Outcomes of Endoscopic Antireflux Mucosectomy for the Treatment of Gastroesophageal Reflux Disease: Systematic Review and Meta-analysis.

OBJECTIVE: Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal disorders in western countries. Endoscopic procedures have recently emerged as an alternative therapy to surgery for patients with GERD. The aim of this study was to determine outcomes after endoscopic antireflux mucosectomy (ARMS). METHODS: A systematic review and meta-analysis were performed to analyze outcomes after ARMS. The main outcomes included patients' satisfaction, GERD health-related quality of life, use of proton pump inhibitors, and DeMeester score. The secondary endpoint was postprocedural adverse events. A meta-analysis of proportions was used to assess the effect of each approach on different outcomes. RESULTS: A total of 22 studies comprising 654 patients were included for analysis. The mean age of patients was 51.83 (36 to 59.39) years, and the mean body mass index was 25.06 (23.5 to 27) kg/m 2 . The weighted pooled proportion of patient satisfaction after ARMS was 65% (95% CI: 52%-76%). The pooled proportion of patients taking proton pump inhibitors decreases from 100% to 40.84% ( P < 0.001). The mean GERD health-related quality of life scores (pre 19.48 vs post 7.90, P < 0.001) and DeMeester score (pre 44.99 vs post 15.02 P = 0.005) significantly improved after ARMS. Overall morbidity rate was 27% (95% CI: 13%-47%), with a weighted pooled proportion of perforation, stricture, and bleeding of 3% (95% CI: 2%-6%), 12% (95% CI: 9%-16%), and 6% (95% CI: 2%-17%), respectively. CONCLUSIONS: Endoscopic ARMS for GERD is associated with symptomatic improvement, reduction of medical therapy, and enhanced quality of life. Refinements of the technique, however, are needed to decrease morbidity.

High-resolution 3-dimensional tomography may be a useful tool for understanding the anatomy of hiatal hernias and surgical planning of patients eligible for laparoscopic or robotic antireflux surgery.

BACKGROUND: 3D computed tomography (CT) has been seldom used for the evaluation of hiatal hernias (HH) in surgical patients. This study aims to describe the 3D CT findings in candidates for laparoscopic or robotic antireflux surgery or HH repair and compare them with other tests. METHODS: Thirty patients with HH and/or gastroesophageal reflux disease (GERD) who were candidates for surgical treatment and underwent high-resolution CT were recruited. The variables studied were distance from the esophagogastric junction (EGJ) to the hiatus; total gastric volume and herniated gastric volume, percentage of herniated volume in relation to the total gastric volume; diameters and area of the esophageal hiatus. RESULTS: HH was diagnosed with CT in 21 (70%) patients. There was no correlation between the distance EGJ-hiatus and the herniated gastric volume. There was a statistically significant correlation between the distance from the EGJ to the hiatus and the area of the esophageal hiatus of the diaphragm. There was correlation between tomographic and endoscopic findings for the presence and size of HH. HH was diagnosed with manometry in 9 (50%) patients. There was no correlation between tomographic and manometric findings for the diagnosis of HH and between hiatal area and lower esophageal sphincter basal pressure. There was no correlation between any parameter and DeMeester score. CONCLUSIONS: The anatomy of HH and the hiatus can be well defined by 3D CT. The EGJ-hiatus distance may be equally measured by 3D CT or upper digestive endoscopy. DeMeester score did not correlate with any anatomical parameter.

Modern insights into the pathophysiology and treatment of pseudoachalasia.

BACKGROUND: Secondary achalasia or pseudoachalasia is a clinical presentation undistinguishable from achalasia in terms of symptoms, manometric, and radiographic findings, but associated with different and identifiable underlying causes. METHODS: A literature review was conducted on the PubMed database restricting results to the English language. Key terms used were "achalasia-like" with 63 results, "secondary achalasia" with 69 results, and "pseudoachalasia" with 141 results. References of the retrieved papers were also manually reviewed. RESULTS: Etiology, diagnosis, and treatment were reviewed. CONCLUSIONS: Pseudoachalasia is a rare disease. Most available evidence regarding this condition is based on case reports or small retrospective series. There are different causes but all culminating in outflow obstruction. Clinical presentation and image and functional tests overlap with primary achalasia or are inaccurate, thus the identification of secondary achalasia can be delayed. Inadequate diagnosis leads to futile therapies and could worsen prognosis, especially in neoplastic disease. Routine screening is not justifiable; good clinical judgment still remains the best tool. Therapy should be aimed at etiology. Even though Heller's myotomy brings the best results in non-malignant cases, good clinical judgment still remains the best tool as well.

Comparison of daytime and nighttime supine gastroesophageal reflux by pH monitoring of individuals with clinical suspicion of gastroesophageal reflux disease.

This study aims to compare pHmetric characteristics of diurnal and nocturnal supine reflux. We studied 500 consecutive individuals with clinical suspicion of gastroesophageal reflux disease (GERD) who underwent esophageal high-resolution manometry and prolonged ambulatory pH monitoring. Patients were classified with supine GERD pattern when the percentage of acid reflux time in the supine position was equal to or greater than 2.2%. Data on acid reflux in the supine position during daytime and nighttime recumbency were: (i) acid exposure time, (ii) number of reflux episodes, (iii) longest reflux episode, (iv) interval between the last meal and the supine position, (v) interval between the supine position and the first acid reflux episode, and (vi) reported symptoms. Of the 500 evaluated patients, 238 (48%) had GERD. Among these, supine pattern was observed in 134 (56%) patients, bipositional in 53 (23%), and orthostatic in 51 (21%). In patients with daytime recumbency, 112 (51% of 217) were pathological refluxers, with a mean DeMeester score of 45 ± 26. Total acid exposure time (P = 0.8) and reported Symptom Index (P = 0.2) did not differ depending on the period, whether diurnal or nocturnal. All other pHmetric parameters were lower during daytime recumbency. In conclusion, diurnal supine reflux has similar acid exposure time and temporal correlation between symptoms and reflux episodes as nocturnal supine reflux. Other pHmetric parameters are lower for diurnal supine reflux.

Esophageal high-resolution manometry demands visual interpretation in addition to mathematical software-based analysis.

PURPOSE: Esophageal high-resolution manometry (HRM) revolutionized esophageal function testing due to the intuitive colorful and agreeable-to-the-eyes plots (Clouse plots). HRM execution and interpretation is guided by the Chicago Classification. The well-established metrics for interpretation allows a reliable automatic software analysis. Analysis based on these mathematical parameters, however, ignores the valuable visual interpretation unique to human eyes and based on expertise. METHODS: We compiled some situations where visual interpretation added useful information for HRM interpretation. RESULTS: Visual interpretation may be useful in cases of hypomotility, premature waves, artifacts, segmental abnormalities of peristalsis, and extra-luminal non-contractile findings. CONCLUSION: These extra findings can be reported apart from the conventional parameters.

The Evolution of the Treatment of Esophageal Achalasia: From the Open to the Minimally Invasive Approach.

BACKGROUND: Achalasia is a primary esophageal motility disorder characterized by lack of esophageal peristalsis and partial or absent relaxation of the lower esophageal sphincter in response to swallowing. This study aimed to provide an overview of the evolution of the surgical treatment for esophageal achalasia, from the open to the minimally invasive approach. METHODS: Literature review. RESULTS: No curative treatment exists for this disorder. At the beginning of the 20th century, surgical esophagoplasties and cardioplasties were mostly done to treat achalasia. The description of the esophageal myotomy by Heller changed the treatment paradigm and rapidly became the treatment of choice. For many years the esophagomyotomy was done with either an open transthoracic or transabdominal approach. With the advancements of minimally invasive surgery, thoracoscopic and laparoscopic operations became available. The ability to add a fundoplication for the prevention of reflux made the laparoscopic Heller myotomy with partial fundoplication the operation of choice. CONCLUSIONS: Surgical management of esophageal achalasia has significantly evolved in the last century. Currently, minimally invasive Heller myotomy with partial fundoplication is the standard surgical treatment of achalasia.

Esophageal Achalasia: Evaluation and Treatment of Recurrent Symptoms.

BACKGROUND: Esophageal achalasia is a primary esophageal motility disorder of unknown origin. Treatment is palliative and its goal is to decrease the resistance posed by a non-relaxing and often hypertensive lower esophageal sphincter. This goal can be accomplished by different treatment modalities such as pneumatic dilatation, laparoscopic myotomy or peroral endoscopic myotomy. In some patients, however, symptoms tend to recur overtime. METHODS: A comprehensive literature search was performed on PubMed focused on the management of recurrent achalasia. RESULTS: The available treatment modalities can be used, alone or in combination. The goal of treatment is to resolve/improve symptoms, avoiding an esophagectomy, an operation linked to significant morbidity. CONCLUSIONS: The treatment of these patients is often very challenging, and the best results are obtained in centers where a multidisciplinary team-radiologists, gastroenterologists, and surgeons-is present.

Treatment of Achalasia and Epiphrenic Diverticulum.

BACKGROUND: Epiphrenic diverticulum (ED) is a pulsion pseudodiverticulum found in the distal 10 cm of the esophagus. Motility disorders are present in the majority of patients with ED explaining the pathophysiology of this rare disease. Achalasia is the most common underlying disorder. We present a review on the diagnosis and management of ED in the setting of achalasia. METHODS: Literature review. RESULTS: Symptoms are most related to the underlying motility disorder. The diagnostic workup should always include an upper digestive endoscopy and a barium esophagogram. Esophageal manometry identifies the motility disorder in most patients. Therapeutic options include laparoscopic, thoracoscopic and endoscopic procedures. While a myotomy must always be performed, diverticulectomy is not always necessary. CONCLUSIONS: Epiphrenic diverticulum is a rare condition whose pathophysiology involves an underlying motility disorder-achalasia in most cases. Symptoms usually include dysphagia, regurgitation, heartburn, and respiratory complaints and correlate with the motility disorder rather than the diverticulum per se. Upper digestive endoscopy and barium esophagogram are needed for the diagnosis-manometry may add useful information but is not imperative for the treatment. Laparoscopic Heller myotomy with a partial fundoplication is the procedure of choice, with satisfactory symptom relief and several advantages over the thoracic approach. Diverticulectomy may be performed in selected patients. Peroral endoscopic myotomy (POEM) are novel techniques, effective and minimally invasive that can be an option for patients unfit for surgery.

The prevalence of gastroesophageal reflux disease in named manometric patterns of dysmotility according to the Chicago Classification 4.0.

Esophageal motility disorders (EMD) may be considered primary disorders only in the absence of gastroesophageal reflux disease (GERD). If GERD is present, treatment should be directed toward correction of the abnormal reflux. The actual prevalence of GERD in manometric dysmotility patterns according to the new Chicago Classification 4.0 (CC4) is still elusive. This study aims to evaluate the prevalence of GERD in patients with esophageal motility disorders according to the CC4. We reviewed 400 consecutive patients that underwent esophageal manometry and pH monitoring. Esophageal motility was classified according to the CC4 and GERD + was defined by a DeMeester score > 14.7. Normal motility or unclassified dysmotility was present in 290 (73%) patients, with GERD+ in 184 of them (63%). There were a total of 110 patients (27%) with named esophageal motility disorders, with GERD+ in 67 (61%). The incidence of ineffective esophageal motility was 59% (n = 65) with 69% GERD +, diffuse esophageal spasm was 40% (n = 44) with 48% GERD +, and hypercontractile esophagus was 0.01% (n = 1) with 100% GERD +. There was no correlation between the presence of GERD and the number of non-peristaltic swallows. Our results show that: (i) manometry only is not enough to select patients' treatment as >60% of patients with named esophageal motility disorders have GERD; (ii) there was no correlation between the presence of GERD and the number of non-peristaltic swallows.

Outcomes of Laparoscopic Redo Fundoplication in Patients With Failed Antireflux Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: The aim of this meta-analysis was to summarize the current available evidence regarding the surgical outcomes of laparoscopic redo fundoplication (LRF). SUMMARY OF BACKGROUND DATA: Although antireflux surgery is highly effective, a minority of patients will require a LRF due to recurrent symptoms, mechanical failure, or intolerable side-effects of the primary repair. METHODS: A systematic electronic search on LRF was conducted in the Medline database and Cochrane Central Register of Controlled Trials. Conversion and postoperative morbidity were used as primary endpoints to determine feasibility and safety. Symptom improvement, QoL improvement, and recurrence rates were used as secondary endpoints to assess efficacy. Heterogeneity across studies was tested with the Chi-square and the proportion of total variation attributable to heterogeneity was estimated by the inconsistency (I2) statistic. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies. RESULTS: A total of 30 studies and 2,095 LRF were included. The mean age at reoperation was 53.3 years. The weighted pooled proportion of conversion was 6.02% (95% CI, 4.16%-8.91%) and the meta-analytic prevalence of major morbidity was 4.98% (95% CI, 3.31%-6.95%). The mean follow-up period was 25 (6-58) months. The weighted pooled proportion of symptom and QoL improvement was 78.50% (95% CI, 74.71%-82.03%) and 80.65% (95% CI, 75.80%-85.08%), respectively. The meta-analytic prevalence estimate of recurrence across the studies was 10.71% (95% CI, 7.74%-14.10%). CONCLUSIONS: LRF is a feasible and safe procedure that provides symptom relief and improved QoL to the vast majority of patients. Although heterogeneously assessed, recurrence rates seem to be low. LRF should be considered a valuable treatment modality for patients with failed antireflux surgery.

The upper esophageal sphincter in the high-resolution manometry era.

BACKGROUND: The evaluation of the upper esophageal sphincter (UES) has been neglected during routine manometric tests for decades, mostly due to the limitations of the conventional manometry which were eventually overcome by high-resolution manometry (HRM). METHODS: This study reviewed the current knowledge of the manometric evaluation of the UES in health and disease in the HRM era. RESULTS: We found that HRM allowed more precise measurements, in addition to the parameters as compared to conventional manometry, but most of them still need confirmation of the clinical significance. The parameters used to evaluate the UES were extension, basal pressure, residual pressure, relaxation duration, relaxation time to nadir, recovery time, intrabolus pressure, and deglutitive sphincter resistance. UES may be affected by different diseases: achalasia (UES is hypertonic with impaired relaxation), gastroesophageal reflux disease (UES is short and hypotonic), globus (UES ranges from normal to impaired relaxation to hypertonic), neurologic diseases (stroke and Parkinson - UES is hypotonic in early-stage to impaired relaxation in end-stage disease), and Zenker's diverticulum (UES has impaired relaxation). CONCLUSION: This review shows that UES dysfunction is part of several disease processes and that the study of the UES is possible and valuable with the aid of HRM.

Upper Esophageal Sphincter Motility and Thoracic Pressure are Determinants of Pressurized Waves in Achalasia Subtypes According to the Chicago Classification.

BACKGROUND: Phenotypes of achalasia are based on esophageal body pressurization during swallow. The reasons that lead to pressurized waves are still unclear. This study aims to evaluate manometric parameters that may determine pressurized waves in patients with achalasia. METHODS: A total of 100 achalasia high-resolution manometry tests were reviewed. We measured before each swallow: upper esophageal sphincter (UES) basal pressure, esophageal length, lower esophageal sphincter (LES) basal pressure, LES length, gastric and thoracic pressure, transdiaphragmatic pressure gradient and the LES retention pressure (LES basal pressure-TPG); during swallow: UES pressure, UES residual pressure, UES recovery time, LES relaxation pressure, gastric and thoracic pressure, transdiaphragmatic pressure gradient and after swallow: esophageal length, LES length, wave pressure, gastric and thoracic pressure and transdiaphragmatic gradient pressure. RESULTS: Univariate analysis showed in pressurized waves before swallow: higher thoracic, UES and LES basal pressure, longer LES length and decrease in LES retention pressure; during swallow: higher thoracic, gastric and UES pressure, higher UES and LES relaxation pressure and after swallow: higher thoracic and gastric pressure. Multivariate analysis in pressurized waves showed as significant before swallow: thoracic and UES basal pressure; during swallow: thoracic, gastric and UES pressure, UES residual pressure and UES recovery time and after swallow: thoracic pressure. CONCLUSIONS: Basal esophageal pressurization and the UES are independent variables that may be associated with pressurized waves.

University Hospital Financial Status Does Not Influence Subjective Perception of General Surgery Residents on Training Adequacy.

BACKGROUND: Surgical residency training is a complex and costly task. Hospital economic health is dependent on different variables, but it is especially linked to the country macroeconomics that may be extremely fluctuating, especially in underdeveloped countries. This study analyzed the correlation between a single-center university hospital financial status and subjective perception of general surgery residents on program support and adequacy. METHODS: We surveyed former residents that started general surgery residency program in a tertiary university hospital between 1999 and 2017. Individuals answered a questionnaire about the perception of the influence of the hospital´s financial status on training. Hospital´s financial status was estimated yearly by the current liquidity ratio (CLR) that measures whether or not a company has enough resources to meet its short-term obligations. RESULTS: Two hundred and fifty-seven (96%) were still in surgical practice; 242 (93%) were satisfied with their residency training; 210 (78%) believed training was affected by financial status; 183 (68%) believed they were prepared for independent practice; 180 (67%) practiced in an academic environment; 146 (54%) felt the need to complete specialty training beyond residency; and 56 (21%) believed hospital financial status was adequate. The rate of positive or negative answers did not correlate with the current liquidity ratio, except for the need to complete specialty training that was indirectly related to CLR. CONCLUSIONS: University hospital financial status did not influence subjective perception of general surgery residents on training, program support and adequacy.

Disparities in esophageal cancer: less treatment, less surgical resection, and poorer survival in disadvantaged patients.

The incidence of esophageal cancer has increased steadily in the last decades in the United States. The aim of this paper was to characterize disparities in esophageal cancer treatment in different racial and socioeconomic population groups and compare long-term survival among different treatment modalities. A retrospective analysis of the National Cancer Database was performed including adult patients (≥18 years old) with a diagnosis of resectable (stages I-III) esophageal cancer between 2004 and 2015. Multivariable logistic regression models were used to determine the odds of being offered no treatment at all and surgical treatment across race, primary insurance, travel distance, income, and education levels. Multivariable Cox proportional hazards models were used to compare 5-year survival rates across different treatment modalities. A total of 60,621 esophageal cancer patients were included. Black patients, uninsured patients, and patients living in areas with lower levels of education were more likely to be offered no treatment. Similarly, black race, female patients, nonprivately insured patients, and those living in areas with lower median residential income and lower education levels were associated with lower rates of surgery. Patients receiving surgical treatment, compared to both no treatment and definitive chemoradiation, had significant better long-term survival in stage I, II, and III esophageal cancer. In conclusion, underserved patients with esophageal cancer appear to have limited access to surgical care, and are, in fact, more likely to not be offered any treatment at all. Considering the survival benefits associated with surgical resection, greater public health efforts to reduce disparities in esophageal cancer are needed.

Minor psychiatric disorders and objective diagnosis of gastroesophageal reflux disease.

BACKGROUND: Symptoms may be unreliable to diagnose gastroesophageal reflux disease (GERD) in patients with minor psychiatric disorders (MPD). This study aims to evaluate the influence of MPD in the diagnosis of GERD. METHODS: We prospectively studied 245 patients (based on a sample size calculation) with suspected GERD. All patients underwent manometry and pH monitoring and MPD evaluation based on the Hospital Anxiety and Depression Scale (HADS). RESULTS: Based on the results of the pH monitoring, patients were classified as GERD + (n = 136, 55% of the total, mean age 46 years, 47% females) or GERD - (n = 109, 45% of the total, mean age 43 years, 60% females). The mean HADS score for GERD + and GERD - for anxiety was 7.8 and 8.5, respectively (p = 0.8) and for depression was 5.4 and 6.1, respectively (p = 0.1). DeMeester score (DS) did not correlate with total HADS score (p = 0.08) or depression domain (p = 0.9) but there was a negative correlation between DS and anxiety level (p < 0.001). A significant threshold accuracy value for HADS to diagnose GERD was not found on receiver operating characteristics curve analysis. CONCLUSION: Almost half of the patients evaluated for GERD did not have the disease on objective evaluation. GERD + and GERD - patients had similar levels of MPD. However, the amount of reflux correlated negatively with the severity of anxiety. Symptoms and HADS cannot accurately diagnose or exclude GERD. pH monitoring should be more liberally used especially in patients with high levels of anxiety.

Cognitive Assessment of Surgeons During Surgical Procedures: Influence of Time and Intraoperative Complications.

INTRODUCTION: Surgeon's performance may be influenced by several factors that may affect skills and judgement, which ultimately represents surgeon´s cognition. Cognition refers to all forms of knowing and awareness, such as perceiving, conceiving, remembering, reasoning, judging, imagining, and problem solving. This report aims to evaluate the effect of operative time and operative complications on surgeon´s cognition. METHODS: Forty-six surgeons (mean age 31 years, 78% males) assigned to an operation expected to last for at least 2 h, volunteered for the study. All participants underwent 3 cognitive tests at the beginning of the operation and hourly, until the end of the procedure: (a) concentration (serial sevens, counting down from 100 by sevens); (b) visual (fast counting, counting the number of circles with the same color among a series of circles); and (c) motor (trail making, connecting a set of numbered dots). Intraoperative complications were recorded. RESULTS: The visual test had a stable behavior along time. Concentration and motor tests tend to be performed faster. Intraoperative complications occurred in 5 (11%) cases (3 hemorrhage and 2 organ injuries). Performance time was stable for concentration and motor tests but visual test tends to be performed faster in cases with an intraoperative complication. CONCLUSION: Our results showed that (1) time does not jeopardize surgeons' cognition, but rather surgeons learned to perform the tests faster, and (2) complications do not decrease surgeons' cognition.

Anatomical analysis of gastric lymph nodes in cancer-free individuals.

Lymphadenectomy is a crucial part of the surgical therapy for gastric cancer. The number of normal lymph nodes could indicate the number of nodes that need to be retrieved during the procedure. The aim of this study is to analyze the number of lymph nodes in cadavers without gastric cancer according to the Japanese Gastric Cancer Association guidelines. Twenty fresh adult cadavers (14 males, mean age 55, range 24-93 years) were used. Abdominal lymph nodes were dissected and classified according to the Japanese Gastric Cancer Association. For total gastrectomy, the median number of lymph nodes that comprised D1 + dissection was 27 (range 15-42). The median and mean number of lymph nodes that comprised D2 dissection was 33, ranging from 18 to 50. For distal gastrectomy, the D1 + level comprised a median of 21 lymph nodes (range 11-38), and the D2 level 22 lymph nodes (range 11-39). In conclusion, considering gastrectomy + D2 lymphadenectomy as the standard treatment for gastric cancer, our results show that adequate lymphadenectomy must encompass around 30 lymph nodes. Clin. Anat., 2018. © 2018 Wiley Periodicals, Inc.

Postoperative outcomes of esophagectomy for cancer in elderly patients.

BACKGROUND: The number of elderly patients with esophageal cancer is expected to increase. We aimed to determine the postoperative outcomes of esophagectomy for esophageal cancer in elderly patients. MATERIAL AND METHODS: A retrospective, population-based analysis was performed using the National inpatient sample for the period 2000-2014. Adult patients ≥18 years old (yo) diagnosed with esophageal cancer who underwent esophagectomy during their inpatient hospitalization were included. Patients were categorized into <70 yo and ≥70 yo. Multivariable linear and logistic regressions were used to assess the potential effect of age on postoperative complications, inpatient mortality, and hospital charges. RESULTS: Overall, 5243 patients were included, with 3699 (70.6%) <70 yo and 1544 (29.5%) ≥70 yo. The yearly rate of esophagectomies among patients ≥70 yo did not significantly changed during the study period (28.4% in 2000 and 26.3% in 2014, P = 0.76). Elderly patients were significantly more likely to have postoperative cardiac failure (odds ratio 1.59, 95% confidence interval [CI] 1.21, 2.09, P = 0.0009) and inpatient mortality (odds ratio 1.84, 95% CI 1.39, 2.45, P < 0.0001). Among the elderly patients, hospital charges were, on average, $16,320 greater (95% CI $3110, $29,530) than patients <70 yo (P = 0.02). The predicted probability of mortality increased consistently across age (1.5% in 40 yo, 2.5% in 50 yo, 3.6% in 60 yo, 5.4% in 70 yo, and 7.0% in 80 yo). CONCLUSIONS: Elderly patients undergoing esophagectomy for cancer have a significantly higher risk of postoperative mortality and pose a higher financial burden on the health care system. Elderly patients with esophageal cancer should be carefully selected for surgery.

Antireflux Surgery and Barrett's Esophagus: Myth or Reality?

BACKGROUND: It may seem questionable if antireflux surgery still has a role in the management of patients with Barrett's esophagus (BE) in the current era when antireflux surgery is facing a steady decline, obesity is increasing, pharmacologic treatment for gastroesophageal reflux disease (GERD) is in its splendor, and endoscopic techniques are used more frequently. It is questionable if patients with BE should be operated to stop GERD and to prevent cancer. The aim of this study was to determine the role of antireflux surgery in patients with BE. METHODS: Literature review. RESULTS: The role of antireflux operations is, in fact, very controversial and neglected. BE is a different phenotype of GERD with a distinct pathophysiology linked to severe reflux of bile and acid, due to a marked anatomic disruption of the gastroesophageal barrier. Published series show that a fundoplication adequately controls GERD and symptoms in BE patients. A fundoplication (or even better a bile diversion antireflux procedure) may prevent esophageal adenocarcinoma. CONCLUSIONS: In conclusion, a fundoplication efficiently controls GERD and symptoms in BE patients. A fundoplication (or even better a bile diversion procedure) may also prevent esophageal adenocarcinoma.

Objective Evaluation of Gastroesophageal Reflux Disease in Patients with Paroxysmal Atrial Fibrillation.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia. Some evidence shows that gastroesophageal reflux disease (GERD) may be a trigger for paroxysmal AF (PAF). Most of the previous studies that correlated GERD and AF used questionnaires to diagnose GERD, not an objective evaluation. This study aims to evaluate in patients with PAF: (a) accuracy of symptoms to diagnose GERD; (b) prevalence of GERD; and (c) temporal correlation between cardiac arrhythmia and reflux. METHODS: Twenty-two patients (59% females, mean age 68 years) with PAF underwent esophageal manometry followed by ambulatory pH monitoring and concurrent Holter. Eight (36%) patients had GERD symptoms. Patients were grouped as GERD+ or GERD- based on the DeMeester score. Temporal correlation between arrhythmia and reflux was recorded. RESULTS: Six (27%) patients were GERD+. Symptoms had sensitivity and specificity of 50 and 70%, respectively, for the diagnosis of GERD. Episodic AF occurred in one patient only (GERD-). There were 23 episodes of AF during the test with 14% correlation with reflux. Persistent AF during the period of the test was found in five patients (60% GERD+). CONCLUSIONS: Our results show: (a) Symptoms have a low accuracy for the diagnosis of GERD; (b) the prevalence of GERD in patients with PAF is low; and