Functional dyspepsia: How to manage the burn and the bloat.

Functional dyspepsia is defined as persistent symptoms of postprandial bloating, early satiety, or pain in the center of the upper abdomen, without findings on upper endoscopy such as peptic ulcer disease to explain these symptoms. It is common, affecting up to 30% of the global population, but it often goes undiagnosed for years. There are 2 subtypes: epigastric pain syndrome (burning and pain) and postprandial distress syndrome (bloating and satiety). The authors discuss how to diagnose and treat both subtypes.

Esophageal Function Testing Patterns in the Evaluation and Management of Lung Transplantation: Results of a National Survey.

GOALS: We surveyed esophageal motility laboratories affiliated with adult pulmonary transplant centers to determine esophageal function testing (EFT) practices. BACKGROUND: Gastroesophageal reflux and esophageal dysmotility are associated with worse lung transplant outcomes, yet no consensus guidelines for EFT exist in this population. STUDY: A deidentified online survey was sent to gastrointestinal motility laboratory directors of 49 academic and community-affiliated medical centers that perform lung transplants. Practice characteristics, including annual lung transplant volume and institutional EFT practices pre-lung transplantation and post-lung transplantation were queried. Respondents were categorized by transplant volume into small and large programs based on median annual volume. RESULTS: Among 35 respondents (71% response rate), the median annual transplant volume was 37, and there were 18 large programs. Institutional EFT protocols were used pretransplant by 24 programs (68.6%) and post-transplant by 12 programs (34.2%). Among small and large programs, 52.9% and 72.2% always obtained high-resolution manometry before transplant, respectively. Endoscopy before transplant was performed more often in small programs (n=17, 100%) compared with large programs (n=15,83.3%). Pretransplant endoscopy ( P =0.04), barium esophagram ( P <0.01), and high-resolution manometry ( P =0.04) were more common than post-transplant. In contrast, post-transplant reflux monitoring off-therapy was more common than pretransplant ( P =0.01). In general, pulmonologists direct referrals for EFT and gastroenterology consultation (n=28, 80.0%), with symptoms primarily prompting testing. CONCLUSIONS: In the absence of established guidelines, substantial variability exists in pretransplant and post-transplant EFT, directed by pulmonologists. Standardized EFT protocols and gastroenterologist-directed management of esophageal dysfunction has potential to improve lung transplant outcomes.

Nutrient Drink Test to Assess Gastric Accommodation in Cyclic Vomiting Syndrome: Single-blinded Parallel Grouped Prospective Study.

Background/Aims: Cyclic vomiting syndrome (CVS) is characterized by episodes of nausea and vomiting, separated by symptom-free intervals. The pathogenesis of CVS is poorly understood. Limited data exist on evaluating impaired gastric accommodation as a mechanistic means for symptoms. We aim to determine if CVS patients demonstrate impaired gastric accommodation applying a nutrient drink test (NDT) protocol. Methods: Through this single-blinded pilot clinical trial, patients with CVS per Rome IV critera and healthy controls were assessed for presence of impaired gastric accommodation by administering an established NDT protocol. Statistical analysis was performed, with data presented as medians and interquartile range. Results: Eleven CVS patients and 15 healthy controls participated in the study between January 2018 and October 2018. Median age was 42.0 years and 37.0 years; majority of subjects were female, 72.7% and 73.3%, respectively. Demographics were similar between CVS and healthy controls. Almost all healthy controls (93.3%) ingested the complete 500 mL protocol, whereas a smaller proportion (72.7%) were able to complete all 4 doses in the CVS group (P = 0.188). Post-prandial visual analogue scale scores of nausea and abdominal pain were found to be significantly higher in CVS patients compared to healthy controls. Conclusions: To our knowledge, this is the first NDT protocol in CVS evaluating the role of impaired gastric accommodation and hypersensitivity as a possible pathophysiologic mechanism. Findings from this study suggest the presence of gastric hypersensitivity in a subset of CVS patients. These results provide the foundational data necessary for future larger testing of NDT and diagnostic accuracy in CVS.

Endoscopic pyloromyotomy is feasible and effective in improving post-lung transplant gastroparesis.

OBJECTIVES: Gastroparesis is a debilitating and difficult to manage problem that has been reported in 20% to 90% of lung and heart-lung transplant recipients. The primary objective was to evaluate the safety and clinical effectiveness of per-oral endoscopic pyloromyotomy in relieving gastroparesis after lung transplant. Secondary objectives evaluated the effect of per-oral endoscopic pyloromyotomy on gastroesophageal reflux and allograft function. METHODS: Fifty-two lung transplant recipients underwent per-oral endoscopic pyloromyotomy for refractory gastroparesis. Gastroparesis was assessed by a pre-per-oral endoscopic pyloromyotomy and post-per-oral endoscopic pyloromyotomy radionuclide gastric emptying test and Gastroparesis Cardinal Symptom Index. Secondary outcomes included 90-day complications, gastroesophageal reflux as measured by pH testing, and longitudinal spirometry measurements. RESULTS: Median time from lung transplant to per-oral endoscopic pyloromyotomy was 10.5 months. Twenty-eight patients had prior pyloric botulinum injection with either no improvement or relapse of symptoms. Post-per-oral endoscopic pyloromyotomy gastric emptying tests were available for 32 patients and showed a decrease in median gastric retention at 4 hours from 63.5% pre-per-oral endoscopic pyloromyotomy to 5.5% post-per-oral endoscopic pyloromyotomy (P < .0001). Complete normalization of gastric emptying time was noted in 19 patients. Gastroparesis Cardinal Symptom Index score significantly improved after per-oral endoscopic pyloromyotomy (median, 23-3.5; P < .0001). Post-per-oral endoscopic pyloromyotomy pH testing showed improved or stable DeMeester score in all patients except 1. Graft function (forced expiratory volume in 1 second) remained stable 1 year after per-oral endoscopic pyloromyotomy. CONCLUSIONS: The improvements in symptom score and radionuclide imaging observed in this uncontrolled study suggest that per-oral endoscopic pyloromyotomy is an effective strategy in the lung transplant population and can be performed with minimal morbidity.

Chronic Intestinal Pseudo-Obstruction Is Associated with Intestinal Methanogen Overgrowth.

BACKGROUND: Chronic intestinal pseudo-obstruction (CIP) is a rare motility disorder characterized by dilated small bowel in the absence of mechanical obstruction. CIP has a known association with small intestinal bacterial overgrowth (SIBO); however, data regarding association with specific subtypes such as methane-positive (M+) and hydrogen-positive (H+) SIBO are limited. Therefore, we conducted this study to characterize subtypes of SIBO in CIP and compare them with non-CIP patients. AIMS: The aim is to explore the association and prevalence of hydrogen and methane subtypes of SIBO in patients with CIP. METHODS: A retrospective chart review was conducted for 494 patients who underwent glucose breath tests (GBT) in 2019. CIP was diagnosed based on clinical suspicion and after ruling out mechanical obstruction. We also reviewed demographic data, including age, gender, body mass index, tobacco and alcohol history, medical comorbidities, use of proton pump inhibitors, and history of colectomy. RESULTS: Among 494 patients, 7.7% (38) had CIP. The prevalence of M+ GBT in CIP patients was higher compared with non-CIP patients, and it was significant [52.6% (20/38) versus 11.8% (54/456), p < 0.001]. The prevalence of H+ GBT in our cohort of CIP patients was similar to that of non-CIP patients [23.7% (9/38) versus 25.7% (117/456), p = 0.941]. CONCLUSION: The prevalence of methane-positive GBT was higher in CIP patients than in patients without CIP. This finding further strengthens the hypothesis that the relationship between motility disorders and methanogen overgrowth is facilitative.

Minimally Invasive "3-Stitch" Modification of the Dor Fundoplication: Simple and Effective.

BACKGROUND: A 180-degree anterior (Dor) fundoplication is usually paired with an esophagogastric myotomy in the surgical treatment of achalasia. The traditional technique, however, is not easily reversible and the execution is variable. This study examined a simplified ''3-stitch'' Dor fundoplication that addressed these challenges and presented the results. METHODS: A prospectively collected, longitudinal surgical achalasia database was queried for patients undergoing a Heller myotomy with '3-stitch 180-degree fundoplication from 2008 to 2019. Preoperative and postoperative Eckardt score, postoperative DeMeester score (24- or 48-hour pH studies), and endoscopic evidence of esophagitis were collected and analyzed to determine the effectiveness and safety of the fundoplication. Length of stay and complications were also considered. RESULTS: The pH testing was performed in 296 patients, with 17% (50 of 296) demonstrating abnormal esophageal acid exposure. Of this group, only 8% (16 of 201) manifested clinical esophagitis on upper endoscopy. A total of 14% (7 of 50) of patients with abnormal esophageal acid exposure were symptomatic. Total postoperative Eckhardt scores for this cohort were 3 or lower in 92% of patients, with a dysphagia-specific score of 0 in 92%. The technical details of a modified 180-degree anterior fundoplication are described. CONCLUSIONS: The 3-stitch Dor fundoplication is an effective addition to a minimally invasive Heller myotomy, with good palliation of symptoms and an acceptable rate of acid reflux. The simplified construction anticipates the potential progression of esophageal dysmotility in patients with achalasia, and the modified technique is reproducible and readily teachable.

Peroral endoscopic myotomy provides effective palliation in type III achalasia.

BACKGROUND: Type III achalasia outcomes have historically been met with limited success after conventional laparoscopic Heller myotomy (LHM) and pneumatic dilation. Peroral endoscopic myotomy (POEM) has emerged as a promising alterative for a multitude of reasons. Our objective was to investigate POEM outcomes in palliating type III achalasia. METHODS: A retrospective analysis of a prospectively maintained database was conducted in a tertiary care institution between April 2014 and July 2019. The primary outcome was postoperative Eckardt score. We also explored the effect of lower esophageal sphincter (LES) integrated resting pressure (IRP) on manometry, barium column height and width, and complications. Standard statistical methods were applied using R. RESULTS: A total of 518 patients in the achalasia database were identified, with 308 patients undergoing LHM and 210 undergoing POEM during the study period. POEM was used for type III achalasia in 36 patients (median age, 60 years; 61.7% male), with a median operative time of 85 minutes (interquartile range [IQR], 71-115 minutes) and follow-up of 1 year (IQR, 0.16-2.25 years). Within the POEM group, 11 patients (33%) had previous interventions, including Botox injections to the LES (n = 7), pneumatic dilation (n = 1), and LHM (n = 3). A significant decrease in median Eckardt score was observed (7 preoperatively [IQR, 6-8.75] vs 0 postoperatively [IQR, 0-1]; P < .01). Similar improvements after POEM were noted in median LES IRPs (25.5 mmHg vs 4.5 mmgHg; P < .01), 1-minute barium column height (10 cm vs 0 cm; P < .01), and 1-minute barium column width (2 cm vs 0 cm; P < .01). Patients reported a return to activities of daily living in a median of 7 days (IQR, 3-7 days). Three patients experienced complications, including mucosal perforation resolving with conservative management (n = 1), readmission for bleeding duodenal ulcer responding to proton pump inhibitors (n = 1), and readmission for dysphagia and rehydration (n = 1). Postoperative esophageal pH studies were conducted in 21 patients (62%), demonstrating a Demeester score of >14.72 in 13 patients (62%). CONCLUSIONS: POEM provides effective and durable palliation for type III achalasia, as demonstrated by symptom relief, esophageal manometry, and radiographic measurement. Considering its low morbidity profile, POEM should be considered as first-line therapy in this challenging disease subtype.

Role of Neuromodulators for the Management of Post-Gastric-Fundoplication Dyspepsia: A Retrospective Series.

Post-fundoplication dyspepsia is a common complication of gastric fundoplication surgeries. This can be attributable to the loss of fundal relaxation, decreased gastric accommodation, and/or alterations in gastric motility and sensitivity following fundoplication. The role of neuromodulators in the management of such symptoms is unknown. We retrospectively assessed the efficacy of neuromodulators such as tricyclic antidepressants, buspirone, and mirtazapine for the management of post-fundoplication dyspepsia.

Peroral endoscopic myotomy is equally safe and highly effective treatment option in achalasia patients with both lower and higher ASA classification status.

INTRODUCTION: The American Society of Anesthesiologists (ASA) physical status classification system was developed as a simple categorization of patients' physiological status that predicts the operative risk. Peroral endoscopic myotomy (POEM) is a less invasive alternative to surgical myotomy in achalasia. As such, POEM seems to be an appealing option for high-risk patients with achalasia. However, there are no studies which systematically analyzed the outcomes of POEM among patients with different ASA classes. Hence, we aimed to compare the safety and efficacy of POEM in patients with lower and higher ASA classes. METHODS: Medical records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients were categorized arbitrarily into two groups, lower ASA class (ASA I and II combined) and higher ASA class (ASA class III and IV combined). Demographic and procedural details, timed barium swallow (TBE), high-resolution esophageal manometry (HREM), pH study findings and Eckardt scores were compared between the two groups. Baseline characteristics were compared using Chi-square test and two-sample t-test for categorical and continuous variables, respectively. RESULTS: A total of 144 patients met our study criteria (lower ASA class, n = 44; and higher ASA class, n = 100). Patients in higher ASA class were significantly more obese and older. More patients in lower ASA class had prior Heller myotomy and more patients in higher ASA Class had prior botulinum toxin injections. Procedural parameters were similar in both groups. Procedural complications were infrequent and were also similar in the two groups. The length of stay, 30-day readmission rate, reflux symptoms and esophageal pH study findings were also comparable between the two groups. Treatment success was similar in both groups, 97.7% in lower ASA class versus 92% in higher ASA class (p = 0.19). At 2-month follow-up, both groups had significant improvement in HREM and TBE parameters. CONCLUSION: POEM is a very safe and highly effective treatment option for achalasia patients with advanced ASA class similar to lower ASA class patients. POEM may be considered as the preferred choice for myotomy in these high-risk achalasia patients due to its low morbidity and high efficacy.

Peroral endoscopic myotomy is highly effective for achalasia patients with recurrent symptoms after pneumatic dilatation.

BACKGROUND: Previous interventions in achalasia such as pneumatic dilation (PD) might lead to difficulties with peroral endoscopic myotomy (POEM) along with sub-optimal outcomes. There are limited data in the literature on outcomes of POEM after PD, especially from the western hemisphere. Hence, we aimed to determine the safety and efficacy of POEM for recurrent symptoms after PD compared to treatment naïve achalasia patients. METHODS: Medical records of achalasia patients who underwent POEM at our institution between April 2014 and October 2019 were reviewed. Patients who had POEM for recurrent symptoms after prior PD were matched at 1:2 ratio with treatment naïve achalasia patients using propensity score matching. Patients who had prior Heller myotomy were excluded. Patient demographics, Eckardt scores, timed barium swallow (TBE), high-resolution esophageal manometry (HREM), and pH study findings were compared between the two groups, pre- and 2 months post-POEM. Treatment success was defined as reduction of Eckardt score to ≤ 3. RESULTS: A total of 39 patients (prior PD = 13; treatment naïve = 26) were included. Patient demographics, procedural, and peri-procedural outcomes were similar in both groups. Treatment success was similar in both groups, 100.0% in prior PD vs 91.7% in treatment naïve group (p = 0.53). On adjusted analysis, there was no significant difference in the pre-post-POEM improvement in Eckardt scores, TBE, and HREM parameters in the two groups. Gastroesophageal reflux disease rates were also similar in both groups. CONCLUSIONS: In achalasia with recurrent symptoms after PD, POEM is a safe and highly effective treatment modality. Prior PD does not seem to influence the outcomes or efficacy of POEM.

Peroral Endoscopic Myotomy Is Safe and Highly Effective Treatment for Advanced Achalasia With Sigmoid Esophagus.

BACKGROUND AND AIMS: In advanced achalasia patients with sigmoid esophagus, peroral endoscopic myotomy (POEM) might be technically challenging and its outcomes are not well known in western population. Hence, our study aims were to assess and compare the safety and efficacy of POEM in achalasia patients with and without sigmoid esophagus. MATERIALS AND METHODS: Medical records of achalasia patients who had POEM at our institution between April 2014 and December 2019 were reviewed. Patients who underwent work-up comprising timed barium esophagram (TBE) and high-resolution esophageal manometry (HREM) before POEM along with 2-month post-POEM esophageal pH study, TBE and HREM were included in the final analysis. Patients were categorized as either sigmoid or no sigmoid esophagus based on the morphology of esophagus on TBE as per Japan Esophageal Society guidelines. Treatment success was defined as reduction of post-POEM Eckardt score to ≤3. RESULTS: A total of 168 patients (sigmoid esophagus=20; no sigmoid esophagus=148) were included. Esophageal width on TBE at 1 minute was significantly higher in sigmoid esophagus group compared with no sigmoid esophagus group (4.9 vs. 3.0 cm, P<0.001). Procedural outcomes and complications were similar in both groups. At 2-month follow-up, both groups had significant improvement in Eckardt scores, TBE, and HREM parameters. Treatment success was high and similar in both sigmoid and no sigmoid groups (94.4% vs. 93.2%, P=0.84). The rates of gastroesophageal reflux disease were also similar in both groups. CONCLUSIONS: Our study findings suggest that POEM is safe and highly effective treatment for achalasia patients with sigmoid esophagus similar to those without sigmoid esophagus in western population. POEM should be considered as the treatment of choice in advanced achalasia with sigmoid esophagus.

Changes in esophageal physiology after paraesophageal hernia repair and Collis gastroplasty.

BACKGROUND: The surgical approach and technique for paraesophageal hernia (PEH) repair is much debated. The changes in the esophageal physiology after PEH repair with a concomitant Collis gastroplasty (PEH-CG) are not clearly known. The aim of this study was to determine the changes in high resolution esophageal manometry (HREM) and esophageal pH testing after PEH-CG. METHODS: Retrospective analysis of all patients who underwent PEH-CG at our institution between 2006 and 2013 was performed. Patients had esophageal pH testing, HREM, barium swallow and an upper endoscopy before and after PEH-CG. RESULTS: A total of 182 patients underwent PEH-CG during the study period. Majority of patients had Nissen fundoplication (176, 96.7%) with Toupet in 6 (3.3%). Basal lower esophageal sphincter pressure (LESP) was lower after fundoplication (20.3 mmHg ± 11.3 vs. 25.8 mmHg ± 15.6, p < 0.001), whereas residual LESP was noted to be higher after fundoplication (7.7 mmHg ± 4.9 vs. 6.1 mmHg ± 6.7, p < 0.009). There were no significant changes in the esophageal motility patterns. There was an improvement in total pH and upright pH but not supine pH post PEH-CG. Normalization of total acid exposure after fundoplication was noted in 31 (59.6%) of the 52 patients who had abnormal total acid exposure prior to fundoplication. CONCLUSIONS: Objective clinical assessment in patients undergoing PEH-CG demonstrates an effective operation for this complex problem. There was an increase in residual LESP but interestingly, decrease in basal LESP. Additionally, there was an improvement in esophageal acid exposure afterwards. These findings will facilitate future management of PEH.

Assessment of Gastric Emptying Times Between Pediatrics and Adults With Cyclic Vomiting Syndrome.

BACKGROUND & AIMS: Cyclic vomiting syndrome (CVS) is characterized by episodes of nausea and vomiting separated by symptom-free intervals. Rome IV guidelines have now distinguished CVS from other disorders such as cannabinoid hyperemesis. The pathogenesis of CVS, however, is poorly understood. Limited data exist on gastric emptying (GE) in patients with CVS. Therefore, the authors aim to measure the GE profile in pediatrics and adults with CVS. MATERIALS AND METHODS: Patients with the diagnosis of CVS (per NASPGHAN and Rome IV) between December 1998 and March 2017 who underwent gastric emptying study (GES) and without documented cannabis use were included. Clinical features including demographics, medication use, and comorbidities were also recorded. Frequency of rapid, normal, and delayed emptying was reported, and multinomial univariate logistic regression was used to identify factors associated with each type of emptying. KEY RESULTS: Sixty-seven subjects were included (50.7% female individuals, pediatrics n=15, adults n=52). At 2-hour retention, 40% of pediatric patients met criteria for rapid, 33.3% for normal, and 26.7% for delayed GE. In adults, 50% met criteria for rapid, 46.2% for normal, and 3.8% for delayed GE. For every 5-year increase in age, odds of rapid emptying on GES increased. CONCLUSIONS: (1) GE is predominantly rapid at 2 hours in pediatrics and adults with CVS. (2) Rapid GE seems to increase with age. (3) Current guidelines do not recommend GE in the initial management, however, further studies may play a role to help differentiate CVS from other functional gastric disorders.

Peroral endoscopic myotomy is a safe and effective treatment modality for geriatric patients with achalasia.

BACKGROUND: Peroral endoscopic myotomy (POEM) is an appealing treatment for older patients, as it is minimally invasive but highly efficacious similar to surgical myotomy. However, there is a lack of systematic studies analyzing POEM outcomes in young (< 65 years) versus geriatric patients (≥ 65 years). Hence, we aimed to compare the safety and efficacy of POEM in young versus geriatric patients. METHODS: Records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients were categorized into two groups: young (< 65 years) and old (≥ 65 years). Demographic and procedural details, timed barium esophagram (TBE), high-resolution manometry (HREM), pH study findings and Eckardt scores were compared between the two groups. Post-POEM Eckhardt score of ≤ 3 was defined as treatment success. RESULTS: A total of 148 patients met the study criteria (young = 93; old = 55). Younger patients were more likely to have lower TBE height at 1 min but wider TBE width at 5 min. The rest of the pre-operative parameters and Eckardt scores were similar in the two groups. Young patients were more likely to have undergone prior Heller myotomy, while Botox injections were common in the older group. The operative details and outcomes were similar in the two groups. Treatment success rates were similar in both groups (94.9% young vs. 94.7% in old patients, p = 1.00). At 2-month follow-up, both groups showed significant improvements in Eckhardt scores and HREM parameters; however, older patients showed greater improvement in TBE height at 1 and 5 min. The rates of symptomatic GERD and abnormal esophageal pH study findings were similar in the two groups. CONCLUSION: POEM was safe and highly effective treatment for geriatric patients with achalasia. These findings suggest that POEM might emerge as the preferred approach for myotomy in this patient population.

Manometric Esophageal Length to Height (MELH) Ratio Predicts Hiatal Hernia Recurrence.

INTRODUCTION: The shortened esophagus is poorly defined and is determined intraoperatively, as there exists no objective test to identify a shortened esophagus before surgical hiatal hernia repair. We devised a unique manometric esophageal length to height (MELH) ratio to define the presence of a shortened esophagus and examined the role of esophageal length in hiatal hernia recurrence. PATIENTS AND METHODS: A retrospective review identified 254 patients with hiatal hernia who underwent preoperative esophageal manometry and either an open hernia repair with Collis gastroplasty and fundoplication (with Collis) or laparoscopic repair and fundoplication without Collis gastroplasty (without Collis) from 2005-2016. The MELH ratio was calculated by measuring the upper to lower esophageal sphincter distance divided by the patient's height. RESULTS: Of 245 patients, 157 underwent repair with Collis, while 97 underwent repair without Collis. The Collis group had a shorter manometric esophageal length (20.2 vs. 22.4 cm, P<0.001) and lower MELH (0.12 vs. 0.13, P<0.001). The Collis group had fewer hernia recurrences (18% vs. 55%, log-rank P<0.001) and fewer reoperations for recurrence (0% vs. 10%, log-rank P<0.001) at 5 years. A 33% decrease in risk of hernia recurrence was seen for every 0.01 U increment in MELH ratio (hazard ratio: 0.67; 95% confidence interval: 0.55-0.83, P<0.001) while repair without Collis (hazard ratio: 6.1; 95% confidence interval: 3.2-11.7, P<0.001) was associated with increased risk of hernia recurrence. CONCLUSION: MELH ratio is an objective predictor of a shortened esophagus preoperatively. Lower MELH is associated with increased risk of recurrence and the risk associated with shortened esophagus can be mitigated with an esophageal lengthening procedure such as Collis gastroplasty.

Obesity Does Not Impact Outcomes or Rates of Gastroesophageal Reflux After Peroral Endoscopic Myotomy in Achalasia.

BACKGROUND: Outcomes of laparoscopic Heller myotomy in obese patients with achalasia are suboptimal along with the increased risk of gastroesophageal reflux disease (GERD). The impact of obesity on treatment success and GERD after peroral endoscopic myotomy (POEM) are not well known. Hence, our study aims were to compare the clinical outcomes and rates of GERD after POEM in nonobese versus obese patients with achalasia. METHODS: Chart review of all achalasia patients who underwent POEM at our institution between April 2014 and June 2018. Patients with timed barium esophagram (TBE) and high-resolution esophageal manometry (HREM) before POEM along with post-POEM TBE, HREM, and esophageal pH study were included. Patients were categorized into 2 groups, nonobese (body mass index <30 kg/m) and obese (body mass index ≥30 kg/m). Patient demographics, TBE, HREM, pH study findings, and Eckardt scores were compared between the 2 groups. RESULTS: A total of 89 patients (46 nonobese; 43 obese) met the study criteria. There were no significant differences in age, gender, achalasia subtype, operative time, length of stay and complication rates between the 2 groups. Treatment success (Eckardt score ≤3) was similar in both groups (97.7% nonobese vs. 92.7% obese, P=0.35). Abnormal DeMeester scores on pH study (>14.72) were similar in nonobese and obese patients (58.7% vs. 46.5%, P=0.25). Symptomatic GERD was also similar in both groups (17.8% in nonobese vs. 20% in obese, P=0.79). CONCLUSIONS: POEM is an equally safe and effective treatment option for both nonobese and obese patients with achalasia in the short-term. Interestingly, POEM does not lead to higher rates of GERD in obese compared with nonobese patients.

Esophageal dysmotility and other preoperative factors associated with acid suppressive therapy after fundoplication.

Background and aims: Acid suppressive therapy (AST) is frequently used after fundoplication. Prior studies show that most patients requiring AST after fundoplication have normal esophageal acid exposure and therefore do not need AST. Our aim was to determine the indications for AST use following fundoplication and the associated factors.Methods: Retrospective analysis of patients who underwent fundoplication at our institution between 2006 and 2013 with pre and postoperative esophageal physiologic studies was performed. Demographic data, symptoms, and findings on high resolution manometry, esophageal pH monitoring and upper endoscopy were collected.Results: Three hundred and thirty-nine patients were included with a median follow up time of 12.8[2.6, 47.7] months. Mean age was 59.6 ± 13.3 years and 71.4% were women. Of those, 39.5% went on AST following fundoplication with a median time to AST use of 15.7[2.8, 36.1] months. The most common reason for AST use was heartburn. Only 29% of patients had objective evidence of acid reflux. Preoperative factors associated with AST use following fundoplication were male gender (HR1.6, p = 0.019), esophageal dysmotility (HR1.7, p = 0.004), proton pump inhibitor use (HR2.3, p < 0.001) and prior history of fundoplication (HR1.8, p = 0.006). In those with paraesophageal hernia repair with Collis gastroplasty (N = 182), esophageal dysmotility (HR1.7, p = 0.047) and NSAID use (HR1.9, p = 0.023) were associated with AST use postoperatively.Discussion: AST use is common after fundoplication. Male gender, preoperative esophageal dysmotility, proton pump inhibitor use and redo fundoplication were associated with AST use following fundoplication. In those undergoing combined Collis gastroplasty, preoperative NSAID use and esophageal dysmotility predicted AST use.