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Background Previous studies suggested that antireflux mucosectomy (ARMS) is effective in reducing reflux symptoms and total acid exposure, although the mechanism is unknown. Our objective was to investigate the effect of ARMS on reflux parameters and its mechanism of action. Methods Gastroesophageal reflux disease (GERD) patients with insufficient symptom control despite a twice-daily proton pump inhibitor (PPI) underwent a piecemeal multiband mucosectomy of 50% of the circumference of the esophagogastric junction (EGJ), extending 2 cm into the cardia. The primary end point was the total number of reflux episodes during 24-hour pH-impedance studies. Results 11 patients (8 men; median age 37 [interquartile range (IQR) 32–57] years) were treated, with one patient subsequently lost to follow-up. ARMS reduced the median (IQR) number of total reflux episodes (74 [60–82] vs. 37 [28–66]; P = 0.008) and total acid exposure time (8.7% [6.4%–12.7%] vs. 5.3% [3.5%–6.7%]; P = 0.03). Treatment reduced the median (IQR) number of transient lower esophageal sphincter relaxations (TLESRs) during a 90-minute postprandial period (4 [1–8] vs. 2 [1–4]; P = 0.03) and reflux symptom scores (3.6 [3.6–3.9] vs. 1.6 [0.7–2.7]; P = 0.005). Treatment did not increase the mean (SD) dysphagia scores (8.2 [7.3] vs. 8.5 [6.5]) or change the EGJ distensibility on impedance planimetry (4.4 [2.1] vs. 4.3 [2.2] mm2/mmHg). One delayed post-procedural bleed requiring repeat endoscopy occurred (10%); no strictures developed. Conclusion ARMS is an effective treatment option in PPI-refractory GERD, reducing acid exposure, reflux episodes, and symptoms. While its working mechanism could not be explained by a difference in distensibility, a reduction in TLESRs might play a role. [ABSTRACT FROM AUTHOR]

It is thought that esophageal hypersensitivity in combination with an impaired mucosal barrier function contributes to PPI-resistant reflux symptoms. Ziverel, a bioadhesive agent that coats the esophageal wall, was shown to have a positive effect on reflux symptoms. However, the mechanisms of action are unclear. We aimed to assess the effect of Ziverel on esophageal sensitivity to acid and mucosal barrier function. We performed a double-blind randomized placebo-controlled crossover trial in PPI-refractory patients with reflux symptoms. Patients were assigned (1:1) to 14 days of Ziverel followed by 14 days of placebo or opposite treatment order. The effect was evaluated using acid perfusion tests, an upper endoscopy with electrical tissue impedance spectroscopy (ETIS) and esophageal biopsies. The primary outcome was the esophageal sensitivity based on perfusion sensitivity score. Secondary outcomes included mucosal barrier function and reflux symptoms and correlations between the different outcomes. Perfusion sensitivity score was not significantly different during treatment with Ziverel (106 (73–115)) and placebo (102 (67–110)) (p = 0.508) along with total RDQ score (2.6 (1.9–3.3) vs 2.8 (1.6–3.5) p = 0.456). ETIS showed comparable values during treatment with Ziverel (13514 (8846–19734)Ω·m) and placebo (13217 (9127–24942)Ω·m (p = 0.650)). Comparing Ziverel and placebo no difference was seen in transepithelial electrical resistance (TEER) 203 (163–267) Ω.cm2 vs 205 (176–240) Ω.cm2 (p = 0.445) and fluorescein flux 775 (17–6964) nmol/cm2/h vs 187 (4–12209) nmol/cm2/h (p = 0.638). Ziverel did not show a benefit on acid sensitivity, reflux symptoms or esophageal mucosal integrity compared to placebo in PPI-refractory patients with reflux symptoms. Trial registration: Netherlands Trial Register number: NL7670 [ABSTRACT FROM AUTHOR]

Introduction: Although inability to belch has previously been linked to dysfunction of the upper esophageal sphincter (UES), its underlying pathogenesis remains unclear. Our aim was to study mechanisms underlying inability to belch and the effect of UES botulinum toxin (botox) injections in these patients. Methods: We prospectively enrolled consecutive patients with symptoms of inability to belch. Patients underwent stationary high‐resolution impedance manometry (HRIM) with belch provocation and ambulatory 24‐h pH‐impedance monitoring before and 3 months after UES botox injection. Results: Eight patients (four males, age 18–37 years) were included. Complete and normal UES relaxation occurred in response to deglutition in all patients. A median number of 33(15–64) gastroesophageal gas reflux episodes were observed. Despite the subsequent increase in esophageal pressure (from −4.0 [−7.7–4.2] to 8 [3.3–16.1] mmHg; p < 0.012), none of the gastroesophageal gas reflux events resulted in UES relaxation. Periods of continuous high impedance levels, indicating air entrapment (median air presence time 10.5% [0–43]), were observed during 24‐h impedance monitoring. UES botox reduced UES basal pressure (from 95.7[41.2–154.0] to 29.2 [16.7–45.6] mmHg; p < 0.02) and restored belching capacity in all patients. As a result, esophageal air presence time decreased from 10.5% (0–43.4) to 0.7% (0.1–18.6; p < 0.02) and esophageal symptoms improved in all patients (VAS 6.0 [1.0–7.9] to 1.0 [0.0–2.5]; p < 0.012). Conclusion: The results of this study underpin the existence of a syndrome characterized by an inability to belch and support the hypothesis that ineffective UES relaxation, with subsequent esophageal air entrapment, may lead to esophageal symptoms. [ABSTRACT FROM AUTHOR]