Endoscopic findings and outcomes of gastric mucosal changes relating to potassium-competitive acid blocker and proton pump inhibitor therapy.

Gastric mucosal changes associated with long-term potassium-competitive acid blocker and proton pump inhibitor (PPI) therapy may raise concern. In contrast to that for PPIs, the evidence concerning the safety of long-term potassium-competitive acid blocker use is scant. Vonoprazan (VPZ) is a representative potassium-competitive acid blocker released in Japan in 2015. In order to shed some comparative light regarding the outcomes of gastric mucosal lesions associated with a long-term acid blockade, we have reviewed six representative gastric mucosal lesions: fundic gland polyps, gastric hyperplastic polyps, multiple white and flat elevated lesions, cobblestone-like gastric mucosal changes, gastric black spots, and stardust gastric mucosal changes. For these mucosal lesions, we have evaluated the association with the type of acid blockade, patient gender, Helicobacter pylori infection status, the degree of gastric atrophy, and serum gastrin levels. There is no concrete evidence to support a significant relationship between VPZ/PPI use and the development of neuroendocrine tumors. Current data also shows that the risk of gastric mucosal changes is similar for long-term VPZ and PPI use. Serum hypergastrinemia is not correlated with the development of some gastric mucosal lesions. Therefore, serum gastrin level is unhelpful for risk estimation and for decision-making relating to the cessation of these drugs in routine clinical practice. Given the confounding potential neoplastic risk relating to H. pylori infection, this should be eradicated before VPZ/PPI therapy is commenced. The evidence to date does not support the cessation of clinically appropriate VPZ/PPI therapy solely because of the presence of these associated gastric mucosal lesions.

Diagnosis and treatment of patients with gastroesophageal reflux disease - a systematic review of cost-effectiveness and economic burden.

BACKGROUND: This study aims to review the existing knowledge on the cost-effectiveness and item costs related to the diagnosis and treatment of gastroesophageal reflux disease (GERD) patients at different stages. METHODS: The study adhered to the PRISMA guidelines. The systematic search involved several steps: finding and identifying relevant articles, filtering them according to the set criteria, and examining the final number of selected articles to obtain the primary information. The number of articles published between 2013 and September 2024 in the Web of Science and PubMed databases was considered. The CHEERS checklist was used for the risk of bias assessment. Ultimately, 36 studies were included. RESULTS: Regarding the cost-effectiveness of GERD treatment, Proton pump inhibitors (PPIs) appeared to be the dominant solution for non-refractory patients. However, this might change with the adoption of the novel drug vonoprazan, which is more effective and cheaper. With advancements in emerging technologies, new diagnostic and screening approaches such as Endosheath, Cytosponge, and combined multichannel intraluminal impedance and pH monitoring catheters should be considered, with potential implications for optimal GERD management strategies. DISCUSSION: The new diagnostic methods are reliable, safe, and more comfortable than standard procedures. PPIs are commonly used as the first line of treatment for GERD. Surgery, such as magnetic sphincter augmentation or laparoscopic fundoplication, is only recommended for patients with treatment-resistant GERD or severe symptoms. OTHER: Advances in emerging technologies for diagnostics and screening may lead to a shift in the entire GERD treatment model, offering less invasive options and potentially improving patients' quality of life.

Association between laryngopharyngeal reflux clinical scores and esophageal multichannel intraluminal impedance pH monitoring interpretation according to Lyon Consensus 2.0.

Laryngopharyngeal reflux remains a diagnostic challenge due to the lack of a definitive diagnostic tool. Esophageal multichannel intraluminal impedance (MII) pH monitoring has been proven reliable for detecting gastric reflux. This study aims to evaluate the association between clinical scores and MII/pH monitoring according to the Lyon Consensus 2.0. Patients with laryngo-pharyngeal symptoms (LPS) who had a reflux symptom index (RSI) ≥13 or reflux finding score (RFS) ≥7 underwent MII/pH monitoring. The findings were analyzed in comparison with clinical scores. A total of 100 patients meeting the inclusion criteria were recruited for this study. MII/pH monitoring revealed a median acid exposure time (AET) of 1.9% (interquartile range [IQR] = 0.2, 4.9), with 22% of patients recording an AET above 6%. The median number of reflux episodes was 29.5 episodes per day (IQR = 19.0, 43.8), with 7% experiencing more than 80 episodes per day. Gas reflux was identified as the most prevalent type. Based on the Lyon Consensus 2.0, 25 patients exhibited conclusive pathological reflux, while 75 patients showed no conclusive evidence of pathological reflux. No significant differences were found in RSI and RFS between these groups. Only gas reflux episodes showed a significant correlation with RSI (r = 0.255, P = 0.011). RSI and RFS among patients with LPS showed no statistically significant differences in identifying pathological reflux or no conclusive evidence of pathological reflux. This finding suggests that the pathophysiology underlying LPS may not be solely attributable to reflux.

Efficacy of One-Anastomosis Gastric Bypass Versus Roux-en-Y Gastric Bypass for Gastroesophageal Reflux Disease: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

This study aimed to investigate the efficacy of one-anastomosis gastric bypass (OAGB) on gastroesophageal reflux disease (GERD) compared with Roux-en-Y gastric bypass (RYGB) in patients with obesity. Three databases (Medline, Cochrane Central, and Scopus) were searched for relevant articles published until August 12, 2024. A total of nine randomized controlled trials, including 643 patients, were selected. OAGB was statistically significantly associated with a higher risk of GERD than RYGB (OR = 3.14, 95% CI 1.23-8.03, p < 0.05). The odds for de novo GERD after OAGB are almost six times higher than after RYGB (OR = 5.65, 95% CI 1.53-20.82, p < 0.05). RYGB has a lower incidence of de novo GERD cases and is more effective than OAGB in reducing GERD.

Subjective improvement of reflux symptoms after conversion of sleeve gastrectomy to Roux-en-Y gastric bypass and concomitant repair of hiatal hernia.

BACKGROUND: Symptoms of reflux after sleeve gastrectomy (SG) are common and may be refractory to medical treatment. OBJECTIVES: To assess outcomes of conversion of SG to Roux-en-Y gastric bypass (RYGB) with concomitant repair of hiatal hernias on symptoms of reflux. SETTING: Tertiary community hospital. METHODS: We reviewed data from all consecutive patients (2018-2021) who underwent conversion from SG to RYGB for refractory reflux symptoms. Concomitant hiatal hernias were diagnosed endoscopically or radiographically. Improvement in reflux symptoms, nausea, vomiting, dysphagia, or abdominal pain and postoperative proton pump inhibitor (PPI) use were compared with McNemar statistical test. Data are reported as mean ± standard deviation. RESULTS: In total, 64 patients (92% female; 48 ± 10 years) underwent conversion from SG to RYGB and repair of concomitant hiatal hernias 4 ± 3 years after the index SG. A hiatal hernia was detected preoperatively in 57 of 64 patients (89%) by either upper gastrointestinal contrast studies, computed tomography scan, or esophagogastroduodenoscopy. At 29 ± 14 months postconversion to RYGB, percent total body weight loss was 14 ± 9% and percent excess weight loss was 37 ± 29%, and body mass index decreased from 37 ± 7 to 32 ± 6 kg/m2. Symptoms of reflux and use of PPI improved during the early follow-up period (median: 14 months; P < .001) and was sustained at late follow-up (median: 32 months; P < .01). Improvement of nausea and dysphagia reached statistical significance at late follow-up (median: 32 months; P < .01). Vomiting and abdominal pain decreased with time but did not reach statistical significance. Postoperative complications were deep surgical-site infection (n = 3), pulmonary embolism (n = 1), bleeding (n = 5), reoperation (n = 3), and 30-day readmission (n = 6). CONCLUSIONS: Conversion of SG to RYGB and repair of concomitant hiatal hernia improves reflux symptoms, nausea, and dysphagia, reduces PPI use, and confers additional weight loss.

Diagnosis and Management of Noncardiac Chest Pain.

Noncardiac chest pain is a challenging condition often encountered by primary care providers, emergency medicine physicians, and gastroenterologists. It is frequently accompanied by persistent symptoms, diagnostic uncertainty, decreased quality of life, and high health care burden. Gastroesophageal reflux disease is the most common esophageal cause followed by functional chest pain, and at least half of patients with noncardiac chest pain have psychiatric comorbidities such as anxiety or depression. Management is focused on identification of an underlying cause to target treatment and address psychiatric comorbidities. This article discusses the evaluation and management of the common gastrointestinal causes of noncardiac chest pain.

Laryngopharyngeal Reflux in Patients Who Received or Declined Nissen Fundoplication.

OBJECTIVE: To evaluate whether Robotic or Laparoscopic Nissen Fundoplication (LNF) improves voice outcomes and symptoms in patients with Laryngopharyngeal Reflux (LPR) compared to patients who were candidates for surgery but elected to receive treatment with antireflux medical management alone. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective chart review was conducted of patients who visited the office of the senior author, received a diagnosis of LPR, and were candidates for LNF. Patients were categorized into two groups: those who received LNF surgery (Nissen-received, n = 50) and those who declined surgery (Nissen-declined, n = 54). Reflux Finding Scores (RFS) collected pre- and post-treatment were compared between groups. 24-hour pH-impedance results also were evaluated pre- and post-treatment. RESULTS: 24-hour pH-impedance testing from patients in the Nissen-received group showed a statistically significant decrease in six recording categories at the proximal sensor and five at the distal sensor, pre- to post-Nissen fundoplication. Proximal sensor categories included: (1) total reflux, (2) supine reflux, (3) acidic reflux, (4) weakly acidic reflux, (5) upright reflux, and (6) total postprandial reflux. Distal sensor categories included: (1) total reflux, (2) weakly acidic reflux, (3) supine reflux, (4) upright reflux, and (5) upright weakly acidic reflux. There were statistically significant differences in the changes from pre- to post-intervention when comparing between the Nissen-received and Nissen-declined groups at three proximal and three distal recordings. The proximal recording categories were (1) total reflux, (2) upright reflux, and (3) upright weakly acidic reflux, and the distal sensor categories were (1) upright reflux, (2) upright weakly acidic reflux, and (3) weakly acidic reflux. The Nissen-received group demonstrated statistically significant improvements in total RFS score, as well as the subcategory score of erythema, from pre- to post-Nissen fundoplication. There were statistically significant differences in the subcategory scores of erythema and diffuse laryngeal edema when comparing the changes from pre- to post-intervention between the Nissen-received and Nissen-declined groups. CONCLUSION: LNF provides improved LPR control compared with treatment with antireflux medication alone.

Effect of sleeve gastrectomy on distal esophagus at 5 and 10 years.

BACKGROUND: Sleeve gastrectomy (SG) is a primary surgical intervention for obesity management. However, several longitudinal studies have documented the emergence of long-term esophageal consequences, notably gastroesophageal reflux disease (GERD) and its associated complications. This study aimed to assess the occurrence of esophageal complications, including esophagitis and Barret's esophagus (BE), 5 and 10 years after SG, in one medical center. METHODS: Two cohorts of consecutive patients who underwent SG were studied: patients who underwent a systematic upper gastro-intestinal endoscopy (UGIE) at five years or conversion to RYGB < 5 years (cohort n°1, n = 219), and patients who underwent UGIE at 10 years or converted to RYGB > 5 years (cohort n°2, n = 72). Patients with missing UGIE before or after SG were excluded. RESULTS: In the cohort n°1, 62.7% of the patients had clinical GERD at the 5-years follow-up (vs. 21.8 before SG, p < 0.0001), 27.4% had esophagitis (vs. 14.2% before SG, p = 0.0006), and 8.3% had BE (vs. 1.8% before SG, p = 0.002) with metaplasia in 1.8%. De novo esophagitis and BE accounted for 19.6% and 7.8%, respectively. In the cohort n°2, at 10 years, 61.5% had clinical GERD (vs.12.5 before SG, p < 0.0001), 23.6% had esophagitis (vs. 9.7% before SG, p = 0.025) including 20.8% de novo, and 8.3% had de novo BE, with metaplasia in 5.6%. De novo esophagitis accounted for 20.8%. One patient developed esophageal adenocarcinoma 10 years after SG. Pre-operative esophagitis was significantly associated with BE on UGIE at 5 or 10 years, while active smoking and preoperative esophagitis were risk factors for esophagitis. CONCLUSION: This study highlights a significant increase in esophageal complications 5 and 10 years after SG. Pre-operative esophagitis should be considered when choosing a surgical technique for obesity management.

Tunnel anastomosis - a modified flap technique in esophagogastrostomy as a novel anti-reflux technique after proximal gastrectomy.

BACKGROUND: The prevalence of proximal gastric cancer (PGC) has been increasing rapidly worldwide. Postoperative reflux esophagitis after conventional Esophagogastrostomy (EG) was a major problem that haunts the surgeons. We designed a novel anti-reflux technique called Tunnel anastomosis in EG after proximal gastrectomy. The aim of this study is to present the detailed procedures of Tunnel anastomosis and to assess its safety and feasibility by comparing the surgical outcomes, reflux, and nutritional status of patients undergoing Tunnel anastomosis versus double tract jejunal interposition reconstruction (DTJIR). METHODS: 1,718 patients undergoing gastrectomy were enrolled in this study. 150 patients undergoing PG were finally analyzed, of which 21 patients underwent Tunnel anastomosis, 129 patients underwent DTJIR. Propensity score matching (PSM) was used to reduce biases. RESULTS: After 1:1 PSM, there were 21 patients in both groups. No significant differences were observed between the two groups in terms of surgical approach, blood loss, operative time, reconstruction time, postoperative hospital stay, morbidity, and mortality. The incidence of reflux esophagitis in both groups was 9.5% (2/21) according to the endoscopic examination at the 12-month postoperative follow-up. No patient in the Tunnel group was classified as grade B or higher according to the Los Angeles classification. Patients in the Tunnel and DTJIR groups exhibited comparable postoperative nutritional status when assessing the body weight, albumin levels and PNI value at 3 and 6 months after surgery. CONCLUSION: Tunnel anastomosis is a safe technique that offers a robust anti-reflux effect and can be performed in some suitable patients with PGC.

Causal Effects of Gastroesophageal Reflux on Chronic Rhinosinusitis: A Bidirectional Two-Sample Mendelian Randomization Study.

INTRODUCTION: Observational studies have shown a bidirectional association between gastroesophageal reflux (GER) and chronic rhinosinusitis (CRS) or chronic rhinitis (CR), but it is not clear whether this association is causal. OBJECTIVES: This study was to investigate the causality between GER and CRS or CR using bidirectional two-sample Mendelian randomization (MR) analysis. METHODS: Using pooled data from large genome-wide association studies (GWAS), genetic loci independently associated with GER, CRS and CR in populations of European and American ancestry were selected as instrumental variables (IVs). The inverse variance weighted (IVW) method was used to analyse the random effects model of MR, and the odds ratio (OR) was used as the evaluation index to explore the bidirectional causality between GER and CRS or CR. Single nucleotide polymorphism (SNP) outliers were detected using MR-pleiotropy Residual Sum and Outliers (MR-PRESSO). The MR-Egger intercept test examined the horizontal pleiotropy of SNPs. The "leave-one-out" sensitivity analysis examined whether MR results were affected by a single SNP. RESULTS: The main results of IVW showed that GER increased the risk of CRS (OR = 1.3795, 95% CI = 1.188-1.603, p < 0.0500) and CR (OR = 1.3941, 95% CI = 1.1671-1.6652, p < 0.0500). The obtained SNPs as IVs for GER, CRS and CR had no significant horizontal pleiotropy, heterogeneity or bias. Regarding the reverse directions, no notable associations could be found. CONCLUSION: This MR analysis revealed that genetically predicted GER had a causal effect on an increased risk of CRS or CR, but not vice versa. These results have great implications for the management of CRS (especially for refractory CRS) or CR in clinical practice.

Effectiveness of Changing Drug Classes in Patients With Refractory Laryngopharyngeal Reflux Disease.

OBJECTIVE: To investigate the effectiveness of drug class changes in patients with refractory laryngopharyngeal reflux disease (LPRD). STUDY DESIGN: Retrospective case series with prospective data. SETTING: Multicenter study. METHODS: The data of patients treated for a refractory LPRD from September 2017 to December 2023 were collected. The effectiveness of drug class changes was assessed through the reflux symptom score (RSS) change. Signs were evaluated with the Reflux Sign Assessment. The RSS reduction was used to categorize the therapeutic responses as mild (20%-40% RSS reduction), moderate (40.1%-60% RSS reduction), high (60.1%-80%), and complete (>80%). RESULTS: Among the 334 medical records, 74 (22.2%) patients had refractory LPRD defined as no RSS change in the pre- to 3-month posttreatment. The mean age was 52.6 ± 15.5 years. Changing drug class was associated with significant 3- to 6-month posttreatment reductions of RSS and RSA. Thirty patients (39%) did not experience symptom reduction after changing drugs. Changing alginate to magaldrate and magaldrate to alginate was associated with the highest responder rate (76.9%). Changing PPI and alginate/magaldrate molecules led to a response rate of 62.5%. In patients initially treated with a combination of PPI and alginate or magaldrate, changing PPI without changing alginate/magaldrate led to a 37.5% response rate. The baseline RSS was predictive of the 3- and 6-month RSS (therapeutic response). CONCLUSION: Changing drug class, especially alginate-to-magaldrate, may be an effective therapeutic approach for patients with a refractory LPRD.

A New Technique for Creation of Femoral Vein Monocusp Neovalve for Patients With Primary Deep Vein Incompetence.

METHODS: Monocusp valve was created by folding the vein wall flap so that both sides of the valve will have intimal surface. RESULT: Patient had excellent symptomatic improvement. The venous ulcer healed with skin grafting and had not recurred at 30 months follow up. Descending venogram and duplex scan showed mild reflux. CONCLUSION: Monocusp neo valve creation for primary DVI is a simple procedure with good long-term result.

Nomogram for predicting reflux esophagitis with routine metabolic parameters: a retrospective study.

Introduction: The prevalence of reflux esophagitis (RE) is relatively high around the world. We investigated routine metabolic parameters for associations with RE prevalence and severity, creating a user-friendly RE prediction nomogram. Material and methods: We included 10,881 individuals who had upper gastrointestinal endoscopy at a hospital. We employed univariate and multivariate logistic regression for independent risk factors related to RE prevalence, and conducted ordinal logistic regression for independent prognostic factors of RE severity. Subsequently, a nomogram was constructed using multivariate logistic regression analysis, and its performance was assessed through the utilization of receiver operating characteristic (ROC) curves, calibration curves, decision curve analysis (DCA), and clinical impact curve (CIC) analysis. Results: In this study, 43.8% (4769 individuals) had confirmed RE. Multivariate analysis identified BMI, age, alcohol use, diabetes, Helicobacter pylori, systolic blood pressure (SBP), diastolic blood pressure (DBP), glucose, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), total cholesterol (TC), albumin, uric acid (UA), fT3, and fT4 as independent RE risk factors (p < 0.05). The personalized nomogram used 17 factors to predict RE, with an AUC of 0.921 (95% CI: 0.916-0.926), specificity 84.02%, sensitivity 84.86%, and accuracy 84.39%, reflecting excellent discrimination. Calibration, decision, and CIC analyses affirmed the model's high predictive accuracy and clinical utility. Additionally, ordinal logistic regression linked hypertension, diabetes, HDL-C, LDL-C, TG, and TC to RE severity. Conclusions: Our study highlights the association between the routine metabolic parameters and RE prevalence and severity. The nomogram may be of great value for the prediction of RE prevalence.

Hepatic hyperechoic lesion in a young, healthy man.

A hyperechoic nodule in the liver has a broad differential; however, the vast majority are benign lesions. We report a case of a 29-year-old man with a history of anxiety and depression who presented to the hospital due to a 12-day history of epigastric pain with radiation to the back, fevers, and night sweats. Initial imaging revealed a small hyperechoic nodule on the liver, originally believed to be an abscess. Image-guided aspiration was attempted but no fluid could be drained. An endoscopic ultrasound was pursued to further evaluate the lesion and obtain a biopsy. An ulcerated esophageal mass was incidentally identified on endoscopy. Hepatic and esophageal biopsies demonstrated moderately differentiated adenocarcinoma, with esophageal adenocarcinoma as the primary source. This case highlights an interesting presentation for the rare occurrence of metastatic esophageal adenocarcinoma in a young, healthy individual without identifiable risk factors.

Hepatic hyperechoic lesions have a vast differential and require a broad workup to identify the true etiology.The incidence of esophageal cancers is steadily increasing worldwide, with projections showing dramatic increases over the next 20 years.Esophageal cancers carry a poor prognosis, with worse outcomes in younger populations.Current guidelines do not include any endoscopy screening recommendations for younger populations, so clinicians must develop strong clinical judgment when evaluating reflux symptoms.

Poor adherence to proper Barrett's esophagus screening and surveillance guidelines in patients with newly diagnosed esophageal adenocarcinoma.

Background: Screening for Barrett's esophagus (BE) remains controversial, even for high-risk populations. Our study aimed to evaluate the proportion of patients diagnosed with esophageal adenocarcinoma (EAC) who were not screened for BE or did not receive recommended BE surveillance screening. We then evaluated the relationship between cancer staging and screening/surveillance opportunities. Methods: This single-center retrospective study included 187 patients from January 2016 to January 2022 with newly diagnosed EAC. Data extracted from patient charts included BE risk factors, and BE, endoscopic, and histologic history. Results: A total of 187 patients had a new diagnosis of EAC. Among this group, 44% had appropriate BE surveillance adherence, and 47% of patients met the criteria for BE screening but had not been screened prior to EAC diagnosis. Adherence to BE surveillance was associated with earlier stages of cancer on biopsy. No significant difference in cancer staging was found in those with missed BE screening opportunities. Discussion: Patients with a diagnosis of BE who adhered to surveillance guidelines had earlier stage EAC at diagnosis, which emphasizes the importance of surveillance. Most of those with an initial diagnosis of EAC had not received any BE screening.

S0-dependent bio-reduction for antimonate detoxification from wastewater by an autotrophic bioreactor with internal recirculation.

Elemental sulfur (S0) autotrophic reduction is a promising approach for antimonate [Sb(V)] removal from water; however, it is hard to achieve effective removal of total antimony (TSb). This study established internal recirculation in an S0 autotrophic bioreactor (SABIR) to enhance TSb removal from Sb(V)-contaminated water. Complete Sb(V) reduction (10 mg/L) with bare residual Sb(III) (< 0.26 mg/L) was achieved at hydraulic retention time (HRT) = 8 h. Shortening HRT adversely affected the removal efficiencies of Sb(V) and TSb; meanwhile, an increased reflux ratio was conducive to Sb(V) and TSb removal at the same HRT. Sulfur disproportionation occurred in the SABIR and was the primary source for SO42- generation and alkalinity consumption. The alkalinity consumption decreased with the shortening HRT and increased with an increased reflux ratio at the same HRT. The generated SO42- was significantly higher (50-100 times) than the theoretical value for Sb(V) reduction. Coefficient of variation (CV), first-order kinetic models, and osmolality analyses showed that internal recirculation did not significantly affect the stability of SABIR but contributed to enhancing TSb removal by increasing mass transfer and reflowing generated sulfide back to the SABIR. SEM-EDS, Raman spectroscopy, XRD and XPS analyses identified that the precipitates in the SABIR were Sb2S3 and Sb-S compounds. In addition, high-throughput sequencing analysis revealed the microbial community structure's temporal and spatial distribution in the SABIR. Dominant genera, including unclassified-Proteobacteria (18.72-38.99%), Thiomonas (0.94-4.87%) and Desulfitobacterium (1.18-2.75%) might be responsible for Sb(V) bio-reduction and removal. This study provides a strategy to remove Sb from water effectively and supports the theoretical basis for the practical application of the SABIR in Sb(V)-contaminated wastewater.

International Society for Diseases of the Esophagus consensus on management of the failed fundoplication.

Fundoplication is a durable, effective, and well-accepted treatment for gastroesophageal reflux disease. Nonetheless, troublesome postoperative symptoms do occasionally occur with management varying widely among centers. In an attempt to standardize definition and management of postfundoplication symptoms, a panel of international experts convened by the Guidelines Committee of the International Society for Diseases of the Esophagus devised a list of 33 statements across 5 domains through a Delphi approach, with at least 80% agreement to establish consensus. Eight statements were endorsed for the domain of Definitions, four for the domain of Investigations, nine for Dysphagia, nine for Heartburn, and four for Revisional surgery. This consensus defined as the treatment goal of fundoplication the resolution of symptoms rather than normalization of physiology or anatomy. Required investigations of all symptomatic postfundoplication patients were outlined. Further management was standardized by patients' symptomatology. The appropriateness of revisional fundoplication and the techniques thereof were described and the role of revisional surgery for therapies other than fundoplication were assessed. Fundoplication remains a frequently-performed operation, and this is the first international consensus on the management of various postfundoplication problems.

Silent Damage by Micro-aspirations: Untangling the Connection of Gastroesophageal Reflux Disease (GERD) and Achalasia With Interstitial Lung Disease.

Gastroesophageal reflux disease (GERD) frequently triggers respiratory conditions such as asthma and pneumonia. Inflammation occurs as a result of aspirated material, leading to symptoms such as cough, sputum production, chest discomfort from the involvement of the lower respiratory tract, and voice hoarseness owing to the involvement of the larynx. Repeated exposure to irritants can lead to fibrosis in the lungs. However, little is known about the association of achalasia with interstitial lung disease (ILD). We present a case of a patient with GERD who presented with cough and reflux for three months. Extensive testing confirmed the diagnosis of achalasia, and pneumatic dilation provided relief. The patient returned after two years with additional symptoms of shortness of breath. A CT scan of the chest showed worsening reticular changes and ground-glass opacity, indicative of ILD. An unremarkable toxin exposure history and a negative autoimmune panel led clinicians to explore the possible relationship between achalasia and ILD, highlighting the need for further exploration and research in this area.

Does the sonic hedgehog signaling pathway play a role in anti-reflux mechanism of bladder in children?

OBJECTIVE: A hedgehog family ligand, namely, sonic hedgehog (SHH), was reported to be important in the development of bladder and ureter smooth muscle. In this prospective study, we aimed to determine protein expression of SHH in resected ureterovesical junction (UVJ) segments of children with vesicoureteral reflux (VUR). MATERIALS AND METHODS: The study group included 19 children; 12 (63%) girls, 7 (37%) boys, who had ureteroneocystostomy operation; 3 (15.7%) right sided, 7 (36.8%) left sided, 9 (47.3%) bilateral, due to primary VUR between years 2015 and 2018. Totally, 28 UVJ segments were examined for Western Blot analysis to determine related protein expression levels. RESULTS: The mean Western blot band area of SHH gene pathway related protein was 3880.69 (2059.55-13941.61) while the mean area of ß-Actin, the house-keeping gene, was 20180.25 (9530.39-26709.75) (p = 0.001). Correlation analyses between grade of reflux and protein expression of SHH gene pathways revealed no significant relation (p = 0.300). When the UV samples were grouped as low- and high-grade reflux and compared in terms of SHH protein expression levels, no statistically significant difference was found between groups (p = 0.818). CONCLUSION: We concluded that SHH signaling molecule which is effective in development of bladder and ureter smooth musculature might also be effective in etiopathology of reflux.

OBJETIVO: Se ha informado que el ligando sonic hedgehog (SHH) es importante en el desarrollo de los músculos lisos de la vejiga y el uréter. Nuestro objetivo fue determinar la expresión proteica de SHH en los segmentos de la unión ureterovesical de niños con reflujo vesicoureteral (RVU). MATERIALES Y MÉTODOS: El grupo de estudio incluyó a 19 niños; 12 (63%) niñas, 7 (37%) niños, que tuvieron operación de ureteroneocistostomía (UNC); 3 (15.7%) derecho, 7 (36.8%) izquierdo, 9 (47.3%) bilateral, por RVU primario entre los años 2015-2018. Se examinaron un total de 28 segmentos de la unión ureterovesical para análisis de transferencia Western para determinar los niveles de expresión de proteínas relacionadas en las muestras. RESULTADOS: El área media de la banda de transferencia Western de la proteína relacionada con la vía del gen SHH fue de 3880.69 (2059.55-13941.61), mientras que el área media de la ß-actina, el gen de limpieza, fue de 20180.25 (9530.39-26709.75) (p = 0.001). Los análisis de correlación entre el grado de reflujo y la expresión de proteínas de las vías del gen SHH no revelaron una relación significativa (p = 0.300). CONCLUSIÓN: Concluimos que la molécula de señalización SHH también podría ser efectiva en la etiopatología del reflujo vesicoureteral.

Esophagitis, treatment outcomes, and long-term follow-up in children with esophageal atresia.

OBJECTIVES: Survival rates in children born with esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) have improved; however, morbidity associated with the disease remains high. This study aimed to assess the prevalence of gastroesophageal reflux disease (GERD), eosinophilic esophagitis (EoE), fungal esophagitis, esophageal strictures, and long-term outcomes in children with EA/TEF. METHODS: We conducted a retrospective chart review on patients with EA/TEF who were seen at Children's Wisconsin from January 2003 to January 2023. Patients born with EA/TEF were included if they underwent at least one endoscopy after 1 year of age. GERD was diagnosed based on abnormal findings on endoscopy, pH-metry, and/or history of fundoplication. EoE and fungal esophagitis were diagnosed based on abnormal endoscopy. Esophageal stricture diagnosis was based on findings on endoscopy and/or esophagram, and clinical symptoms necessitating esophageal dilation. RESULTS: Eighty-five patients (64.7% males, mean age 7.5 years) were included, the majority had type C EA/TEF (90.6%). GERD was diagnosed in 61.1% (n = 52), 49.4% (n = 42) by macro and/or microscopic endoscopic findings, 22.3% (n = 19) by abnormal pH-metry, and 21.1% (n = 18) by the need for fundoplication for refractory reflux and/or esophageal stricture. Risk of GERD increased with lower gestational age (p = 0.0030), lower birth weight (p = 0.023), and long-gap EA (p = 0.034). In children diagnosed with GERD, only 13.4% of patients (n = 7/52) were able to be weaned off proton pump inhibitor (PPI) without disease recurrence. However, overall, at the completion of the study, 44.7% (n = 38) of patients were successfully weaned off PPI without evidence of GERD. EoE was diagnosed in 20% of the patients (n = 17). All patients diagnosed with EoE required escalation of therapy from PPI alone to swallowed corticosteroids in 52.9% (n = 9), dupilumab in 23.5% (n = 4), elemental formula in 17.6% (n = 3), and elemental formula and swallowed steroids in 5.8% (n = 1). Fungal esophagitis was diagnosed in 15.3% of patients (n = 13). An esophageal stricture requiring dilation was diagnosed in 77.6% (n = 66) of patients at a mean age of 28.5 months, with over 60% diagnosed by 24 months of age. CONCLUSIONS: Children born with EA/TEF continue to be at high risk of developing GERD, EoE, fungal esophagitis, and esophageal stenosis. Diagnostic and therapeutic endoscopy remains a high-yield test to identify and treat these comorbidities.