Salvatore Tolone

Effects of omega-loop bypass on esophagogastric junction function.

BACKGROUND At present, no objective data are available on the effect of omega-loop gastric bypass (OGB) on gastroesophageal junction and reflux. OBJECTIVES To evaluate the possible effects of OGB on esophageal motor function and a possible increase in gastroesophageal reflux. SETTING University Hospital, Italy; Public Hospital, Italy. METHODS Patients underwent clinical assessment for reflux symptoms, and endoscopy plus high-resolution impedance manometry (HRiM) and 24-hour pH-impedance monitoring (MII-pH) before and 1 year after OGB. A group of obese patients who underwent sleeve gastrectomy (SG) were included as the control population. RESULTS Fifteen OGB patients were included in the study. After surgery, none of the patients reported de novo heartburn or regurgitation. At endoscopic follow-up 1 year after surgery, esophagitis was absent in all patients and no biliary gastritis or presence of bile was recorded. Manometric features and patterns did not vary significantly after surgery, whereas intragastric pressures (IGP) and gastroesophageal pressure gradient (GEPG) statistically diminished (from a median of 15 to 9.5, P<.01, and from 10.3 to 6.4, P<.01, respectively) after OGB. In contrast, SG induced a significant elevation in both parameters (from a median of 14.8 to 18.8, P<.01, and from 10.1 to 13.1, P<.01, respectively). A dramatic decrease in the number of reflux events (from a median of 41 to 7; P<.01) was observed after OGB, whereas in patients who underwent SG a significant increase in esophageal acid exposure and number of reflux episodes (from a median of 33 to 53; P<.01) was noted. CONCLUSIONS In contrast to SG, OGB did not compromise the gastroesophageal junction function and did not increase gastroesophageal reflux, which was explained by the lack of increased IGP and in GEPG as assessed by HRiM.

Esophagogastric junction morphology is associated with a positive impedance-pH monitoring in patients with GERD

High‐resolution manometry (HRM) provides information on esophagogastric junction (EGJ) morphology, distinguishing three different subtypes. Data on the correlation between EGJ subtypes and impedance‐pH detected reflux patterns are lacking. We aimed to correlate the EGJ subtypes with impedance‐pH findings in patients with reflux symptoms.

Evaluation of Helicobacter Pylori eradication in pediatric patients by triple therapy plus lactoferrin and probiotics compared to triple therapy alone

BackgroundTo evaluate whether the addition of a probiotic could improve Helicobacter pylori (H.P.) eradication rates and reduce the side effects of treatment in children.MethodsBetween July 2008 and July 2011 all patients with a clinical, laboratory and endoscopic diagnosis of H.P. positive gastritis referred to our Unit were included in the study. Patients suffering from allergy to any of drugs used in the study, with previous attempts to eradicate H.P. and those who received antibiotics, PPIs or probiotics within 4 weeks were excluded from the present study. Patients were randomized into two therapy regimens (group A and B): both groups received standard triple treatment (omeprazole, amoxicillin and clarithromycin) while only group B patients were also given a probiotic (Probinul - Cadigroup). Patients compliance was evaluated at the end of the treatment. Successful eradication was defined as a negative 13 C-urea breath test (C13-ubt) result four weeks after therapy discontinuation.ResultsA total of 68 histopathologically proven H.P.-infection children (32 male and 36 females) were included in the study. All of the patients in both groups used more than 90% of the therapies and no patients were lost at follow up. All side effects were selflimiting and disappeared once the therapy was terminated. Epigastric pain was observed in 6 (17.6%) group A vs 2 (5.8%) group B patients (P<0.05), nausea in 3 (8.8%) group A vs 1 (2.9%) group B patients (P<0.05); vomiting and diarrhea were observed in 2(5.8%) and 8 (23.5%) group A patients, respectively and never in group B (P<0.05). There was no significant difference between the two groups in terms of constipation (5.8% in group A and B). Four weeks after the completion of therapy, 56/68 patients (82.3%) tested negative for H.P. on C13-ubt. H.P. was eradicated in 26 patients (76.4%) in group A and in 30 patients (88.2%) in group B. There was no significantly difference in the rate of H.P. eradication between group A and group B (p=0.1), although the success rate for H.P. eradication was higher in group B than in group A.ConclusionThe addition of a probiotic formula to triple therapy significantly decreased the frequency of epigastric pain, nausea, vomiting and diarrhea.

Laparoscopic Nissen-Rossetti fundoplication with routine use of intraoperative endoscopy and manometry: technical aspects of a standardized technique.

BackgroundSeveral different ways of fashioning a total fundoplication lead to different outcomes. This article addresses the technical details of the antireflux technique we adopted without modifications for all patients with GERD beginning in 1972. In particular it aims to discuss the relation between the mechanism of function of the wrap and the physiology of the esophagus.MethodsThe study population consisted of 380 patients affected by GERD with a 1-year minimum of follow-up who underwent laparoscopic Nissen-Rossetti fundoplication by a single surgeon.ResultsNo conversion to open surgery and no mortality occurred. Major complications occurred in 4 patients (1.1%). Follow-up (median 83 months; range: 1–13 years) was achieved in 96% of the patients. Ninety-two percent of the patients were satisfied with the results of the procedure and would undergo the same operation again. Postoperative dysphagia occurred in 3.5% of the patients, and recurrent heartburn was observed in 3.8%.ConclusionsLaparoscopic Nissen-Rossetti fundoplication with the routine use of intraoperative manometry and endoscopy achieved good outcomes and long-term patient satisfaction with few complications and side-effects. Appropriate preoperative investigation and a correct surgical technique are important in securing these results.

Esophagogastric junction contractility for clinical assessment in patients with GERD: a real added value?

The role of esophagogastric junction contractile integral (EGJ‐CI) as assessed by high‐resolution manometry (HRM) is unclear. We aimed to correlate the EGJ‐CI with impedance‐pH findings in gastro‐esophageal reflux disease (GERD) patients.

The added diagnostic value of postreflux swallow-induced peristaltic wave index and nocturnal baseline impedance in refractory reflux disease studied with on-therapy impedance-pH monitoring

On‐therapy impedance‐pH monitoring in proton pump inhibitor (PPI)‐refractory gastroesophageal reflux disease (GERD) yielded conflicting results. We aimed to assess the diagnostic value of postreflux swallow‐induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI) in PPI‐refractory heartburn.

Impact of total fundoplication on esophageal transit: analysis by combined multichannel intraluminal impedance and manometry.

Background: Laparoscopic total fundoplication is considered the most effective surgical option for gastroesophageal reflux (GER) disease. Some authors assume that total fundoplication may expose the patient to delayed transit of the swallowed bolus and increased risk of dysphagia, particularly when peristaltic dysfunction is present. We undertook this study to evaluate by means of combined multichannel intraluminal impedance and esophageal manometry (MII-EM) the impact of fundoplication on esophageal physiology. An objective measurement of the influence of the total wrap on bolus transit may be helpful in refining the optimal antireflux wrap (ie, partial vs. total). Methods: In this study, 25 consecutive patients who underwent laparoscopic Nissen-Rossetti fundoplication had MII-EM and combined 24-hour pH and multichannel intraluminal impedance (MII-pH) before and after the surgical procedure. All patients completed preoperative and postoperative symptom questionnaires. The following were calculated for liquid and viscous deglutition lower esophageal sphincter pressure and relaxation, distal esophageal amplitude, the number of complete esophageal bolus transits and the mean total bolus transit time. The acid and nonacid GER episodes were calculated by MII-pH with the patient in both upright and recumbent positions. Results: The postoperative MII-EM showed an increased lower esophageal sphincter pressure (P<0.05), whereas lower esophageal sphincter relaxation and distal esophageal amplitude did not change after surgery (P=NS). Complete esophageal bolus transits and bolus transit time did not change for liquid swallows (P=NS), but was more rapid for viscous after surgery (P<0.05). Twenty-four hour pH monitoring confirmed the postoperative reduction of both acid and nonacid reflux (P<0.05). Conclusions: Laparoscopic Nissen-Rossetti is effective in controlling both acid and nonacid GER without impairment of esophageal function. Appropriate preoperative investigation, meticulous patient selection and correct surgical technique are extremely important in securing good results.

Vigor of peristalsis during multiple rapid swallows is inversely correlated with acid exposure time in patients with NERD

Multiple rapid swallowing (MRS) during high‐resolution manometry (HRM) is increasingly utilized as provocative test to assess esophageal peristaltic reserve. The aim of this study was to evaluate the correlation between MRS response and impedance and pH (MII‐pH) parameters in endoscopy negative heartburn (ENH) patients.

The GerdQ questionnaire and high resolution manometry support the hypothesis that proton pump inhibitor-responsive oesophageal eosinophilia is a GERD-related phenomenon.

Little is known about the relationship between proton pump inhibitor‐responsive oesophageal eosinophilia (PPI‐REE), eosinophilic esophagitis (EoE) and gastro‐oesophageal reflux disease (GERD).

Epiphrenic diverticula mini-invasive surgery: a challenge for expert surgeons--personal experience and review of the literature.

Background and Aims: While in the past, thoracotomy represented the traditional surgical approach for the treatment of epiphrenic diverticula, actually mini-invasive approach seems to be the preferred treatment as many series have been published in the recent years. This article describes the authors’ experience with the laparoscopic approach for performing diverticulectomy, myotomy, and Nissen–Rossetti fundoplication. Material and Methods: From 1994 to 2010, 21 patients (10 men and 11 women), mean age 58.5 years (range 45–74 years), with symptomatic epiphrenic diverticulum underwent laparoscopic diverticulectomy, myotomy and Nissen–Rossetti fundoplication. Results: The mean operative time was 135 min (range = 105–190 min). Mean hospital stay was 14.2 days (range = 7–25 days). In 5 patients (23.8%), a partial suture staple line leak was observed. Conservative treatment achieved leak resolution in all the cases. One patient (4.8%) died of a myocardial infarction in the postoperative period. After a mean clinical follow-up period of 78 months (range = 6–192 months), excellent or good outcome was referred with no dysphagia in 16 patients (80%) and only mild occasional dysphagia in 4 patients (20%). Conclusions: Surgical treatment of epiphrenic diverticula remains a challenging procedure also by mini-invasive approach, with major morbidity and mortality rates. For this reason, indications must be restricted only to selected and symptomatic patients in specialized centers.