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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.

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BACKGROUND: The current definition for hypercontractile esophagus was arbitrarily set at the uppermost range in volunteers for a specific equipment. OBJECTIVE: This study aims to critically analyze the concept of hypercontractile waves to redefine hypercontractile esophagus parameters. METHODS: We reviewed 500 unselected and consecutive HRM tests (5000 waves) performed in a water -perfused system. RESULTS: Mean distal contractility integral (DCI) was 825±1492 (0-42775) mmHg.cm.s, two standard deviations above average = 3810; 95th percentile = 2798 mmHg.cm.s. CONCLUSION: In healthy volunteers, two standard deviations above average is 4000 mmHg.cm.s, we thus suggest this value to define hypercontractile waves and define hypercontractile esophagus in a water-perfused HRM system.

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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.

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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.

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ABSTRACT Background: The current definition for hypercontractile esophagus was arbitrarily set at the uppermost range in volunteers for a specific equipment. Objective: This study aims to critically analyze the concept of hypercontractile waves to redefine hypercontractile esophagus parameters. Methods: We reviewed 500 unselected and consecutive HRM tests (5000 waves) performed in a water -perfused system. Results: Mean distal contractility integral (DCI) was 825±1492 (0-42775) mmHg.cm.s, two standard deviations above average = 3810; 95th percentile = 2798 mmHg.cm.s. Conclusion: In healthy volunteers, two standard deviations above average is 4000 mmHg.cm.s, we thus suggest this value to define hypercontractile waves and define hypercontractile esophagus in a water-perfused HRM system.

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Introduction: Patients with obesity are often affected by gastroesophageal reflux disease (GERD). Roux-en-Y gastric bypass (RYGB) is considered the ideal operation for patients with severe obesity and GERD. Although the majority of patients improve their reflux with the operation, some might persist symptomatic and others can even develop de novo GERD. The aim of this study was to determine pathophysiologic factors involved in the development of GERD after RYGB surgery and define potential treatments for this condition. Materials and Methods: Studies including patients with GERD before and after RYGB and/or analyzing possible GERD therapies were analyzed by the authors. Searches were conducted in PubMed, Cochrane Library, and Embase databases. Results: GERD can persist, worsen, or develop after RYGB. There are certain technical elements of the operation identified as potential risk factors for GERD. Medical therapy is effective in the majority of patients. Both endoscopic and surgical procedures can also help resolving GERD after RYGB. Conclusions: Although the majority of patients with GERD after RYGB can be effectively managed with medical therapy, some may require endoscopic or surgical treatment. Critical technical elements of RYGB should be considered to reduce the risk of postoperative GERD.

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PURPOSE: Gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG) may be related to surgical technique. The fact that there is a lack of technical standardization may explain large differences in GERD incidence. The aim of this study is to evaluate auto- and hetero-agreement for SG technical key points based on recorded videos. METHODS: Ten experienced (minimum of 5 years performing bariatric surgery, minimum of 30 SG per year) bariatric surgeons (9 (90%) males) were selected. Participants were invited to send an unedited video with a typical laparoscopic SG (first round of the Delphi process). Videos were cropped into small clips comprising 11 key points of the technique. All anonymized clips (including their own) were returned to all surgeons. Individuals were asked to agree or not with the technique demonstrated (second round). The percentage of agreement was presented to the entire group that was asked for a second vote (third round). RESULTS: Agreement was poor/fair for all points except hiatal repair that had a very good agreement in the second round. For the third round, there was a slight increase in agreement for distance esophagogastric junction/proximal stapling and gastric mobilization for stapling and a slight decrease in agreement for gastric tube final shape. Only 1 (10%) surgeon recognized that he evaluated his own video. Five (50%) surgeons disagreed with themselves on 1 or more points. CONCLUSION: SG lacks intrasurgeon and intersurgeon agreement in technical key points that may justify significant differences in GERD incidence after the procedure.

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Sleeve gastrectomy (SG) is deemed a refluxogenic operation but with a low incidence of postoperative Barrett´s esophagus (BE). We aimed to shed some light on the potential paradox of the weak association between SG, BE and esophageal adenocarcinoma (EAC). The high incidence of GERD after SG is not followed by an increased rate of BE and EAC, as these rates are similar to the general population. We hypothesized that this paradox may occur due to a difference in the gastro-esophageal reflux composition secondary to a lower content of bile, to a decrease in inflammation due to weight loss and hormonal changes, and to acquisition of healthier habits such as exercise, smoking cessation, and better eating behavior.

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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.

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BACKGROUND: Gastroesophageal reflux disease (GERD) pathophysiology is multifactorial. Greater importance has been attributed to a defective lower esophageal sphincter (LES) in comparison to an altered transdiaphragmatic pressure gradient (TPG). This study aims to evaluate the role of the TPG and LES disfunction in GERD pathogenesis. METHODS: Five hundred consecutive esophageal function tests from patients with clinically suspected GERD were reviewed. Patients were classified according to the pH monitoring in GERD positive or GERD negative. Abdominal pressure, thoracic pressure, TPG (abdominal-thoracic pressures), LES resting pressure (mid-respiratory, expiratory, and EGJ-CI), and LES retention pressure (LES resting pressure-TPG) were determined. RESULTS: GERD was present in 296 (59%) individuals. GERD-positive patients were mostly males. LES resting pressure (by all parameters) and thoracic pressure were not different between groups. Abdominal pressure and TPG were higher in GERD-positive patients. LES retention pressure (by all parameters) was lower in GERD-positive patients. DeMeester score had a positive correlation with LES resting pressure, TPG, and LES retention pressure (by all parameters) but not with abdominal pressure and thoracic pressure. CONCLUSIONS: LES valvular competency as measured by absolute resting pressure was not reliable to predict GERD; however, it was associated with GERD severity. Relative LES pressure (LES retention pressure) predicted GERD presence and severity, but no parameter showed superiority. TPG plays an important role in the pathophysiology of GERD since it is related to GERD presence and severity; still TPG is altered mostly based on a higher abdominal pressure.

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