The Efficacy of Peroral Endoscopic Myotomy vs Pneumatic Dilation as Treatment for Patients With Achalasia Suffering From Persistent or Recurrent Symptoms After Laparoscopic Heller Myotomy: A Randomized Clinical Trial.

BACKGROUND & AIMS: For patients with achalasia experiencing persistent or recurrent symptoms after laparoscopic Heller myotomy (LHM), pneumatic dilation (PD) is the most frequently used treatment. Per-oral endoscopic myotomy (POEM) is increasingly being investigated as rescue therapy. This study aimed to determine the efficacy of POEM vs PD for patients with persistent or recurrent symptoms after LHM. METHODS: This randomized multicenter controlled trial included patients after LHM with an Eckardt score >3 and substantial stasis (≥2 cm) on timed barium esophagogram and randomized to POEM or PD. The primary outcome was treatment success, defined as an Eckardt score of ≤3 and without unscheduled re-treatment. Secondary outcomes included the presence of reflux esophagitis, high-resolution manometry, and timed barium esophagogram findings. Follow-up duration was 1 year after initial treatment. RESULTS: Ninety patients were included. POEM had a higher success rate (28 of 45 patients [62.2%]) than PD (12 of 45 patients [26.7%]; absolute difference, 35.6%; 95% CI, 16.4%-54.7%; P = .001; odds ratio, 0.22; 95% CI, 0.09-0.54; relative risk for success, 2.33; 95% CI, 1.37-3.99). Reflux esophagitis was not significantly different between POEM (12 of 35 [34.3%]) and PD (6 of 40 [15%]). Basal lower esophageal sphincter pressure and integrated relaxation pressure (IRP-4) were significantly lower in the POEM group (P = .034; P = .002). Barium column height after 2 and 5 minutes was significantly less in patients treated with POEM (P = .005; P = .015). CONCLUSIONS: Among patients with achalasia experiencing persistent or recurrent symptoms after LHM, POEM resulted in a significantly higher success rate than PD, with a numerically higher incidence of grade A-B reflux esophagitis. NETHERLANDS TRIAL REGISTRY: NL4361 (NTR4501), https://trialsearch.who.int/Trial2.aspx?TrialID = NTR4501.

Effects of anxiety and depression in patients with gastroesophageal reflux disease.

BACKGROUND & AIMS: Increased levels of anxiety and depression have been associated with esophageal hyperalgesia and an increased risk of gastroesophageal reflux disease (GERD). We investigated the effects of anxiety and depression on GERD symptoms and the perception of reflux episodes in a well-characterized group of patients. METHODS: We performed a prospective study of 225 consecutive patients who had symptoms of GERD evaluated. Patients underwent ambulatory 24-hour pH impedance monitoring, and levels of anxiety and depression were assessed using the Hospital Anxiety and Depression Scale. RESULTS: GERD was diagnosed in 147 patients (78 patients had functional heartburn); 36 patients were hypersensitive to gastroesophageal reflux. Among patients with GERD, increased levels of anxiety were associated with more severe retrosternal pain and retrosternal burning. Furthermore, increased levels of anxiety and depression each were associated with lower scores of the mental component of quality of life questionnaire. Levels of anxiety or depression were not associated with the number of reflux symptoms reported during 24-hour pH impedance monitoring or with the number of symptoms associated with a reflux event. Among GERD patients with hypersensitivity to reflux, levels of anxiety and depression and decreases in quality of life were similar to those of other patients with GERD. Patients with functional heartburn had higher levels of anxiety than patients with GERD. CONCLUSIONS: In patients with GERD, increased levels of anxiety are associated with increased severity of retrosternal pain and heartburn and reduced quality of life. Patients with GERD with hypersensitivity to gastroesophageal reflux have similar levels of anxiety and similar quality-of-life scores as other patients with GERD.

Utilization of esophageal function testing for the diagnosis of the rumination syndrome and belching disorders.

Rumination is a phenomenon characterized by retrograde flow of gastric contents into the mouth, otherwise known as regurgitation. Repetitive excessive occurrence of rumination is considered pathologic and is known as the rumination syndrome. Belching occurs occasionally in everyone and is often not related to a disease or a pathologic condition. Gastric belches are physiologic events caused by retrograde flow of air into the esophagus and mouth; however, supragastric belching is associated with belching disorders and is considered pathologic behavior.