higher than in the NERD group(P=0.017).For both EA groups,there was strong correlation with index of proximal events(IPE)and total proximal events(EA with GERD:0.96,P<0.001;EA without GERD:0.97,P<0.001)but level of IPE was significantly lower than in GERD patients without any surgical treatment(P<0.001).Data on distal mean nocturnal baseline impedance were significantly different between the EA with GERD group(P<0.001)and the two control groups but not between EA without GERD and the two control groups.CONCLUSION Mean nocturnal baseline impedance may have diagnostic value for GERD in EA children after open surgical repair.IPE might be an additional parameter of pHimpedance monitoring.

Clinical features of acute esophageal mucosal lesions and reflux esophagitis Los Angeles classification grade D: A retrospective study

BACKGROUND Acute esophageal mucosal lesions(AEMLs)are an underrecognized and largely unexplored disease.Endoscopic findings are similar,and a higher percentage of AEML could be misdiagnosed as reflux esophagitis Los Angeles classification grade D(RE-D).These diseases could have different pathologies and require different treatments.AIM To compare AEML and RE-D to confirm that the two diseases are different from each other and to clarify the clinical features of AEML.METHODS We selected emergency endoscopic cases of upper gastrointestinal bleeding with circumferential esophageal mucosal injury and classified them into AEML and RE-D groups according to the mucosal injury’s shape on the oral side.We examined patient background,blood sampling data,comorbidities at onset,endoscopic characteristics,and outcomes in each group.RESULTS Among the emergency cases,the AEML and RE-D groups had 105(3.1%)and 48(1.4%)cases,respectively.Multiple variables exhibited significantly different results,indicating that these two diseases are distinct.The clinical features of AEML consisted of more comorbidities[risk ratio(RR):3.10;95%confidence interval(CI):1.68–5.71;P<0.001]and less endoscopic hemostasis compared with RE-D(RR:0.25;95%CI:0.10–0.63;P<0.001).Mortality during hospitalization was higher in the AEML group(RR:3.43;95%CI:0.82–14.40;P=0.094),and stenosis developed only in the AEML group.CONCLUSION AEML and RE-D were clearly distinct diseases with different clinical features.AEML may be more common than assumed,and the potential for its presence should be taken into account in cases of upper gastrointestinal bleeding with comorbidities.

Analysis of the Effectiveness of Biling Weitong Granules Combined with Trimethoprim and Vonoprazan in The Treatment of Reflux Esophagitis

Objective:To analyze the effectiveness of Biling Weitong Granules(BLWTG)combined with trimethoprim and vonoprazan in treating reflux esophagitis.Methods:Sixty patients with reflux esophagitis admitted to our hospital from March 2020 to March 2023 were selected as study subjects and randomly divided into a control group and an experimental group,with 30 cases in each group.The control group received only the combination treatment of trimethoprim and vonoprazan,while the experimental group was treated with BLWTG based on the control group.The acid reflux and heartburn symptom scores,quality-of-life scores,clinical efficacy,Chinese medicine symptom incidences,and the occurrence of adverse reactions before and after treatment in the two groups were compared.Results:After treatment,the acid reflux and heartburn symptom scores of patients in the experimental group were lower than those of the treatment control group,and the quality-of-life scores were higher than those of the treatment control group(P<0.05).The total clinical efficacy of the experimental group was 96.66%,which was significantly higher than that of the control group(73.33%,P<0.05).After treatment,the incidence of Chinese medicine symptoms,such as nausea and vomiting,abdominal distension and abdominal pain,and loss of appetite of the patients in the experimental group were significantly lower than those of the control group(P<0.05).During the treatment period,there was no significant difference in the incidence of adverse reactions between the two groups,which indicated that the safety of the two treatments was comparable(P>0.05).Conclusion:BLWTG combined with trimethoprim and vonoprazan was safe and reliable in treating reflux esophagitis,effectively relieving the symptoms and improving its clinical efficacy.This treatment is worthy of popularization.

Study on the Application of Refined Nursing Care in The Care for Elderly Patients with Reflux Esophagitis

Objective: To investigate the application effect of refined nursing care in the care for elderly patients with reflux esophagitis. Methods: Following the difference in nursing style, 84 cases of elderly patients with reflux esophagitis admitted to our hospital from May 2022 to May 2023 were randomly grouped into a control group and a research group, with 42 cases each. The control group was given conventional nursing care and the research group was given refined nursing care. The psychological state and treatment adherence of the two groups of patients after the nursing intervention were compared. Results: After the nursing intervention, the self-rating anxiety scale (SAS) and self-rating depression scale (SDS) scores of the research group were lower than those of the control group (P < 0.05). The treatment compliance of the research group was better than the control group (P < 0.05). Conclusion: The implementation of refined nursing care for elderly patients with reflux esophagitis exhibited a significant effect on improving the patient’s psychological state, treatment compliance, and rehabilitation.

The Therapeutic Effect of Biling Weitong Granules Combined with Oryz-Aspergillus Enzyme and Pancreatin Tablet on Reflux Esophagitis with Functional Dyspepsia

Objective:To investigate the therapeutic effect of Biling Weitong Granules combined with oryz-aspergillus enzyme and pancreatin tablets on patients with reflux esophagitis with functional dyspepsia.Methods:Sixty patients diagnosed with reflux esophagitis with functional dyspepsia who were admitted to the Affiliated Hospital of Hebei University between June 2020 and June 2023 were selected and divided into two groups:the control group and the observation group,each consisting of 30 cases.The control group received oryz-aspergillus enzyme and pancreatin tablets only,while the observation group received Biling Weitong Granules in addition to the tablets.The clinical efficacy,Chinese medicine syndrome points,esophageal kinetic indexes,gastrointestinal hormone levels,and therapeutic safety of both groups were evaluated.Results:The total efficiency of the observation group reached 93.33%,significantly higher than the 73.33%of the control group(P<0.05).After treatment,patients in the observation group exhibited significantly lower scores for Chinese medicine symptoms such as early satiety,belching,abdominal distension,abdominal pain,and loss of appetite compared to the control group(P<0.05).Furthermore,the observation group showed significantly higher upper esophageal sphincter pressure,lower esophageal sphincter pressure,and distal esophageal contraction scores compared to the control group(P<0.05).Additionally,levels of gastric motility hormone,vasoactive intestinal peptide,and gastrin were significantly higher in the observation group compared to the control group(P<0.05).Throughout the treatment period,there was no significant difference in the incidence of adverse reactions between the two groups,indicating comparable safety of the two treatment modalities(P>0.05).Conclusion:The combination of Biling Weitong Granules with oryz-aspergillus enzyme and pancreatin tablets demonstrates significant efficacy in the treatment of reflux esophagitis with functional dyspepsia,with a better safety profile.This finding warrants further clinical promotion.

Huoxue Tongjiang decoction-resisted reflux esophagitis by activation stem cell factor/c-kit/interstitial cell of cajal pathway and regulating the T-helper 17/regulatory T-cells balance in rats

Background:Huoxue Tongjiang decoction(HXTJD)is an effective prescription for treating reflux esophagitis(RE).We investigated the effects of HXTJD on esophageal motility and mucosal inflammation in a rat RE model.Methods:Chemical composition of HXTJD was analyzed by ultrahigh-performance liquid chromatography Q-Orbitrap mass spectrometry(MS).The change rates of mean contraction tension forces,mean amplitudes,and mean frequencies for the lower esophageal sphincter(LES)were recorded using the isolated tissue bath system,mechanical tension transducer,and PowerLab physiological recorder.After weighing the stomach,the phenol red labeling method was used to measure the gastric emptying rate.The LES ultrastructure was observed through transmission electron microscopy.Immunofluorescence and western blotting were used to detect the number of interstitial cells of Cajal(ICC)and the expression levels of c-kit protein,connexin43(Cx43),and stem cell factor(SCF).Flow cytometric analysis and enzyme-linked immunosorbent assay were conducted to detect the percentages of T helper 17(Th17)cells and regulatory T(Treg)cells and the serum concentrations of interleukin 6(IL-6),interleukin 17(IL-17),and interleukin 10(IL-10)in the rats.Results:We identified 28 chemical constituents in HXTJD.Regarding esophageal motility,we revealed that HXTJD increased the mean contraction tension forces,mean amplitudes,and mean frequency change rate of LES and the gastric emptying rate;decreased stomach weight;and improved the LES ultrastructure.Additionally,HXTJD increased the number of ICC-positive cells,and c-kit,Cx43,and SCF expression levels.Regarding esophageal inflammation,HXTJD significantly decreased the percentage of Th17 cells,and IL-6 and IL-17 concentrations,and increased the percentage of Treg cells and IL-10 concentration.Conclusion:HXTJD was found to be efficacious in the rat RE model.It may promote esophageal motility and alleviate the inflammatory response by activating the SCF/c-kit/ICC pathway and regulating the Th17/Treg cell balance.

Relationship among symptoms, mucosal injury, and acid exposure in gastroesophageal reflux disease

Background Symptoms,endoscopy,and pH monitoring form the basis of diagnosis of gastroesophageal reflux disease （GERD）.Their relationship was meaningful for primary care physicians,but still unclear.Our research aimed to compare questionnaire,endoscopy,and pH monitoring and to analyze their correlations.Methods Three hundred patients who underwent the Reflux Disease Questionnaire （RDQ）,endoscopy,and esophageal 24-hour pH monitoring from March 2007 to December 2010 in Peking University People＇s Hospital were enrolled.We analyzed the characteristics of different investigations and their relationships.Results Male （OR for mild reflux esophagitis （RE） =2.433,severe RE =8.386）,body mass index （BMI） （OR for mild RE =1.222,severe RE =1.297）,and hernia （OR for mild RE =6.059,severe RE =17.547）,were found to be the risk factors for RE; age （OR=1.074） was correlated with severe RE.The consistency of questionnaire,endoscopy,and pH monitoring was poor：RDQ did not agree well with pH monitoring （K=0.061）,nor with endoscopy （K=0.044）; pH monitoring did not agree well with endoscopy （K=0.316）.However,the severity of mucosa injury in RE was associated with pathological acid exposure （PAE）：reflux episodes of ＞5 minutes （P=0.035）,the percentage time pH ＜4 （P=0.017）,and the DeMeester score （P=0.016） increased significantly in patients with severe RE.Chest pain had poor relationship with RE or PAE.Conclusions Male,age,BMI,and hernia were probably risk factors for esophagitis.RDQ,endoscopy,and pH monitoring have their own focus and reinforce each other in diagnosis.Of the GERD symptoms,chest pain had negative correlation with RE or PAE.

Diagnosis of gastroesophageal reflux disease in elderly subjects using 24-houres ophageal pH monitoring

Objective To evaluate the relationship between the parameters of 24 hour esophageal pH monitoring and gastroesophageal reflux disease (GERD) among elderly subjects. Methods Twenty four hour esophageal pH monitoring was carried out in 20 elderly subjects without apparent GERD symptoms (controls) and 69 suspected GERD subjects.Results Normal values of the parameters from 20 elderly controls were obtained. Percent of total time, percent of supine time and percent of upright time in which the pH was <4 (indicating reflux) were less than 3.3%, 1.4%, 5.5%, respectively. The number of reflux episodes and episodes lasting longer than 5 minutes were less than 65 and 2 times respectively. The values obtained in 66 GERD suspected subjects were significantly different from those in norrmal controls. The differences of reflux parameters between the esophagitis group and non esophagitis group, such as percent of total time with pH<4, percent of supine time with pH<4 and number of reflux lasting longer than 5 minutes were also significant. Conclusions About 51.6% patients (34/66) with reflux symptoms but without endoscopic evidence of esophagitis were definitely diagnosed as GERD by esophageal pH monitoring. Duration of esophageal acid exposure correlated with the severity of GERD.

Expression of CXC receptor 1 and 2 in esophageal mucosa of patients with reflux esophagitis

AIM: Interleukin 8 (IL-8) mediates neutrophil trafficking via its receptors. Recent studies have shown that IL-8 is likely involved in the development and progression of erosive reflux esophagitis (RE), yet little is known about the two distinct receptors, CXC receptor (CXCR)-1 and -2.The purpose of this study was to determine CXCR-1 and -2 messenger RNA expression levels in RE.METHODS: We studied 26 patients with RE and 15asymptomatic controls. Paired biopsy samples were taken from the esophagus 3 cm above the gastroesophageal junction; one biopsy was snap frozen for measurement of CXCR-1 and -2 mRNA levels by semiquantitative reverse transcriptase polymerase chain reaction (RT-PCR), and another was formalin-fixed for histopathological evaluation.We also examined the association of the expression levels of CXCR-1 and -2 mRNA with histopathological hallmarks of RE.RESULTS: The relative CXCR-1 and -2 mRNA expression levels were rather decreased in esophageal mucosa of patients with RE, compared to those in normal esophagus of controls. There were no significant difference in the relative mRNA expression levels of CXCR-1 and -2 among endoscopic grades of RE based on the Los Angeles classification. Each histopathological hallmark of GERD was not associated with the expression levels of CXCR-1 and -2 mRNA.CONCLUSION: Apart from overexpression of IL-8, the relative expression levels of CXCR-1 and -2 mRNA were rather lower than expected in the affected esophageal mucosa of patients with RE.

Double-tract reconstruction is superior to esophagogastrostomy in controlling reflux esophagitis and enhancing quality of life after proximal gastrectomy:Results from a prospective randomized controlled clinical trial in China

Objective:The aim of this study was to prospectively compare double-tract reconstruction(DTR)and esophagogastrostomy(EG)after proximal gastrectomy(PG)regarding the incidence of reflux esophagitis,quality of life(QOL),nutritional status and surgical safety.Methods:This study was a randomized controlled trial.Patients eligible for PG were enrolled and randomly assigned to the EG group and DTR group.The characteristics of patients,parameters for surgical safety,incidence of reflux esophagitis,nutrition status and QOL were collected and compared between the two groups.Univariate analysis and multivariate analysis were performed to determine the significant factors affecting the incidence of reflux esophagitis after PG.Results:Thirty-seven patients of the EG group and 36 patients of the DTR group were enrolled.The incidence of reflux esophagitis was significantly lower in the DTR group than in the EG group(8.3%vs.32.4%,P=0.019).The DTR group demonstrated a more favorable QOL than the EG group after PG.The nutritional status was balanced within the EG group and the DTR group.The operation time was longer in the DTR group than in the EG group(191 min vs.221 min,P=0.001),while surgical safety was similar in the two groups.Conclusions:Our research demonstrated that DTR is superior to EG after PG in terms of the incidence of reflux esophagitis and provides a more satisfactory QOL without increasing surgical complications or sacrificing nutritional status.

Anti-reflux effects of a novel esophagogastric asymmetric anastomosis technique after laparoscopic proximal gastrectomy

BACKGROUND Reflux esophagitis is a common postoperative complication of proximal gastrectomy.There is an urgent need for a safer method of performing esophageal-gastric anastomosis that reduces the risk of reflux after proximal gastrectomy.We hypothesize that a novel technique termed esophagogastric asymmetric anastomosis(EGAA)can prevent postoperative reflux in a safe and feasible manner.To observe a novel method of EGAA to prevent postoperative reflux.METHODS Initially,we employed a thermal stress computer to simulate and analyze gastric peristalsis at the site of an esophagogastric asymmetric anastomosis.This was done in order to better understand the anti-reflux function and mechanism.Next,we performed digestive tract reconstruction using the EGAA technique in 13 patients who had undergone laparoscopic proximal gastrectomy.Post-surgery,we monitored the structure and function of the reconstruction through imaging exams and gastroscopy.Finally,the patients were followed up to assess the efficacy of the anti-reflux effects.RESULTS Our simulation experiments have demonstrated that the clockwise contraction caused by gastric peristalsis and the expansion of the gastric fundus caused by the increase of intragastric pressure could significantly tighten the anastomotic stoma,providing a means to prevent the reverse flow of gastric fluids.Thirteen patients with esophagogastric junction tumors underwent laparoscopic proximal gastrectomy,with a mean operation time of 304.2±44.3 min.After the operation,the upper gastroenterography in supine/low head positions showed that eight patients exhibited no gastroesophageal reflux,three had mild reflux,and two had obvious reflux.The abdominal computed tomography examination showed a valve-like structure at the anastomosis.During followup,gastroscopy revealed a closed valve-like form at the anastomosis site without stenosis or signs of reflux esophagitis in 11 patients.Only two patients showed gastroesophageal reflux symptoms and mild reflux esophagitis and were treated with proton pump inhibitor therapy.CONCLUSION EGAA is a feasible and safe surgical method,with an excellent anti-reflux effect after proximal gastrectomy.

Transcutaneous cervical esophagus ultrasound in adults: Relation with ambulatory 24-h pH-monitoring and esophageal manometry

AIM: To determine the gastroesophageal refl uxate in the cervical esophagus (CE) and measure transcutaneous cervical esophageal ultrasound (TCEUS) f indings [anterior wall thickness (WT) of CE, esophageal luminal diameter (ELD), esophageal diameter (ED)]; to compare TCEUS findings in the patient subgroups divided according to 24-h esophageal pH monitoring and manometry; and to investigate possible cut-off values according to the TCEUS f indings as a predictor of gastroesophageal refl ux (GER). METHODS: In 45/500 patients, refl uxate was visualized in TCEUS. 38/45 patients underwent esophagogastroduo denoscopy (EGD), 24-h pH monitoring and manometry. RESULTS: The 38 patients were grouped according to 24-h pH monitoring as follows: Group A: GER-positive (n = 20) [Includes Group B: isolated proximal refl ux (PR) (n = 6), Group C: isolated distal reflux (DR) (n = 6), and Group D: both PR/DR (n = 8)]; Group E: no refl ux (n = 13); and Group F: hypersensitive esophagus (HSE) (n = 5). Groups B + D indicated total PR patients (n = 14), Groups E + F refl ux-negatives with HSE (n = 18), and Groups A + F refl ux-positives with HSE (n = 25). When the 38 patients were grouped according to manometry fi ndings, 24 had normal esophageal manometry; 7 had hypotensive and 2 had hypertensive lower esophageal sphincter (LES); and 5 had ineffective esophageal motility disorder (IEM). The ELD measurement was greater in group A + F than group E (P = 0.023, 5.0 ± 1.3 vs 3.9 ± 1.4 mm). In 27/38 patients, there was at least one pathologic acid refl ux and/or pathologic manometry fi nding. The cut-off value for ELD of 4.83 mm had 79% sensitivity and 61% specificity in predicting the PRbetween Groups B + D and E (AUC = 0.775, P = 0.015). CONCLUSION: Visualizing refluxate in TCEUS was useful as a pre-diagnostic tool for estimating GER or manometric pathology in 71.1% of adults in our study, but it was not diagnostic for CE WT.

Laryngopharyngeal reflux in patients with reflux esophagitis

AIM: To assess the prevalence of laryngopharyngeal reflux (LPR) in patients with reflux esophagitis and dis-close factors contributing to the development of LPR. METHODS: A total of 167 patients who proved to have reflux esophagitis by endoscopy were enrolled. They received laryngoscopy to grade the reflux find-ings for the diagnosis of LPR. We used validated ques-tionnaires to identify the presence of laryngopharyn-geal symptoms, and stringent criteria of inclusion to increase the specificity of laryngoscopic findings. The data of patients were analyzed statistically to find out factors related to LPR. RESULTS: The prevalence rate of LPR in studied sub-jects with reflux esophagitis was 23.9%. Age, hoarse- ness and hiatus hernia were factors significantly as-sociated with LPR. In 23 patients with a hiatus hernia, the group with LPR was found to have a lower trend of esophagitis grading. CONCLUSION: Laryngopharyngeal reflux is present in patients with reflux esophagitis, and three predicting factors were identified. However, the development of LPR might be different from that of reflux esophagi-tis. The importance of hiatus hernia deserves further study.

In vitro effect of pantoprazole on lower esophageal sphincter tone in rats

AIM:To investigate the in vitro effects of pantoprazole on rat lower esophageal sphincter(LES)tone.METHODS:Rats weighing 250-300 g,provided by the Yeditepe University Experimental Research Center(Yü-DETAM),were used throughout the study.They were anesthetized before decapitation.LES tissues whose mucosal lining were removed were placed in a stan-dard 30-mL organ bath with a modif ied Krebs solution and continuously aerated with 95% oxygen-5% carbon dioxide gas mixture and kept at room temperature.The tissues were allowed to stabilize for 60 min.Sub-sequently,the contractile response to 10-6 mol/L carba-chol was obtained.Different concentrations of freshly prepared pantoprazole were added directly to the tis-sue bath to generate cumulative concentrations of 5×10-6 mol/L,5×10-5 mol/L,and 1.5×10-4 mol/L.Activi-ties were recorded on an online computer via a 4-channeltransducer data acquisition system using the software BSL PRO v 3.7,which also analyzed the data.RESULTS:Pantoprazole at 5×10-6 mol/L caused a small,but statistically insignif icant,relaxation in the car-bachol-contracted LES(2.23% vs 3.95%).The 5×10-5 mol/L concentration,however,caused a signif icant relax-ation of 10.47% compared with the control.1.5×10-4 mol/L concentration of pantoprazol caused a 19.89% relaxation in the carbachol contracted LES(P<0.001).CONCLUSION:This is the fi rst study to demonstrate that pantoprazole has a relaxing effect in isolated LESs.These results might have signif icant clinical implications for the subset of patients using proton pump inhibitors who do not receive full symptomatic alleviation from gastroesophageal reflux disease.

Circular smooth muscle contributes to esophageal shortening during peristalsis

AIM:To study the angle between the circular smooth muscle(CSM) and longitudinal smooth muscle(LSM) fibers in the distal esophagus.METHODS:In order to identify possible mechanisms for greater shortening in the distal compared to proximal esophagus during peristalsis,the angles between the LSM and CSM layers were measured in 9 cadavers.The outer longitudinal layer of the muscularis propria was exposed after stripping the outer serosa.The inner circular layer of the muscularis propria was then revealed after dissection of the esophageal mucosa and the underlying muscularis mucosa.Photographs of each specimen were taken with half of the open esophagus folded back showing both the outer longitudinal and inner circular muscle layers.Angles were measured every one cm for 10 cm proximal to the squamocolumnar junction(SCJ) by two independent investigators.Two human esophagi were obtained from organ transplant donors and the angles between the circular and longitudinal smooth muscle layers were measured using micro-computed tomography(micro CT) and Image J software.RESULTS:All data are presented as mean ± SE.The CSM to LSM angle at the SCJ and 1 cm proximal to SCJ on the autopsy specimens was 69.3 ± 4.62 degrees vs 74.9 ± 3.09 degrees,P = 0.32.The CSM to LSM angle at SCJ were statistically significantly lower than at 2,3,4 and 5 cm proximal to the SCJ,69.3 ± 4.62 degrees vs 82.58 ± 1.34 degrees,84.04 ± 1.64 degrees,84.87 ± 1.04 degrees and 83.72 ± 1.42 degrees,P = 0.013,P = 0.008,P = 0.004,P = 0.009 respectively.The CSM to LSM angle at SCJ was also statistically significantly lower than the angles at 6,7 and 8 cm proximal to the SCJ,69.3 ± 4.62 degrees vs 80.18 ± 2.09 degrees,81.81 ± 1.75 degrees and 80.96 ± 2.04 degrees,P = 0.05,P = 0.02,P = 0.03 respectively.The CSM to LSM angle at 1 cm proximal to SCJ was statistically significantly lower than at 3,4 and 5 cm proximal to the SCJ,74.94 ± 3.09 degrees vs 84.04 ± 1.64 degrees,84.87 ± 1.04 degrees and 83.72 ± 1.42 degrees,P = 0.019,P = 0.008,P = 0.02 respectively.At 10 cm above SCJ the angle was 80.06 ± 2.13 degrees which is close to being perpendicular but less than 90 degrees.The CSM to LSM angles measured on virtual dissection of the esophagus and the stomach on micro CT at the SCJ and 1 cm proximal to the SCJ were 48.39 ± 0.72 degrees and 50.81 ± 1.59 degrees.Rather than the angle of the CSM and LSM being perpendicular in the esophagus we found an acute angulation between these two muscle groups throughout the lower 10 cm of the esophagus.CONCLUSION:The oblique angulation of the CSM may contribute to the significantly greater shortening of distal esophagus when compared to the mid and proximal esophagus during peristalsis.

Impact of minimally invasive surgery on the treatment of benign esophageal disorders

Thanks to the development of minimally invasive surgery, the last 20 years have witnessed a change in the treatment algorithm of benign esophageal disorders. Today a laparoscopic operation is the treatment of choice for esophageal achalasia and for most patients with gastroesophageal reflux disease. Because the pathogenesis of achalasia is unknown, treatment is palliative and aims to improve esophageal emptying by decreasing the functional obstruction at the level of the gastro-esophageal junction. The refinement of minimally invasive techniques accompanied by large, multiple randomized control trials with long-term outcome has allowed the laparoscopic Heller myotomy and partial fundoplication to become the treatment of choice for achalasia compared to endoscopic procedures, including endoscopic botulinum toxin injection and pneumatic dilatation. Patients with suspected gastroesophageal reflux need to undergo a thorough preoperative workup. After establishing diagnosis, treatment for gastroesophageal reflux should be individualized to patient characteristics and a decision about an operation made jointly between surgeon and patient. The indications for surgery have changed in the last twenty years. In the past, surgery was often considered for patients who did not respond well to acid reducing medications. Today, the best candidate for surgery is the patient who has excellent control of symptoms with proton pump inhibitors. The minimally invasive approach to antireflux surgery has allowed surgeons to control reflux in a safe manner, with excellent long term outcomes. Like achalasia and gastroesophageal reflux, the treatment of patients with paraesophageal hernias has also seen a major evolution. The laparoscopic approach has been shown to be safe, and durable, with good relief of symptoms over the long-term. The most significant controversy with laparoscopic paraesophageal hernia repair is the optimal crural repair. This manuscript reviews the evolution of these techniques.