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Important Note: The following information
is provided for your education. It should not be relied upon for
personal diagnosis or treatment. If you believe that a
particular therapy applies to you or someone you care about, be
sure to consult a doctor before trying it.
Gastroesophageal Reflux Disease Research:
2002-2006
J Pineal Res. 2006 Oct;41(3):195-200.
Regression of gastroesophageal reflux disease symptoms using
dietary supplementation with melatonin, vitamins and aminoacids: comparison with
omeprazole.
Pereira RD.
Depto. de Farmacia-Universidade Estadual da Paraiba, Av das Baraunas, 351/Campus
Universitario, Bodocongo/Campina Grande-PB-Brazil-CEP 58109-753, Brazil.
The prevalence of gastroesophageal reflux disease (GERD) is increasing. GERD is
a chronic disease and its treatment is problematic. It may present with various
symptoms including heartburn, regurgitation, dysphagia, coughing, hoarseness or
chest pain. The aim of this study was to investigate if a dietary
supplementation containing: melatonin, l-tryptophan, vitamin B6, folic acid,
vitamin B12, methionine and betaine would help patients with GERD, and to
compare the preparation with 20 mg omeprazole. Melatonin has known inhibitory
activities on gastric acid secretion and nitric oxide biosynthesis. Nitric oxide
has an important role in the transient lower esophageal sphincter relaxation (TLESR),
which is a major mechanism of reflux in patients with GERD. Others biocompounds
of the formula display anti-inflammatory and analgesic effects. A single blind
randomized study was performed in which 176 patients underwent treatment using
the supplement cited above (group A) and 175 received treatment of 20 mg
omeprazole (group B). Symptoms were recorded in a diary and changes in severity
of symptoms noted. All patients of the group A (100%) reported a complete
regression of symptoms after 40 days of treatment. On the other hand, 115
subjects (65.7%) of the omeprazole reported regression of symptoms in the same
period. There was statiscally significant difference between the groups (P <
0.05). This formulation promotes regression of GERD symptoms with no significant
side effects.
-----
Digestion. 2006 Aug 29;74(1):1-14 [Epub ahead of print]
Endoscopic Therapy for Gastroesophageal Reflux Disease: A
Systematic Review.
Sgouros SN, Bergele C.
Department of Gastroenterology, Athens Naval Hospital, Athens, Greece.
The high prevalence of gastroesophageal reflux disease (GERD) in Western
societies has accelerated the need for new modalities of treatment. Currently,
medical and surgical therapies are widely accepted among patients and
physicians. The minimally invasive treatment revolution, however, has stimulated
several new endoscopic techniques for GERD. Up to now, the data is limited and
further studies are necessary to compare the advantages and disadvantages of the
various endoscopic techniques to medical and laparoscopic management of GERD.
This systematic review reports the efficacy and durability of various endoscopic
therapies for GERD whilst the potential for widespread use of these techniques
is also discussed. Despite the limited number of studies and remarkable
differences between various trials, strict criteria were used for the pooled
data presented and an effort was made to avoid bias by including only studies
that used off-antisecretory medication scoring as baseline and intent to treat.
Copyright (c) 2006 S. Karger AG, Basel.
-----
Dig Dis Sci. 2006 Aug 22; [Epub ahead of print]
Intravenous Pantoprazole as Initial Treatment in Patients With
Gastroesophageal Reflux Disease and a History of Erosive Esophagitis: A
Randomized Clinical Trial.
Pratha V, Hogan DL, Lynn RB, Field B, Metz DC.
Clinical Applications Laboratories, 3330 Third Ave, Suite 330, San Diego,
California, 92103, USA, dhogan@calincresearch.com.
We sought to evaluate safety and efficacy of IV pantoprazole when used as
initial therapy in patients with gastroesophageal reflux disease (GERD) and a
history of erosive esophagitis (EE) in a double-blind, placebo-controlled,
randomized, parallel-group study. Patients were randomized to 7 days of
once-daily IV or oral pantoprazole (40 mg) or placebo. Efficacy variables
included maximal acid output, basal acid output, and changes from baseline in
frequency/severity of GERD symptoms, and frequency of antacid usage.
Seventy-eight patients were randomized (n=26/27/25 [IV/oral/placebo]). Mean
maximal acid output was 8.4, 6.3, and 20.9 mEq/h for IV or oral pantoprazole,
and placebo, respectively. For pantoprazole versus placebo, maximal and basal
acid output were significantly lower (P<.001) and there was a numerical trend
toward improved GERD and antacid usage. Both treatments were well tolerated. In
conclusion, IV/oral pantoprazole were similarly effective in suppressing basal
and pentagastrin-stimulated gastric acid secretion in GERD patients with a
history of EE.
-----
Schweiz Rundsch Med Prax. 2006 Aug 2;95(31-32):1179-83.
[Gastroesophageal reflux disease and dyspepsia—drug therapy]
[Article in German]
Grater H.
Klinik fur Onkologie, Gastroenterologie und Allgemeine Innere Medizin,
Stadtische Kliniken Esslingen.
Proton pump inhibitors (PPI) are the antisecretory drugs of choice to manage
GERD-related problems. The therapeutic goal in patients with non erosive reflux
disease (NERD) and low-grade-GERD is to relieve symptoms, therefore PPI are
given "on demand". Severe GERD requires long term treatment to heal lesions and
to prevent relapses and complications. Barrett's esophagus has to be regarded as
a precancerous lesion, therefore surveillance strategy is required. Functional
dyspepsia is a common reason for upper gastrointestinal symptoms. If there are
no alarming symptoms, you can omit endoscopy in younger patients. The treatment
is empirical and symptom driven. Psychologic therapy is a promising avenue in
some patients.
-----
Paediatr Drugs. 2006;8(4):265-70.
Ranitidine (Zantac®) Syrup
versus Ranitidine Effervescent Tablets (Zantac®)
(EFFERdose®) in Children: A Single-Center
Taste Preference Study.
Ameen VZ, Pobiner BF, Giguere GC, Carter EG.
Clinical Pharmacology and Discovery Medicine, Research and Development,
GlaxoSmithKline, Research Triangle Park, North Carolina, USA.
BACKGROUND: The histamine H(2) receptor antagonist ranitidine is US FDA-approved
for the treatment of gastroesophageal reflux disease and healing of erosive
esophagitis in children >/=1 month of age. A low-dose strength of ranitidine is
now available in a citrus-flavored 25mg effervescent tablet (dissolved in 5mL of
water); this formulation was developed to facilitate use in infants and smaller
children. Ranitidine syrup is available in a peppermint-flavored 15 mg/mL
formulation. OBJECTIVE: To compare taste preferences for ranitidine (Zantac®)
syrup and ranitidine effervescent tablets dissolved in water (Zantac®)
EFFERdose®) in healthy children aged 4-8
years and their adult caregivers. STUDY DESIGN AND METHODS: A randomized,
single-blind, crossover, taste test trial was conducted in 102 children and 102
parents/legal guardians. All subjects received a single 45mg dose of each
formulation. After tasting both preparations children were asked: "Now that you
have tasted both medicines, which one of these medicines do you think tastes
better?" Adults were asked four questions to assess whether they would
administer the medication to the children. RESULTS: Seventy-one percent (72/102)
of the children preferred the taste of the ranitidine effervescent tablets
compared with 29% (30/102) who preferred the syrup (p < 0.001). The majority of
adults (71%) responded that they would prefer to administer the effervescent
formulation based on taste. Adverse events consistent with product labeling were
mild and were reported in four children and three adults: headache (n = 3),
drowsiness (n = 1), abdominal pain/cramps (n = 2), and bloating/gas (n = 1).
CONCLUSION: The taste of the ranitidine effervescent formulation dissolved in
water is preferred over the ranitidine syrup. Better taste acceptance may
facilitate ease of administration and compliance in pediatric patients.
-----
Pediatrics. 2006 Aug;118(2):746-52.
Metoclopramide for the treatment of gastroesophageal reflux
disease in infants: a systematic review.
Hibbs AM, Lorch SA.
Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia,
Pennsylvania, USA. annamariahibbs@hotmail.com
OBJECTIVES: Metoclopramide is a commonly used drug to treat gastroesophageal
reflux disease in infants. Given its widespread use and growing concern about
toxicity in this population, we conducted a systematic review of metoclopramide
for the treatment of gastroesophageal reflux disease in infants. METHODS: We
performed a systematic search of PubMed and bibliographies of relevant review
articles. We included cohort, case-control, and intervention studies of the
efficacy, effectiveness, or toxicity of metoclopramide therapy for
gastroesophageal reflux disease in infants. We excluded case reports, case
series, review articles, and abstracts. RESULTS: Twelve articles met our
inclusion criteria. Of these, 11 were prospective trials, and 5 were randomized,
blinded clinical trials. Study size ranged from 6 to 77 patients. Eight studies
showed patient improvement with metoclopramide in at least 1 measured outcome; 1
study showed worsening symptoms with metoclopramide. Of the 5 randomized,
blinded trials, 2 showed no effect of metoclopramide on any outcome, and 2
showed a significant placebo effect. Four studies commented on adverse effects
of therapy, with irritability being the most frequently reported potential
adverse effect of therapy. Other reported adverse effects included dystonic
reactions, drowsiness, oculogyric crisis, emesis, and apnea. Among studies,
there was marked heterogeneity in the patient populations, dosing, and outcomes
studied. Therefore, a meta-analysis was not performed. We both agreed on a US
Preventive Service Task Force rating of "poor" for the level of evidence,
leading to an "inconclusive" recommendation for the safety and efficacy of
metoclopramide in infants. CONCLUSIONS: The current literature is insufficient
to either support or oppose the use of metoclopramide for gastroesophageal
reflux disease in infants. In the future, large blinded randomized clinical
trials are needed to determine the efficacy and toxicity of metoclopramide in
this population.
-----
Dig Dis Sci. 2006 Aug;51(8):1307-12. Epub 2006 Jul 27.
A very low-carbohydrate diet improves gastroesophageal reflux and
its symptoms.
Austin GL, Thiny MT, Westman EC, Yancy WS Jr, Shaheen NJ.
Division of Gastroenterology and Hepatology and the Center for Esophageal
Diseases and Swallowing, University of North Carolina, Chapel Hill, North
Carolina, USA.
Obese patients with gastroesophageal reflux disease (GERD) may experience
resolution of symptoms utilizing a very low-carbohydrate diet. The mechanism of
this improvement is unknown. This studied aimed to prospectively assess changes
in distal esophageal acid exposure and GERD symptoms among obese adults
initiating a very low-carbohydrate diet. We studied obese individuals with GERD
initiating a diet containing less than 20 g/day of carbohydrates. Symptom
severity was assessed using the GERD Symptom Assessment Scale-Distress Subscale
(GSAS-ds). Participants underwent 24-hr esophageal pH probe testing and
initiated the diet upon its completion. Within 6 days, a second pH probe test
was performed. Outcomes included changes in the Johnson-DeMeester score,
percentage total time with a pH<4 in the distal esophagus, and GSAS-ds scores.
Eight participants were enrolled. Mean Johnson-DeMeester score decreased from
34.7 to 14.0 (P=0.023). Percentage time with pH<4 decreased from 5.1% to 2.5%
(P=0.022). Mean GSAS-ds score decreased from 1.28 to 0.72 (P=0.0004). These data
suggest that a very low-carbohydrate diet in obese individuals with GERD
significantly reduces distal esophageal acid exposure and improves symptoms.
-----
Drugs. 2006;66 Suppl 1:7-13; discussion 29-33.
Non-erosive reflux disease and atypical gastro-oesophageal reflux
disease manifestations: treatment results.
Galmiche JP.
Department of Gastroenterology and Hepatology, CIC INSERM-CHU, Nantes
University, France. jeanpaul.galmiche@chu-nantes.fr
Gastro-oesophageal reflux disease (GERD) is a widespread complex disorder that
may be responsible for a variety of different symptoms and clinical features.
Despite the presence of symptoms, the majority of patients do not have
endoscopic lesions of oesophagitis. Non-erosive reflux disease (NERD) is a
chronic, relapsing condition that can adversely affect the quality of life
despite the absence of mucosal breaks at endoscopy. In many patients GERD is
associated with extra-oesophageal or atypical manifestations, including cough,
asthma, laryngitis or non-cardiac chest pain. Acid suppression with proton pump
inhibitors (PPI) remains the mainstay of GERD therapy. However, patients with
NERD and extra-oesophageal manifestations are often poorly responsive to PPI
therapy. Accurate diagnosis followed by adequate PPI dosage and compliance with
therapy are essential for the successful control of NERD and extra-oesophageal
manifestations. The better detection and characterization of acid and non-acid
reflux episodes using developing technologies, such as combined pH-impedance
monitoring, is extending our understanding of the pathophysiology of NERD and
the extra-oesophageal manifestations of GERD, and will lead to the improved
management of these often poorly responsive conditions. This article reviews the
treatment results and outlines approaches to the evaluation, diagnosis and
therapy of NERD and atypical GERD manifestations.
-----
South Med J. 2006 Jul;99(7):735-41; quiz 742, 752.
Management of gastroesophageal reflux disease.
Liu JJ, Saltzman JR.
Harvard Medical School, Brigham and Women's Hospital, Boston, MA 02115, USA.
Gastroesophageal reflux disease is the most common and expensive digestive
disease with complex and multi-factorial pathophysiologic mechanisms. Transient
inappropriate relaxation of the lower esophageal sphincter is the predominant
mechanism in the majority of patients with mild to moderate disease. Hiatal
hernias and a reduced lower esophageal sphincter pressure have a significant
role in patients with moderate to severe disease. Typical manifestations of
gastroesophageal reflux disease include heartburn, regurgitation, and dysphagia.
Atypical symptoms, such as noncardiac chest pain, pulmonary manifestations of
asthma, cough, aspiration pneumonia, or ENT manifestations of globus and
laryngitis, can be seen in patients with or without typical symptoms of
gastroesophageal reflux disease. Endoscopy and ambulatory pH tests are best to
evaluate the anatomic and physiologic impact ofgastroesophageal reflux disease.
Complications of chronic gastroesophageal reflux disease include peptic
strictures and Barrett metaplasia. Barrett esophagus is a major risk factor for
esophageal adenocarcinoma, and upper endoscopy with surveillance biopsies is
recommended for patients with Barrett esophagus. Medical therapy with anti-secretory
agents (H2 blockers and proton pump inhibitors) is effective for most patients
with gastroesophageal reflux disease. Surgical fundoplications and endoscopic
treatment modalities are mechanical treatment options for patients with
gastroesophageal reflux disease.
-----
Surg Endosc. 2006 Apr;20 Suppl 2:S500-2. Epub 2006 Mar 16.
Endoluminal surgery: past, present and future.
Ponsky JL.
Case Western Reserve University, Cleveland, Ohio, USA. jponsky@yahoo.com
Flexible endoscopy has evolved from a diagnostic tool practiced predominantly by
gastroenterologists to a minimally invasive surgical tool. Therapeutic
endoluminal procedures have become the standard of care for many gastric,
biliary, pancreatic and colonic maladies. New technologies are under
investigation for endoscopic treatment of gastroesophageal reflux, morbid
obesity, and ablation of premalignant tissue. In the future flexible endoscopes
may play a role in "natural orifice" surgery, performing operations through the
mouth or rectum without the need for external incisions.
-----
Am Surg. 2006 Mar;72(3):207-12.
Laparoscopic Nissen fundoplication offers high patient
satisfaction with relief of extraesophageal symptoms of gastroesophageal reflux
disease.
Rakita S, Villadolid D, Thomas A, Bloomston M, Albrink M, Goldin S, Rosemurgy A.
Department of Surgery, University of South Florida College of Medicine, Tampa,
Florida, USA.
Nissen fundoplication is applied for patients with gastroesophageal reflux
disease (GERD), usually because of symptoms of esophageal injury. When
presenting symptoms are extraesophageal, there is less enthusiasm for operative
control of reflux because of concerns of etiology and efficacy. This study was
undertaken to evaluate the efficacy of laparoscopic Nissen fundoplication in
palliating extraesophageal symptoms of GERD. Patients were asked to score their
symptoms before and after laparoscopic Nissen fundoplication on a Likert scale
(0 = never/none to 5 = always/every time I eat). A total of 322 patients with
extraesophageal symptoms (asthma, cough, gas/bloat, chest pain, and odynophagia)
of 4 to 5 were identified and analyzed. After fundoplication, all
extraesophageal symptom scores improved (P < 0.0001 for all, Wilcoxon
matched-pairs test). Likewise, postoperative symptoms were noted to be greatly
improved or resolved in 67 per cent to 82 per cent of patients for each symptom.
Furthermore, after fundoplication, patients were less likely to modify their
dietary (82% vs 49%) or sleeping habits (70% vs 28%) to avoid initiating/
exacerbating symptoms. Although extraesophageal symptoms are conventionally
thought to be inadequately palliated by surgery, this study documents excellent
relief of extraesophageal symptoms after laparoscopic Nissen fundoplication,
denotes high patient satisfaction, and encourages application of laparoscopic
Nissen fundoplication.
-----
Am J Gastroenterol. 2006 Mar;101(3):440-5.
Endoscopic treatment for atypical manifestations of
gastroesophageal reflux disease.
Liu JJ, Carr-Locke DL, Osterman MT, Li X, Maurer R, Brooks DC, Ashley SW,
Saltzman JR.
Division of Gastroenterology, Brigham and Women's Hospital, 75 Francis Street,
Boston, MA 02115, USA.
OBJECTIVES: Atypical manifestations are common in patients with gastroesophageal
reflux disease (GERD). The aim of this study was to evaluate the response of
atypical manifestations of GERD to endoscopic antireflux treatment. METHODS:
Patients with atypical manifestations of GERD including hoarseness, cough,
wheezing, and non-cardiac chest pain were studied. Endoscopic antireflux
treatment consisted of placement of sutures below the squamo-columnar junction.
Clinical response was defined as complete resolution of the atypical symptom.
Patients were followed clinically for up to 3 yr after the procedure. Short-term
response was evaluated within 6 months of the procedure, and long-term follow-up
was determined 1-3 yr after the procedure. RESULTS: Forty-three patients met the
inclusion criteria; four patients underwent repeat procedures during the study
period and were excluded from the analysis. Long-term follow-up was available in
all 39 patients. Short-term response counts were: hoarseness, 12 of 19 patients,
cough, 17 of 19; wheezing, 8 of 9; and chest pain, 13 of 18. Long-term follow-up
of patients (mean of 18 months) for these symptoms was not significantly
different compared to short-term response. CONCLUSIONS: Endoscopic suturing of
the gastroesophageal junction appears to be a possible treatment option for
atypical manifestations of GERD and future studies are needed to determine its
role in management.
-----
Am J Gastroenterol. 2006 Mar;101(3):431-6. Comment in: Am J Gastroenterol. 2006
Mar;101(3):437-9.
Comparison of transesophageal endoscopic plication (TEP) with
laparoscopic Nissen fundoplication (LNF) in the treatment of uncomplicated
reflux disease.
Mahmood Z, Byrne PJ, McMahon BP, Murphy EM, Arfin Q, Ravi N, Weir DG, Reynolds
JV.
Department of Surgery & Medicine, Trinity Centre for Health Sciences, St James's
Hospital, Dublin 8, Ireland.
BACKGROUND: Transesophageal endoscopic plication (TEP) is a novel
endotherapeutic approach in the management of gastroesophageal reflux disease (GERD).
This non-randomized prospective study compares TEP with laparoscopic Nissen
fundoplication (LNF). METHODS: Twenty-four consecutive patients treated with LNF,
and 27 managed by TEP were studied. Symptom severity scores, endoscopy, 24 h
esophageal pH and esophageal manometry and quality-of-life assessments were
obtained pre- and posttreatment. RESULTS: In the LNF group the mean age was 36
yr (17-68) compared with 39 yr (22-62) in the TEP group. Symptom scoring, acid
regurgitation score, reduction in the requirements of proton pump inhibitors (PPIs),
and quality of life remained significantly improved in both groups at a median
of 1 yr [10-18 months] follow-up post procedure. However, the improvement was
significantly better in symptom score (p= 0.0383) and the control of acid reflux
in the LNF group (p= 0.0007). Post-procedure dysphagia was more common in the
LNF group. CONCLUSION: Both techniques improved symptom score, acid
regurgitation, quality of life, and reduced the requirements for PPIs. The
control of heartburn and acid reflux was better for LNF. TEP, like LNF, is a
safe and effective method of management of symptomatic GERD but further
developments are necessary to ensure control of esophageal acid reflux.
-----
Am J Gastroenterol. 2006 Mar;101(3):422-30. Comment in: Am J Gastroenterol. 2006
Mar;101(3):437-9.
Endoluminal gastroplasty (EndoCinch) versus endoscopic polymer
implantation (Enteryx) for treatment of gastroesophageal reflux disease: 6-month
results of a prospective, randomized trial.
Domagk D, Menzel J, Seidel M, Ullerich H, Pohle T, Heinecke A, Domschke W,
Kucharzik T.
Department of Medicine B, University of Muenster, Albert-Schweitzer-Strasse 33,
D-48129 Muenster, Germany.
OBJECTIVES: The aim of this study was to compare and determine the efficiency
and safety of two newly introduced endoscopic antireflux procedures in the
treatment of gastroesophageal reflux disease (GERD). METHODS: In a prospective,
randomized trial, endoluminal gastroplasty (EndoCinch) was compared with polymer
injection (Enteryx) employing 51 consecutive patients dependent on proton pump
inhibitor therapy. Follow-up evaluation included drug consumption, symptoms,
quality-of-life scoring, endoscopy, pH monitoring, manometry, and documentation
of adverse events. RESULTS: Twenty-six patients were assigned to EndoCinch
treatment, 23 patients received Enteryx implantation, and two patients dropped
out before applying endoscopic therapy. At 6 months, proton pump inhibitor
therapy could be stopped or dosage was reduced by > or =50% in 20 of 26 (77%)
EndoCinch-treated patients and in 20 of 23 patients treated by Enteryx (87%, p=
0.365), which differed significantly in both groups compared to the
pre-interventional status (p < 0.0001). Esophageal acid reflux (pH < 4)
decreased from 14.5% to 9.6% in EndoCinch-treated patients (p= 0.071) and from
15.5% to 13.9% in patients treated by Enteryx (p= 0.930). Heartburn symptom
score, modified DeMeester score, gastrointestinal life quality index, and SF-36
physical health survey score improved significantly in both groups
postinterventionally (p < 0.0001). Approximately 25% of the patients in both
groups required retreatment in an attempt to achieve symptom control.
CONCLUSIONS: This is the first prospective, randomized study directly comparing
two endoscopic anti-GERD techniques. EndoCinch and Enteryx seem to be equally
successful in the treatment of GERD significantly reducing the proton pump
inhibitor dosages, and also by improving symptoms of patients. Both endoluminal
antireflux procedures may be promising therapeutic options; long-term evaluation
will have to show if the positive initial results can be maintained.
-----
Arch Surg. 2006 Mar;141(3):289-92; discussion 292.
Laparoscopic fundoplication in elderly patients with
gastroesophageal reflux disease.
Tedesco P, Lobo E, Fisichella PM, Way LW, Patti MG.
Department of Surgery and Anesthesia, University of California, San Francisco,
USA.
HYPOTHESIS: It is unclear if age should be considered a factor in the choice of
treatment for gastroesophageal reflux disease (GERD) and if fundoplication in
elderly patients is as safe and effective as it is in younger patients. We
hypothesized that the outcome of laparoscopic antireflux operations in patients
younger than 65 years is similar to that of patients 65 years and older. DESIGN:
Retrospective review of findings from a prospectively acquired database.
SETTING: University-based tertiary care center. PATIENTS: Three hundred four
consecutive patients underwent laparoscopic fundoplication for GERD. Two hundred
forty-one patients were younger than 65 years (group A; median age, 46 years),
and 63 patients were 65 years or older (group B; median age, 69 years). MAIN
OUTCOME MEASURES: Presence, duration, and severity of GERD symptoms; presence of
a hiatal hernia or esophageal stricture; duration of operation; incidence of
complications; and length of hospital stay. RESULTS: Elderly patients more often
had regurgitation and respiratory symptoms in addition to heartburn. Hiatal
hernias were more common among elderly patients (77% vs 51%). The duration of
the operation was similar for the 2 groups. The incidence of intraoperative and
postoperative complications was low and similar in the 2 groups. The median
hospital stay was 24 hours for each group. Heartburn resolved in approximately
90% of patients in each group. CONCLUSIONS: Elderly patients more often had
hiatal hernias and respiratory symptoms. Laparoscopic antireflux surgery was as
safe in elderly patients as it was in younger patients, and clinical outcomes
were as good.
-----
Schweiz Rundsch Med Prax. 2006 Mar 29;95(13):483-7.
[Long-term treatment of patients with symptomatic
gastroesophageal reflux disease comparing costs and efficacy over 6 months of
treatment with Nexium On-Demand Treatment or Nexium continuous treatment. An
open, randomised multi-center study]
[Article in German]
Beglinger C, Thalmann C, Szucs T, Michetti P.
Gastroenterologie, Universitatsspital Basel. beglinger@tmr.ch
This open, randomized study (ONE: On-demand Nexium Evaluation) compared the two
long-term management options with esomeprazole 20 mg--continuous daily or
on-demand treatment--in endoscopically uninvestigated patients seeking primary
care for symptoms suggestive of gastroesophageal reflux disease (GERD) who
demonstrated complete relief of symptoms after four weeks of initial treatment
with esomeprazole 40 mg. In total 1904 patients were randomized. During 26 weeks
913 patients received continuous daily therapy with esomeprazole 20 mg, once
daily, while 991 patients were treated with esomeprazole 20 mg on-demand. The
continuous therapy offered slightly better relief of the symptom heartburn,
however esomeprazole 20 mg taken on-demand was associated with lower direct
medical costs. Esomeprazole was generally well tolerated.
-----
Minerva Chir. 2006 Feb;61(1):9-15.
Surgical therapy for patients with extraesophageal symptoms of
gastroesophageal reflux disease.
Bresadola V, Dado G, Favero A, Terrosu G, Barriga Sainz M, Bresadola F.
Department of General Surgery, University of Udine, Udine, Italy.
AIM: The last 20 years have seen a systematic reappraisal of the physiopathology
and diagnosis of gastroesophageal reflux disease (GERD) and its associated
typical symptoms, while less attention has been paid to correlating GERD with
certain extraesophageal symptoms and the value of surgery for their treatment.
The aim of this study was to determine the clinical and physiopathological
features and the outcome of surgery, in a group of patients who underwent
laparoscopic fundoplication for GERD with atypical symptoms, and to compare the
results with another group of patients operated for GERD with typical symptoms.
METHODS: Two hundred and forty-one patients were evaluated for GERD at our
Digestive Physiopathology outpatients surgery from January 2001 to January 2003.
Of the 36 patients who underwent laparoscopic fundoplication, 23 had the typical
symptoms of GERD and 13 had atypical symptoms. Twelve months after surgery,
these patients were compared in terms of 24-h pH monitoring, esophageal
manometry, regression of symptoms and degree of satisfaction. RESULTS:
Postoperatively, patients with atypical symptoms had a smaller increase in
effective peristalsis (P=0.06) and a more limited improvement in symptoms (54%
vs 91%, P=0.001), and they expressed less satisfaction with the surgical
treatment (5.9 vs 8.2, P=0.003). CONCLUSIONS: The results of surgery in GERD
patients with atypical symptoms are worse than in those with typical symptoms. A
careful preoperative work-up, based on 24-h pH monitoring, is fundamental for
patients with atypical symptoms, who also need to be informed of the high
likelihood of surgery proving clinically unsuccessful.
-----
Rev Med Suisse. 2006 Feb 22;2(54):518-20, 523-5.
[How to deal with gastroesophageal reflux in childhood]
[Article in French]
Schuler Barazzoni M, Belli DC, Schappi M.
Service de gastro-enterologie et transplantation pediatriques, Departement de
pediatrie, HUG, Hopital des Enfants 1211 Geneve 14. mirjam.schuler@hcuge.ch
Gastroesophageal reflux is frequent source of consultation at the
paediatrician's room, although most GER resolve spontaneously in infancy. In
most cases, after a thorough anamnesis and a full physical examination
prokinetic and anti-acid medications are started, as well as postural change,
without the assistance of a specialist. When reflux is complicated by either
oesophagitis, respiratory symptoms, failure to thrive or when the above
treatment fail, further investigations need to be undertaken. Their option will
depend on the clinical presentation. Rarely GER will lead to surgery.
-----
Surg Endosc. 2006 Jan 2; [Epub ahead of print]
Five-year results of laparoscopic Toupet fundoplication as the
primary surgical repair in GERD patients: Is it durable?
Zehetner J, Holzinger F, Breuhahn T, Geppert C, Klaiber C.
Department of Surgery, Aarberg Hospital, Aarberg, Switzerland, joerg.zehetner@akh.linz.at.
INTRODUCTION: Most surgeons operate on gastroesophageal reflux disease (GERD)
patients using the concept of "tailored approach," which depends on esophageal
motility. We have abandoned this concept and performed laparoscopic Toupet
fundoplication in all patients suffering from GERD, independent of their
esophageal motility. METHODS: In a prospective trial we have assessed and
evaluated our 5-year results of the first 100 consecutive patients treated with
laparoscopic Toupet fundoplication. All patients were evaluated preoperatively
by endoscopy and 24-h pH manometry. The patients were followed up clinically 1,
2, 6, 12 and 60 months postoperatively. The course of clinical DeMeester score,
appearance and treatment of wrap-related side-effects as well as long-term
outcome and patient satisfaction were evaluated. RESULTS: The 5-year follow-up
rate was 87%. Laparoscopic Toupet fundoplication achieved a 5-year healing rate
of GERD in 85%. Of all operated patients, 3.5% had to be reinstalled on a
regular PPI treatment because of postoperative GERD reappearance. The median
clinical DeMeester score decreased from 4.27 +/- 1.5 points preoperatively to
0.47 +/- 0.9 points 5 years postoperatively (p < 0.0005). Because of persistent
postoperative dysphagia, 5% of the patients required endoscopic dilatation
therapy. Persistent postoperative gas-bloat syndrome occurred in 1.1%. Wrap
dislocation was identified in 3.4% of patients. Reoperation rate was 5%. Total
morbidity rate was 19.5% and operative related mortality rate was 0%. Overall,
96.6% of patients were pleased with their outcome at late follow-up, and 95.4%
of patients stated they would consider undergoing laparoscopic fundoplication
again if necessary. CONCLUSION: Our long-term results showing a low recurrence
and morbidity rate of laparoscopic Toupet fundoplication encourage us to
continue to perform this procedure as the primary surgical repair in all GERD
patients, independent of their esophageal motility. Laparoscopic Toupet
fundoplication has proven to be a safe and successful therapeutic option in GERD
patients.
-----
Surg Endosc. 2006 Jan;20(1):159-65. Epub 2005 Dec 7.
Clinical results of laparoscopic fundoplication at ten years
after surgery.
Dallemagne B, Weerts J, Markiewicz S, Dewandre JM, Wahlen C, Monami B, Jehaes C.
Department of Digestive Surgery, CHC-Les Cliniques Saint Joseph, Belgium.
bernard.dallemagne@skynet.be
BACKGROUND: Several studies have demonstrated laparoscopic antireflux surgery
(LAS) for the treatment of gastroesophageal reflux disease (GERD) to be
efficient at short- and midterm follow-up evaluations. The aim of this study was
to evaluate the results for LAS 10 years after surgery. METHODS: The 100
consecutive patients who underwent LAS by a single surgeon in 1993 were entered
into a prospective database. Nissen fundoplication was performed for 68
patients, and partial posterior fundoplication (modified Toupet procedure) was
performed for 32 patients. Evaluations of the outcome were made 5 and 10 years
after surgery. A structured symptom questionnaire and upper gastrointestinal
barium series were used at 5 years. The same questionnaire and an added
quality-of-life questionnaire (the Gastrointestinal Quality of Life Index [GIQLI])
were used at 10 years. RESULTS: Seven patients died of unrelated causes during
the 10-year period. Four patients underwent revision surgery: one patient for
persistent dysphagia and three patients for recurrent reflux symptoms. Three
patients were lost to any follow-up study. At 5 years, 93% of the patients were
free of significant reflux symptoms. At 10 years, 89.5% of the patients still
were free of significant reflux (93.3% after Nissen, 81.8% after Toupet). Major
side effects (flatulence and abdominal distension) were related to "wind"
problems. The GIQLI scores at 10 years were significantly better than the
preoperative scores of the patients under medical therapy with proton pump
inhibitors. CONCLUSIONS: Elimination of GERD symptoms improved quality of life
and eliminated the need for daily acid suppression in most patients. These
results, apparent 5 years after the operation, still were valid at 10 years.
-----
Dis Esophagus. 2006;19(1):1-4.
Nonsurgical factors affecting symptomatic outcomes of antireflux
surgery.
Velanovich V.
Division of General Surgery, Henry Ford Hospital, Detroit, Michigan, USA.
SUMMARY. A small number of patients will have persistent or new symptoms after
antireflux surgery for gastroesophageal reflux disease (GERD). Most of these
symptoms are due to recurrent reflux or some complication or side-effect of the
operation. However, a few of these patients will be symptomatic without
objective findings to explain these symptoms. The purpose of this review is to
highlight potential non-surgical factors that may proceed to a poor symptomatic
outcome after antireflux surgery. These factors include underlying esophageal
pathophysiology, issues related to chronic pain and pain perception, personality
and psychoemotional disorders, functional esophageal and/or bowel disorders, and
the nocebo phenomenon. Awareness of these other causes can lead to more
appropriate treatments.
-----
Pharm World Sci. 2005 Dec;27(6):432-5.
Treatment of gastroesophageal reflux disease.
Pettit M.
Clinical Pharmacy Unit, Royal Sussex Country Hospital, University of Brighton,
Eastern Road, Brighton, BN2 5BE, UK, Pettit@bsuh.nhs.uk.
AIM OF THE REVIEW AND METHODS: This review brings together information on the
treatment of gastroesophageal reflux disease. Published manuscripts were
identified from Medline. The articles were then screened for relevance prior to
inclusion in the review. RESULTS AND CONCLUSION: Up to 40% of people in Western
countries are estimated to regularly experience heartburn, the most
characteristic symptom of gastroesophageal reflux disease (GERD). Treatment
options available for GERD range from over-the-counter (OTC) antacids to proton
pump inhibitors (PPIs) and anti-reflux surgery. Many patients self-medicate with
OTC medications such as antacids and low-dose histamine H(2)-receptor
antagonists (H(2)RA) to relieve episodic or food-related symptoms of GERD, and
may not seek medical advice unless symptoms persist or worsen. However, GERD is
a chronic disease that frequently affects health-related quality of life and, if
not properly managed, the complications of GERD may include erosive oesophagitis
(EO), Barrett's oesophagus and adenocarcinoma. Adequate control of acid
secretion is key to the successful treatment of the condition. OTC medications
provide effective symptom relief to about one quarter of patients suffering from
GERD. H(2)RAs can also provide effective symptomatic relief, particularly in
patients with milder GERD, but become less-effective over time. PPIs are the
agents of choice for the suppression of gastric acid production and have become
the mainstay of therapy for acid-related diseases. PPIs produce significantly
faster and more complete symptomatic relief, significantly faster and more
complete healing of erosive GERD compared with H(2)RAs and are also
significantly more effective at preventing relapse of EO. There are a number of
existing guidelines for the treatment of GERD. Recommendation for initial
therapy consist of general measures, such as lifestyle advice in combination
with antacids and/or alginates. When general measures fail, the next step is
empirical therapy. Two options exist for the expirical treatment of GERD,
so-called "step-up" or "step-down" therapy. There are no clear data to support
either treatment strategy as a universal approach to all patients; consequently,
physicians must always choose the course best suited to the individual patient.
-----
Am Surg. 2005 Nov;71(11):950-3; discussion 953-4.
Amelioration of gastroesophageal reflux symptoms following
Roux-en-Y gastric bypass for clinically significant obesity.
Nelson LG, Gonzalez R, Haines K, Gallagher SF, Murr MM.
Department of Surgery, Interdisciplinary Obesity Treatment Group, University of
South Florida Health Sciences Center, Tampa, Florida 33601, USA.
Symptoms of gastroesophageal reflux disease (GERD) are frequent in patients with
clinically significant obesity and are reported to improve after Roux-en-Y
gastric bypass (RYGB). The purpose of this study is to determine timing and
duration of improvement of GERD symptoms in patients undergoing RYGB.
Prospectively collected data from patients who underwent RYGB from January 1998
to August 2004 were analyzed. Patients answered a standardized questionnaire
pre- and postoperatively inquiring about frequency of GERD symptoms (none, one
episode/ week, one episode/day, more than one episode/day) and medication use.
Of 606 patients undergoing RYGB, 239 patients (39%) reported GERD symptoms
preoperatively (mean age 43 +/- 1 years; body mass index 51 +/- 1 kg/m2). Of
these, 89 per cent of patients reported improved at 3 months post-op and 94 per
cent of patients 9 months post-op (P < 0.001). Medication usage decreased from
30 per cent to 3 per cent by 3 months and 5 per cent beyond 9 months (P <
0.001). Percentage of excess weight loss was 18 +/- 1 per cent and 75 +/- 2 per
cent at 3 and 9 months, respectively. Symptoms of GERD significantly improve and
use of antireflux medications is reduced after RYGB independent of weight loss.
RYGB may be the treatment of choice for GERD in obese patients.
-----
Rev Gastroenterol Disord. 2005;5 Suppl 2:S18-30.
Intravenous proton pump inhibitor therapy: a rationale for use.
Armstrong D.
Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada.
Proton pump inhibitors (PPIs) are used widely in the management of acid-related
disorders and, for the majority of patients, oral therapy is highly effective.
Not all patients with acid-related disorders respond completely to standard,
once-daily PPI therapy, but most nonresponders will generally respond to an
increase in the dose or frequency of PPI therapy. At equivalent doses, oral and
intravenous (IV) PPIs produce comparable acid suppression; thus there are very
few clinical indications for IV PPI therapy. IV PPIs are an appropriate
substitute for oral PPIs, at an equivalent dose, for patients with, for example,
gastroesophageal reflux disease, peptic ulceration, or Zollinger-Ellison
syndrome, who cannot take oral medication. For patients with nonvariceal, upper
gastrointestinal hemorrhage, profound acid suppression (gastric pH . 6.0)
optimizes clot stability and reduces the risk of rebleeding; this is achieved
most effectively with an initial IV PPI bolus followed by a continuous infusion.
High-dose, IV PPI therapy is beneficial and cost-effective in patients who have
a high-risk lesion at endoscopy and it should be preceded by effective
endoscopic hemostasis if possible. IV PPIs, preoperatively and in the intensive
care setting, effectively reduce gastric acidity, but there are no convincing
data that this confers any significant clinical benefit compared with other
therapeutic strategies.
-----
Schweiz Rundsch Med Prax. 2005 Nov 30;94(48):1899-906.
[Gastroesophageal reflux disease]
[Article in German]
Grater H.
Klinik fur Onkologie, Gastroenterologie und Aligemeine Innere Medizin,
Stadtische Kliniken Esslingen.
Gastroesophageal reflux disease (GERD) includes different manifestations of
esophageal and extraesophageal affections, such as erosive reflux disease,
Barrett's esophagus, laryngitis and even pulmonary diseases. Typical symptoms
are heartburn and acid regurgitation, but there are a lot of atypical
disturbances like hoarseness or chronic cough. Endoscopy is the most important
diagnostic procedure for elderly patients and for those with atypical symptoms.
Younger people without alarming symptoms can be tested for GERD by treatment
with proton pump inhibitors (PPI). The therapeutic approach depends on the
endoscopic findings. PPI are preferred drugs to manage most GERD-related
problems. Anti reflux surgery is appropriate for selected patients. Long-term
followup data will help to define the benefit of new endoscopic procedures.
Barrett's esophagus has to be regarded as a precancerous lesion, therefore
surveillance strategy is required.
-----
Dis Esophagus. 2005;18(6):370-3.
Histamine-2 receptor antagonists at night improve
gastroesophageal reflux disease symptoms for patients on proton pump inhibitor
therapy.
Rackoff A, Agrawal A, Hila A, Mainie I, Tutuian R, Castell DO.
Digestive Diseases Center, Medical University of South Carolina, Charleston,
South Carolina 29425, USA. rackoff@musc.edu
While night-time symptoms of gastroesophageal reflux disease (GERD) are common,
considerable controversy exists regarding the use of histamine-2 receptor
antagonists (H2Ras) for night-time reflux control. Some studies have suggested
possible tolerance to H2RA while others have suggested that long-term efficacy
of gastric acid control can be maintained with night-time H2RA use. The aim of
this study was to identify if GERD patients have sustained symptom improvement
with long-term use of night-time H2RA. Records of 56 consecutive GERD patients
on twice daily proton pump inhibitor (PPI) and night-time H2RA therapy were
reviewed. During a phone interview patients were asked a 5-item questionnaire,
which included overall assessment of symptoms, night-time symptoms, sleep
disturbance, duration and frequency of therapy. Of the 56 patients, 39 (31
women, mean age 56) completed the questionnaire (15 were not reached and 2 did
not recall enough information). All respondents had taken night-time H2RA for at
least 1 month (28/39 patients with > 6 months duration) with 33/39 patients
taking H2RAs every night. The addition of H2RA led to an improvement in overall
symptoms in 28/39 (72%) patients, improvement in night-time reflux symptoms in
25/34 (74%) patients and improvement of GERD-associated sleep disturbance in
18/27 (67%) patients. Five (13%) patients had stopped the H2RA on their own,
stating that its efficacy waned after 1 month. Our results suggest that the
majority of patients report persistent improvement in GERD symptoms from
night-time H2RA use and that possible clinically important tolerance to H2RAs
occurs in a small number of patients. Further prospective, placebo-controlled
studies may help confirm that there is a role for night-time H2RAs in GERD
symptom control.
-----
Drugs. 2005;65 Suppl 1:59-66.
Maintenance therapy in gastro-oesophageal reflux disease.
Bixquert M.
Department of Medicine, University of Valencia, Spain. miguel.bixquert@uv.es
Gastro-oesophageal reflux disease (GORD) is a chronic condition. Symptom control
and the maintenance of healing of erosive oesophagitis, if present, are
important topics. In patients responding to a proton pump inhibitor (PPI) and
showing no treatment symptoms it is appropriate to consider long-term treatment
strategies, whether continuous, intermittent or on demand. Maintenance PPI
therapy is well tolerated for up to 10 years of continuous use. Furthermore,
tachyphylaxis does not occur during long-term maintenance PPI therapy. Previous
concerns about risks of long-term PPI therapy in Heliobacter pylori-negative or
H. pylori-positive patients have not materialized, while no cases of intestinal
metaplasia with dysplasia or adenocarcinoma were found. The choice between
medical and surgical therapy should depend upon informed patient preference. The
optimal candidate for antireflux surgery is a young patient, with typical GORD
symptoms, with erosive oesophagitis, with previous complete symptom resolution
on acid-suppression therapy and unable to undergo continuous therapy, or
alternatively in patients with regurgitation predominating over heartburn as
long as the surgical procedures are conducted by an expert surgical team.
Endoscopic therapy for erosive GORD should currently be regarded as
experimental. The endoscopic procedures are safe, although they remain untested
in patients with severe erosive oesophagitis and/or significant hiatal hernia.
-----
Langenbecks Arch Surg. 2005 Nov 18;:1-8 [Epub ahead of print]
Long-term experience of treating 185 patients with
gastroesophageal reflux disease (GERD) by anti-reflux surgery respecting the
functional-morphological restoration of the esophagus.
Horstmann R, Classen C, Rottgermann S, Langer M, Palmes D.
Department of Surgery, Herz Jesu-Krankenhaus Muenster-Hiltrup, Westfalenstrasse
109, 48151, Muenster, Germany, chirurgie@herz-jesu-kh-ms.de.
BACKGROUND: According to anatomical investigations the whole esophagus plays a
crucial role as reflux barrier in the pathogenesis of gastroesophageal reflux
disease (GERD). Morphologically, the spirally arranged muscle fibres present a
tension-dependent "stretch closure" and in the event of any reduction of
tension, as for example caused by an axial hiatus hernia, the organ may become
inefficient. The aim of this study was to evaluate quality of life as the main
success criterion after anti-reflux surgery based strictly on the restoration of
functional morphology. METHODS: Between January 1999 and December 2000, 185
patients with GERD were treated by surgery in accordance with
functional-morphological principles. After dissecting the mediastinum, the
gastroesophageal junction was displaced into the abdomen with consecutive
retensioning the esophagus. The esophageal hiatus was reconstructed with
non-absorbable single knot sutures and strengthened with alloplastic material.
The application of a 180 degrees fundus cuff around the posterior esophageal
circumference served as a "spacer" and also restored the angle of His.
Preoperatively, all patients underwent endoscopy, pH metry and manometry. During
postoperative follow-up, recurrence rate and quality of life were evaluated via
a disease-specific scale. RESULTS: Preoperatively, 85% of the patients had an
elevated DeMeester Score with a median of 81.4; 64% had reflux esophagitis and
37% had reduced lower esophageal sphincter pressure. All 185 operations were
performed without conversion in a median operating time of 74 min. In one
patient a lesion of the esophagus was treated during the operation; two patients
had lesions of the splenic capsule which were also dealt with during the
operation. Postoperatively, pleural effusions occurred in 15 patients and
puncture was deemed necessary in one subject. Ninety-three percent were followed
up for a median of 45 months and the recurrence rate was 2.3%. The quality of
life index was 81.6+/-12.4 points preoperatively, and had significantly improved
to 125.2+/-12.7 points in the follow-up. CONCLUSION: Through the
functional-morphological concept of anti-reflux surgery comprising the
restoration of the tension-dependent "stretch closure" of the esophagus,
significant long-term improvement in quality of life with a low recurrence rate
and perioperative morbidity can be achieved.
-----
Dig Dis Sci. 2005 Nov;50(11):2009-18.
Efficacy of rabeprazole in the treatment of symptomatic
gastroesophageal reflux disease.
Kahrilas PJ, Miner P, Johanson J, Mao L, Jokubaitis L, Sloan S.
Northwestern University Feinberg School of Medicine, Chicago, Illinois.
The purpose of this study was to assess the rapidity of symptom relief and
4-week efficacy of rabeprazole 20 mg in patients with moderately severe
nonerosive gastroesophageal reflux disease. Data were analyzed from 2 similarly
designed, double-blind, placebo-controlled, multicenter, U.S. trials. After a
2-week placebo run-in period, patients (N = 261) were randomized to 4 weeks of
rabeprazole 20 mg once daily or placebo. Patients kept symptom diaries and
scored symptom severity. Median time to first 24-hour heartburn-free interval
was 3.5 days for the rabeprazole group compared with 19.5 days for the placebo
group (P </= .0002). Complete heartburn relief at week 4 was 32% with
rabeprazole and 3.8% with placebo (P </= .001). Rabeprazole also significantly
improved other GERD-associated symptoms (e.g., regurgitation, belching, early
satiety) by week 4 compared with placebo (P </= .05). Rabeprazole provides fast
and potent relief from heartburn and other symptoms of nonerosive
gastroesophageal reflux disease.
-----
Arch Surg. 2005 Oct;140(10):946-51.
Laparoscopic antireflux surgery: five-year results and beyond in
1340 patients.
Pessaux P, Arnaud JP, Delattre JF, Meyer C, Baulieux J, Mosnier H.
Department of Digestive Surgery, University Hospital, CHU Angers, 4 Rue Larrey,
49033 Angers Cedex 01, France.
BACKGROUND: Although the long-term results of open fundoplication for
gastroesophageal reflux disease are well documented, few reports exist on the
long-term results of laparoscopic fundoplication. DESIGN: Retrospective study
with clinical evaluation or mailed survey for patients unable to return to the
hospital center. SETTING: Multicenter studies (ie, private medical centers,
institutional hospitals, and university hospitals). PATIENTS: Between January
1992 and December 1998, 2684 patients with gastroesophageal reflux disease
underwent laparoscopic fundoplication in 31 hospital centers. Outcome data
covering a period of 5 or more years after surgery were available for 1340
patients: 711 who underwent complete fundoplication, 559 who underwent partial
posterior fundoplication, and 70 who underwent partial anterior fundoplication.
MAIN OUTCOME MEASURES: Evaluation of clinical and quality-of-life actions used
to treat the symptoms of gastroesophageal reflux disease. RESULTS: The overall
residual severe dysphagia rate was 5.1% (n = 68). A further surgical procedure
was required for 59 patients (4.4%) for a total of 63 interventions. Subsequent
operation was performed laparoscopically in 32 cases (50.8%). Twelve of these
procedures were for the repair of a paraesophageal hiatus hernia, 11 were for
dysphagia (4 because of a tight esophageal hiatus and 7 for conversion of Nissen
fundoplication to a posterior partial fundoplication procedure), 31 were for
recurrent reflux (wrap undone), 2 were for intestinal obstruction (adhesiolysis),
1 was for incisional hernia, 1 was for abdominal abscess (drainage), and 1 was
for gastroparesis (pyloroplasty). The recurrence rate was 10.1% (n = 136), and
122 patients (9.1%) resumed taking antisecretory medication. Gas bloat syndrome
was present in 101 patients (7.5%). A total of 93.1% of the patients were
satisfied (Visick classification, grades 1 and 2) and 6.9% were unsatisfied,
with no difference among the 3 procedures. CONCLUSION: After 5 years of
experience, laparoscopic fundoplication remains an effective antireflux
procedure.
-----
Curr Opin Pharmacol. 2005 Oct 5; [Epub ahead of print]
Gastroesophageal reflux disease.
Armstrong D.
Division of Gastroenterology, HSC-2F55, McMaster University Medical Centre, 1200
Main Street West, Hamilton, Ontario Canada L8N 3Z5.
Gastroesophageal reflux disease (GERD) is increasingly common worldwide;
symptoms differ between individuals and endoscopically visible injury is present
in only about 50% of cases. Although GERD is a disorder of gastrointestinal
motility and structure, the most effective therapy is based on the use of acid
antisecretory drugs. Proton pump inhibitors (PPIs), the most effective class of
acid suppression agents to date, have revolutionised the management of GERD.
However, PPIs do have some shortcomings and recent developments include
documentation of increased healing rates with more prolonged acid suppression,
more prolonged acid suppression with a new PPI (tenatoprazole) and more rapid
onset of acid suppression with a new class of drugs, the reversible,
potassium-competitive acid blockers. Studies with motility agents, such as the
5-HT(4) partial agonist tegaserod and the GABA(B) agonist baclofen, indicate
that motility is important in the pathogenesis of GERD but, for several reasons,
it will be a challenge to develop new classes of drug that outperform current
PPIs with respect to efficacy, broad applicability and safety.
-----
Eur J Intern Med. 2005 Oct;16(6):391-401.
Gastroesophageal reflux.
Zamir D.
Department of Internal Medicine D, Barzilai Medical Center, Ashkelon, 78306,
Israel.
Gastroesophageal reflux disease (GERD) is the most common disease of the
gastrointestinal system. Heartburn, regurgitation, and dysphagia are the most
common symptoms of GERD. However, chest pain, chronic cough, laryngitis,
hoarseness, and other otolaryngologic manifestation can be the primary
manifestations of the disease. Endoscopy, barium studies, and especially pH
monitoring and therapeutic trials may help in establishing the diagnosis of GERD.
The introduction of H2 antagonists and especially of proton pump inhibitors (PPI)
has brought symptomatic relief in most patients. However, surgical procedures,
especially laparoscopic fundoplication, are still required in some patients.
Barrett's esophagitis is the most common complication of GERD and is associated
with a high prevalence of esophageal adenocarcinoma. Whether or not treatment
with either PPIs or H2 antagonists can prevent this complication is still under
investigation.
-----
Int J Clin Pract. 2005 Oct;59(10):1204-9.
Recent advances in the treatment of GERD in the elderly: focus on
proton pump inhibitors.
Pilotto A, Franceschi M, Paris F.
IRCCS, Casa Sollievo della Sofferenza, Istituto di Ricovero e Cura a Carattere
Scientifico, San Giovanni Rotondo, Italy. alberto.pilotto@libero.it
The prevalence of gastroesophageal reflux disease (GERD) increases with age, and
older people are more likely to develop severe disease. Studies of elderly
patients with GERD indicate differences in presentation and diagnosis, compared
with GERD in younger adults. Indeed, an older patient with GERD may present with
atypical symptoms such as dysphagia, vomiting, weight loss, anaemia and
anorexia, and less frequently with typical symptoms such as heartburn or acid
regurgitation. These findings are attributed to pathophysiological changes in
esophageal function that occur with age. Therefore, GERD in elderly patients is
more likely to be poorly diagnosed or undiagnosed. Although few studies have
concentrated specifically on elderly patients, the proton pump inhibitors (PPIs)
have been shown to be more effective than histamine receptor antagonists for
healing reflux esophagitis and for preventing its recurrence when they are given
as maintenance therapy. In addition, the PPIs seem to be safe both in short- and
in long-term therapy of elderly patients with GERD.
-----
Surg Endosc. 2005 Oct;19(10):1309-14. Epub 2005 Aug 11.
European multicenter survey on the laparoscopic treatment of
gastroesophageal reflux in patients aged less than 12 months with
supraesophageal symptoms.
Mattioli G, Bax K, Becmeur F, Esposito C, Heloury Y, Podevin G, Lima M,
MacKinlay GA, Goessler A, Tovar JA, Valla J, Tuo P, Nahum L, Ottonello G, Sacco
O, Gentilino V, Pini-Prato A, Caponcelli E, Jasonni V.
Pediatric Surgery, Gaslini Research Institute, University of Genova, Italy.
girolamomattoli@ospedale-gaslini.ge.it
BACKGROUND: This multicenter survey includes neonates and infants who underwent
surgery for primary gastroesophageal reflux (GER) who presented with
supraesophageal symptoms of unknown origin with a minimum of 12 months
postoperative follow-up. METHODS: A total of 726 patients underwent GER surgery
in 10 European Centers in the period 1998-2002. Respiratory symptoms were
present in 204 patients (28%); 135 patients (17%) had surgery under 1 year of
age, and 46 of them (6.3%) because of respiratory symptoms. Surgery was
performed without any previous medical treatment in 10 cases (21%). The type of
procedure included 37 complete 360 degrees wraps (80%) (Nissen, 12, and Rossetti,
25) and nine partial wraps (20%) (Thal five, Lortat Jacob one, Toupet one,
others two). Gastrostomy was associated in 17 cases (37%) (6 PEG and 11 modified
Stamm). No gastric emptying procedures were recorded. RESULTS: No major
intraoperative complications were reported. Six patients developed complications
(13%) and a redo operation was performed in three (6.5%). Respiratory outcome
after antireflux surgery was good in 35 patients (76%) and fair with
significantly improved respiratory symptoms in 11 (24%). CONCLUSIONS: This
multicenter survey underlines that GER has to be suspected and aggressively
treated in infants with difficult-to-treat supraesophageal symptoms, and also in
high-risk cases, in order to prevent major complications.
-----
Clin Gastroenterol Hepatol. 2005 Sep;3(9):831-9.
Endoscopic antireflux procedures: a good wrap?
Wakelin DE, Sampliner RE.
Section of Gastroenterology, Southern Arizona VA Health Care System and
University of Arizona Health Sciences Center, 3601 S. 6th Avenue, Tucson, AZ
85723, USA.
BACKGROUND & AIMS: Gastroesophageal reflux disease (GERD) is prevalent
worldwide. Until recently patients and physicians have had a choice between
long-term medical therapy, usually in the form of proton pump inhibitors (PPIs),
or surgical fundoplication. During the past several years, endoscopic antireflux
therapies have been approved for GERD patients to potentially obviate the risks
of surgery and avoid long-term medication use. The objective of this review was
to critically evaluate existing literature on endoscopic antireflux therapies
with regards to efficacy and safety. METHODS: A review of human studies by using
Pub Med was performed. RESULTS: Injectable LES implants, endoscopically placed
gastric plications, and radio frequency energy application to the LES comprise
the 3 modes of antireflux therapies. These techniques received approval by the
Food and Drug Administration on the basis of symptomatic evidence supplied by
numerous uncontrolled trials. As a group, these techniques have demonstrated
efficacy less than medical and surgical options, and yet they carry a rare but
significant risk of serious complications and even death. CONCLUSIONS: The field
is still evolving at this stage, and there is a need for more randomized sham
and placebo-controlled trials to better define the subjective and objective
outcomes of these endoscopic procedures. At this time endoscopic antireflux
procedures should be used with caution after discussing risks and benefits with
the patient.
-----
Am J Gastroenterol. 2005 Sep;100(9):1914-22.
Effect of esomeprazole on nighttime heartburn and sleep quality
in patients with GERD: a randomized, placebo-controlled trial.
Johnson DA, Orr WC, Crawley JA, Traxler B, McCullough J, Brown KA, Roth T.
Eastern VA School of Medicine, Norfolk, Virginia, USA.
OBJECTIVES: Sleep disturbances are common in patients with gastroesophageal
reflux disease (GERD). This study examined the effects of esomeprazole on
nighttime heartburn, GERD-related sleep disturbances, sleep quality, work
productivity, and regular activities. METHODS: This multicenter, randomized,
double-blind, placebo-controlled trial included adults with GERD-associated
sleep disturbances and moderate-to-severe nighttime heartburn (recorded by
patient diary during screening). Patients received oral esomeprazole 40 mg (n =
220) or 20 mg (n = 226) or placebo (n = 229) once daily for 4 wk. The primary
outcome was relief of nighttime heartburn. Secondary outcomes included
resolution of sleep disturbances, sleep quality measured by the Pittsburgh Sleep
Quality Index (PSQI) questionnaire, and work productivity measured by the Work
Productivity and Activity Impairment Questionnaire. RESULTS: Nighttime heartburn
was relieved in 53.1% (111/209), 50.5% (111/220), and 12.7% (28/221) of patients
who received esomeprazole 40 mg, esomeprazole 20 mg, and placebo, respectively.
Differences (95% CI) versus placebo were 40.5% (32.4%, 48.5%) and 37.8% (29.9%,
45.7%) and were highly significant (p < 0.0001). GERD-related sleep disturbances
resolved in significantly more (p < 0.0001) patients who received esomeprazole
40 (73.7%) or 20 mg (73.2%) than in those who received placebo (41.2%). Both
esomeprazole groups had greater PSQI global score changes from baseline (p <
0.0001 vs placebo) and more (p < 0.0001 vs placebo) work hours saved per week
per patient compared with baseline (esomeprazole 40 mg, 11.6 h; esomeprazole 20
mg, 12.3 h; placebo, 6.2 h). CONCLUSIONS: Esomeprazole reduced nighttime
heartburn and GERD-related sleep disturbances and improved sleep quality and
work productivity.
-----
Digestion. 2005;72(2-3):76-85. Epub 2005 Aug 19.
On-demand therapy with pantoprazole 20 mg as effective long-term
management of reflux disease in patients with mild GERD: the ORION trial.
Scholten T, Dekkers CP, Schutze K, Korner T, Bohuschke M, Gatz G.
Medizinische Klinik des Allgemeinen Krankenhauses Hagen, Hagen, Germany.
scholten@akh-hagen.de
AIMS: To compare safety and efficacy of on-demand pantoprazole 20 mg/40 mg
versus placebo in the long-term management of patients with mild
gastroesophageal reflux disease (GERD) after heartburn relief. METHODS: A total
of 634 patients with endoscopically confirmed GERD grade 0/I and heartburn were
included. During the acute phase, patients were treated with pantoprazole 20 mg
once daily for 4 weeks. Those patients relieved from heartburn entered the
long-term phase, and were randomly assigned to either treatment group
pantoprazole 20 mg, 40 mg or placebo. Over 6 months, patients took study
medication on demand (antacids as rescue medication) and discontinued the drug
once symptoms abated. RESULTS: After 4 weeks a total of 87.1%/90.0% of patients
were free of heartburn (ITT/PP), and entered the subsequent long-term phase. The
perceived average daily symptom load (placebo: 3.93, pantoprazole 20 mg: 2.91,
pantoprazole 40 mg: 2.71, ITT) and the number of antacid tablets taken (average
number, placebo: 0.68, pantoprazole 20 mg: 0.45, pantoprazole 40 mg: 0.33, ITT)
were significantly higher in the placebo than in both pantoprazole groups
(p<0.0001), with no statistically significant difference between the two
pantoprazole groups. The discontinuation rate due to insufficient control of
heartburn was significantly lower in both pantoprazole groups compared to
placebo (placebo: 10.9, pantoprazole 20 mg: 2.8, pantoprazole 40 mg: 0.9, ITT).
CONCLUSIONS: Our findings favor on-demand treatment with pantoprazole 20 mg for
the long-term management of heartburn in patients with uncomplicated GERD (grade
0/I) with superiority to placebo. Copyright (c) 2005 S. Karger AG, Basel.
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Thorac Surg Clin. 2005 Aug;15(3):405-15.
Lower esophageal sphincter injections for the treatment of
gastroesophageal reflux disease.
Watson TJ, Peters JH.
Division of Thoracic and Foregut Surgery, Department of Surgery, University of
Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box Surgery,
Rochester, NY 14642, USA. thomas_watson@urmc.rochester.edu
Endoscopic therapies for the control of GERD offer the potential for significant
symptomatic improvement while obviating many of the potential drawbacks
associated with long-term medical therapy with acid suppressive or neutralizing
medications and traditional antireflux surgery. Such endoluminal therapies are
intended to be safe with a brief learning curve, easily administered in an
outpatient setting without the need for general anesthesia, reproducible, and
durable. LES injection therapies share the common theoretic method of action of
bulking at the GEJ, leading to loss of sphincter compliance and distensibility.
In the case of Enteryx, this sustained effect has been demonstrated to be
secondary to chronic inflammation, fibrosis, and encapsulation resulting from a
foreign body response to the injectate. Available data suggest that a majority
of patients respond to LES injection therapies, as demonstrated by a decreasing
usage of PPIs after implantation, the ability of many patients to terminate PPI
use completely, and improved GERD-HRQOL scores. Responses seem reasonably
durable in follow-up assessment up to 24 months post treatment. Although there
may be some placebo effect associated with treatment, patients injected with
Enteryx respond better than a control group of sham-treated subjects.
Individuals treated with LES injections, however, represent a select subgroup of
the overall population of refluxers. Study subjects, by and large, have had
uncomplicated GERD with typical reflux symptoms of heartburn or regurgitation
that have responded to PPIs. Patients who have severe anatomic derangements,
such as esophageal strictures, persistent esophagitis, Barrett's esophagus, or
sizeable hiatal hernias, are excluded from clinical trials, as are patients who
have severe motility disorders or significant comorbid conditions. Similarly,
patients who have responded poorly to PPIs and those who have primarily
extraesophageal manifestations of GERD have not been studied. Outcomes to date
have been assessed over the short to medium term; long-term outcome studies are
lacking. The durability of response, therefore, remains largely unknown, as does
the incidence of any long-term complications or side effects. A postmarket study
to assess the long-term safety and durability of Enteryx therapy up to 36 months
is under way, as required by the FDA, with a target enrollment of 300 patients.
Detailed cost analyses have yet to be reported. Such data are important not only
for comparing the various endoluminal therapies but also for comparison to
standard medical therapy and antireflux surgery. At present, no randomized
trials are completed that compare injection therapies to other accepted
treatments of GERD. The ability to perform fundoplication safely and effectively
after failed LES injection therapy is not well known, in that the number of
subsequent surgical cases is small and the results largely anecdotal to date.
Likewise, the ability to use LES injection as salvage therapy after failed
fundoplication has not been tested. The data regarding endoluminal injection
therapies are similar to those after endoscopic plication and radiofrequency
application to the LES, in that a definite symptomatic response is observed, but
the objective documentation of diminished esophageal acid exposure lags behind.
Esophageal acid exposure is normalized in a minority of treated subjects and
improved in an additional subgroup, whereas the rate of symptomatic response
exceeds these objective improvements. The reasons for this disconnect are the
subject of much speculation and controversy. A placebo effect has been
discussed, but clearly more factors are at play. Perhaps a study effect also is
important, in that patients enrolled in clinical trials for GERD control may be
more likely to modify their dietary and lifestyle habits in an effort to bring
about symptom relief. Maybe the understanding of the perception of reflux events
is lacking, and these endoluminal therapies work mainly by altering the
perception of reflux more than the amount of reflux itself. A recent technologic
review of injection therapies for GERD concludes that the "data for Enteryx are
as compelling as those of any other open-label evaluation of an endoluminal
therapy for GERD". There is much to be learned about all endoluminal techniques.
For now, LES injections are promising therapies lacking supportive evidence of
long-term safety and efficacy. The available data justify their use only in
patients who have GERD symptoms responsive to PPIs and who do not have
significant comorbidities or complications associated with GERD. Whether or not
the role of LES injection techniques will be expanded to include more
complicated cases, patients who are partially responsive to PPIs, combination
therapy with other endoluminal techniques, or salvage therapy after failed
fundoplication awaits further study.
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Am J Gastroenterol. 2005 Aug;100(8):1844-52.
Antireflux surgery outcomes in pediatric gastroesophageal reflux
disease.
Diaz DM, Gibbons TE, Heiss K, Wulkan ML, Ricketts RR, Gold BD.
Pediatric Gastroenterology and Nutrition, Emory University School of Medicine,
Atlanta, Georgia.
OBJECTIVES: Antireflux surgery is performed frequently in children with
gastroesophageal reflux disease (GERD). Few comparative studies exist which
assess the indications for and short- or long-term outcome of open Nissen
fundoplication (ONF) and laparoscopic Nissen fundoplication (LNF) for pediatric
GERD. We investigated the frequency of reoperation and factors that might
influence its occurrence. METHODS: We performed a retrospective, follow up
cohort study of all children </=5 years, who underwent LNF or ONF at our
institution from January 1, 1997 to December 31, 2002, where five pediatric
surgeons perform fundoplication. Mean follow up time was 36.2 months. The
following information was obtained: surgical indications, hospital course data,
and long-term surgical outcomes. Data were analyzed using univariate and
multiple logistic regressions. RESULTS: Overall, 456 (150 [32.9%] ONF vs. 306
[67.1%] LNF) cases were analyzed. Reoperation was performed in 55 (12.06%), LNF
43 (14.05%), and ONF 12 (8%). The mean interim to reoperation for LNF was 11
months compared to 17 months for ONF (p= 0.007). The reoperation rate at 12 and
24 months were 10.5%, 13.4% and 4%, 6.7% respectively, when LNF was compared to
ONF (p= 0.01). The multivariate analysis showed that initial LNF and prematurity
were the main predictors for reoperation. CONCLUSIONS: The majority of
reoperations for both LNF and ONF occurred in the first year after initial
operation; LNF had a significantly higher reoperation rate than ONF. The
probability of reoperation for LNF and ONF increases with the presence of
comorbidities, especially prematurity and chronic respiratory conditions. (Am J
Gastroenterol 2005;100:1844-1852).
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J Long Term Eff Med Implants. 2005;15(4):375-88.
Management of gastroesophageal reflux disease: medications,
surgery, or endoscopic therapy? (Current status and trends).
Zhi XT, Kavic SM, Park AE.
Department of General Surgery, Qilu Hospital, Shandong University, Jinan,
Shandong, P. R. China.
Gastroesophageal reflux disease (GERD) is a common chronic disorder in the
Western world. The basic cause of GERD has been well characterizedthe
fundamental defect is a loss of integrity of the gastroesophageal barrier. What
is less clear is the most appropriate means of addressing this reflux. GERD has
a variety of symptoms, ranging from typical presentations of heartburn and
regurgitation (without esophagitis) to atypical presentations, such as severe
erosive esophagitis and its associated complications. Because of its symptomatic
diversity, physicians may select from a variety of therapeutic approaches.
Medical therapy aims at decreasing acidity by suppressing proton secretion and
has been well established. Available medications include antacids and alginates,
H2-receptor antagonists, motility agents, and proton pump inhibitors (PPIs).
Antireflux surgery, commonly performed laparoscopically, aims at reinforcing and
repairing the defective barrier through plication of the gastric fundus. The
earliest performed successful procedures were the Nissen and Toupet
fundoplications, to which several modifications have since been made. It has
been demonstrated in preliminary studies and long-term outcomes of such open
surgery and preliminary studies of such laparoscopic surgery that antireflux
surgery is an effective approach, with overall outcomes superior to those
achieved with medications. The precise indications for the surgical treatment of
patients with GERD, however, remain controversial. In recent years, endoscopic
intraluminal antireflux approaches have attracted the attention of physicians,
surgeons, and commercial companies, especially after the approval of two
endoscopic intraluminal methods by the United States FDA in 2000. The common
element is prevention of acid reflux by construction of a functional or
controlled barrier in the lower esophageal sphincter zone. Three main methods
are currently employed: endoscopic intraluminal valvuloplasty, endoscopic
radiofrequency therapy, and endoscopic injection or implantation of foreign
material. The endoluminal suturing method is highly demanding technically, and
its short-term results are encouraging, although largely dependent on the
experience of the endoscopist. Several prospective cohort studies have shown
that the radiofrequency procedure (Stretta(R)) significantly improves GERD
symptoms and quality of life while reducing esophageal acid exposure and
eliminating the need for antisecretory medications in the majority of patients
within 6-12 months. Most recently, some researchers have studied the endoluminal
implantation of polymers, such as Plexiglastrade mark (polymethyl-methylacrylate),
Gatekeeper(R) hydrogel, and Enteryx(R) (ethylene vinyl alcohol copolymer). The
preliminary results of these studies showed that the implantation method was
feasible and safe; however, the only multicenter trial related to outcome that
has been published has included just 1 year of follow-up. Here, we review the
treatment of GERD: medical, surgical, and endoscopic. In addition, we provide an
algorithm based on symptoms and response to treatment for management of these
patients.
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Can J Gastroenterol. 2005 Jul;19(7):425-7.
Should we test for Helicobacter pylori before treating
gastroesophageal reflux disease?
Moayyedi P.
McMaster University, Hamilton, Canada.
Gastroesophageal reflux disease (GERD) is a common problem in childhood. The
cause is uncertain but because the incidence of GERD is increasing in developed
countries and the prevalence of Helicobacter pylori is decreasing, it has been
suggested that this infection protects against GERD. Observational data from 95
children, however, suggest that H pylori eradication does not have a deleterious
effect on GERD and this is supported by randomized controlled trials in adults.
H pylori eradication may also reduce the efficacy of proton pump inhibitor
therapy in infected patients. There are no data from children but inferences
from randomized controlled trials in adults suggest this effect is likely to be
modest and of uncertain clinical significance. H pylori is an important risk
factor for distal gastric adenocarcinoma. It is likely that treating the
infection in childhood will prevent pre-malignant changes associated with H
pylori from developing in the future. A meta-analysis of four randomized
controlled trials suggest that there is a statistically significant impact on
healing of chronic gastritis after one year compared with placebo (RR of chronic
gastritis: 0.27; 95% CI 0.23 to 0.32). H pylori eradication is therefore
recommended in children with GERD that are having an endoscopy. However, when
the diagnosis of GERD is being made clinically or by pH monitoring, it is not
necessary to screen for H pylori.
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Can J Gastroenterol. 2005 Jul;19(7):399-408.
Canadian Helicobacter Study Group Consensus Conference: Update on
the approach to Helicobacter pylori infection in children and adolescents - An
evidence-based evaluation.
Jones NL, Sherman P, Fallone CA, Flook N, Smaill F, van Zanten SV, Hunt R,
Thomson A.
The Hospital for Sick Children, Toronto, Canada.
As an update to previously published recommendations for the management of
Helicobacter pylori infection, an evidence-based appraisal of 14 topics was
undertaken in a consensus conference sponsored by the Canadian Helicobacter
Study Group. The goal was to update guidelines based on the best available
evidence using an established and uniform methodology to address and formulate
recommendations for each topic. The degree of consensus for each recommendation
is also presented. The clinical issues addressed and recommendations made were:
population-based screening for H pylori in asymptomatic children to prevent
gastric cancer is not warranted; testing for H pylori in children should be
considered if there is a family history of gastric cancer; the goal of
diagnostic interventions should be to determine the cause of presenting
gastrointestinal symptoms and not the presence of H pylori infection; recurrent
abdominal pain of childhood is not an indication to test for H pylori infection;
H pylori testing is not required in patients with newly diagnosed
gastroesophageal reflux disease; H pylori testing may be considered before the
use of long-term proton pump inhibitor therapy; testing for H pylori infection
should be considered in children with refractory iron deficiency anemia when no
other cause has been found; when investigation of pediatric patients with
persistent or severe upper abdominal symptoms is indicated, upper endoscopy with
biopsy is the investigation of choice; the 13C-urea breath test is currently the
best noninvasive diagnostic test for H pylori infection in children; there is
currently insufficient evidence to recommend stool antigen tests as acceptable
diagnostic tools for H pylori infection; serological antibody tests are not
recommended as diagnostic tools for H pylori infection in children; first-line
therapy for H pylori infection in children is a twice-daily, triple-drug regimen
comprised of a proton pump inhibitor plus two antibiotics (clarithromycin plus
amoxicillin or metronidazole); the optimal treatment period for H pylori
infection in children is 14 days; and H pylori culture and antibiotic
sensitivity testing should be made available to monitor population antibiotic
resistance and manage treatment failures.
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Ann Chir. 2005 Jul 5; [Epub ahead of print]
[The outcomes of laparoscopic fundoplication for gastro-oesophageal
reflux disease. Long term results.]
[Article in French]
Dan S, Brigand C, Pierrard F, Rohr S, Meyer C.
Service de chirurgie generale et digestive, Centre de chirurgie viscerale et de
transplantation, CHU de Strasbourg, Hautepierre, avenue Moliere, 67098
Strasbourg, France.
Introduction. - The aim of this study was to evaluate the long term efficacy of
laparoscopic treatement of gastroesophageal reflux disease (GERD). Patient and
methods. - Between 1(st) January 1992 and 31 December 1996, 161 patients
underwent complete or partial laparoscopic fundoplication for a symptomatic GERD.
One hundred and twenty three patients were submitted to Nissen-Rossetti
fundoplication, 26 patients to Nissen fundoplication and 12 patients to a
partial posterior Toupet fundoplication.141 patients were evaluated at 3 months,
2-years and 5-years. Since undergoing the operation, four patients died of
unrelated causes, 16 patients could not be contacted for follow up (10%). pH
monitoring and oesophageal manometry were performed preoperatively and at 3
months postoperatively. The patients were evaluated 2 and 5-years after surgery
by specific phone questionnaire. Results. - There was no mortality, the
morbidity rate was 1.2% and the conversion rate was 5%. Incidence of dysphagia 3
months after surgery was 23.4%, and 5-years after 12%; 12% of patients had
recurrent symptoms at 5 years. Conclusion. - The overall satisfaction rate at 5
years was 91.4%. Nissen-Rossetti fundoplication seems to have better results at
5-years regarding postoperative dysphagia and symptoms recurrence.
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Gastrointest Endosc. 2005 Jul;62(1):24-30.
Long-term results of photodynamic therapy with 5-aminolevulinic
acid for superficial Barrett's cancer and high-grade intraepithelial neoplasia.
Pech O, Gossner L, May A, Rabenstein T, Vieth M, Stolte M, Berres M, Ell C.
Department of Medicine II, HSK Wiesbaden, Teaching Hospital of the University of
Mainz, Germay.
BACKGROUND: Photodynamic therapy (PDT) with 5-aminolevulinic acid (ALA) has
proven to be safe and effective in patients with early neoplasia in Barrett's
esophagus. However, long-term results in patients with high-grade
intraepithelial neoplasia (HGIN) or with early cancer are still lacking.
METHODS: The aim of the study was to evaluate the efficacy of ALA-PDT and the
survival of patients with early Barrett's neoplasia. ALA-PDT was carried out in
66 patients. Protoporphyrin IX induced by oral administration of ALA (60 mg/kg
body weight orally applied 4-6 hours before PDT) was used as the photosensitizer.
Acid suppression was maintained in all patients. RESULTS: Between September 1996
and September 2002, 667 patients with early neoplasia in Barrett's esophagus
were referred for local endoscopic therapy. A total of 558 patients fulfilled
the criteria for local endoscopic therapy, and 66 patients (mean [standard
deviation] age 61.4 [10.2] years) with HGIN (group A; n = 35) and early
adenocarcinoma (group B; n = 31) were treated by PDT. A total of 82 ALA-PDT were
performed. A total of 34 of the 35 patients in group A (97%) and all patients in
group B (100%) achieved a complete response during a median follow-up period of
37 months (interquartile range 23-55) (not significant). One local recurrence
was observed in group A and 10 in group B (p < 0.005). Seven patients died
during follow-up; but, all deaths were not tumor related. No major complications
were observed. Disease-free survival in patients with HGIN was 89%, and, in
patients with mucosal cancer, it was 68%. The calculated 5-year survival was 97%
in group A and 80% in group B, but there occurred no death related to Barrett's
neoplasia. CONCLUSIONS: The excellent long-term results of PDT with ALA in
patients with HGIN or mucosal cancer might offer PDT with ALA as an alternative
to surgical esophagectomy and endoscopic resection, especially in cases with
multifocal Barrett's neoplasia.
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Curr Opin Gastroenterol. 2005 Jul;21(4):490-7.
Endoscopic therapeutic esophageal interventions: what is new?
What needs further study? What can we forget?
Siersema PD.
Department of Gastroenterology & Hepatology, Erasmus MC University Medical
Center, Rotterdam, The Netherlands. p.siersema@erasmusmc.nl
PURPOSE OF THIS REVIEW: Endoscopic esophageal interventions form an important
part of gastrointestinal endoscopy. This article reviews the most notable
results of esophageal endoscopy and interventions published in 2004. RECENT
FINDINGS: Both argon plasma coagulation and photodynamic therapy were shown to
have high success rates in removing Barrett's epithelium. After ablative
treatment, residual Barrett's esophagus still poses an increased esophageal
cancer risk and is a concern. Endoscopic resection is now an accepted
alternative to surgical resection of early-stage squamous cell and
adenocarcinoma of the esophagus. Four studies convincingly demonstrated that
covered plastic stents could be used in the initial therapy of patients with
refractory benign esophageal strictures, and anastomotic leaks after esophageal
surgery. Evidence was presented that intraluminal radiotherapy (brachytherapy)
is a valuable alternative to stent placement in patients with malignant
dysphagia. It has become clear that injections with botulinum toxin at the
gastroesophageal junction in patients with achalasia are often only temporarily
effective. It was shown that endoluminal gastroplication produced good
symptomatic results; however, data on the reduction of esophageal acid exposure
were less impressive. Finally, the first results of endoscopic implantation of
expandable antireflux prostheses (Gatekeeper Reflux Repair System, Medtronic
Europe, Tolochenaz, Switzerland) in the distal esophageal submucosa were
reported. SUMMARY: In 2004, new data on available esophageal therapeutic
techniques became available. In addition, new information on an old established
technique (brachytherapy for malignant dysphagia) and a new device (Gatekeeper
system for the prevention of reflux) were presented.
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Curr Opin Gastroenterol. 2005 Jul;21(4):461-5.
Barrett's esophagus.
Bonino JA, Sharma P.
Division of Gastroenterology and Hepatology University of Kansas School of
Medicine and Veterans Affairs Medical Center, Kansas City, Missouri 64128-2295,
USA. psharma@kumc.edu
PURPOSE OF REVIEW: Significant advances have been made over the past year to
identify individuals with Barrett's esophagus, who are at increased risk of
malignant transformation. We summarize some of the important advances in that
regard including: improved understanding in areas of epidemiology of those with
Barrett's esophagus, identification of the pathways responsible for dysplastic
and metaplastic development, selection of patient populations who would most
benefit from surveillance protocols, and identification of biomarkers signifying
progression of metaplastic changes. RECENT FINDINGS: Barrett's esophagus is
being better recognized in patients presenting with extra-esophageal symptoms of
gastroesophageal reflux such as chronic cough and asthma. Recent reports from
some surgical series further suggest the importance of gastric and even duodenal
reflux in the etiology of esophageal metaplastic development. In vitro
experiments using acidic environments, to stimulate MAPK pathways, suggest an
etiology for increased COX-2 expression. There appears to be a select group of
individuals with familial predilection for the development of Barrett's
esophagus. Retrospective studies continue to show apparent survival benefit in
individuals with Barrett's esophagus undergoing surveillance endoscopy.
Endoscopic ablative therapy may provide clinicians an attractive alternative to
surgical resection in individuals with high-grade esophageal dysplasia and early
adenocarcinoma. SUMMARY: The past year has brought many advances in the
epidemiology, pathogenesis, surveillance, and treatment of those with Barrett's
esophagus. Clinicians will benefit from review of these advances, and use of the
most up-to-date data to ensure better patient outcomes.
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Rev Esp Enferm Dig. 2005 May;97(5):328-37.
Surgery for gastroesophageal reflux disease: a comparative study
between the open and laparoscopic approaches.
[Article in English, Spanish]
Trullenque Juan R, Torres Sanchez T, Marti Martinez E, Martinez Abad M,
Trullenque Peris R, Delgado Gomis F.
Service of General Surgery, Hospital Dr. Peset, 46017 Valencia, Spain. ramtrull@yahoo.es
OBJECTIVE: Given the demonstrated effectiveness of medical treatment together
with the eminent acceptance of the laparoscopic approach, the indications of
surgery in the treatment of gastroesophageal reflux disease (GERD) are currently
subject to continuous controversy. To participate in this debate, we have the
following work hypothesis: "The results of the 360 masculine short and floppy
laparoscopic fundoplication are superior to those of open surgery". CLINICAL
DESIGN: Prospective, clinical, non-randomized study. PATIENTS: Our work was
developed between November 1991 and December 1998 by means of a prospective,
non-randomized clinical rehearsal with two groups of patients: Group I (n = 75):
360 degree short and floppy laparoscopic fundoplication in Hospital Dr. Peset,
Valencia (Spain). Group II (n = 28): 360 degree short and floppy, open
fundoplication in Hospital General, Valencia (Spain).We evaluated the
preoperative parameters and found no differences, which allows us to know that
both groups were comparable. RESULTS: The analysis of peroperative results
(morbidity and surgical time) and of clinical follow-up (every three months and
later annually) and instrumental follow-up (TEGD, upper digestive endoscopy,
pHmetry and manometry) show no differences, while the postoperative analysis
shows statistically significant (s.s.) differences regarding recovery (pain,
oral intake, hospital stay and return to previous activities). CONCLUSIONS: The
results of the 360 degree short and floppy laparoscopic fundoplication are
similar to those of the open approach, but favor the former approach with a
better postoperative tolerance.
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Dis Esophagus. 2005;18(2):75-86.
Molecular targets for treatment of Barrett's esophagus.
Feagins LA, Souza RF.
Department of Medicine, Dallas VA Medical Center and University of Texas
Southwestern Medical School, Dallas 75216, USA.
SUMMARY. Esophageal cancer is one of the most deadly forms of gastrointestinal
cancer with a mortality rate exceeding 90%. The major risk factors for
esophageal adenocarcinoma are gastroesophageal reflux disease (GERD) and its
sequela, Barrett's esophagus. GERD commonly leads to esophagitis. In a minority
of patients however, ongoing GERD leads to replacement of esophageal squamous
mucosa with metaplastic, intestinal-type Barrett's mucosa. In the setting of
continued peptic injury, Barrett's mucosa can give rise to esophageal
adenocarcinoma. Despite the widespread use of potent acid suppressive therapies
for patients with GERD, the incidence of esophageal adenocarcinoma, among white
men in the USA, the UK and Europe has continued to rise. Cancers in Barrett's
esophagus arise through a sequence of genetic events that endow the cells with
six essential physiologic hallmarks of cancer as described by Hanahan and
Weinberg in 2000. These cancer hallmarks include the ability to proliferate
without exogenous stimulation, to resist growth-inhibitory signals, to avoid
triggering the programmed death mechanism (apoptosis), to resist cell
senescence, to develop new vascular supplies (angiogenesis), and to invade and
metastasize. While the acquisition of these essential attributes is not specific
to the neoplastic progression of Barrett's esophagus, this review will focus on
the genetic alterations that occur in Barrett's cells that contribute to the
acquisition of each of the hallmarks. Moreover, potential diagnostic and
therapeutic strategies for Barrett's patients aimed at each of these cancer
hallmarks will be reviewed.
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Endoscopy. 2005 May;37(5):470-8.
Endoscopic treatment of gastroesophageal reflux disease.
Annese V, Caletti G, Cipolletta L, Costamagna G, D'Onofrio V, Leandro G, Koch M,
Pace F, Penagini R, Repici A, Ricci E, Vigneri S, Zaninotto G.
U.O. Gastroenterologia, Ospedale CSS-IRCCS, San Giovanni Rotondo, Italy.
Gastroesophageal reflux disease is a common chronic disorder which has a severe
effect on the patient's quality of life. In view of the high cost of medical
therapy and the limitations of surgery, a variety of endoscopic techniques have
been developed for the treatment of this condition, and these have shown
apparently encouraging results, at least in the short term. However, promising
results have been obtained in only around two-thirds of patients over a
short-term follow-up period of about 6 months. Moreover, several inconsistencies
have emerged between the efficacy of this form of treatment in improving
symptoms and quality of life and a lack of improvement of objective parameters,
such as lower esophageal sphincter pressure and esophageal acid exposure. The
authors strongly endorse the need for comprehensive evaluation of clinical
evidence on this topic. After an extensive evaluation of existing literature, we
suggest that controlled studies are urgently needed in order to clarify the
potential of endoscopic therapy, either in terms of cost-effectiveness or in
comparison with standard therapy. Meanwhile, with regard to current practice,
the use of endoscopic treatment should be limited to clinical trials, which
should incorporate the provision of comprehensive and unbiased information to
study patients.
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Am J Gastroenterol. 2005 May;100(5):1002-8.
Fundoplication and the risk of esophageal cancer in
gastroesophageal reflux disease: a veterans affairs cohort study.
Tran T, Spechler SJ, Richardson P, El-Serag HB.
Department of Medicine, Baylor College of Medicine, Houston, Texas.
BACKGROUND AND AIMS: It has been proposed that fundoplication can reduce the
risk of esophageal cancer in patients with gastroesophageal reflux disease (GERD).
In this cohort study, we assessed the effect of fundoplication on the incidence
of esophageal cancer. METHODS: We identified all Veterans Affairs (VA) patients
with GERD who had fundoplication between 1986 and 1990 and matched (1-2) to
controls with GERD and no fundoplication and to controls with no GERD. We
calculated incidence rates for esophageal cancer through October 2002 and
examined the effect of fundoplication on the risk of esophageal cancer using
Kaplan-Meier survival analysis and Cox proportional hazard analysis. We
calculated and adjusted for the propensity score for receiving fundoplication.
RESULTS: We identified 946 patients who had fundoplication, 1,892 patients who
had GERD without fundoplication, and 5,676 patients with no GERD. The mean age
was 55 yr and 97.5% were men in all three groups. During a follow-up of 11,156
patient-years (PY), there were eight cases of esophageal cancer (72/100,000) in
the fundoplication group. During a follow-up of 20,115 PY, there were eight
cases of esophageal cancer (40/100,000) in the GERD without fundoplication
group. During a follow-up of 59,439 PY, no patients in the group with no GERD
developed esophageal cancer. The Kaplan-Meier analysis showed no significant
difference in cumulative esophageal cancer rates between the fundoplication
group and the GERD no-fundoplication group. The adjusted hazard ratio of
esophageal cancer with fundoplication was 1.88 (95% CI: 0.70-5.03). CONCLUSIONS:
GERD is a risk factor for esophageal cancer, but there is insufficient evidence
that fundoplication reduces that risk. (Am J Gastroenterol 2005;100:1002-1008).
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Cochrane Database Syst Rev. 2005 Apr 18;2:CD004823.
Gastro-oesophageal reflux treatment for prolonged non-specific
cough in children and adults.
Chang A, Lasserson T, Gaffney J, Connor F, Garske L.
Respiratory Medicine, Royal Children's Hospital, Herston Road, Herston,
Brisbane, Queensland, AUSTRALIA, 4029.
BACKGROUND: Cough is a very common symptom presenting to medical practitioners.
Gastroesophageal reflux disease (GORD) is said to be the causative factor in up
to 41% of adults with chronic cough. However cough and GORD are common ailments
and their co-existence by chance is high. Also cough can induce reflux episodes.
Treatment for GORD includes conservative measures (diet manipulation),
pharmaceutical therapy (motility or prokinetic agents, H(2) antagonist and
proton pump inhibitors (PPI)) and fundoplication. OBJECTIVES: To evaluate the
efficacy of GORD treatment on chronic cough in children and adults with GORD and
prolonged cough that is not related to an underlying respiratory disease i.e.
non-specific chronic cough. SEARCH STRATEGY: The Cochrane Register of Controlled
Trials (CENTRAL), the Cochrane Airways Group Specialised Register Collaboration
and Cochrane Airways Group, MEDLINE and EMBASE databases, review articles and
reference lists of relevant articles were searched. The date of last search was
4th April 2004. SELECTION CRITERIA: All randomised controlled trials on GORD
treatment for cough in children and adults without primary lung disease. DATA
COLLECTION AND ANALYSIS: Results of searches were reviewed against
pre-determined criteria for inclusion. Two independent reviewers selected,
extracted and assessed data for inclusion. Authors were contacted for further
information. Data was analysed as "intention to treat" as well as "treatment
received". Paediatric and adults data were considered separately. Sensitivity
analyses were performed. MAIN RESULTS: 11 studies (3 paediatric, 8 adults; 383
participants) were included. None of the paediatric studies could be included in
meta-analysis. In adults, analysis on use of H(2) antagonist, motility agents
and conservative treatment for GORD were not possible (from lack of data) and
there were no controlled studies on fundoplication as an intervention. Five
adult studies comparing PPI (2-3 months) to placebo were analysed for various
outcomes in the meta-analysis. Enrolment of subjects for two studies were
primarily from medical clinics and another three studies were otolaryngeal
clinic patients. Using "intention to treat", pooled data from three studies
resulted in no significant difference between treatment and placebo in total
resolution of cough. Pooled data revealed no significant improvement in cough
outcomes (end of trial or change in cough scores). Significant differences were
only found in sensitivity analysis. A significant improvement in change of cough
scores was found in end of intervention (2-3 months) in those receiving PPI with
a standardised mean difference of -0.41 (95%CI -0.75, -0.07) using GIV analysis
on cross over trials. Two studies reported improvement in cough after 5 days to
2 weeks of treatment. Significant heterogeneity was found between studies using
omeprazole and other PPIs. AUTHORS' CONCLUSIONS: There is insufficient evidence
to definitely conclude that GORD treatment with PPI is beneficial for cough
associated with GORD in adults. The beneficial effect was only seen in
sub-analysis and its effect was small. The optimal duration of such a trial of
therapy to evaluate response could not be ascertained in the meta-analysis
although two RCTs reported significant change by two weeks of therapy.
Clinicians should be cognisant of a period (natural resolution with time) and
placebo effect in studies that utilise cough as an outcome measure. Data in
children are inconclusive. Future paediatric and adult studies are needed
whereby studies should be double blind, randomised controlled, parallel design,
using treatments for at least two months, with validated subjective and
objective cough outcomes and include ascertainment of time to respond as well as
assessment of acid and/or non acid reflux whilst on therapy.
-----
Am J Gastroenterol. 2005 Mar;100(3):537-42.
Reversibility of GERD ultrastructural alterations and relief of
symptoms after omeprazole treatment.
Calabrese C, Bortolotti M, Fabbri A, Areni A, Cenacchi G, Scialpi C, Miglioli M,
Di Febo G.
Dipartimento di Medicina Interna e Gastroenterologia, Sezione di Anatomia
Patologica, Universita di Bologna, Italy.
BACKGROUND: Dilation of intercellular spaces (DIS) of human esophageal
epithelium, evident at transmission electron microscopy (TEM), is an early
marker of damage caused by gastroesophageal reflux, but its reversibility after
therapy has not been investigated. AIM: To evaluate whether omeprazole can
induce the healing of DIS. METHODS: Thirty-eight symptomatic patients, 22 with
nonerosive reflux disease (NERD) and 16 with erosive esophagitis (EE),
classified on the basis of 24-h pH monitoring, were enrolled. During upper
gastrointestinal endoscopy, six biopsies from apparently normal mucosa were
taken within the lower 5 cm of the esophagus for histological and TEM analysis.
One hundred computer measurements were taken on TEM photomicrographs of the
specimens in each patient. After 3 months of omeprazole 40 mg/die a further
endoscopy with biopsies was performed. In patients with persistent heartburn
and/or incomplete ultrastructural recovery of esophageal epithelium, a new
endoscopy was performed after 3 more months of treatment. RESULTS: After 3
months of therapy, 35 patients (92.1%) showed a complete recovery of DIS and
resolution of heartburn. Three patients required 3 more months of therapy
because of an incomplete recovery of the epithelium correlated with sporadic
heartburn. Healing of the mucosa was achieved in two patients, whereas one had
an incomplete recovery of DIS with persistent heartburn. CONCLUSIONS: Three and
six months of omeprazole therapy led to a complete recovery of DIS in 92.1% and
97.4% of cases, respectively. No significant differences of DIS between NERD and
EE were noted. Complete recovery of DIS was accompanied by regression of
heartburn in all cases.
-----
Eur J Cardiothorac Surg. 2005 Mar;27(3):357-60.
The incidence of gastroesophageal reflux after transthoracic
esophagocardio-myotomy without fundoplication: a long term follow-up.
Lindenmann J, Maier A, Eherer A, Matzi V, Tomaselli F, Smolle J, Smolle-Juettner
FM.
Department of Surgery, Division of Thoracic- and Hyperbaric Surgery, University
Medical School Graz, Auenbruggerplatz 29, 8036 Graz, Austria. jo.lindenmann@meduni-graz.at
OBJECTIVE: Evaluation of the long term results of Heller's myotomy performed
over a lateral thoracotomy without additional fundoplication. Methods: Forty
patients (17 males, 23 females; mean age 43.2 years; range: 14-63 years) were
operated between 1985 and 2000. Preoperative evaluation included clinical
scoring of symptoms, esophagogram, endoscopy, manometry and 24-h ph-metry. At
the follow-up investigation, the preoperative evaluation was repeated in all
patients, adding a histological workup of the distal esophageal mucosa. The mean
duration of follow-up after surgery was 10.3 years, ranging from 3-16 years.
RESULTS: The clinical scores improved significantly: Excellent relief from
dysphagia was present in 86%, little or no regurgitation was found in 79%,
little or no retrosternal spasms were reported by 72% of the patients.
Esophagogram showed an overall esophageal dilatation in all patients but no
significant obstruction at the esophagogastric junction. Endoscopically, 2.5%
had candida-esophagitis, 5% showed signs of a GERD I, 92.5% had a
macroscopically insuspect esophageal mucosa. Histologically, 53% showed a mild
chronic inflammation. Manometry demonstrated distinct hypomotility of the
esophagus in all cases, yet no elevated pressure of the lower sphincter; pH-metry
showed moderate reflux in 46%. CONCLUSIONS: Transthoracic cardiomyotomy is a
valid method for the treatment of achalasia, but it will not improve the
esophageal motility, which slowly deterioriates in these cases. The patient's
subjective assessment of the postoperative result was positive in the majority
of cases. Although fundoplication was not done in any of these patients, none of
them showed signs of clinically relevant reflux.
-----
J Pediatr Gastroenterol Nutr. 2005 Mar;40(3):319-27.
Efficacy and safety of lansoprazole in adolescents with
symptomatic erosive and non-erosive gastroesophageal reflux disease.
Fiedorek S, Tolia V, Gold BD, Huang B, Stolle J, Lee C, Gremse D.
The Pediatric Clinic, P.A., North Little Rock, AR 72117, USA. scfiedorek@thepediatric.com
OBJECTIVES: To assess the efficacy and safety of lansoprazole in the treatment
of adolescents with symptomatic, endoscopically proven, non-erosive
gastroesophageal reflux disease and erosive esophagitis. METHODS: Adolescents
between 12 and 17 years of age with esophagitis were enrolled in this open-label
trial and treated with lansoprazole 15 mg (non-erosive) or 30 mg (erosive) once
daily for 8 weeks. If unhealed at week 8, those with erosive esophagitis were
treated with an additional 4 weeks of lansoprazole 30 mg once daily. RESULTS:
Lansoprazole produced a significant reduction from baseline in the median
percentage of days with reflux symptoms (91 to 43% in the 64 adolescents with
non-erosive disease and 85 to 16% in the 23 adolescents with erosive esophagitis,
P < or = 0.001 for each comparison). At week 8, mucosal healing had occurred in
95% (21 of 22) of those with erosive esophagitis. Treatment-related adverse
events were reported by 19% of patients with non-erosive and 4% of patients with
erosive esophagitis. Headache (7%), abdominal pain (5%), nausea (3%) and
dizziness (3%) were the most frequently reported adverse events. One patient
discontinued treatment early because of dizziness and vomiting. An elevation in
mean serum gastrin from baseline (59 pg/mL at pretreatment to 80 pg/mL at final
visit) was observed. CONCLUSION: Lansoprazole 15 mg or 30 mg once daily reduced
symptoms of gastroesophageal reflux in adolescents with non-erosive
gastroesophageal reflux disease and erosive esophagitis, respectively.
Lansoprazole 30 mg once daily for 8 weeks was effective in healing erosive
esophagitis. Both treatment regimens were considered safe.
-----
J Pediatr. 2005 Mar;146(3 Suppl):S3-12.
Decisions in diagnosing and managing chronic gastroesophageal
reflux disease in children.
Hassall E.
Division of Pediatric Gastroenterology, BC Children's Hospital/University of
British Columbia, Vancouver, Canada.
Gastroesophageal reflux disease (GERD) presents in different ways in children,
most commonly with vomiting, or with esophageal symptoms such as regurgitation,
heartburn, or dysphagia. Extraesophageal symptoms and signs also frequently
occur. Less well recognized is that abdominal pain is a relatively common mode
of presentation. Although abdominal pain is common in school-aged children, GERD
and other acid-related disorders such as peptic ulcer disease are relatively
uncommon causes of such. A careful history will usually determine whether an
acid-related disorder is in the differential diagnosis of abdominal pain. Early
detection and treatment of GERD in children may prevent, attenuate, or heal
complications such as failure to thrive or feeding refusal as well as pulmonary,
ear-nose-and-throat disorders, erosive esophagitis, and peptic stricture. In
children with persistent or severe symptoms and/or complications of GERD such as
erosive esophagitis, the major treatment options are pharmacologic management
with acid-suppressing medication, specifically proton pump inhibitors (PPIs), or
antireflux surgery. For many patients, PPI treatment offers advantages over
surgery. When given in adequate doses, PPIs can safely effect relief of GERD
symptoms and healing of esophagitis in children. Antireflux surgery may work
well in selected patients, but it carries significant risk of morbidity,
including high failure rates, even in the short term. Some postoperative studies
report that more than 60% of patients are back on medical treatment with proton
pump inhibitors for recurrence of GERD symptoms, and a similar percentage have
new symptoms that were not present before surgery. Death is uncommon but does
occur and is an unacceptable risk in an otherwise healthy, low-risk individual.
Laparoscopic surgery may have some disadvantages compared with open surgery,
including a higher rate of redo operations. Studies show that many children
undergo surgery for unclear indications, often with few preoperative diagnostic
studies. The availability of highly effective medical therapy, together with
more careful selection of patients for surgery, may result in better patient
outcomes, with much lower operative rates.
-----
Ther Umsch. 2005 Feb;62(2):96-9.
[Laparoscopic fundoplication for gastroesophageal reflux disease
(GERD)]
[Article in German]
Wehrli H.
Zentrum fur Viszeralchirurgie, Klinik Hirslanden, Zurich. hwehrli@freesurf.ch
Laparoscopic fundoplication became the gold standard in the surgical therapy of
GERD. In comparison with open procedures, laparoscopic antireflux surgery has a
lower morbidity rate, a better early and late postoperative outcome and is more
cost-effective. Antireflux surgery can be performed after a critical evalutation
of the patient including gastroscopy, biopsy, 24h-pH-manometry and after a long
lasting conservative medical treatment. Indications for antireflux surgery are
given by a failed medical treatment, an insufficient compliance, complications
of GERD, i.e. stenosis, Barrett-esophagus and atypical reflux symptoms like
chronic cough, hoarseness or thoracic pain with presence of a pathological
pH-monitoring. Laparoscopic 360 degrees Nissen-fundoplication with crurorrhaphy
is our standard procedure, whereas the 270 degrees Toupet technique in our
tailored approach is the technique of choice for esophageal motility disorders.
Results of antireflux surgery published in literature are discussed and compared
with our own ten years experience with 124 cases of laparoscopic fundoplication.
-----
Mo Med. 2005 Jan-Feb;102(1):67-9.
Laparoscopic Nissen fundoplication in a community hospital:
analysis of 202 patients.
Tucker LE, Blatt C, Richardson NL, Richardson DT, Cassat JD, Riechers TB.
Department of Medicine, Division of Gastroenterology, St. John's Mercy Hospital,
Washington, Missouri, USA.
We analyzed 202 patients undergoing Laparoscopic Nissen fundoplication. One
hundred and three patients (90.6%) had typical reflux symptoms. Hiatal hernias
were present in 84.6%. Most patients had erosive esophagitis; sixty-four
patients (31.6%) had strictures. Complications occurred in 38 patients (18.8%),
with major complications in 15 patients (7.4%). Major complications included
bleeding in six, two requiring transfusion, slipped Nissen in three,
pneumothorax in two, and esophageal leak in two patients. Eleven patients had
postoperative dysphagia that responded to dilation therapy within three months.
There was no mortality.
-----
Curr Treat Options Gastroenterol. 2005 Feb;8(1):71-83.
Robotic Laparoscopic Fundoplication.
Stefanidis D, Korndorffer JR, Scott DJ.
Tulane Center for Minimally Invasive Surgery, Tulane University Health Sciences
Center, 1430 Tulane Ave., SL-22, New Orleans, LA 70112-2699, USA.. dscott@tulane.edu.
Gastroesophageal reflux disease is a very common disorder, and both medical and
surgical treatments have shown outstanding results. Whereas proton pump
inhibitors are the mainstay of treatment, laparoscopic fundoplication has become
a very attractive alternative due to its efficacy and low morbidity. There are
defined patient categories that may benefit more from laparoscopy than medical
therapy, but a conclusive comparison between the two is lacking. Robotic
laparoscopic fundoplication can be performed safely without increased morbidity.
Potential advantages include enhanced precision, improved dexterity, and remote
telesurgical applications. Disadvantages include increased cost and prolonged
operative times. Further studies and more long-term outcome data are needed to
fully evaluate the procedure. Robotic surgery is currently in its infancy and
not cost effective but has a very promising future. With further development of
automatization and miniaturization features, robotic surgery may prove more
efficient than conventional laparoscopy.
-----
Curr Treat Options Gastroenterol. 2005 Feb;8(1):51-57.
Enteryx Implant for Gastroesophageal Reflux Disease.
Johnson DA.
Eastern Virginia School of Medicine, 844 Kempsville Road, Norfolk, VA 23502,
USA. dajevms@aol.com.
Although pharmacologic therapy is safe and effective for gastroesophageal reflux
disease (GERD), patients requiring chronic drug treatment often seek
alternatives. Surgical alternatives to chronic drug treatment are associated
with increased morbidity and long-term failure rates in more than 50% of
surgically treated patients. Newer endoluminal therapies using modifications of
standard endoscopy techniques are under evaluation as alternatives to chronic
drug treatment or surgical intervention for GERD. Appropriate patient selection
is KEY. Patients considered for any endoluminal therapy should have well
documented GERD and demonstrated appropriate and successful response to medical
therapy with a proton pump inhibitor (PPI). The Enteryx implant is an injectable
biocompatible polymer approved by the US Food and Drug Administration for the
management of GERD symptoms. Clinical trial data indicate that the Enteryx
procedure is a safe and effective GERD treatment that manages symptoms of GERD
and addresses the underlying anatomic and functional aspects of the disorder.
Multicenter clinical trials have shown that the Enteryx procedure safely and
effectively eliminates or significantly reduces PPI use in approximately 84% of
patients at 1 year and 72% of patients at two years. The risk-benefit profile of
this procedure and alternative treatment options should be carefully evaluated
for each patient considered a candidate for Enteryx and all endoluminal
therapies. Randomized-controlled studies comparing the Enteryx procedure to
placebo and cost-effective analyses comparing treatment options will further
define the use of the Enteryx implant in patients with GERD.
-----
Am J Gastroenterol. 2005 Jan;100(1):190-200.
Updated guidelines for the diagnosis and treatment of
gastroesophageal reflux disease.
DeVault KR, Castell DO.
Department of Medicine, Mayo Clinic College of Medicine, Jacksonville, FL, USA.
Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD)
were published in 1995 and updated in 1999. These and other guidelines undergo
periodic review. Advances continue to be made in the area of GERD, leading us to
review and revise previous guideline statements. GERD is defined as symptoms or
mucosal damage produced by the abnormal reflux of gastric contents into the
esophagus. These guidelines were developed under the auspices of the American
College of Gastroenterology and its Practice Parameters Committee, and approved
by the Board of Trustees. Diagnostic guidelines address empiric therapy and the
use of endoscopy, ambulatory reflux monitoring, and esophageal manometry in GERD.
Treatment guidelines address the role of lifestyle changes, patient directed
(OTC) therapy, acid suppression, promotility therapy, maintenance therapy,
antireflux surgery, and endoscopic therapy in GERD. Finally, there is a
discussion of the rare patient with refractory GERD and a list of areas in need
of additional study.
-----
Obes Surg. 2004 Nov-Dec;14(10):1373-80.
Laparoscopic gastric bypass after antireflux surgery for the
treatment of gastroesophageal reflux in morbidly obese patients:
initial experience.
Raftopoulos I, Awais O, Courcoulas AP, Luketich JD.
Department of Surgery, Division of Thoracic and Foregut Surgery, University of
Pittsburgh Medical Center, Pittsburgh, PA 15232, USA. raftopoulosi@upmc.edu
BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been proven
effective against gastroesophageal reflux disease (GERD) in morbidly obese
patients. We present our experience with revision of antireflux procedures to
LRYGBP in obese patients with recurrent GERD, weight gain or a combination of
both and discuss the indications and technical considerations involved. METHODS:
Between June 2000 and December 2003, 7 morbidly obese patients with a mean BMI
of 37.5 kg/m(2) underwent revision of an antireflux procedure to LRYGBP by our
group. Important steps of the revision include dissection of the diaphragmatic
crura and gastroesophageal fat pad, reduction and repair of hiatal hernia, and
complete take-down of the wrap to avoid stapling over the fundoplication which
can create an obstructed, septated pouch. RESULTS: Mean operative time was 6 hr
12 min and length of stay was 4.8 days. There were 3 major complications
postoperatively and no deaths. During follow-up, 5 patients developed
anastomotic strictures and 2 patients were re-explored for gastric remnant
herniation and intestinal obstruction. At a mean follow-up of 24 (3-44) months,
mean excess weight loss was 70.7% and 14/20 (70%) co-morbid conditions were
improved or resolved. GERD evaluation with the GERD-HRQL scale showed a
significant reduction of GERD scores postoperatively (P =0.006). CONCLUSIONS:
Although LRYGBP after antireflux surgery is a technically more difficult
procedure with a higher morbidity, it is feasible and effective for the
treatment of recurrent GERD and worsening obesity with the additional advantage
of weight loss and improvement of co-morbidities.
-----
Best Pract Res Clin Gastroenterol. 2004;18 Suppl:55-66.
GERD 2004: issues from the past and a consensus for the future.
Modlin I, Kidd M.
Department of Surgery, Yale University School of Medicine, 333 Cedar St, New
Haven, CT 06520-8062, USA. imodlin@optonline.net
In the early 1900's, gastroesophageal reflux disease (GERD) was an almost
unknown entity with less than 200 cases reported worldwide. Currently the
disease is regarded as almost endemic with as much as 25% of the population in
some countries exhibiting signs or symptoms of reflux. Early therapies directed
at chemical neutralization (milk drip, antacids) were of modest effect and
required constant administration for efficacy. The introduction of histamine 2
receptor antagonists in the 1970's dramatically improved the management of GERD,
but was limited by problems of tachyphylaxis and adverse events. The advent of
the PPI class of drugs revolutionized medical care of GERD, given their efficacy
and safety profile. As a consequence, the surgical approach with its pronounced
dependence on individual operator skill and its high morbidity and even
mortality has fallen into disregard. Thus, modest surgical outcome results as
compared to the efficacy of PPIs has led to the widespread recognition that
pharmacological therapy for GERD represents the platinum standard of care and
the current consensus is that the PPI class of drugs provide the safest and most
effective form of therapy for GERD. Furthermore, it is apparent based on acid
suppression, symptom relief and healing rates, that all PPIs are on a milligram
for milligram basis similarly efficacious for the management of GERD. While a
consensus exists in regard to the current management of GERD with PPIs there is
little agreement as to the management of the associated mucosal metaplastic
process. At this time there is inadequate understanding of the biological basis
of the mucosal transformation and minimal information about the mechanistic
regulation of this event and its perpetuation. A future consensus thus requires
the identification of the appropriate tools to detect Barrett's early, identify
the specific molecular markers associated with neoplastic transformation and
establish a definitive therapeutic algorithm.
-----
Dis Esophagus. 2004;17(4):274-8.
Comparison of efficacy of pantoprazole alone versus pantoprazole
plus mosapride in therapy of gastroesophageal reflux disease: a randomized
trial.
Madan K, Ahuja V, Kashyap PC, Sharma MP.
Department of Gastroenterology, All India Institute of Medical Sciences, New
Delhi, India.
SUMMARY The present study aimed to compare the efficacy for the therapy of GERD
of pantoprazole alone with a combination of pantoprazole and mosapride. The
study was a prospective, randomized trial involving 68 patients suffering
heartburn and/or regurgitation at least twice a week for 6 weeks. Sixty-one
patients consented to be randomized to receive either pantoprazole 40 mg b.i.d.
(n = 33, group A) or pantoprazole 40 mg b.i.d. plus mosapride 5 mg t.d.s. (n =
28, group B) for 8 weeks. Twenty-four-hour esophageal pH-metry and endoscopy
were conducted at recruitment and endoscopy was repeated at 8 weeks in all the
patients studied. There were no differences in symptomatic responses to therapy
between the groups (69.7% vs 89.2%; P = 0.11). The mean symptom score after 8
weeks was significantly lower in group B (3.78 +/- 3.62 vs 1.67 +/- 2.09; P =
0.009). Nonerosive esophagitis was present in 29 patients. In patients with
nonerosive GERD there was no significant difference in symptomatic response to
either regimen (17/20 in group A and 7/9 in group B responded; P = 0.63). In
erosive esophagitis, symptomatic responses occurred more frequently in group B,
18/19 (94.7%), than in group A, 6/13 (46.2%; P = 0.003). However endoscopic
healing of esophagitis occurred equally with either regimen (6/11, 54.5% in
group A; 12/17, 70.5% in group B; P = 0.44). In nonerosive GERD, the addition of
mosapride offers no benefit over pantoprazole alone. A combination of
pantoprazole and mosapride is more effective than pantoprazole alone in
providing symptomatic relief to patients with erosive GERD.
-----
Schweiz Rundsch Med Prax. 2004 Nov 17;93(47):1963-9.
[Reflux disease therapy]
[Article in German]
Allescher HD.
Zentrum fur Innere Medizin, Gastroenterologie, Hepatologie und Stoffwechsel,
Klinikum Garmisch-Partenkirchen. hans.allescher@klinikum-gap.de
The frequency of gastroesophageal reflux disease is on a constant rise in
western countries. Reflux therapy can be subdivided into the treatment of acute
erosive reflux esophagitis and the subsequent recurrence prophylaxis, and into
the treatment of non-erosive reflux disease as well as the atypical reflux
symptoms. Based on conventional large-scale studies, a highly effective therapy
is available which offers virtually complete acid blockade using proton pump
inhibitors (PPI) of the prazole type. Used for acute treatment, they offer a
cure for reflux esophagitis and freedom from symptoms in approx. 90% of the
cases, while also showing high efficacy in recurrence prophylaxis. Conversely,
the rate of side effects, particularly serious ones, is very low and the
long-term safety of this therapy has been good. Since the risk of erosive reflux
esophagitis recurring is > 80% without PPI therapy, the majority of the patients
will require a long-term, potentially even life-long therapy with PPI. Other
therapeutic options are being discussed as alternatives to such long-term
prophylaxis. In selected cases, surgical therapy by laparoscopic fundoplication
is one option. Alternatively, endoscopical anti-reflux procedures are
increasingly coming into use; their merit in long-term prophylaxis however,
cannot yet be evaluated. Whenever PPI therapy does not lead to complete freedom
from symptoms, an alternative therapeutic approach should be given consideration
even in patients with atypical reflux symptoms. The therapy of the Barrett's
esophagus, a potentially long-term sequelae of reflux disease, will not be dealt
with in this overview, as it is the subject of a separate presentation.
-----
Schweiz Rundsch Med Prax. 2004 Nov 17;93(47):1951-7.
[Barrett's esophagus]
[Article in German]
Neuhaus H.
Medizinische Klinik, Evangelisches Krankenhaus Dusseldorf. medizinischeklinik@evk-duesseldorf.de
The diagnosis of Barrett's esophagus is rendered based on proof of intestinal
metaplasia in the tubular portion of the esophagus. Barrett's develops in a
percentage of patients with gastroesophageal reflux disease; risk factors
include a long history of the disease, age over 40 years and Caucasian skin.
Specifics about a genetic predisposition have not become known to date. Each
year, around one out of every 200 patients with Barrett's epithelium develop
adenocarcinoma of the esophagus, the incidence of which has risen dramatically
over the past two decades. Apart from the early stages, the prognosis for this
type of Barrett's carcinoma is extremely unfavorable, even after esophagectomy.
It therefore appears sensible to examine patients with a long history of reflux
and/or frequently recurrent reflux symptoms and to develop screening strategies
for timely detection of persons with Barrett's esophagus along with subsequent
monitoring. This would involve regular endoscopic studies accompanied by
biopsies aimed at excluding or demonstrating the intraepithelial neoplasms that
count as direct precursors to cancer. Treatment of nonneoplastic Barrett's
esophagus can be symptomatic. Although theoretically logical, the benefits of
normalizing esophageal acid exposure have not been proven. When high-grade
intraepithelial neoplasms or mucosal carcinomas have been confirmed, local
endoscopical resection and/or ablation appear sufficient, since the risk of
lymph node metastasis is extremely low. Previous studies on this subject have
been very promising, but should be continued and/or verified. Definitive therapy
of more advanced tumor stages is currently given according to multimodal
concepts established in an interdisciplinary manner.
-----
Eur J Cardiothorac Surg. 2004 Nov;26(5):875-80.
Redo antireflux surgery--the importance of a tailored approach.
Khan OA, Kanellopoulos G, Field ML, Knowles KR, Beggs FD, Morgan WE, Duffy JP.
Thoracic Unit, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK.
omarkhan@iname.com
OBJECTIVE: Although several studies have examined early outcome following redo
antireflux surgery, there is little data on the long-term efficacy of these
procedures. We reviewed our experience of these operations in order to assess
the long-term results which can be achieved by choosing redo antireflux
procedures based on the results obtained from pre-operative oesophageal function
testing. METHODS: The case notes of 26 patients who underwent a repeat
antireflux procedure between 1981 and 2000 were reviewed. Clinical history,
examination, endoscopy, pH studies, oesophageal manometry and video barium
contrast studies were performed on all patients prior to re-operation. In all
cases, a standardised pre-formulated algorithm, based on the results of the
pre-operative oesophageal function tests, was used to determine the choice of
surgical procedure. Post-operatively, patients were classified into three
groups: Group A (those with no symptoms), Group B (symptoms controlled by
medication) and Group C (symptoms refractory to medical treatment). Patients in
Groups B and C underwent repeat oesophageal function studies. RESULTS: In all
cases, the indication for re-operation was gastro-oesophageal reflux symptoms
refractory to medical treatment. Twenty-one patients (81%) underwent a left
thoracotomy, of whom 11 patients (42%) underwent a gastroplasty. The mean
follow-up period was 8.27 years (range 1.5-19.8 years), after which 14 patients
(54%) were classified as Group A; 10 patients (38%) as Group B; and 2 patients
(8%) as Group C. Within Groups B and C, manometry showed that re-operation had
increased basal lower oesophageal sphincter pressure (4.6 vs 12.7 mmHg, pre- vs
post-operative P=0.03), and in all, but one case pH studies showed no evidence
of recurrent acid reflux. CONCLUSIONS: Redo antireflux surgery can provide
complete symptomatic relief in approximately 50% of patients and symptomatic
improvement over 90% of patients. We advocate a tailored approach in the
selection of re-operative procedures based on the results of pre-operative
oesophageal function testing.
-----
Surgery. 2004 Oct;136(4):786-94.
Delivery of radiofrequency energy to the lower esophageal
sphincter improves symptoms of gastroesophageal reflux.
Go MR, Dundon JM, Karlowicz DJ, Domingo CB, Muscarella P, Melvin WS.
Department of Surgery, The Ohio State University Medical Center, Columbus, Ohio
43210, USA.
BACKGROUND: The Stretta procedure has been proposed as a novel therapeutic
alternative to antireflux surgery for gastroesophageal reflux disease (GERD).
Early reports indicated improvement in GERD symptoms overall, but improvement in
patients who have poor outcome after surgery remains unclear. METHODS: Patients
with reflux who did not have a hiatal hernia were offered the procedure. All
were administered a GERD Health Related Quality of Life survey at preprocedure
and at greater than 3 months postprocedure. Differences in pre- and
postprocedure responses were deemed significant with the use of the Wilcoxon
rank sum test with P <.05. RESULTS: Fifty patients underwent the Stretta
procedure. There were no complications. All were evaluated postprocedure, with
74% completing a postprocedure survey. Overall heartburn score improved from
3.19 (scale, 0-5) preprocedure to 1.74 postprocedure (P=.0012). Overall symptoms
satisfaction score improved from 3.92 to 1.63 (P=.0001). Symptoms satisfaction
score of patients who failed antireflux surgery improved from 3.5 to 1.75
(P=.0166), and, in those with a body mass index >30, it improved from 4.11 to
1.56 (P=.0024). Four patients went on to have antireflux surgery after having
the Stretta procedure. CONCLUSIONS: Stretta improves heartburn symptoms both
overall and in patients with poor outcome after antireflux surgery, with a low
procedural risk. It may have a role in the treatment of patients with primary
reflux and in those who have failed antireflux surgery or who are a high risk
for surgery.
-----
Chirurg. 2004 Oct 20 [Epub ahead of print]
[Conventional and minimally invasive surgical methods for
gastroesophageal reflux.]
[Article in German]
Fuchs KH.
Klinik fur Visceral-, Gefass- und Thoraxchirurgie, Markus-Krankenhaus,
Frankfurter Diakonie-Kliniken.
The introduction of minimally invasive techniques has had great influence on the
indication and surgical therapy for gastroesophageal reflux disease. This
analysis is an overview of the current evidence-based status and a critical
reprisal of open and laparoscopic antireflux surgery.Results: The analysis of
randomized trials showed an advantage for patients after laparoscopy for total
and partial fundoplication because of reduced morbidity, shorter postoperative
hospitalization due to faster recovery, and significantly fewer scar and wound
problems. The functional results of open and laparoscopic techniques were
similar. Five-year follow-up results for the latter showed effective reflux
control in at least 85% of patients. Randomized trials regarding technical
variations did not show an advantage for division of the short gastric vessel. A
bougie for the cardia calibration can prevent postoperative dysphagia after
fundoplication.
-----
Minerva Chir. 2004 Oct;59(5):427-35.
Endoscopic therapy for gastroesophageal reflux disease: can it
replace antireflux surgery?
Oleynikov D, Oelschlager B, Dibaise J.
Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
This article addresses emergent endoluminal technologies currently available for
the treatment of gastroesophageal reflux disease (GERD) and compares it to the
laparoscopic Nissen fundoplication. To date the mainstay of GERD therapy has
been achieved with either open or laparoscopic fundoplication or life-long
medical treatment. Endoluminal treatment modalities attempt to augment the
gastroesophageal junction (GEJ) function by various techniques. We searched the
Medline database from 1980 to 2004 for studies on endoscopic GERD techniques and
laparoscopic fundoplications. Product investigators were contacted for data
presented in abstract form only. Endoluminal management of GERD include using
radiofrequency energy, injection of biocompatible polymers and endoluminal
sutures to alter the GEJ and reduce reflux. Early results while encouraging,
should be evaluated thoroughly and with caution before widespread use can be
advocated. Endoscopic treatment of GERD has future promise, however, more
experience and perhaps further refinement in techniques and technology must
occur before widespread clinical application can be encouraged.
-----
Internist (Berl). 2004 Oct 7 [Epub ahead of print]
[Reflux disease management-more than acid reduction?]
[Article in German]
Frieling T.
Medizinische Klinik II, Klinikum Krefeld.
Because gastroesophageal reflux disease (GERD) is a motility disorder, acid
reduction with proton pump inhibitors (PPI) remains a symptomatic therapy with a
recurrence rate of over 90% after discontinuation of acid suppression. This
"therapeutic dilemma" becomes obvious in patients not responding sufficiently to
the conventional medication (therapy resistance, necessity of high PPI doses,
volume reflux). In this manuscript we analyze additional factors that may play a
role in the pathogenesis and interpretation of GERD. These additional factors
include gastroesophageal motility and esophageal barrier functions as well as
duodenogastroesophageal reflux and Helicobacter pylori infection. In addition,
basic problems in interpretation of therapeutic success such as placebo effect,
spontaneous remission of GERD, the role of sensory function and subjective
interpretation of symptoms and the overlap between physiological and
pathological reflux as well as functional disorders will be discussed.
-----
Am J Med. 2004 Sep 6;117 Suppl 5A:56S-62S.
Extraesophageal symptoms: what role for the proton pump
inhibitors?
Nord HJ.
Division of Digestive Diseases and Nutrition, University of South Florida,
College of Medicine, Tampa, Florida 33606-3568, USA.
The esophageal complications of gastroesophageal reflux disease (GERD) are well
described and include erosive esophagitis, stricture, Barrett esophagus, and
adenocarcinoma. Primary care physicians often encounter patients with "extraesophageal"
manifestations of GERD in the absence of heartburn. Patients may present with
symptoms involving the pulmonary system, noncardiac chest pain, and ear, nose,
and throat disorders. The diagnosis of reflux disease in these individuals may
be challenging because, in addition to the absence of heartburn, endoscopy is
often negative. Laryngoscopy and 24-hour dual-channel intraesophageal pH-metry
may have greater diagnostic yields, but they are costly, invasive, and
time-consuming. A trial of proton pump inhibitor (PPI) therapy is increasingly
being considered a first-line diagnostic test in those with suspected
reflux-related extraesophageal symptoms. The duration as well as dose of PPI
should be based on the presenting symptoms, with patients having pulmonary
manifestations often requiring twice-daily therapy for 2 to 3 months. In
contrast, symptoms of reflux-related noncardiac chest pain may be relieved with
a 1-week, standard-dose treatment trial. Patients who fail to experience symptom
resolution or improvement should undergo further diagnostic evaluations
including 24-hour esophageal pH studies while continuing their PPI therapy to
establish persistent versus absent acid reflux. The role of fundoplication or
other surgical/laparoscopic procedures in these patients has yet to be
determined.
-----
Am J Med. 2004 Sep 6;117 Suppl 5A:49S-55S.
Managing gastroesophageal reflux disease for the lifetime of the
patient: evaluating the long-term options.
Metz DC.
Department of Gastroenterology, Hospital of University of Pennsylvania,
Philadelphia, Pennsylvania 19104-4283, USA.
Lifetime management goals of gastroesophageal reflux disease (GERD) are to
control esophageal as well as extraesophageal symptoms, maintain a stable
noninflamed esophageal mucosa, and prevent complications. Large randomized
clinical trials and >16 years of worldwide experience have confirmed the high
rate of efficacy and excellent safety profile of proton pump inhibitor (PPI)
therapy in individuals with all grades of GERD, making these agents the mainstay
of treatment. Despite these outcomes, some individuals may desire an alternative
to pharmacologic therapy. In such patients, laparoscopic fundoplication may
produce symptom relief and healing of esophagitis, but its invasiveness, cost,
and inherent surgical risks have created an interest in a variety of endoscopic
therapies for reflux disease. Several short-term uncontrolled trials of these
endoscopic therapies have reported encouraging preliminary results; however,
careful patient selection as well as clinician experience is critical for their
success. In addition to clinician expertise with the procedure, success has been
observed only in patients with nonerosive GERD and a hiatal hernia <3 cm,
abnormal pH monitoring, and normal esophageal motility studies, as well as in
those who have experienced at least partial symptom relief with PPI therapy.
Endoscopic therapy should not be considered the standard of care in patients
with erosive disease or large hiatal hernias.
-----
Am J Med. 2004 Sep 6;117 Suppl 5A:23S-29S.
Gastroesophageal reflux disease: could intervention in childhood
reduce the risk of later complications?
Gold BD.
Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics,
Emory University School of Medicine, Atlanta, Georgia 30322, USA.
Gastroesophageal reflux (GER) is a ubiquitous disorder in infants. Whereas
infants typically outgrow regurgitation by 1 year of age, the prevalence of
gastroesophageal reflux disease (GERD) symptoms in those aged 3 to >18 years
ranges from 1.8% to 22%. The pathophysiology of GERD in children is similar to
that in adults. However, children may present with gastroesophageal and
extraesophageal symptoms distinct from classic heartburn. In addition to a
growing awareness of the high prevalence of the disorder, increasing evidence
supports GERD being a lifelong condition in some individuals that begins in
childhood. Although the diagnostic workup in children compared with adults may
differ, studies suggest that the early detection and treatment of GERD in
childhood may result in better adult disease outcomes, improved quality of life,
and decreased overall healthcare burden. Studies of proton pump inhibitor
therapy in children confirm high rates of mucosal healing and GER symptom
resolution, even in children whose symptoms did not respond to H2-receptor
therapy or fundoplication procedures. Omeprazole, lansoprazole, and esomeprazole
are formulated as capsules containing enteric-coated granules that can be
sprinkled onto applesauce or other soft foods. Lansoprazole is also formulated
as strawberry-flavored granules for suspension. These as well as other
alternative dosing formulations expand the ability to administer these agents to
children. Moreover, long-term studies in adults and in children demonstrate that
these agents are safe and well tolerated, even at the higher milligram per
kilogram doses that are often required in pediatric patients because of their
greater hepatic metabolic capacity.
-----
Am J Med. 2004 Sep 6;117 Suppl 5A:14S-22S.
Therapeutic choices in reflux disease: defining the criteria for
selecting a proton pump inhibitor.
Freston JW.
University of Connecticut Health Center, Farmington, Connecticut 06030-1111,
USA.
Gastroesophageal reflux disease (GERD) is among the most common disorders of the
gastrointestinal tract, with symptoms affecting a substantial proportion of the
US population on a daily basis. Heartburn and related symptoms arise from a
number of pathophysiologic mechanisms, including dilated intercellular spaces,
increased duration of acid reflux, greater proximal extent of reflux, and
esophageal sensitivity. Chronic reflux may result in serious complications, such
as esophageal erosions or ulceration, stricture, and Barrett esophagus. The
goals of GERD therapy are to relieve patients' symptoms and prevent
complications. Proton pump inhibitors (PPIs) represent the most effective
treatment option for GERD, relieving symptoms, healing erosions, and maintaining
a healed mucosa. Differences in the pharmacokinetics and pharmacodynamics among
the PPIs may result in differences in intragastric pH holding time as well as
the onset of symptom relief. Lansoprazole and esomeprazole produce similar
degrees and onset of symptom relief, with both providing greater symptom relief
as compared with omeprazole. Although manufactured as capsules containing
enteric-coated granules, lansoprazole, omeprazole, and esomeprazole maintain
their high level of pharmacologic efficacy when the capsule contents are emptied
into soft foods or various liquids. Lansoprazole and pantoprazole also are
manufactured as intravenous formulations, and lansoprazole is available as
strawberry-flavored granules for oral suspension and as an orally disintegrating
tablet. These alternative routes of administration are particularly beneficial
in the management of acid-related disorders in infants, children, the elderly,
and patients of all ages who have difficulty swallowing or are unable to swallow
intact capsules or tablets and those in the critical care setting.
-----
Dig Dis. 2004;22(2):161-70.
Surgery of gastroesophageal reflux disease: a competitive or
complementary procedure?
Lundell L.
Division of Surgery, Karolinska University Hospital, Huddinge, Stockholm,
Sweden. lars.lundell@kus.se
The management of chronic gastroesophageal reflux disease (GERD) has both been
simplified and immensely improved by the development of modern medical
therapies. These are built entirely on the concept of profound acid inhibition,
which is very successful in a substantial proportion of GERD patients. Despite
the efficacy of proton pump inhibitors (PPIs) some failures are unavoidable, and
some patients experience incomplete control of major GERD symptoms on ordinary
dosing of PPIs. Although the safety profile of PPIs is very reassuring, some
people express some concern about the safety of drug treatment extending beyond
10 years especially when alternative therapeutic strategies are available. Some
patients complain of alleged respiratory complications to severe reflux, and in
those situations as well as in cases with e.g. Barrett's esophagus, a complete
control of reflux also incorporating the duodenal components in the refluxate
may be warranted. In all those situations antireflux surgery can be considered
indicated for the treatment of chronic GERD and thus be looked upon as
complementary to medical therapy. Furthermore, some patients who have their GERD
symptoms under control on PPIs still want to have an operation to avoid
dependency on drugs. Hence in none of these clinical situations does antireflux
surgery play a competitive role in relation to medical therapy. However, in the
very few randomized clinical trials in which a head-to-head comparison has been
completed between medical and surgical therapy, the latter has been found to be
somewhat more effective in terms of reflux control. The other side of the coin
is that antireflux surgery has some side effects that signify the importance of
this surgery being performed in specialized centers. Copyright 2004 S. Karger
AG, Basel
-----
Dig Dis. 2004;22(2):148-60.
Treatment of gastroesophageal reflux disease in adults: an
individualized approach.
Galmiche JP, Stephenson K.
Department of Gastroenterology and Hepatology, CIC INSERM-CHU, Nantes, France.
jeanpaul.galmiche@chu-nantes.fr
Until the 1990s, most therapeutic trials in gastroesophageal reflux disease (GERD)
focussed upon endoscopic lesions. In fact the correlation between patient
symptoms and both the presence and grade of esophagitis is very poor. The
classical criteria for the assessment of therapeutic efficacy in GERD have
therefore been revised, and there is now a consensus that the relief of symptoms
and the long-term control of the disease are the primary aims of therapy for the
majority of patients. Proton pump inhibitors (PPIs) represent the mainstay of
therapy for patients with non-erosive reflux disease (NERD) as well as
esophagitis. Although a stepwise strategy has been recommended in the past, a
step-down strategy (starting with a full-dose PPI) appears to be a more
cost-effective approach. There are as yet insufficient data to establish the
clear superiority of one PPI over others. PPIs have a number of limitations.
Symptom relief is significantly inferior in NERD than in erosive esophagitis.
The heterogeneity of the NERD group may be one of the most influential factors,
but the role of esophageal hypersensitivity has been suggested especially in
patients with normal acid exposure. The role of non-acid reflux should also be
scrutinized. Long-term control of the disease can be achieved by drug therapy,
anti-reflux surgery and now with a variety of endoscopic procedures. The
different drug management strategies can be divided into (i) continuous
maintenance therapy and (ii) discontinuous therapy which can again be divided
into two categories, intermittent and on-demand drug therapy. A case-by-case
approach is recommended to determine the personal therapeutic needs and
preferences of each individual. Many patients with NERD or mild esophagitis do
not require continuous maintenance therapy and recent studies have shown
excellent results with different PPI on-demand therapy regimens. Finally when
making a choice between different long-term strategies both the clinician and
the informed patient have to consider efficacy, safety, tolerability and cost.
The potential efficacy of new drugs, especially the GABA(B) agonists and the
fast onset acid suppressors, as well as the cost-effectiveness of non-drug
strategies (surgery and endoluminal therapies) should be further evaluated.
Copyright 2004 S. Karger AG, Basel
-----
Curr Treat Options Gastroenterol. 2004 Aug;7(4):273-278.
Noncardiac Chest Pain.
Wong WM, Fass R.
Southern Arizona VA Health Care System, 3601 South Sixth Avenue (1-111G-1),
Tucson, AZ 85723, USA. Ronnie.fass@med.va.gov
Noncardiac chest pain (NCCP) is a common condition with significant morbidity
and economic implications. Psychological factors, gastroesophageal reflux
disease (GERD), alteration in pain perception, and esophageal dysmotility play
an important role in the pathogenesis of the disorder. Proton pump inhibitor (PPI)
therapy is the most effective medical intervention for the treatment of GERD-related
NCCP, as well as the most cost-effective diagnostic strategy for this condition.
Pain modulators such as tricyclic antidepressants, trazodone, and selective
serotonin reuptake inhibitors infer a visceral analgesic effect and consequently
are the treatment of choice for patients with non-GERD-related NCCP.
Furthermore, cognitive behavioral therapy has also been shown to be useful in
the management of subset of patients with non-GERD-related NCCP. Newer
therapeutic modalities and interventions such as lower esophageal sphincter
injection of botulinum toxin in NCCP patients with spastic esophageal motility
disorders, theophylline, and 5-HT4 receptor agonists may supplement or replace
current treatment for non-GERD-related NCCP. Future compounds may include new
visceral analgesics or medications that interfere with the development of
peripheral or central sensitization.
-----
Chirurg. 2004 Jul 1 [Epub ahead of print]
[Endoscopic therapy methods for gastroesophageal reflux]
[Article in German]
Schumacher B, Neuhaus H.
Evangelisches Krankenhaus Dusseldorf.
Gastroesophageal reflux disease (GERD) is prevalent in 10% of the population. In
addition to the established therapy, endoscopic antireflux procedures have been
developed to improve the gastroesophageal reflux barrier. This can achieved by
endoscopically placed sutures, application of radio frequency energy, or
injection of biocompatible materials. These new techniques might be effective in
some patients with GERD. To date, there are limited data on the effectiveness
and safety of these methods. During a follow-up of 1-2 years, subjective
parameters improved in 70-75% of the test patients such that no antisecretory
treatment was required. Further, randomized, placebo-controlled studies are
needed for objective evaluation of these promising new methods.
-----
Curr Opin Otolaryngol Head Neck Surg. 2004 Jun;12(3):191-6.
The endoscopic radiofrequency approach to management of GERD.
Lutfi RE, Torquati A, Richards WO.
Department of Surgery, Vanderbilt University Medical Center, Nashville,
Tennessee 37232, USA.
PURPOSE OF REVIEW: Endoscopic treatment has been recently introduced as a new
option for treating gastroesophageal reflux disease. In this article the authors
review the radiofrequency approach known as the Stretta procedure, as more
evidence has linked reflux to upper airway disease. RECENT FINDINGS: Since 1968,
when laryngeal disorders were linked to gastroesophageal reflux disease, more
upper airway diseases such as chronic laryngitis, subglottic stenosis, and even
laryngeal carcinoma were found to be occasionally caused by extraesophageal
reflux. Most otolaryngologists treat these patients with proton pump inhibitors,
which improve symptoms in two thirds of patients. Antireflux surgery remains the
treatment of choice, relieving symptoms in more than 90% of patients. Endoscopic
treatment has recently emerged as an option for treatment of gastroesophageal
reflux disease. The Stretta procedure delivers radiofrequency energy to the
gastroesophageal junction. This has proved to be effective in controlling reflux
by inhibiting transient, inappropriate lower esophageal sphincter relaxation,
increasing postprandial lower esophageal spincter pressure, and decreasing lower
esophageal sphincter compliance. Stretta is among the earliest endoscopic
technologies to be approved by the Food and Drug Administration for the
treatment of reflux. It has the longest term follow-up published to this date,
and the most durable effect. It is performed under intravenous sedation on an
outpatient basis and has a low incidence of complications. SUMMARY: The Stretta
procedure is an endoscopic, noninvasive modality for the treatment of
gastroesophageal reflux disease. It should be considered in the treatment of
reflux-related upper airway diseases.
-----
Curr Gastroenterol Rep. 2004 Jun;6(3):213-9.
Gastroesophageal reflux disease and baclofen: is there a light at
the end of the tunnel?
Wise J, Conklin JL.
Department of Internal Medicine, Cedars-Sinai Medical Center, 8635 West Third
Street, Suite 770W, Los Angeles, CA 90048, USA.
Transient lower esophageal sphincter relaxations (TLESRs) are rapid and
prolonged relaxations of the lower esophageal sphincter (LES) that are not
associated with swallowing. They are the mechanism by which most
gastroesophageal reflux episodes occur in normal people and in patients with
esophagitis. Transient LES relaxations appear to be mediated by a vagovagal
reflex initiated by gastric distention. Baclofen is a g-aminobutyric acid (GABA)
derivative that inhibits the production of TLESRs by acting as a GABA(B)
receptor agonist at one or more loci along the vagovagal reflex arc. Animal and
human studies suggest that baclofen decreases the number of reflux events and
amount of esophageal acid exposure. Baclofen or another GABA(B) receptor agonist
may be clinically useful in treatment of gastroesophageal reflux disease.
-----
BMJ. 2004 Jun 12;328(7453):1417. Epub 2004 May 04.
Randomised controlled trial of effects of Helicobacter pylori
infection and its eradication on heartburn and gastro-oesophageal reflux:
Bristol helicobacter project.
Harvey RF, Lane JA, Murray LJ, Harvey IM, Donovan JL, Nair P; Bristol
Helicobacter Project.
Frenchay Hospital, North Bristol NHS Trust, Bristol BS16 1LE. richard.harvey1@virgin.net
OBJECTIVES: To investigate the effects of Helicobacter pylori infection and its
eradication on heartburn and gastro-oesophageal reflux. DESIGN: Cross sectional
study, followed by a randomised placebo controlled trial. SETTING: Seven general
practices in Bristol, England. PARTICIPANTS: 10,537 people, aged 20-59 years,
with and without H pylori infection (determined by the (13)C-urea breath test).
MAIN OUTCOME MEASURES: Prevalence of heartburn and gastro-oesophageal acid
reflux at baseline and two years after treatment to eradicate H pylori
infection. RESULTS: At baseline, H pylori infection was associated with
increased prevalence of heartburn (odds ratio 1.14, 95% confidence interval 1.05
to 1.23) but not reflux (1.05, 0.97 to 1.14). In participants with H pylori
infection, active treatment had no effect on the overall prevalence of heartburn
(0.99, 0.88 to 1.12) or reflux (1.04, 0.91 to 1.19) and did not improve
pre-existing symptoms of heartburn or reflux. CONCLUSIONS: H pylori infection is
associated with a slightly increased prevalence of heartburn but not reflux.
Treatment to eradicate H pylori has no net benefit in patients with heartburn or
gastro-oesophageal reflux.
-----
Surg Endosc. 2004 Jun;18(6):879-97. Epub 2004 Apr 27.
Evaluation of quality of life after laparoscopic surgery:
evidence-based guidelines of the European Association for Endoscopic Surgery.
Korolija D, Sauerland S, Wood-Dauphinee S, Abbou CC, Eypasch E, Caballero MG,
Lumsden MA, Millat B, Monson JR, Nilsson G, Pointner R, Schwenk W, Shamiyeh A,
Szold A, Targarona E, Ure B, Neugebauer E; European Association for Endoscopic
Surgery.
University Surgical Clinic, Clinical Hospital Center Zagreb, Zagreb, Kispaticeva
12, 10 000, Zagreb, Croatia.
BACKGROUND: Measuring health-related quality of life (QoL) after surgery is
essential for decision making by patients, surgeons, and payers. The aim of this
consensus conference was twofold. First, it was to determine for which diseases
endoscopic surgery results in better postoperative QoL than open surgery.
Second, it was to recommend QoL instruments for clinical research. METHODS: An
expert panel selected 12 conditions in which QoL and endoscopic surgery are
important. For each condition, studies comparing endoscopic and open surgery in
terms of QoL were identified. The expert panel reached consensus on the relative
benefits of endoscopic surgery and recommended generic and disease-specific QoL
instruments for use in clinical research. RESULTS: Randomized trials indicate
that QoL improves earlier after endoscopic than open surgery for
gastroesophageal reflux disease (GERD), cholecystolithiasis, colorectal cancer,
inguinal hernia, obesity (gastric bypass), and uterine disorders that require
hysterectomy. For spleen, prostate, malignant kidney, benign colorectal, and
benign non-GERD esophageal diseases, evidence from nonrandomized trials supports
the use of laparoscopic surgery. However, many studies failed to collect
long-term results, used nonvalidated questionnaires, or measured QoL components
only incompletely. The following QoL instruments can be recommended: for benign
esophageal and gallbladder disease, the GIQLI or the QOLRAD together with SF-36
or the PGWB; for obesity surgery, the IWQOL-Lite with the SF-36; for colorectal
cancer, the FACT-C or the EORTC QLQ-C30/CR38; for inguinal and renal surgery,
the VAS for pain with the SF-36 (or the EORTC QLQ-C30 in case of malignancy);
and after hysterectomy, the SF-36 together with an evaluation of urinary and
sexual function. CONCLUSIONS: Laparoscopic surgery provides better postoperative
QoL in many clinical situations. Researchers would improve the quality of future
studies by using validated QoL instruments such as those recommended here.
-----
Am J Med. 2004 Jun 1;116(11):740-8.
Lansoprazole in the treatment of functional dyspepsia: two
double-blind, randomized, placebo-controlled trials.
Peura DA, Kovacs TO, Metz DC, Siepman N, Pilmer BL, Talley NJ.
University of Virginia, Charlottesville, Virginia, USA. DAP8V@hscmail.mcc.virginia.edu
PURPOSE: The efficacy of proton pump inhibitor therapy for symptom resolution in
patients with functional dyspepsia remains controversial. This study was
designed to compare the efficacy of lansoprazole with placebo in relieving upper
abdominal discomfort in patients with functional dyspepsia. METHODS: We enrolled
921 patients with functional dyspepsia (defined as persistent or recurrent upper
abdominal discomfort during the prior 3 months) and moderate upper abdominal
discomfort on at least 30% of screening days; none of the patients had
predominant symptoms suggestive of gastroesophageal reflux or endoscopic
evidence of erosive or ulcerative esophagitis, or gastric or duodenal ulcer or
erosion. Patients were assigned randomly to receive lansoprazole 15 mg (n =
305), lansoprazole 30 mg (n = 308), or placebo (n = 308) daily for 8 weeks.
Patients recorded the frequency and severity of symptoms in daily diaries.
RESULTS: At week 8, significantly (P <0.001) greater mean reductions in the
percentage of days with upper abdominal discomfort were reported in patients
treated with lansoprazole 15 mg (35%) or 30 mg (34%) compared with those treated
with placebo (19%). Similarly, more patients treated with lansoprazole 15 mg
(44%) or 30 mg (44%) reported complete symptom resolution (defined as no
episodes of upper abdominal discomfort in the 3 days before the study visit) at
8 weeks than did placebo-treated patients (29%, P <0.001). Improvement of upper
abdominal discomfort, however, was seen only in patients who had at least some
symptoms of heartburn at enrollment. CONCLUSION: Lansoprazole, at a daily dose
of 15 mg or 30 mg, is significantly better than placebo in reducing symptoms of
persistent or recurrent upper abdominal discomfort accompanied by at least some
symptoms of heartburn.
-----
J Clin Gastroenterol. 2004 May-Jun;38(5):390-402.
Gastroesophageal reflux disease: then and now.
Modlin IM, Moss SF, Kidd M, Lye KD.
Department of Gastroenterological Surgery, Yale University School of Medicine,
New Haven, CT 06520-8062, USA. imodlin@optonline.net
Although Galen first described esophagitis almost 2000 years ago, its relation
to acid was only recognized in the 19th century by Rokitansky. Considerably more
interest in the symptoms and complications of esophagitis has been evident over
the last century, as gastroesophageal reflux disease displaced peptic ulceration
and became the principal acid-related disease of our times. Of particular
interest has been the recognition of the clinical significance of the previously
overlooked extraesophageal manifestations of the disease such as laryngitis,
asthma, and sleep disturbance. The evolution of highly effective medical therapy
has over the last decade drastically reduced the need for surgical intervention
for control of symptoms except under select conditions, especially
volume-related reflux and children with refractory symptoms. The proton pump
inhibitor class of drugs is indisputably the most effective overall form of
management, while individual proton pump inhibitors appear to be equivalent in
their efficacy. Issues that remain to be resolved include the management of
nonerosive gastroesophageal reflux disease, the long-term dependence of many
patients on acid-suppressing medication, and the recognition of atypical
manifestations and rare but serious complications of gastroesophageal reflux
disease. In this respect, Barrett's esophagus still presents a major biologic
and management conundrum for the physicians and scientists alike.
-----
Hepatogastroenterology. 2004 May-Jun;51(57):697-700.
Nissen fundoplication in infants and children: a long-term
clinical study.
Zeid MA, Kandel T, el-Shobary M, Talaat AA, Fouad A, el-Enien AA, el-Badrawy T,
el-Hak NG, el-Wahab MA, Ezzat F.
Gastroenterology Surgery Center, Mansoura University, Mansoura, Egypt.
m_abu_zead@hotmail.com
BACKGROUND/AIMS: Infants and children who underwent open Nissen fundoplication
for gastroesophageal reflux disease were retrospectively evaluated to assess the
success and complications of this operation. METHODOLOGY: Twenty-six
neurologically normal children (16 boys and 10 girls between 6 months and 11
years old) underwent Nissen fundoplication for intractable or complicated
gastroesophageal reflux between October 1982 and February 2002. Before surgery
and at follow-up visits, all children were subjected to thorough history, barium
meal study and gastroscopy with multiple esophageal biopsies. The median
follow-up period was 28 months (range: 11 months-19 years). RESULTS: Persistent
vomiting or regurgitation since birth was the main symptom (24 patients, 92.3%),
chest symptoms occurred in 5 patients (19.2%), malnutrition and retarded growth
were found in 4 patients (15.4%), hematemesis and/or melena occurred in 2
patients (7.7%) and dysphagia due to esophageal stricture occurred in 4 patients
(15.4%). There was no mortality. The mean hospital stay was 4.1 days. Twenty-two
patients (84.6%) had no recurrent reflux. Reflux symptoms recurred in 4 cases
(15.4%). One of these cases had no evidence of recurrent pathological reflux, 2
cases with preoperative stricture developed wrap disruption, recurrent reflux
and re-stricture. Both refused a second operation. The fourth case developed
melena and reflux esophagitis due to wrap herniation through the hiatus and was
successfully managed by a second operation. CONCLUSIONS: Nissen fundoplication
is an effective operation to correct gastroesophageal reflux in infants and
children when the drug therapy fails. The operation should be done before
occurrence of complications to decrease the recurrence of reflux.
-----
Pediatr Surg Int. 2004 May;20(5):326-8. Epub 2004 May 12.
Results of the Mutaf procedure in patients with gastroesophageal
reflux disease.
Sanal M, Korkmaz M, Karadag E, Kocabasoglu U, Konca Y, Guvenc H.
Kinderchirurgie, Anichstrasse 35, 6020, Innsbruck, Austria, alimsanal@mail.com
Operations to treat complicated gastroesophageal reflux disease (GERD) have
become the third most commonly performed general surgical procedure in large
pediatric centers, and many surgical techniques have come into use to prevent
gastroesophageal reflux. This paper presents our experience with gastric tube
cardioplasty, a new procedure described by Oktay Mutaf (Mutaf procedure). Eleven
children with GERD were successfully operated on. The postoperative period was
uneventful, and all patients were symptom-free.
-----
Br J Surg. 2004 May;91(5):552-9.
Randomized clinical trial of laparoscopic versus open
fundoplication for gastro-oesophageal reflux.
Nilsson G, Wenner J, Larsson S, Johnsson F.
Department of Nursing, Lund University, Lund, Sweden. gunilla.nilsson@omv.lu.se
BACKGROUND: The aim of this study was to compare the long-term results of
laparoscopic and open antireflux surgery in a randomized clinical trial by
investigating subjective and objective outcomes. METHODS: Sixty patients with
gastro-oesophageal reflux disease (GORD) were randomized to laparoscopic or open
360 degrees fundoplication. Subjective evaluation using disease-specific and
generic questionnaires and structured interviews, and objective evaluation by
endoscopy, oesophageal manometry and 24-h pH monitoring, were performed before
operation and 1 month, 6 months and 5 years after surgery. RESULTS: Two patients
in the laparoscopic group had reoperations for hiatal stricture; one patient in
the open group had repair of an incisional hernia, and one patient in each group
had surgery for intestinal obstruction. There were no differences in the
subjective outcomes of diet, sleep, medication, patient satisfaction and
symptoms of GORD after 5 years. Nor were there any differences in objective
outcomes determined by endoscopy, manometry or 24-h pH monitoring. Well-being
was decreased in all patients before operation but was restored to normal or
above-normal values after fundoplication, regardless of the type of surgery.
Seven of 28 patients in the open group had complaints regarding the scar.
CONCLUSION: Elimination of GORD symptoms improved well-being and eliminated the
need for daily acid suppression in most patients, no matter which procedure was
employed. These results were apparent 1 month after the operation and were still
valid 5 years later. Copyright 2004 British Journal of Surgery Society Ltd.
-----
Am Fam Physician. 2004 May 1;69(9):2113-8.
Barrett's esophagus.
Shalauta MD, Saad R.
Department of Family and Preventive Medicine, University of California, San
Diego, School of Medicine, San Diego, California, USA. mshalauta@ucsd.edu
Gastroesophageal reflux disease (GERD) is a condition commonly managed in the
primary care setting. Patients with GERD may develop reflux esophagitis as the
esophagus repeatedly is exposed to acidic gastric contents. Over time, untreated
reflux esophagitis may lead to chronic complications such as esophageal
stricture or the development of Barrett's esophagus. Barrett's esophagus is a
premalignant metaplastic process that typically involves the distal esophagus.
Its presence is suspected by endoscopic evaluation of the esophagus, but the
diagnosis is confirmed by histologic analysis of endoscopically biopsied tissue.
Risk factors for Barrett's esophagus include GERD, white or Hispanic race, male
sex, advancing age, smoking, and obesity. Although Barrett's esophagus rarely
progresses to adenocarcinoma, optimal management is a matter of debate. Current
treatment guidelines include relieving GERD symptoms with medical or surgical
measures (similar to the treatment of GERD that is not associated with Barrett's
esophagus) and surveillance endoscopy. Guidelines for surveillance endoscopy
have been published; however, no studies have verified that any specific
treatment or management strategy has decreased the rate of mortality from
adenocarcinoma.
-----
J Clin Gastroenterol. 2004 Apr;38(4):332-40.
40 mg pantoprazole and 40 mg esomeprazole are equivalent in the
healing of esophageal lesions and relief from gastroesophageal reflux
disease-related symptoms.
Gillessen A, Beil W, Modlin IM, Gatz G, Hole U.
Ruhr-Universitat Bochum, Universitatsklinik Marienhospital Herne, Germany.
Anton.Gillessen@ruhr-uni-bochum.de
BACKGROUND: Proton pump inhibitors are regarded as the most effective class of
acid suppressive medication for gastroesophageal reflux disease treatment. There
is considerable interest regarding the dose equivalence between various proton
pump inhibitors. GOALS: To compare the efficacy of pantoprazole and esomeprazole
with regard to healing and relief from gastroesophageal reflux disease-related
symptoms. STUDY: Multicenter, randomized, double-blind study. Patients with
gastroesophageal reflux disease grades B/C (Los Angeles classification) received
40 mg pantoprazole daily (n = 113) or 40 mg esomeprazole daily (n = 114).
Healing (endoscopy) and relief from gastroesophageal reflux disease-related
symptoms (direct questioning) were assessed at first and final visit (after 4,
6, 8, or 10 weeks of treatment). RESULTS: Overall healing in both treatment
groups was 88% of patients (intention-to-treat population), 95% (pantoprazole),
and 90% (esomeprazole) (per-protocol population); statistically, this indicates
"at least equivalence" between treatments. Overall relief from gastroesophageal
reflux disease-related symptoms was similar for pantoprazole (55%) and
esomeprazole (51%, per-protoco). No correlation between healing and symptom
relief was seen. The majority of reported adverse events were assessed as "not
related" to the study drug. Pantoprazole and esomeprazole have comparably good
safety and tolerability. CONCLUSION: In patients with gastroesophageal reflux
disease, 40 mg pantoprazole daily and 40 mg esomeprazole daily are equally
effective for healing of esophageal lesions and relieving gastroesophageal
reflux disease-related symptoms.
-----
Gastroenterol Nurs. 2004 Mar-Apr;27(2):44-9.
Efficacy of esomeprazole in patients with acid-peptic disorders.
Beck J.
Aurora Sinai Medical Center, Milwaukee, WI, USA. jean.beck@aurora.org
Esomeprazole (Nexium) is a new proton pump inhibitor that provides more
effective acid control compared with other proton pump inhibitors. In patients
with gastroesophageal reflux disease, standard doses of esomeprazole maintain
intragastric pH above 4 for significantly longer periods compared with standard
doses of other proton pump inhibitors after 5 days of treatment. Esomeprazole is
approved for the treatment of symptomatic gastroesophageal reflux disease, the
healing of erosive esophagitis, and maintenance of healing. In clinical trials,
esomeprazole 40 mg once daily for up to 8 weeks provided higher rates of healing
of erosive esophagitis and a greater proportion of patients with sustained
resolution of heartburn, than either omeprazole 20 mg or lansoprazole 30 mg once
daily. For the maintenance of healing, esomeprazole 20 mg once daily provided
significantly higher rates of maintained healing of erosive esophagitis after 6
months of treatment compared with lansoprazole 15 mg once daily. Esomeprazole is
also approved for use as part of a triple-drug therapy regimen in combination
with amoxicillin and clarithromycin for the eradication of Helicobacter pylori
in patients with duodenal ulcer disease. The side effect profile of esomeprazole
is similar to that of omeprazole. Many patients with acid-related disorders may
benefit from the more rapid symptom relief, higher rates of healing of erosive
esophagitis, and improved maintenance of healing that can be achieved with
esomeprazole.
-----
J Clin Gastroenterol. 2004 Mar;38(3):209-17.
Endoluminal therapies for gastroesophageal reflux disease.
Behm BW, Stollman N.
East Bay Center for Digestive Health, 3300 Webster Street, Suite 312, Oakland,
CA 94609, USA.
While medical therapy, particularly with proton pump inhibitors, is effective
for the large majority of patients with reflux disease, there remains a subset
of patients who are dissatisfied, due to cost, side effects of medications, or
persistent symptoms such as regurgitation. For this population, surgical
fundoplication has been, and remains, an appropriate option. A new class of
endoluminal interventions, attempting to create a mechanical antireflux barrier,
has emerged recently. Three such devices are currently approved and available,
and a number of others are in various stages of evaluation. This article will
review the approved technologies, as well as selected promising emerging ones.
with particular emphasis on the scientific evidence available to date supporting
their efficacy.
-----
Pol Merkuriusz Lek. 2004 Mar;16(93):275-8.
[Endoscopic treatment of gastroesophageal reflux disease--new
possibilities]
[Article in Polish]
Piotrowska-Staworko G, Baniukiewicz A, Laszewicz W.
Klinika Gastroenterologii i Chorob Wewnetrznych Akademii Medycznej w Bialymstoku.
Gastro-esophageal reflux disease (GERD) is one of the most important problems of
gastroenterology at present. The symptoms of GERD have negative influence of
patients' life on a daily basis. The principal aim of reflux disease treatment
is to eliminate or alleviate the symptoms, to heal tissue damages and to reduce
the frequency and duration of recurrences. Lifestyle and dietary modification
are of only limited value in GERD treatment. Proton pump inhibitors (PPI) are
the mainstay of GERD pharmacotherapy for both initial episode and long-term
management. Surgical treatment is indicated in: complicated GERD, in patients
who need high effective dose of medication, young patients who need lifelong PPI,
patients with big hiatus hernia. Laparoscopic Nissen fundoplication has become
the operation of choice. Nevertheless patients who have undergone fundoplication
may experience adverse post operative complication. The useful alternatives in
the management of GERD may indeed eventually prove the new endoscopic methods of
minimally invasive treatment which are currently under thorough evaluation. The
most promising methods of endoscopic treatment of GERD have been discussed:
radiofrequency ablation (the Streett's procedure), endoscopic gastroplasty,
endoscopic implantation of biopolymer hydrogel prosthesis.
-----
Pol Merkuriusz Lek. 2004 Mar;16(93):217-9.
[Effectiveness of omeprazole therapy in children with
gastroesophageal reflux diseases(GERD)]
[Article in Polish]
Czerwionka-Szaflarska M, Mierzwa G, Kuczynska R.
Katedra i Klinika Pediatrii, Alergologii i Gastroenterologii Akademii Medycznej
w Bydgoszczy.
THE AIM: Of the study was retrospective analysis of omeprazole (Polprazol)
therapy efficacy in children with GERD. MATERIAL AND METHODS: The analyzed group
consisted of 78 children with gastroesophageal reflux disease. GERD was detected
on the base of questionnaire, pH-metry and/or endoscopy. The questionnaire was
conducted in all patients, 24-hour pH-metric examination in 47% and endoscopy in
53% children. Than omeprazole therapy was introduced (0.5-1.0 mg/kg daily).
RESULTS: Before omeprazole therapy rebounding was observed in 94% children,
heartburn in 84%, vomits in 38% and abdominal pain in 90% children. After 8
weeks of therapy analyzed symptoms were significantly reduced--rebounding was
observed in 31% children, heartburn in 28% vomits in 5% and abdominal pain in
26% children. CONCLUSION: Omeprazole therapy is effective in children with
gastroesophageal reflux disease.
-----
Drugs Today (Barc). 2004 Mar;40 Suppl A:3-8.
GERD 2003: issues from the past and a consensus for the future.
Modlin I, Kidd M.
Gastric Pathology Research Group, Department of Surgery, Yale University, School
of Medicine, New Haven, CT 06520-8062, USA.
Gastroesophageal reflux disease (GERD) has evolved from a scarcely reported,
little understood disease process just a century ago to a now highly prevalent
disease with up to 25% of the population complaining of symptoms of reflux.
Throughout history attempts have been made to delineate the esophagus and
related pathologies, but it has not been until relatively recently that enough
has been understood about its screening, diagnosis and treatment to make a
substantial impact on sufferers. Although the use of antacids and thereafter
histamine 2 receptor antagonists dramatically improved the management of GERD,
it was the advent of the proton pump inhibitor (PPI) class of drugs that
revolutionized medical care. Although the relationship of hiatus hernia to
reflux was well accepted, the modest results of open fundoplication fell into
further disregard given the efficacy of PPIs. The PPIs are currently the most
effective form of therapy and are equivalent on a milligram for milligram basis.
While currently no novel drugs or devices are of proven efficacy for GERD, the
development of an acid-suppressive agent of equal efficiency to a PPI but with a
more rapid onset of action and a greater duration of effectiveness would be of
particular clinical utility for the future. (c) 2004 Prous Science
-----
Surg Today. 2004;34(6):506-9.
Laparoscopic nissen fundoplication for gastroesophageal reflux
disease in Japan.
Takeyama S, Numata A, Nenohi M, Shibata Y, Okushiba S, Katoh H.
Department of Surgery, Asahikawa City Hospital, 1-1-65 Kinsei-cho, 070-8610,
Asahikawa, Japan.
PURPOSEMETHODS. Between 1998 and 2001 we performed laparoscopic Nissen
fundoplication in 23 patients to evaluate the efficiency of this technique. We
examined the following four parameters pre- and postoperatively: symptoms,
endoscopic findings, gastroesophagogram findings, and the results of
intraesophageal 24-h pH monitoring. We also examined the operation time, blood
loss, intraoperative complications, and postoperative complications. RESULTS.
The operation was safely performed in all patients, regardless of age, and there
were no intraoperative complications. Postoperatively, more than three
parameters were effectively normalized in 17 (89.5%) of 19 patients. The only
postoperative complications were delayed gastric emptying in three patients and
persistent dysphagia in five patients. During follow-up, esophagitis recurred in
two patients, one of whom underwent laparoscopic refundoplication, which
normalized the condition. CONCLUSION. Laparoscopic Nissen fundoplication is
highly effective for GERD and could become the standard surgical treatment in
Japan.Laparoscopic antireflux surgery is the standard treatment for
gastroesophageal reflux disease (GERD) in Western countries where this disorder
is common; however, it has only recently been introduced in Japan. We examined
the effectiveness of laparoscopic antireflux surgery in a small series of
Japanese patients.
-----
Issues Emerg Health Technol. 2004 Mar;(54):1-4.
Endoscope-based treatments for gastroesophageal
reflux disease.
Hailey D.
Endoscope-based products for the treatment of more severe forms
of gastroesophageal reflux disease provide an alternative to the
use of drugs or surgery. Results from case series have shown that
selected patients benefit through relief of symptoms and reduction
of medication. Reported adverse effects appear to be minor. Efficacy
has been mostly assessed over short periods and there is little
information on comparison with other treatments.Procedural skills
and appropriate training in their use are required. These technologies
are promising, but their place in health care is not established.
------
Dtsch Med Wochenschr. 2004 Mar 26;129(13):671-5.
[Long-term course of reflux symptoms following
Helicobacter pylori eradication]
[Article in German]
Peitz U, Raps S, Plein K, Leodolter A, Hotz Dagger J, Malfertheiner
P.
Klinik fur Gastroenterologie, Hepatologie und Infektiologie, Otto-von-Guericke-Universitat
Magdeburg.
BACKGROUND AND OBJECTIVE: Conflicting data regarding new onset
or deterioration of gastroesophageal reflux disease (GORD) following
eradication of Helicobacter pylori infection have been reported.
Successful eradication therapy may influence gastric acid output.
The study aimed to to investigate whether patients with pre-existing
GORD or peptic ulcer disease may experience deterioration of GORD.
PATIENTS AND METHODS: 75 consecutive patients of a prospective
longitudinal study (median age 66 years, n = 45 males) had received
successful H. pylori eradication therapy because of the following
main diagnosis: peptic ulcer (n = 37), GORD (n = 16), functional
dyspepsia (n = 22). Two to three years later, they had an interview
regarding the course of their dyspeptic and reflux symptoms. Negative
H. pylori status at present was confirmed by (13)C-urea breath
test in all patients. Ten patients were excluded because of proton
pump inhibitor treatment. RESULTS: Patients with deterioration
of GORD (new onset or increasing reflux symptoms) were found significantly
more frequently in the group with functional dyspepsia (36 %)
compared to pre-existing GORD (16 %) or peptic ulcer disease (5
%). Improvement of pre-existing reflux complaints were reported
mostly by patients with peptic ulcer disease. There was no significant
impact of initial reflux manifestations like reflux symptoms or
reflux oesophagitis on the course. CONCLUSIONS: During long-term
follow-up after H. pylori eradication, patients experience improvement
as frequently as deterioration of reflux symptoms. There is a
tendency towards improvement of reflux symptoms if peptic ulcer
disease had been the indication for eradication, but towards deterioration
in patients with initial functional dyspepsia. A clinical relevant
prediction, however, is not feasible.
-----
Gastrointest Endosc Clin N Am. 2003 Jan;13(1):157-65, xi.
The history and future of implantation therapy
for gastroesophageal reflux disease.
Lehman GA.
Indiana University Medical Center, 550 North University Boulevard,
Suite 4100, Indianapolis, IN 46202, USA. glehman@iupui.edu
The initial development of endoscopic implantation techniques
for the treatment of gastroesophageal reflux disease in the 1980s
helped set the stage for current implantation techniques and studies,
which now include more than 500 patients. The relative simplicity
of these techniques adds to their attraction. Ultimately, multiple
factors, including therapeutic efficacy durability, safety, simplicity,
and cost-effectiveness, will determine clinical application of
these techniques. This article focuses on transoral endoscopic
implantation, although surgical, transcutaneous, and other endoscopic
routes have been used as well.
-----
Gastrointest Endosc Clin N Am. 2003 Jan;13(1):147-55.
Clinical experience with the Stretta procedure.
Triadafilopoulos G.
Gastroenterology Section, VA Palo Alto Health Care System, (111-G1),
3801 Miranda Avenue, Palo Alto, CA 94304, USA. vagt@stanford.edu
The benchmarks in GERD therapy comprise the commonly prescribed
anti-secretory drugs (H2RAs and PPIs) and anti-reflux surgery.
Although drugs are typically safe, cost and patient compliance
are challenges to long-term management. Furthermore, while heartburn
may be controlled with aggressive medical therapy, other symptoms
such as regurgitation may persist, reducing patient satisfaction
and adversely affecting quality of life. Surgical anti-reflux
procedures, most commonly laparoscopic Nissen fundoplication,
improve GERD symptoms and normalize esophageal acid exposure in
most patients. Patient perception of the potential risk of abdominal
surgery and general anesthesia may limit willingness to undergo
surgery resulting in only a small portion of GERD sufferers that
actually undergo anti-reflux surgery each year. Overall, the Stretta
procedure is well tolerated, with an acceptably low incidence
of complications and obviates the need for anti-secretory drug
therapy for most patients at the 6- and 12-month follow-up. GERD
symptom scores, heartburn, satisfaction, and SF-36 scores significantly
improve over the baseline and this effect lasts at least 12 months.
The symptomatic improvement after Stretta at 12 months in one
trial (GERD score, 27 to 9) is similar to that reported by Velanovich
after fundoplication (GERD score, 27 to 3). Furthermore, the significant
reduction in median esophageal acid exposure time (distal 10.6%
to 6.2%, proximal 1.9% to 0.9%), provides objective evidence of
an anti-reflux effect. Although the reported studies have been
non-randomized, the objective improvement observed in esophageal
acid exposure and the persistence of GERD symptom score improvement
with repeated measure analysis over a course of 12 months make
a significant placebo effect unlikely. Stretta is a promising
new technology for the treatment of GERD that should be considered
for patients who wish to discontinue a lifelong anti-secretory
medication regimen or who have incomplete GERD symptom control
on drugs, but are not yet accepting anti-reflux surgery.
-----
Gastrointest Endosc Clin N Am. 2003 Jan;13(1):103-8.
Wilson-Cook sewing device: the device, technique,
and preclinical studies.
Rosen M, Ponsky J.
Center for Minimally Invasive Surgery, Cleveland Clinic Foundation,
Cleveland, OH 44195, USA.
Endoscopic treatment of GERD is still in its infancy, however
the potential benefits of an endoscopic treatment for GERD are
great. These procedures can be performed on an outpatient basis,
without the risks of general anesthesia. The absence of abdominal
incisions eliminates the morbidity of wound infections and hernia
formation. The procedures are certainly less painful than laparoscopic
or open surgery for reflux disease. These procedures might even
be more cost effective than long-term acid suppression. These
benefits make endoscopic treatment for reflux disease an appealing
alternative. While the ideal endoscopic therapy has not been developed,
all of these approaches have promise for the future and with further
study the role of endoscopic therapy for GERD will continue to
be defined.
-----
Gastrointest Endosc Clin N Am. 2003 Jan;13(1):109-16, ix-x.
Endoscopic full-thickness plication: the device,
technique, pre-clinical and early clinical experience.
Chuttani R.
Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston,
MA 02215, USA. rchuttan@caregroup.harvard.edu
The endoscopic full-thickness plication device is designed
to inhibit reflux with a single plication near the gastroesophageal
junction. Full-thickness plication of the proximal stomach may
improve the competency of the gastroesophageal barrier by restoring
the valvular mechanism of the gastroesophageal junction. Other
potential mechanisms include alteration of the angle of His, and
reduction of the compliance of the gastric cardia and fundus.
The procedure is easily and safely performed and, in the human
pilot study, has been shown to reduce symptoms and medication
use associated with gastroesophageal reflux disease.
-----
Gastrointest Endosc Clin N Am. 2003 Jan;13(1):89-101.
Endoscopic suturing for gastroesophageal reflux
disease: clinical outcome with the Bard EndoCinch.
Rothstein RI, Filipi CJ.
Section of Gastroenterology Dartmouth Hitchcock Medical Center,
One Medical Drive, Lebanon, NH 03756, USA. richard.rothstein@dartmouth.edu
From a review of the single peer reviewed published report
and the brief preliminary studies presented in abstract form,
the BARD EndoCinch procedure seems safe and demonstrates an acceptable
efficacy for symptom control during short-term follow-up. Most
patients (about 2 out of 3) do well with improvement of GERD symptoms
during the first post-procedural year. This benefit may wane over
time. Objective benefit is lacking with the minority of treated
individuals achieving normalization of 24-hour total acid exposure,
and no significant effect has been seen in healing of esophagitis.
This may focus the treatment towards that group of GERD patients
with mild or non-erosive disease. The authors have no information
that the endoscopic therapy could prevent reflux-related complications,
and long-term data is awaited from accumulated clinical experience
to establish the maintenance profile of this novel treatment.
The outcomes from the sham trial, and long-term follow-up data
will help to define the role of this anti-reflux therapy. The
authors need additional studies to define the effect of endoluminal
plication on the function of the lower esophageal sphincter to
optimize its benefit for patients.
-----
Gastrointest Endosc Clin N Am. 2003 Jan;13(1):57-68.
Overview of medical therapy for gastroesophageal
disease.
Ramakrishnan A, Katz PO.
Department of Medicine, Graduate Hospital, 1800 Lombard Street,
Suite 501, Pepper Pavilion, Philadelphia, PA 19146, USA.
The last twenty years have seen an evolution of much improved
strategies in the medical treatment of GERD. Current therapy is
targeted at acid suppression, to deal with consequences of mucosal
injury and afford resolution of symptoms. Given their modest efficacy,
there is no longer much support for initial treatment with H2RAs.
PPIs have been shown to provide the highest levels of symptom
relief and esophageal healing, in addition to preventing relapse
and complications. With this class of agents, the clinician is
able to prescribe a drug that is as highly effective as surgery
for the purpose intended, without worrying about long term sequelae
of acid suppression. It appears that patients with extraesophageal
GERD must be treated with higher doses of pharmacologic therapy,
principally with the PPIs, for longer periods of time to achieve
complete relief of symptoms when compared to patients with heartburn
and erosive esophagitis. There is still no clear consensus as
to whether aggressive acid suppression alters the natural history
of Barrett's esophagus. Based on their initial success, it appears
that the next generation of evolving medical therapies will continue
to play an important role in the management of GERD. The outcome
from medical therapy is the standard against which the results
of the novel endoscopy anti-reflux treatments will be measured.
-----
Rev Gastroenterol Disord. 2003 Spring;3(2):59-69.
Optimizing medical therapy for gastroesophageal
reflux disease: state of the art.
Katz PO.
Department of Medicine, Graduate Hospital, Philadelphia, PA, USA.
Potential interventions for gastroesophageal reflux disease
include lifestyle modifications, antacids, mucosal protectants,
prokinetic (promotility) agents, H2 receptor antagonists (H2RAs)
and, the agents of choice in 2003, proton pump inhibitors (PPIs).
This article reviews the current state of the art in use of these
agents. Lifestyle changes, though sound in their intent and in
many cases based on solid laboratory research, can today be considered
only adjuncts to pharmacologic therapy. The mainstay of pharmacologic
therapy in 2003 is antisecretory therapy. Both H2RAs and PPIs
inhibit acid secretion and raise intragastric pH. H2RAs only block
one receptor, have limited effect on acid reduction, and are relatively
weak inhibitors of meal-stimulated acid secretion. PPIs provide
superior control of intragastric pH over a 24-hour period compared
with H2RAs and effect greater symptom relief and healing.
-----
Dig Dis Sci. 2003 Apr;48(4):657-62.
Reductions in symptom distress reported by patients
with moderately severe, nonerosive gastroesophageal reflux disease
treated with rabeprazole.
Damiano A, Siddique R, Xu X, Johanson J, Sloan S.
Covance Health Economics and Outcomes Services Inc., Gaithersburg,
Maryland 20878, USA.
Gastroesophageal reflux disease (GERD) is characterized by
heartburn and related symptoms that are distressing to patients
and interfere with everyday functioning and well-being. A measure
of symptom distress, the GERD Symptom Assessment Scale (GSAS),
was included in two randomized, placebo-controlled trials of rabeprazole
among patients with nonerosive GERD. The age (mean +/- SD) of
the 223 patients was 43.5 +/- 11.9 years, and most were female
(67%) and Caucasian (78%). Significantly greater reductions in
symptom distress were observed among patients receiving rabeprazole
20 mg daily for 4 weeks relative to those receiving placebo (-0.62
vs -0.36, P < 0.0001). The magnitude of this treatment difference
was comparable to the differences observed between levels of overall
symptom improvement on the patient global rating (0.2 and 0.3
points; P < 0.0001). In conclusion, reducing symptom distress
is an important goal of therapeutic interventions for GERD. Rabeprazole
significantly reduced the distress associated with a broad range
of GERD symptoms, and the magnitude of this effect was meaningful
to patients.
-----
Br J Surg. 2003 May;90(5):560-2.
Day-case laparoscopic Nissen fundoplication.
Bailey ME, Garrett WV, Nisar A, Boyle NH, Slater GH.
Minimal Access Therapy Training Unit, Royal Surrey County Hospital,
Egerton Road, Guildford GU7 5XX, UK. meb@mattu.org.uk
BACKGROUND: The aim was to assess the acceptability and safety
of day-case laparoscopic fundoplication for gastro-oesophageal
reflux disease (GORD). METHODS: This prospective study commenced
in December 1999 and lasted for 18 months. All patients had proven
symptomatic GORD. Inclusion criteria were American Society of
Anesthesiologists grade I or II with adequate home support. A
standard anaesthetic, analgesic and antiemetic protocol was used.
Patients were contacted by telephone on the night of discharge
and arrangements were made for a nurse to visit the following
day. Postoperative pain and nausea were assessed using visual
analogue scores (scale 0-10) on a self-completion questionnaire.
RESULTS: Twenty patients were included. There were no postoperative
complications. All patients were discharged on the day of surgery.
Median time to discharge was 6 h 30 min (range 4.5 to 9 h). One
patient reattended casualty the following morning but none required
readmission. There was no significant difference in median pain
or nausea scores the evening after surgery or the next morning.
All patients were satisfied with the information given and aftercare
provided. All would recommend it to a friend and 19 of 20 would
undergo the procedure as a day case again. CONCLUSION: This study
suggests that day-case laparoscopic fundoplication is feasible.
Patients find it acceptable and it appears safe. Copyright 2003
British Journal of Surgery Society Ltd. Published by John Wiley
& Sons, Ltd.
-----
Drugs Today (Barc). 2003 Mar;39 Suppl A:21-8.
Endoscopic antireflux treatment: fact, fiction
or future?
Hochberger J, Tex S, Maiss J, Muehldorfer S, Hahn EG.
Department of Medicine I, University of Erlangen, Erlangen, Germany.
juehochber@aol.com
Medical therapy with proton pump inhibitors (PPIs), aside from
surgery, is the established and most effective treatment approach
for chronic gastroesophageal reflux disease (GERD). Recently developed
endoscopic antireflux procedures may be an alternative for a subset
of patients with uncomplicated, mild GERD. Given the perioperative
morbidity and mortality risk of laparoscopic fundoplication, less
invasive semi-surgical and flexible endoscopic techniques may
be an option for patients who cannot or wish not to take long-term
medication. These clinical procedures include endoscopic suturing
devices, focal radiofrequency coagulation in the cardia and bioimplants.
While many of these techniques have shown good results in preliminary
studies, long-term results are not yet available and therefore
all such procedures have to be considered experimental. Their
effectiveness will need to be compared with that of established
treatment forms.
-----
Drugs Today (Barc). 2003 Mar;39 Suppl A:15-20.
Management of gastroesophageal reflux disease.
Stanghellini V.
Department of Internal Medicine and Gastroenterology, University
of Bologna, Italy.
Gastroesophageal reflux disease (GERD) is a frequent clinical
condition which leads to reduced quality of life. Atypical manifestations
of the disease can confound diagnosis, and even the typical symptoms
of heartburn and regurgitation can lead to misinterpretation.
Proton pump inhibitors (PPIs) are the standard treatment for GERD
and the different formulations show equivalence on a milligram
to milligram basis in terms of efficacy and tolerability. With
standard dosing, 8 weeks of treatment has been shown to heal most
patients. However, as GERD is a chronically relapsing disease,
maintenance treatment with lower dose PPIs is frequently required.
Pantoprazole is the only PPI found not to interact with the metabolism
of other drugs and is therefore the treatment of choice especially
for patients with co-morbidities and co-medication.
-----
J Gastroenterol. 2003 Mar;38 Suppl 15:13-9.
Therapeutic approaches to reflux disease, focusing
on acid secretion.
Kinoshita Y, Adachi K, Fujishiro H.
Department of Internal Medicine II, Shimane Medical University,
89-1 Enya-cho, Izumo 693-8501, Japan.
Gastroesophageal reflux disease (GERD) is caused by a combination
of esophageal motor dysfunction accompanied by maintained gastric
acid secretion. Noninvasive medical treatment of GERD is mainly
provided by inhibiting gastric acid secretion, because this is
easier than restoring esophageal motor function by administration
of drugs. Proton pump inhibitors (PPIs) and histamine H2 receptor
antagonists (H2RAs) are two major acid-suppressing drugs used
for the treatment of GERD. PPIs have better characteristics for
the long-term treatment of GERD, because they have a long-lasting,
strong effect of raising intragastric pH and have no tachyphylaxis/tolerance
phenomena on repeated dosing. Some patients with Helicobacter
pylori-negative high-grade GERD may show nocturnal decreases in
pH during treatment with PPIs and resistance to treatment with
PPI. For these patients, addition of H2RAs to PPIs can be useful
for controlling GERD, at least for short-term treatment. For long-term
control of such cases, further studies are necessary.
-----
Am J Gastroenterol. 2003 Mar;98(3 Suppl):S49-55.
Rabeprazole-based therapy in the management of
symptomatic gastroesophageal reflux disease.
Sloan S.
Department of Medical Affairs, Janssen Pharmaceutica Inc., 1125
Trenton-Harbourton Road, Titusville, NJ 08560-0200, USA.
Gastroesophageal reflux disease (GERD) is associated with several
symptoms, such as heartburn, belching, and regurgitation, which
arise from esophageal exposure to gastric acid. Symptoms may occur
in the absence of endoscopically observed esophageal mucosal damage
and inflammation. These patients represent the majority of those
who present with GERD symptoms. Although acid suppression therapy
is a logical approach to relieving GERD symptoms, it has been
thought to relieve symptoms less reliably in patients with endoscopically
negative, or symptomatic GERD than in those with erosive GERD.
Two multicenter, randomized, double-blind, placebo-controlled
clinical trials were conducted in the United States to evaluate
the efficacy of rabeprazole sodium 10 mg and 20 mg compared with
placebo for the relief of heartburn and other symptoms associated
with symptomatic GERD. Results from these studies indicated that
rabeprazole 10 or 20 mg once daily relieved heartburn within the
first 1 or 2 days of treatment and also had significant positive
effects on other GERD symptoms, including regurgitation, belching,
bloating, satiety, and nausea. Overall, these results suggest
that rabeprazole may hold a significant therapeutic advantage
in the treatment of heartburn and other symptoms associated with
endoscopically negative GERD, particularly in the majority of
patients who often are treated empirically without, or before,
endoscopic evaluation.
-----
Laryngorhinootologie. 2003 Feb;82(2):118-22.
[Gastroesophageal reflux -- a common illness?]
[Article in German]
Issing WJ.
Klinik und Poliklinik fur Hals-, Nasen- und Ohrenkranke, Klinikum
Grosshadern, Ludwig-Maximilians-Universitat Munchen, Munich. wolfgang.issing@web.de
For a long time heartburn was not considered a symptom for
serious illness. By now, however, it is accepted that the incidence
of secondary carcinoma of the esophagus caused by chronic GERD
has increased dramatically since the nineteen-seventies. Mechanisms
leading to GERD are complex and its incidence is not necessarily
pathological. However pathological reflux in the lower esophagus
(pH lower than 4 in 6 % of 24 hours), caused by decreased sphinctertonus,
impaired peristalsis and clearance of the esophagus, may lead
to complications. Helicobacter pylori may play a key role in GERD.
There is strong evidence for a protective effect of Hp-infection
in the development of GERD. In pangastritis, caused by Hp-infection,
gastric acid production is inhibited resulting in a reduction
of stomach-acid-concentration. This may be caused by either the
chronic infection itself and the resulting atrophy of the stomach-mucosa,
by the ammonia-producing HP-bacteria, or an increase in acid re-absorbtion
of gastric epithelium. Laryngopharyngeal reflux (LPR) often results
in atypical manifestations with oral, pharyngeal, laryngeal, and
pulmonary disorders. Laryngopharyngeal reflux is known to contribute
to posterior acid laryngitis and laryngeal contact ulceration
or granuloma formation, laryngeal cancer, chronic hoarseness,
pharyngitis, asthma, pneumonia, nocturnal choking, and dental
diseases. Today, PPI are the medication of choice in both acute
and long-term (prophylactic) therapy of GERD. The so called "step-up-strategy"
of medication is no longer recommended. Here, patients were first
treated with antacids, then prokinetics followed by H2-blockers
and finally low-dose PPI. Only in the case of persisting symptoms
medication was further increased to high-dose PPI therapy. In
the past this increase in medication lead to a prolonged healing
process and consequently to higher medication costs. Studies have
shown that a "step-down"-therapy, beginning with high
dose PPI, is highly preferable, since it is much more effective.
Depending on the degree of the symptoms, however, medication may
also be applied "on-demand". The BfArM has approved
this kind of medication application only for Esomeprazol (Nexium
mups 20 mg).
-----
J Fam Pract. 2003 Mar;52(3):240-7.
Gastroesophageal reflux disease.
Howden CW, Chey WD.
Division of Gastroenterology, Northwestern University, Feinberg
School of Medicine, Chicago, IL, USA.
Heartburn on 2 or more days a week warrants medical attention,
as patients are likely to suffer from gastroesophageal reflux
disease (GERD). Chronic GERD can lead to the development of complications
including erosive esophagitis, stricture formation, and Barrett's
esophagus, which increases the risk of esophageal adenocarcinoma.
A trial with a proton pump inhibitor (PPI) is the quickest and
most cost-effective way to diagnose GERD, and is at least as sensitive
as 24-hour intra-esophageal pH monitoring. As PPIs only bind to
actively secreting proton pumps, they should be dosed 30 to 60
minutes before a meal. Despite these recommendations, a recent
survey of over 1000 US primary care physicians found that 36%
instructed their patients to take a PPI with or after a meal or
did not specify the timing of dosing. The patients who will have
the best response to surgical therapy for GERD are those who had
clearly documented acid reflux with typical symptoms, and who
have responded to PPI treatment. Unfortunately, the same survey
found that most physicians recommend antireflux surgery for patients
in whom medical therapy has failed.
-----
Aliment Pharmacol Ther. 2003 Feb;17 Suppl 1:53-7.
Overview: initial and long-term management of
gastro-oesophageal reflux disease.
Dent J, Talley NJ.
Department of Gastroenterology, Hepatology and General Medicine,
Royal Adelaide Hospital, Adelaide, SA 5000, Australia. jdent@mail.rah.sa.gov.au
Initial management of gastro-oesophageal reflux disease aims
to confirm a symptom-based diagnosis, to relieve symptoms, to
reassure the patient as to the treatable nature of reflux disease,
and to initiate risk management and healing of oesophagitis. The
aims of long-term management include adequate control of symptoms,
prevention of complications, and improvement of quality of life.
Management options in terms of use of proton pump inhibitors are
either daily therapy (maintenance), intermittent courses of therapy
(for example, 4 weeks, then cease and observe), or on-demand therapy.
This overview discusses the advantages and disadvantages of these
different strategies for the management of reflux disease.
-----
Aliment Pharmacol Ther. 2003 Feb;17 Suppl 1:18-20.
Review article: initial therapy of reflux disease
with esomeprazole.
Dent J.
Department of Gastroenterology, Hepatology and General Medicine,
Royal Adelaide Hospital, Adelaide, SA 5000, Australia. jdent@mail.rah.sa.gov.au
Large clinical trials in patients with reflux oesophagitis
have shown esomeprazole, 40 mg once daily, to be convincingly
superior in the healing of oesophagitis when compared with both
omeprazole, 20 mg once daily, and lansoprazole, 30 mg once daily.
The greatest advantage for esomeprazole is with healing of the
more severe grades of oesophagitis. Esomeprazole, 40 mg once daily,
has also been shown to be significantly superior in the treatment
of heartburn. Studies in endoscopy-negative patients, or in both
oesophagitis and endoscopy-negative patients, have demonstrated
good efficacy for esomeprazole, with high levels of symptom control
achieved in the first 7 days of therapy.
-----
Aliment Pharmacol Ther. 2003 Feb;17 Suppl 1:10-5; discussion
16-7.
Review article: gastric acidity--comparison of
esomeprazole with other proton pump inhibitors.
Hatlebakk JG.
Department of Medicine, Haukeland Sykehus, University of Bergen,
N-5021 Bergen, Norway. jhat@haukeland.no
Gastric acid suppression is the most effective medical therapy
to control acidic gastro-oesophageal reflux: individuals in whom
therapy fails usually have inadequate acid suppression. Twenty-four-hour
intragastric pH-metry measures the percentage of time that gastric
pH is above 4 or 3, the critical thresholds for tissue damage
and symptom generation in the distal oesophagus. Effective medical
therapy must control gastric acidity throughout the daytime, including
the postprandial period. It is therefore useful to report the
percentage of patients in whom gastric acidity is controlled above
pH 4 for at least 16 out of 24 h. Esomeprazole was compared with
standard-dose proton pump inhibitors in healthy volunteers and
patients with gastro-oesophageal reflux disease. Esomeprazole,
40 mg daily, was significantly more effective at controlling gastric
acidity above pH 4 for more than 16 h than lansoprazole, 30 mg
daily (38% of individuals vs. 5%, respectively). Esomeprazole,
40 mg daily, also suppressed gastric acidity more effectively
and in more individuals than pantoprazole, 40 mg daily, and rabeprazole,
20 mg daily. Esomeprazole, 20 mg daily, was significantly more
effective at controlling gastric acidity than lansoprazole, 15
mg daily. The improved acid control with esomeprazole compared
with other proton pump inhibitors is likely to result in superior
healing rates and improved symptom relief, with fewer therapy-resistant
patients.
-----
Lancet. 2003 Mar 29;361(9363):1119-21.
Endoluminal therapies for gastro-oesophageal reflux
disease.
Galmiche JP, Bruley des Varannes S.
Department of Gastroenterology and Hepatology, CIC INSERM, CHU
Nantes, 44093, Nantes, France. galmiche@easynet.fr <galmiche@easynet.fr>
CONTEXT: Gastro-oesophageal reflux disease (GORD) is a common
chronic disorder that has severe impact on quality of life and
often requires continuous acid-suppression therapy. Proton-pump
inhibitors (PPIs) are extremely effective but expensive, and do
not restore the normal antireflux barrier at the gastro-oesophageal
junction. Antireflux surgery, even with the laparoscopic approach,
has not proven more cost-effective than maintenance therapy with
PPIs. Postoperative morbidity is substantial, especially when
procedures are done outside expert centres. In the past few years
several endoscopic techniques have been developed to treat chronic
GORD on an outpatient basis. These techniques include radiofrequency-energy
delivery and endoscopic suturing, although other approaches are
now under development. STARING POINT: Two prospective open-label
studies have recently reported 1-year follow-up of GORD patients
treated either by radiofrequency-energy delivery (G Triadafilopoulos
and colleagues Gastrointest Endosc 2002; 55:149-56) or endoscopic
suturing (Z Mahmood and colleagues Gut 2003; 52:34-39). In a US
multicentre trial, Triadafilopoulos and colleagues delivered radiofrequency
energy to the cardia and distal oesophagus in patients with chronic
heartburn, regurgitation or both (the Stretta procedure). All
patients were on continuous acid-suppression therapy, but none
had severe oesophagitis or hiatus hernia of more than 2 cm. At
12 months, 94 patients available for follow-up showed significant
improvement in GORD symptoms, quality of life, and oesophageal
acid-exposure. The need for PPI therapy fell from 98% to 30% of
patients. In the Mahmood study, 26 similar patients had endoscopic
suturing in a single centre. After 1 year, symptoms and quality
of life improved and the need for PPIs was reduced to 36% from
100%. In both studies, only minor complications occurred, none
of which required specific therapeutic intervention. WHERE NEXT?
An effective outpatient procedure to treat chronic GORD would
represent a major step forward. However, further studies are needed
before an endoscopic approach can be adopted, as none of the published
trials are well-controlled studies. Longer follow-up is needed
to ensure that relapses do not occur rapidly, complications do
not occur more frequently with less skilled operators, or that
endoscopic-induced changes do not complicate or compromise subsequent
antireflux surgery. Comparative studies of the cost-effectiveness
of endoscopic therapy should also include medical strategies such
as intermittent or on-demand PPI therapy.
-----
Dig Liver Dis. 2002 Dec;34(12):870-7.
On-demand proton pump inhibitor therapy in patients
with gastro-oesophageal reflux disease.
Pace F, Pallotta S, Bianchi Porro G.
Gastrointestinal Unit, L. Sacco University Hospital, University
of Milan, Italy.
On-demand therapy is an established modality in long-term therapy
with histamine-2-receptor antagonists, in cases of mild non-erosive
gastro-oesophageal reflux disease. In the literature, only a few
studies have specifically addressed the problem of proton pump
inhibitors on-demand treatment. The evidence, so far, available
suggests that this might be an effective modality of long-term
treatment in the majority of patients with non-erosive gastro-oesophageal
reflux disease. This treatment modality appears to be the most
cost-effective and the best tolerated medical regimen for gastro-oesophageal
reflux disease. It also seems to be able to restore the impairment
of health-related quality of life due to gastro-oesophageal reflux
disease symptoms. Although the current standard of care for patients
with non-erosive gastro-oesophageal reflux disease is maintenance
therapy with daily administration of a proton pump inhibitor agent,
on-demand therapy, with the same drug, may be a reasonable long-term
choice. The ideal proton pump inhibitors for such treatment will
be those with a more rapid onset of action, more profound acid
inhibition, more predictable therapeutic effect and less drug-drug
interactions. Newer proton pump inhibitors, like esomeprazole,
the S-chiral isomer of omeprazole, are promising drugs for on-demand
treatment of gastro-oesophageal reflux disease.
-----
Kongressbd Dtsch Ges Chir Kongr. 2002;119:184-7.
[Laparoscopic fundoplication--what is proven?]
[Article in German]
Stein HJ.
Chirurgische Klinik und Poliklinik, Klinikum rechst der Isar der
Technischen Universitat Munchen, Ismaningerstrasse 22, 81675 Munchen.
stein@nt1.chir.med.tu-muenchen.de
Laparoscopic fundoplication has become a popular procedure
but several questions remain unresolved. Although randomised trials
suggest that antireflux surgery is a good alternative to continuous
medical therapy, the selection of patients for surgery remains
crucial to achieve success. There is currently no proof that antireflux
surgery will reduce the risk for developing esophageal adenocarcinoma.
Complications, side effects and failures appear to be higher after
a laparoscopic approach as compared to conventional open surgery,
particularly in un-experienced hands. Partial fundoplications
and tailored approaches have so far not shown convincingly better
results than those that can be achieved by short and floppy 360
fundoplication.
-----
Eur J Gastroenterol Hepatol. 2002 Sep;14 Suppl 1:S5-9.
Proton pump inhibitors in the elderly population.
Whitaker M.
Didsbury Medical Centre, 645 Wilmslow Road, Didsbury, Manchester
M20 6BA, UK. mark.whitaker@gp-p84678.nhs.uk
Accurate diagnosis and effective treatment of acid-related
diseases, including gastro-oesophageal reflux disease (GORD),
are important health care priorities, particularly in the elderly.
Both the prevalence and severity of GORD are increased in older
individuals. The reason for the age-related increase in the prevalence
of GORD is not completely understood, but it appears to result
from both age-related changes in physiology and effects of the
medications often taken by older people. The diagnosis of GORD
in the elderly is also difficult because of its potential atypical
presentation in these patients, as well as the overlap between
GORD symptoms and those of other chronic conditions, including
coronary artery disease and chronic obstructive pulmonary disease.
Proton pump inhibitors (PPIs) are now considered the treatment
of choice for patients with GORD, and these drugs have excellent
efficacy and safety profiles. One of the newer drugs in this class,
rabeprazole, may be particularly suited for use in older patients.
Rabeprazole requires no dosing adjustment in the elderly or in
patients with renal insufficiency or mild-to-moderate hepatic
disease. It is also relatively free of clinically significant
drug-drug interactions, which strongly differentiates rabeprazole
from omeprazole, the prototype PPI. Overall, the clinical and
pharmacokinetic profiles for rabeprazole suggest that it is an
excellent first choice for the management of older patients with
GORD.
-----
Eur J Surg. 2002;168(8-9):441-5.
Repeat antireflux surgery: effectiveness of a
toupet partial posterior fundoplication.
Johnsson E, Lundell L.
Department of Surgery, Sahlgrenska University Hospital, Gothenburg,
Sweden.
OBJECTIVE: To report the feasibility and efficacy of posterior
partial fundoplication for patients with recurrent reflux after
previous antireflux operations. DESIGN: Prospective non-randomised
single hospital study. SETTING: University hospital, Sweden. PATIENTS:
32 consecutive patients who required reoperation after failure
of previous operations for gastro-oesophageal reflux disease.
MAIN OUTCOME MEASURES: Control of symptoms, oesophageal acid reflux.
RESULTS: Most patients were referred for reoperation because of
recurrent reflux, but six patients had a symptomatic intrahoracic
herniation of the wrap with a life-threatening perforation in
one patient. Three patients had recurrent reflux within 6 months
of the operation and another two were classified as failures.
The remaining 27 (84%) were classified as having a successful
outcome during a mean follow-up period of 20 months. CONCLUSION:
A posterior partial fundoplication can be done safely in a repeat
operation for patients whose antireflux operation has failed.
-----
Gastroenterol Clin North Am. 2002 Dec;31(4 Suppl):S89-109.
Surgical and endoscopic treatment of gastroesophageal
reflux disease.
Waring JP.
Digestive Healthcare of Georgia, 95 Collier Road, Suite 4075,
Atlanta, GA 30309, USA.
There is no evidence to advocate medical or surgical therapy
as the best therapy for GERD. The decision to have antireflux
surgery must be individualized. All patients taking long-term
medications for GERD should receive advice on the safety and wisdom
of staying on that therapy and information on antireflux surgery.
Fundoplication should be considered in three circumstances [4]:
1. Patients who are intolerant of PPI therapy because of side
effects should be considered for surgery. This situation will
be less common now with five PPIs, however. 2. Patients who are
poorly responsive to PPI therapy should be considered for surgery.
This situation is probably not common, given the effectiveness
of the currently available PPIs. It is more common in patients
with atypical GERD. The gastroenterologist should be as certain
as possible that the patient not only has GERD, but also that
the patient's symptoms are reflux related. 3. Surgery should be
considered when patients desire a permanent solution to free them
of the need to take medications. These patients must be warned
about the potential suboptimal results, including the frequent
need for medication within a few years of having the procedure
and the small but real possibility of becoming worse after the
operation. Even in experienced hands, 1% to 2% of patients are
worse after the procedure. A careful preoperative evaluation to
ensure that the patient's symptoms are reflux related and that
the right operative procedure is performed offers the patient
the best opportunity for success. Widespread use of endoscopic
therapy for GERD is probably still several years away. The best
endoscopic therapy is yet to be determined, but it will need to
be safe, effective, and easy to use.
-----
Rev Gastroenterol Disord. 2002 Fall;2(4):189-99.
Esomeprazole: update and clinical review.
Baker DE.
College of Pharmacy, Washington State University, Spokane, Washington,
USA.
The U.S. Food and Drug Administration's Nonprescription Drugs
Advisory Committee and Gastroenterological Drugs Advisory Committee
recommended approval of omeprazole as an over-the-counter treatment
of heartburn in patients who have at least two episodes of heartburn
each week. The consumer studies that have been conducted indicate
that the majority of patients understand the proposed labeling
and could use the proposed label to determine if the omeprazole
therapy was appropriate for them. Esomeprazole is an effective
agent in the treatment of gastroesophageal reflux disease (GERD)
and erosive esophagitis. Newer studies continue to support its
efficacy and safety in the treatment of these conditions. Several
of the most recent studies have included comparisons with other
proton pump inhibitors. The results of these studies indicate
that all the proton pump inhibitors are effective in treating
GERD and erosive esophagitis and that some patients would benefit
from esomeprazole therapy.
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