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Concept: Cardia

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The motility change after per-oral endoscopic myotomy (POEM) in achalasia is currently focused on lower esophageal sphincter (LES). This study aims to investigate the correlation of motility response between distal and proximal esophagus after POEM.

Concepts: Digestive system, Stomach, Gastroesophageal reflux disease, Esophagus, Cardia, Achalasia, Esophageal cancer, Esophageal arteries

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Elevated body mass index (BMI, kg m(-2)) has been consistently associated with oesophageal adenocarcinoma (EA) and gastric cardia adenocarcinoma (GCA) incidence. However, effects of adiposity over the life course in relation to EA/GCA have not been thoroughly explored.

Concepts: Obesity, Mass, Body mass index, Cardia

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Patients with gastroesophageal reflux disease (GERD) often seek alternative therapy for inadequate symptom control, with over 40 % not responding to medical treatment. We evaluated the long-term safety, efficacy, and durability of response to radiofrequency treatment of the lower esophageal sphincter (Stretta).

Concepts: Medicine, Obesity, Gastroesophageal reflux disease, Esophagus, Cardia, Esophageal cancer, Barrett's esophagus, Stretta procedure

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Background/Aims: Pneumatic balloon dilation and surgical myotomy are the most effective treatments for achalasia. While there is controversy which method is best, the aim of the current study was to identify predictors of symptom recurrence after endoscopic or surgical therapy. Methodology: Patients undergoing pneumatic balloon dilatation (30mm) or laparoscopic Heller myotomy with Dor fundoplication were included in the study. Analyzed parameters include total symptom score (sum of 0-5 point intensity for dysphagia, regurgitation and chest pain), width and height of esophageal column at 2 and 5 minutes after oral barium ingestion, lower esophageal sphincter (LES) length, resting (LESP) and residual pressure (LESRP) before and 3 months after intervention. Patients with symptoms score <3 at the 3-month follow-up visit were considered asymptomatic. Results: Twenty-one patients underwent pneumatic dilation (14) or laparoscopic myotomy (7). Total symptom score improved (p<0.01) from pre- (7.2±2.7) to post-intervention (1.7±2.6). Eleven (85.8%) patients in the endoscopic group vs. 7 (100%) patients in the surgical group were symptom-free 3 months after intervention. Therapies improved LESP (24.4±8.2mmHg pre- vs. 15.4±10.3mmHg post-therapy; p=0.003) and mean LESRP (7.9±4.3mmHg pre- vs. 5.3±6.7mmHg post-therapy; p=0.03). Univariate linear regression analysis identified barium contrast column width >5cm at 2 minutes (p=0.04), LES length <2cm (p=0.003) and LESRP >10mmHg (p=0.02) as predictors for persistent symptoms. Conclusions: While >85% of achalasia patients responded well to 30mm pneumatic balloon dilation, patients with elevated LES pressure, short LES and wide esophagus should be considered as primary surgical candidates.

Concepts: Regression analysis, Linear regression, Surgery, Gastroesophageal reflux disease, Esophagus, Cardia, Achalasia, Heller myotomy

27

The prevalence of gastroesophageal reflux disease (GERD) symptoms in pregnancy is very high, up to 80%, with a maximum peak during the third trimester. Together with lifestyle modifications, antacids and antisecretive agents, such as proton pump inhibitors (PPIs) and histamine H2receptor antagonists (H2RAs), are commonly prescribed in non-pregnant, adult population. In certain Countries these drugs are not allowed in or are allowed only during the late stages of pregnancy. Alginate-based formulations have been used for the symptomatic treatment of heartburn for decades, as they usually contain sodium or potassium bicarbonate. In the presence of gastric acid, a foamy raft is created above the gastric contents. The alginate raft moves into the esophagus in place or ahead of acidic gastric contents during reflux episodes physically preventing reflux of gastric contents into the esophagus. Alginate-based formulations are allowed with no restrictions also in pregnancy: their safety profile make them a very valid option taking into account the risk/benefit ratio for both parturient and unborn baby. This systematic review paper aims to explore the use of medications for treating GERD in pregnancy, including alginate raft-forming-agents, highlighting the benefits for both the mother and the fetus. Electronic search in databases was conducted on databases such as Medline, PubMed, Ovid retrieving data concerning the reflux treatments in pregnancy, with a special focus on alginate raft forming antireflux agents. From the literature on alginate use in pregnancy, no particular risks have been shown to date for both parturient and unborn baby when alginate had been administered during all the pregnancy trimesters. The physical mode of action ensures the maximum esophageal protection by the neutral foam floating in the stomach, maintaining physiological pH values at stomach level, without interfering with the digestive processes. The symptoms' healing has been markedly improved during the weeks of observation; the symptoms monitored in all studies were: heartburn, regurgitation, pain (chest). After four weeks of treatment little or no change was observed in maternal mean sodium or potassium concentrations. No sodium restriction diet has been adopted. No edema of lower limbs or weight gain occurred. No adverse reactions related to the testing drug had been reported and all the authors concluded that alginate was safe for the unborn baby. Nowadays pharmacological treatments for GER are available as OTC drugs, including antacids, antisecretive agents, PPIs and H2RAs, and as medical devices, such as alginate raft forming antireflux agents (i.e.: Reflubloc™, Novartis NCH Italy). On this last product, considering the specific indication in pregnancy and the safety profile, without restrictions of administration during the whole pregnancy period, furthermore the physical mode of action, it gives the gynecologists a very important option in treating GER in pregnancy, taking care of both pregnant and fetus. Raft-forming-antireflux agents are safe and effective in GER treatment during pregnancy.

Concepts: Pregnancy, Stomach, Gastroesophageal reflux disease, Digestion, Gastric acid, Cardia, Esophageal cancer, Antacid

27

BACKGROUND: The aim of the present study was to clarify the efficacy of peroral endoscopic myotomy (POEM) for esophageal achalasia. PATIENTS AND METHODS: Twenty-eight esophageal achalasia patients who underwent POEM in our institution between August 2010 and October 2012 were enrolled. Under general anesthesia with tracheal intubation, initial incision was made on the anterior wall of the esophagus after submucosal injection. Submucosal tunnel was created and extended below the lower esophageal sphincter (LES) onto the gastric cardia. Subsequently, myotomy was done using triangle tip knife. After confirmation of smooth passage of scope through the esophagogastric junction, the entry was closed. Esophagogram and manometry study was done before and after the procedure. Also, subjective symptom score and Eckardt score were assessed before and 3 months after POEM. RESULTS: POEM was successfully done in all cases without any severe complications such as perforation and mediastinitis.Mean procedure time was 99.1 min (range 61-160) and mean myotomy length was 14.4 cm (range 10-18). Significant improvement was achieved in both esophagogram and endoscopic findings. Mean LES pressure was 71.2 mmHg (35.8-119.0) and 21.0 mmHg (6.7-41.0) before and after the procedure (P < 0.05), respectively. Mean Eckardt score was 6.7 (3-12, median 7) and 0.7 (0-3, median 1) before and 3 months after POEM, respectively (P < 0.05). Symptomatic gastroesophageal reflux disease that was easily controlled by the usual dose of proton pump inhibitor was seen in six cases (21.4%) after the procedure. CONCLUSION: POEM could be a curative standard treatment of choice for esophageal achalasia.

Concepts: Gastroenterology, Stomach, Gastroesophageal reflux disease, Esophagus, Cardia, Achalasia, Esophageal cancer, Dysphagia

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BACKGROUND: Revision antireflux surgery and large hiatal hernia repair require extensive dissection at the gastroesophageal junction. This may lead to troublesome symptoms due to delayed gastric emptying, eventually requiring gastrectomy. The aim of this study was to evaluate the outcome of gastrectomy for severely delayed gastric emptying after large hiatal hernia repair or redo antireflux surgery. METHODS: Eleven patients were treated between 1995 and 2010 and entered in the study. Preoperative and operative data were retrospectively collected. Standardized questionnaires were sent to all of the patients to evaluate symptomatic outcome. RESULTS: The primary intervention was Nissen fundoplication in nine patients, Toupet fundoplication in one, and cruroplasty in another. The repairs were for refractory gastroesophageal reflux disease in five patients and a symptomatic large hiatal hernia in six. Subsequent gastrectomy was partial in four patients, subtotal in six, and total in one. There was one minor postoperative complication. After a mean (±SD) duration of 102 ± 59 months, nine patients were available for symptomatic follow-up. Eight patients experienced daily symptoms related to dumping. Daily symptoms indicative of delayed gastric emptying were present in seven patients at follow-up. Mean general quality of life was increased from 3.8 ± 2.2 before gastrectomy to 5.4 ± 1.8 at follow-up. Eight patients reported gastrectomy as worthwhile. CONCLUSION: Gastrectomy after previous antireflux surgery or large hiatal hernia repair is safe with the potential to improve quality of life. Although upper gastrointestinal symptoms tend to persist, gastrectomy can be considered a reasonable, last-resort surgical option for alleviating upper gastrointestinal symptoms after this kind of surgery.

Concepts: Surgery, Gastroenterology, Gastroesophageal reflux disease, Abdomen, Cardia, Nissen fundoplication, Achalasia, Hiatus hernia

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The mainstay of pharmacological therapy for GERD is gastric acid suppression with proton pump inhibitors (PPIs), which are superior to histamine-2 receptor antagonists for healing erosive esophagitis and achieving symptomatic relief. However, up to one-third of patients may not respond to PPI therapy, creating the need for alternative treatments. Potential approaches include transient lower esophageal sphincter relaxation inhibitors, augmentation esophageal defense mechanisms by improving esophageal clearance or enhancing epithelial repair, and modulation of sensory pathways responsible for GERD symptoms. This review discusses the effectiveness of acid suppression and the data on alternative pharmacological approaches for the treatment of GERD.

Concepts: Medicine, Stomach, Receptor antagonist, Gastroesophageal reflux disease, Esophagus, Gastric acid, Cardia, Body of stomach

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High-resolution manometry (HRM) with 36 pressure transducers spanning the esophagus has revolutionized the diagnosis and treatment of esophageal motility disorders, especially with respect to achalasia. The three major contributions of HRM are as follows: (a) Integrated relaxation pressure (IRP) at the esophagus gastric junction (EGJ) >15 mmHg has a sensitivity of 97 % for the diagnosis of achalasia; (b) there are three distinct subtypes of achalasia-type 1 (no distal pressurization), type II (panesophageal pressurization), and type III (spastic contractions); and © subtypes predict the success of treatment with type II patients doing the best and type III being the most difficult to treat. Recent studies also suggest that HRM is superior to conventional manometry for diagnosis of achalasia. Other useful observation from HRM is the recognition of EGJ outflow obstruction (type IV achalasia) with normal peristalsis which may be due to mechanical or functional impairment at the EGJ. Finally, after successful treatment of achalasia, the IRP falls to less than 15 mmHg and the achalasia pressurization pattern resolves sometimes with the return of weak peristalsis. This complements well with the information obtained by the timed barium esophagram.

Concepts: Stomach, Cardia, Achalasia, Esophageal cancer, Esophageal motility study, Barium swallow, Peristalsis, Esophageal motility disorder

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We present the case of a 79-year-old woman with recurrent achalasia following a laparoscopic Heller’s cardiomyotomy. The patient presented to the emergency department, with epigastric pain, severe dyspnoea and profound respiratory acidosis. She required intubation and ventilation followed by gastric decompression with nasogastric tube and the administration of intravenous antibiotics for a lower respiratory tract infection. Once stable, she underwent a CT scan revealing a massively dilated oesophagus causing marked tracheal compression. She received a period of continuous positive airway pressure ventilation while on the intensive care unit, for persistent low saturations, however, this was promptly ceased due to exacerbation of gastric dilation and fears over perforation. The patient responded well to conservative measures and was discharged home 18 days later awaiting follow-up with operating consultant surgeon.

Concepts: Hospital, Surgery, Intensive care medicine, Respiratory system, Upper respiratory tract, Lower respiratory tract, Cardia, Heller myotomy