Conventional Versus Traction-Assisted Endoscopic Submucosal Dissection for Esophageal, Gastric, and Colorectal Neoplasms: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Endoscopic submucosal dissection (ESD) is increasingly being utilized for the resection of superficial gastrointestinal neoplasms. However, the long procedure time poses a technical challenge for conventional ESD (C-ESD). Traction-assisted ESD (T-ESD) was developed to facilitate the procedure by reducing its duration. This study compares the efficacy and safety of C-ESD versus T-ESD in the treatment of esophageal, gastric, and colorectal neoplasms. Nine randomized controlled trials (RCTs) were analyzed. Traction-assisted ESD exhibited shorter mean dissection times for the esophagus and colorectal regions and lower perforation rates in colorectal cases. No significant differences were observed in en bloc resection or bleeding rates. Traction-assisted ESD proves to be more efficient in mean procedure time for esophageal and colorectal cases and safer in perforation rates for colorectal cases, but similar rates are noted for en bloc resection or bleeding.

Spirulina Platensis Attenuates Rebound Dyspeptic Symptoms After Proton Pump Inhibitors' Discontinuation: Phase 2 Placebo-controlled Trial.

Context: Rebound acid hypersecretion after cessation of proton pump inhibitors (PPIs) can provoke dyspeptic symptoms. The search for alternatives to minimize the dyspeptic rebound symptoms after PPI discontinuation is warranted. Spirulina platensis, a dietary supplement made from blue-green algae, might be an alternative. Objective: The study intended to assess whether Spirulina platensis, through its anti-inflammatory and analgesic properties, can minimize rebound symptoms after PPI withdrawal. Design: The research team performed a randomized, phase 2, double-blinded, placebo-controlled clinical trial. Setting: The study took place at São Vicente de Paulo Hospital (trial registry number NCT04988347) in Passo Fundo, Brazil. Participants: Participants were 45 Brazilian patients in the clinical practice of two of the research team's member between November 2010 and February 2012, who were using PPIs regularly. Interventions: Participants underwent clinical and endoscopic evaluations after a 28-day run-in phase of 40 mg/day of pantoprazole. In the absence of a large hiatal hernia, peptic ulcer, or severe reflux esophagitis, participants stopped using PPIs, and the research team randomly assigned them to receive either 1.6g/day of spirulina or of a placebo for two months, followed by clinical and endoscopic reevaluations. Outcome measures: Using an intention-to-treat analysis, the primary outcomes postintervention were dyspepsia and typical reflux symptoms, either the appearance or maintenance of symptoms of >50% from baseline. Results: The median time of continuous PPI use was 32 months. The research team excluded two participants due to large hiatal hernias. Among the remaining 43 participants, 18 received spirulina (42%), and 25 used a placebo (58%). Two months later, 12 participants who had received spirulina (67%) and 18 who had received the placebo (72%) completed the study (P = .968). Rebound dyspepsia occurred in 10 out of 18 patients treated with spirulina (55.56%) and in 22 out of 25 patients treated with placebo (88%), with relative risk=0.63, CI95% (0.41-0.98), and P = .039. Reflux symptoms postintervention occurred in 72% and 76%, with the relative risk=0.95, CI95% (0.66-1.36), and P > .05, respectively. No significant side effects occurred in either group. The findings from endoscopy and gastric histology didn't differ between groups. Conclusions: A two-month course of Spirulina platensis was able to attenuate rebound dyspepsia but not reflux symptoms after PPI discontinuation. Considering its good safety profile, spirulina might be useful to relieve dyspeptic symptoms after PPI discontinuation.

The brain-esophagus axis in subjects with and without obesity assessed by esophageal acid perfusion and functional brain imaging.

Background: Gastroesophageal reflux disease (GERD) has a complex pathophysiology and a heterogeneous symptom profile. The brain-esophageal axis in GERD has been studied with functional brain imaging during the last decades, but data from obese patients was just recently reported. A comparison of such a group with non-obese subjects is lacking in the literature. This study aimed to evaluate heartburn perception and brain connectivity responses during esophageal acid stimulation in subjects with and without obesity, controlling for the presence of typical reflux symptoms. Methods: In this cross-sectional study, 25 patients with obesity (body mass index ≥30 kg/m2) and 46 subjects without obesity underwent functional magnetic resonance imaging (fMRI) of the brain with esophageal water and acid perfusion. The fMRI paradigm and connectivity were assessed. Results: About two-thirds of the participants had reflux symptoms. Heartburn perception during fMRI did not differ between subjects with and without obesity. The presence of reflux symptoms was associated with lower activation in frontal brain regions during acid perfusion compared to water perfusion. Compared to subjects without obesity, patients with obesity presented significantly lower connectivity within the anterior salience network. Corrected clusters included left caudate, left putamen and left anterior cingulate gyrus. Conclusions: The brain-esophagus axis showed differences between subjects with and without obesity. Even without symptomatic differences following esophageal acid perfusion, patients with reflux symptoms showed less brain activation in frontal areas, while obese individuals presented lower connectivity within the anterior salience network.

Association between masticatory dysfunction and gastroesophageal reflux disease: A population-based study in the elderly.

BACKGROUND: Caries and periodontal disease may cause tooth losses and chewing difficulty, especially in the elderly. Ingesting poorly chewed food may delay gastric emptying and favour the development of gastroesophageal reflux disease (GERD). OBJECTIVE: This study investigated the association between masticatory dysfunction and GERD in the elderly from a rural area in southern Brazil. METHODS: This census invited all 489 elderly from a city to participate. The study used a GERD symptoms questionnaire, followed by an oral examination. Masticatory dysfunction was analysed based on the chewing difficulty for some food groups. Tooth loss and chewing self-perception were also considered as exposure variables. Poisson regression determined the association among variables by calculating the prevalence ratio [PR (95% confidence interval)]. RESULTS: The response rate was 93.1% (n = 455, average age of 70.9 years, 50.5% men). The prevalence of GERD in this population was 36.9%. GERD was associated with chewing difficulty for vegetables (PR = 1.54), meats (PR = 1.34) and cereals (PR = 1.43) but not with poor chewing self-perception (PR = 0.80) and tooth loss (PR = 1.22). GERD was also associated with xerostomia (PR = 1.63) and the female gender (PR = 1.35). CONCLUSION: Elderly people from a rural area with a reduced number of teeth present chewing difficulty and a high prevalence of GERD, indicating an association between GERD and masticatory dysfunction.

Reduced mastication is a risk factor for Rome IV postprandial distress syndrome in patients investigated with upper endoscopy.

BACKGROUND AND AIMS: Reduced mastication could force the stomach to do extra work on crushing food and contribute to dyspeptic symptoms. This study aimed to assess the relationship between mastication and dyspepsia. METHODS: This cross-sectional study involved 209 consecutive patients referred for elective upper endoscopy. Before endoscopy, an expert dentist performed an oral examination and scored chewing function in three levels (normal, regular, and reduced), and applied questionnaires for assessment of dyspepsia (Rome IV), xerostomia, and mastication (normal, regular, and reduced). A reduced masticatory function was defined when an oral examination or mastication questionnaire rated the chewing as poor. Associations between mastication, confounders, and dyspepsia were estimated by prevalence ratio [PR (95% Confidence Interval)] using Poisson regression. RESULTS: Thirty-four patients showed relevant organic conditions in the upper gastrointestinal tract (moderate to severe reflux oesophagitis, peptic ulcer, neoplasia, and surgical modification) and were excluded. Among 175 patients with non-organic diseases (aging 51.3 ± 15.7 years; 61.7% women), 50 (28.6%) had reduced mastication, and 125 (71.4%) had normal/regular mastication. After adjusting for age and xerostomia, reduced mastication was associated with postprandial distress syndrome [PR = 1.93 (95%CI 1.27 - 2.91)] but not with epigastric pain syndrome [PR = 1.09 (95%CI 0.75 - 1.60)]. CONCLUSIONS: In patients referred for upper digestive endoscopy, reduced mastication was associated with postprandial distress syndrome but not with epigastric pain syndrome. An interdisciplinary approach with dentists and physicians might benefit dyspeptic patients with postprandial distress syndrome.

Short-term intestinal effects of water intake in fibre supplementation in healthy, low-habitual fibre consumers: a phase 2 clinical trial.

A randomised clinical trial was conducted on 20 healthy, low-habitual fibre consumers to assess the short-term effects of water intake (2 l/day) on fibre supplementation with wheat bran, pectin, and green banana flour. During the 14-days trial, fibre intake doubled in both fibre (n = 10) and fibre/water (n = 10) interventions (p < 0.001), whereas daily water intake increased from 538 to 1990 ml in the fibre/water group (p < 0.001). Weekly bowel movements increased similarly in both interventions (fibre: 6.8-8.8; fibre/water: 8.6-10; p < 0.01), while faecal weight (71-126 g; p = 0.009) increased in the fibre/water group. This group showed higher counts of faecal Bacteroides and Prevotella, Faecalibacterium prausnitzii, and Bifidobacterium, whereas both interventions decreased the count of Desulfovibrio. Transient abdominal symptoms occurred less frequently in the fibre/water than in the fibre group (3 vs. 9 participants; p = 0.020). In healthy, low-habitual fibre consumers, short-term water intake helps the intestinal adaptation to fibre supplementation.CLINICAL TRIAL REGISTRATION NUMBER: NCT02838849.

Gastroesophageal reflux disease and dental erosion: The role of bile acids.

OBJECTIVES: To identify the bile acids in the saliva of patients with and without gastroesophageal reflux disease (GERD), and evaluate their effect on tooth surface. DESIGN: A cross-sectional study involved 26 GERD patients and 40 controls without GERD. Dental erosions were identified, saliva was collected and analyzed with chromatography for bile acid identification. An in vitro study assessed the effect of enamel exposition to taurocholic acid in concentrations of 1 µM, 10 µM, and a mixture of taurocholic acid and glycocholic acid at 10 µM on enamel microhardness, calcium release, and surface topography. RESULTS: Salivary bile acids were analyzed from 22 GERD patients and 40 controls. All these participants presented taurocholic acid and glycocholic acid in the saliva. The salivary amount of taurocholic acid was greater than glycocholic acid in both GERD patients (area under the curve: 7946 vs. 1361; p < 0.001) and controls (10,815 vs. 1290; p < 0.001). The salivary amount of taurocholic acid was greater in controls than in GERD patients (10,815 vs. 7946; p < 0.001). Dental erosion was more prevalent in GERD patients than in controls (27% vs. 7%; p = 0.041). In the GERD presence, the amount of glycocholic acid was greater in patients with dental erosion (1777 vs. 1239; p = 0.041). Enamel exposed to taurocholic acid at 10 µM, combined or not with glycocholic acid, had their microhardness increased, accompanied by calcium release, with no changes in surface topography. CONCLUSIONS: Taurocholic acid was the predominant salivary bile acid, particularly in controls without GERD. This bile acid had no deleterious effect on the enamel structure.

Disruption of the brain-esophagus axis in obese patients with heartburn.

Obesity is a risk factor for gastroesophageal reflux disease. Studies addressing the brain-esophagus axis in obese are lacking. In obese with and without heartburn, we assessed: (i) the brain responses to esophageal acid perfusion during functional brain imaging; (ii) esophageal impedance baseline before and after acid perfusion; and (iii) abdominal fat distribution. In this exploratory study, 26 obese underwent functional magnetic resonance imaging (fMRI) of the brain combined with esophageal acid perfusion. Esophageal impedance baseline was determined before and after fMRI, followed by tomographic quantification of the abdominal fat. Among 26 obese (54% men, 39.7 years old, 33.5 kg/m2), there were 17 with heartburn and 9 without heartburn. Before fMRI, the esophageal impedance baseline was lower in obese with heartburn than without heartburn (median 1187 vs. 1890 Ω; P = 0.025). After acid perfusion, impedance baseline decreased in obese with heartburn (from 1187 to 899 Ω; P = 0.011) and was lower in this group than in obese without heartburn (899 vs. 1614 Ω; P = 0.001). fMRI task-residual analysis showed that obese with heartburn presented higher functional connectivity in several brain regions than obese without heartburn. Abdominal fat area did not differ between obese with and without heartburn either for total (72.8 ± 4.4% vs. 70.3 ± 6.0%; P = 0.280), subcutaneous (42.2 ± 9.0% vs. 37.4 ± 9.0%; P = 0.226), or visceral (30.6 ± 7.9% vs. 33.0 ± 7.8%; P = 0.484). In subjects with obesity, the brain-esophagus axis is disrupted centrally with higher functional brain connectivity and peripherally with decreased esophageal mucosa integrity in the presence of heartburn.

Reduced masticatory function predicts gastroesophageal reflux disease and esophageal dysphagia in patients referred for upper endoscopy: A cross-sectional study.

BACKGROUND: The role of mastication on gastroesophageal reflux disease (GERD) is unknown. AIMS: To assess whether reduced masticatory function predicts GERD and esophageal dysphagia in patients investigated with upper endoscopy. METHODS: In this cross-sectional study, 179 adult patients referred for elective upper gastrointestinal endoscopy agreed to participate. Before endoscopy, an expert dentist performed an oral examination and scored chewing function in three levels (normal, regular, and reduced). Patients replied questionnaires for assessment of GERD (heartburn, regurgitation, and dysphagia), xerostomia, and mastication (normal, regular, and reduced). Poor chewing was defined when either oral examination or mastication questionnaire rated the chewing function as reduced. Associations of mastication with GERD and dysphagia were estimated using Poisson regression. RESULTS: Eleven patients were excluded. Among 168 analyzed (aging 49.8 ± 15.5 years; 58.9% women), 46 had reduced masticatory function (27.4%), and 122 had regular/normal mastication (72.6%). Reduced mastication was associated with GERD [PR = 1.38 (95%CI 1.12 - 1.70)], adjusting for age, and with esophageal dysphagia [PR = 2.03 (95%CI 1.02 - 4.04)], adjusting for age and xerostomia. CONCLUSIONS: In outpatients referred for upper gastrointestinal endoscopy, reduced masticatory function defined by an expert dentist may be a risk factor for GERD and esophageal dysphagia.

Lactobacillus brevis CD2 attenuates traumatic oral lesions induced by fixed orthodontic appliance: A randomized phase 2 trial.

OBJECTIVE: To evaluate the effect of the probiotic Lactobacillus brevis CD2 on the prevention of early traumatic oral lesions induced by a fixed orthodontic appliance. SETTINGS AND SAMPLE POPULATION: Twenty orthodontic patients (14-57 yo) were recruited from a private clinic. SUBJECTS AND METHODS: In a phase 2, double-blind clinical trial, all patients were randomly allocated (1:1 ratio) to a 21-day course of soluble tablets containing L brevis CD2 (4 billion colony-forming units after breakfast, lunch and dinner) or placebo, starting at the day of orthodontic appliance placement. The primary outcomes were days with oral lesions and lesion-related pain [ranging between 0 (no pain) and 10 (maximum pain)]. Oral health-related quality of life was measured using OHIP-14 before and after treatments. RESULTS: All patients completed the study. Ten were treated with L brevis (28.1 ± 13.3 yo, 70% women), and 10 received placebo (27.5 ± 9.1 yo, 60% women). The oral lesions lasted significantly less time (P = .018) in patients treated with L brevis (2.5 ± 1.0 days) than with placebo (4.9 ± 3.0 days). Pain score was significantly lower (P = .039) when L brevis was used [median (min-max): 0 (0-4) vs. 3 (0-5)]. OHIP-14 scores were not significantly different between treatments. CONCLUSIONS: Lactobacillus brevis CD2 reduced almost 50% the persistence of traumatic oral lesions in patients with fixed orthodontics. Yet, there was no improvement in quality of life compared to placebo, suggesting that such differences in persistency and pain related to oral lesions may be considered clinically irrelevant.

Abdominal Palpation Does Not Modify the Number of Bowel Sounds in Healthy Volunteers and Gastrointestinal Outpatients.

BACKGROUND: The effect of abdominal palpation on bowel sounds is controversial. The authors developed an auscultation apparatus to count bowel sounds and determined whether abdominal palpation modifies the number of bowel sounds in healthy volunteers and gastrointestinal outpatients. METHODS: Four medical students developed an auscultation apparatus by attaching a Littmann stethoscope to an electret condenser microphone. The students examined 20 healthy volunteers and 20 gastrointestinal outpatients between March and June 2018. Abdominal auscultation lasting 4 minutes (1-minute each quadrant) was performed before and after abdominal palpation with registration of sound tracings. The software Audacity was used to count the bowel sounds. The effect of palpation on bowel sounds was analyzed using Generalized Estimating Equations. RESULTS: The volunteers were predominantly young (mean ± SD, 21 ± 2 years) and men (70%), whereas the outpatients were older (60 ± 11 years) and women (80%). The apparatus was able to generate sound tracings with good quality from all participants. In the comparison before/after palpation, the number of bowel sounds did not differ either in volunteers (mean ± SD, 12.6 ± 4.7 and 11.6 ± 3.5; P = 0.482) or in patients (15.6 ± 7.5 and 15.8 ± 7.9; P = 0.714). In the analysis of all participants, the difference before-after palpation was not statistically significant (mean ± SD, 14.1 ± 6.3 and 13.7 ± 6.4, respectively; P = 0.550; mean difference = 0.4; 95% CI -1.2 to 2.0) and did not depend on the group studied. CONCLUSIONS: Using an apparatus devised by medical students, the authors found that abdominal palpation did not modify the number of bowel sounds in healthy volunteers and gastrointestinal outpatients.

Predictors of dental erosions in patients evaluated with upper digestive endoscopy: a cross-sectional study.

The most studied medical condition related with dental erosions is gastroesophageal reflux disease (GERD). The aim of this study was to assess other predictors of dental erosions besides GERD in outpatients referred for upper digestive endoscopy. In a cross-sectional study, we prospectively evaluated 235 patients who underwent upper digestive endoscopy. Patients were interviewed and examined by a trained dentist before the endoscopies, addressing dental health as well as clinical information and food intake. Dental erosion was classified using Basic Erosive Wear Examination score. Potential predictors for dental erosions were: gender, age, chronic use of antidepressants and proton pump inhibitors (PPI), diabetes mellitus, body mass index, heartburn and acid regurgitation scores, chocolate intake, reflux esophagitis and hiatal hernia. Overall prevalence of dental erosions was 23.4%. The most parsimonious Poisson regression model for dental erosions considered age, chocolate intake and acid regurgitation as predictors. Dental erosions were associated with acid regurgitation in patients younger than 50 years [adjusted prevalence ratio (PR) = 1.8 (95% CI 1.1-2.9)] and with chocolate intake in patients older than 50 years [PR = 2.1 (95% CI 1.2-3.9]. The surfaces most eroded were palatine/lingual (n = 25) and occlusal (n = 25), followed by vestibular (n = 5). In outpatients evaluated with upper digestive endoscopy, the variables associated with dental erosions were age younger than 50 years, acid regurgitation and chocolate intake. Referral for dental evaluation should be considered for young patients with GERD and frequent acid regurgitation.

Predictive Factors of Gastroesophageal Reflux Disease in Bariatric Surgery: a Controlled Trial Comparing Sleeve Gastrectomy with Gastric Bypass.

OBJECTIVE: To evaluate the impact of laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) on gastroesophageal reflux disease (GERD) in patients with obesity. METHODS: Patients with class II or III obesity were treated with LSG or LRYGB. Procedure choice was based on patients and surgeon preferences. GERD symptoms, endoscopy, barium swallow X-ray, esophageal manometry, and 24-h pH monitoring were obtained before and 1 year after surgery. RESULTS: Seventy-five patients underwent surgery (83% female, 39.3 ± 12.1 years, BMI of 41.5 ± 5.1 kg/m2): 35 (46.7%) had LSG and 40 (53.3%) LRYGB. LSG patients had lower BMI (40.3 ± 4.0 kg/m2 vs. 42.7 ± 5.7 kg/m2; p = 0.041) and trend toward lower prevalence of GERD (20% vs. 40%; p = 0.061). One year after surgeries, GERD was more frequent in LSG patients (74% vs. 25%; p < 0.001) and all LSG patients with preoperative GERD continue to have GERD postoperatively. De novo GERD occurred in 19 of 28 (67.9%) of LSG patients and 4 of 24 (16.7%) patients treated with LRYGB (OR 10.6, 95%CI 2.78-40.1). Independent predictors for post-operative GERD were as follows: LSG (OR 12.3, 95%CI 2.9-52.5), preoperative esophagitis (OR 8.5, 95% CI 1.6-44.8), and age (OR 2.0, 95%CI 1.1-3.4). CONCLUSIONS: One year after surgery, persistent or de novo GERD were substantially more frequent in patients treated with LSG compared with LRYGB. LSG was the strongest predictor for GERD in our trial. Preoperative counseling and choice of bariatric surgical options must include a detailed assessment and discussion of GERD-related surgical outcomes.

Are Lactobacillus salivarius G60 and inulin more efficacious to treat patients with oral halitosis and tongue coating than the probiotic alone and placebo? A randomized clinical trial.

BACKGROUND: The combination of probiotics and prebiotics might be useful to treat oral halitosis. The aim of this study was to assess the effect of Lactobacillus salivarius G60 (LS) and inulin on oral halitosis and tongue coating. METHODS: In this double-masked, randomized, phase II clinical trial, 45 patients (aged 35 ± 15 years, 66% female) with oral halitosis and tongue coating were allocated to three treatment groups (n = 15) using gums of oral dissolution (one gum every 12 hours) for 10 days. Each gum contained LS (1 billion colony forming units [CFUs]) + inulin (1 g), LS (1 billion CFU) or placebo. Primary outcomes were organoleptic test, Halimeter, and tongue coating, whereas secondary outcomes were quality of life (QOL) and treatment safety. Generalized linear models were used, adjusting for age and sex. In vitro tests were performed to verify whether LS interacts with inulin and whether LS inhibits the growth of Porphyromonas gingivalis and Prevotella intermedia. RESULTS: Forty-four patients (97%) completed the study. Patients treated with LS + inulin showed greater reduction in halitosis measured by Halimeter compared with placebo (adjusted post-intervention average: 96.7 versus 142.5 ppb; P = 0.003), whereas LS and placebo did not differ (115.7 versus 142.5 ppb; P = 0.097). Organoleptic measurements and coating index showed a similar decrease for all groups. QOL improved in patients treated with LS + inulin compared with placebo (P = 0.029). Side effects were mild and transient in all groups. LS did not metabolize inulin but inhibited the growth of P. gingivalis and P. intermedia after 72 hours. CONCLUSIONS: Treatment with L. salivarius G60 combined or not with inulin showed significant decrease in the outcomes organoleptic test, Halimeter, and coating index, improving oral halitosis. However, no significant difference was obtained between the groups.