[Two-stage treatment of Barrett's esophagus]. / Radikal'noe dvukhetapnoe lechenie bol'nykh s pishchevodom Barretta.

OBJECTIVE: To evaluate the results of treatment of Barrett's esophagus using laparoscopic 270° Toupet fundoplication or radiofrequency ablation (RFA) and their combination. MATERIAL AND METHODS: We have analyzed data for the period 2011-2018. Antireflux surgery was performed in the first group, RFA - in the second group, both procedures were done in the third group. The majority of patients with hiatal hernia underwent cruroraphy, laparoscopic 270° Toupet fundoplication, endoscopic treatment as the second stage was performed in some of them. Patients without hiatal hernia and no signs of reflux underwent RFA without antireflux surgery. Control endoscopic examination was carried out after 3, 6 and 12 months and then annually. RESULTS: There were 84 patients with Barrett's esophagus. We performed 51 RFA procedures in 47 patients and fundoplication in 71 patients. Antireflux surgery as the first stage was preferred in patients with hiatal hernia (n=60), subsequent radiofrequency ablation (RFA) was performed in 28 of them. Seven patients without hiatal hernia, but with significant gastroesophageal reflux underwent antireflux surgery too. Other 12 patients without hiatal hernia underwent RFA alone. Need for delayed antireflux surgery after endoscopic treatment occurred in 23.5% of patients. Complete regression of metaplasia was noted in 95.2% after 1 procedure and in 100% after 2 procedures. Recurrent metaplasia was registered in 4.3% of patients. Progression to dysplasia was not detected. CONCLUSION: Two-stage surgical approach including antireflux surgery and radiofrequency ablation in combination with drug therapy is optimal. Endoscopic therapy is recommended for all types and length of metaplasia.

ANTIREFLUX RESECTION OF MUCOUS MEMBRANE OF ESOPHAGOGASTRIC ANASTOMOSIS IN TREATMENT OF BARRETT'S ESOPHAGUS: INITIAL EXPERIENCE.

Antireflux resection of mucous membrane of esophagogastric anastomosis (ARMS) was performed on 6 patients with typical symptoms of gastroesophageal reflux disease (GERD). The patients had a short segment of сolumnar-celled metaplasia (1-2 cm) without radiological and endoscopic signs of hiatal hernia. All the patients received medicamentous therapy by antisecretory agents more than 3 years. The operation included the endoscopic resection of2/3 circle of mucous membrane of esophagogastric anastomosis and resection of the area of columnar-celled metaplasia. The results of treatment were assessed during 3-7 months after ARMS. There was noted an absence of clinical manifestations of GERD, regression of inflammatory signs of mucous coat of esophagus in 4 out of 6 patients. Symptoms of GERD remained in 2 patients, although the intensity of signs significantly decreased.

Follow-up of adult patients with repaired esophageal atresia: how, when, and for how long?

Esophageal atresia (EA) is the most common congenital anomaly of the esophagus. With the progress of surgical and anesthetic techniques, the survival is now more than 90% and the majority of children survives and eventually reaches adulthood. However, even if the continuity of the esophagus is anatomically replaced by the surgery, there are some new pieces of evidence that suggest considerable long-term morbidity. In this paper, we will illustrate how symptomatic gastroesophageal reflux, dysphagia, and esophageal motility disturbances, as well as columnar epithelial metaplasia, are common in adults with repaired EA. The ideal follow-up for adult patients born with EA has not been clearly defined, and routine endoscopic assessment has not been widely advocated. It is well known that the patient's symptoms have a poor correlation with histological findings. However, routine follow-up may be expensive and time consuming. With the growing number of children reaching adulthood, it is now essential to know and understand the natural history of this condition to improve the management of these patients.

Evaluation and treatment of GERD and upper GI complaints in athletes.

Athletes are susceptible to upper gastrointestinal complaints just like the general population. The most common etiologies are gastroesophageal reflux disease (GERD) and functional heartburn. If the signs and symptoms are compatible with GERD and the clinician has considered more serious pathology unlikely, a therapeutic trial with a proton pump inhibitor (PPI) can be initiated without further evaluation. The treatment for pure exertional GERD is similar but is guided by expert opinion only. Surgery has a limited role, but new techniques are evolving that may change the risk-to-benefit ratio. Chronic PPI therapy generally is safe, but there is a small risk of osteoporosis with concomitant fracture. There is no evidence for routine endoscopic screening for Barrett's esophagus or esophageal adenocarcinoma. For those who do not respond to treatment, the most likely diagnosis is functional heartburn. This is a diagnosis of exclusion, and referral to gastroenterology is warranted for diagnostic testing.

[Diagnosis and treatment of gastroesophageal reflux disease].

The lecture presents modern interpretation of the term "gastroesophageal reflux disease" (GERD) and Montreal classification of this disease with emphasis on non-erosive reflux disease and risk to develop Barret's esophagus which is a widely prevalent precancer condition frequently transforming into esophageal adenocarcinoma. Description is given of GERD causes, mechanisms of development, diagnostic and differential diagnostic signs of the disease, a high risk of bronchial asthma in GERD patients, basic treatment principles including healthy way of life, pharmacotherapy (antacids, alginates, prokinetics, proton pump inhibitors, etc.).

Management of Barrett's esophagus with dysplasia refractory to radiofrequency ablation.

Radiofrequency ablation (RFA) is very effective for eradication of flat Barrett's mucosa in dysplastic Barrett's esophagus after endoscopic resection of raised lesions. However, in a minority of the time, RFA may be ineffective at eradication of the Barrett's mucosa. Achieving complete eradication of intestinal metaplasia can be challenging in these patients. This review article focuses on the management of patients with dysplastic Barrett's esophagus refractory to RFA therapy. Management strategies discussed in this review include optimizing the RFA procedure, optimizing acid suppression (with medical, endoscopic, and surgical management), cryotherapy, hybrid argon plasma coagulation, and EndoRotor resection.

[An evaluation of web-based information about Barrett's esophagus in Korea].

BACKGROUND/AIMS: Internet has become an important source of medical information not only for doctors but also patients. However, information available in the Internet may provide wrong or even harmful knowledge to the public. The aim of this study was to evaluate the quality of Internet-based medical information about Barrett's esophagus in Korea. METHODS: The first 50 Internet links were retrieved from the Google using the key word Barrett's esophagus. The quality of information from a total of 49 websites was evaluated using a checklist. RESULTS: Among total 49 sites related to Barrett's esophagus, only 4 sites (8.2%) were made by hospitals or clinics, and 11 sites (22.4%) were for patients. Of the 49 sites, only one web site (2.0%) had all HON CODE principles (authority, complementarity, confidentiality, attribution, justifiability, transparency of authorship, transparency of sponsorship, honesty in advertising and editorial policy). Sixteen Internet links (32.0%) had fair contents for the definition, and 24 links (48.0%) for the diagnosis, and 15 links (30.0%) for the treatment. CONCLUSIONS: Information about Barrett's esophagus was incomplete in the majority of medical web sites. It will bring about confusion in patients who want to get information about Barrett's esophagus from the Internet. There is a need for better evidence-based information about Barrett's esophagus on the web.

[Gastroesophageal reflux disease--diagnosis and management]. / Choroba refluksowa przelyku--rozpoznawanie i leczenie.

Gastroesophageal reflux disease is a serious clinical problem. In clinical classification of gastroesophageal reflux disease we differentiate esophageal and non-esophageal syndromes. In case of esophageal syndromes we differentiate based on clinical signs and syndromes with esophageal mucosal lesions based diagnosed on base of upper alimentary tract endoscopic and histopathologic assessment. In clinical diagnosis establishing basics are clinical symptoms as heartburn, regurgitation. Usually, recently found typical symptoms of light intensification can be concluded with diagnosis gastroesophageal reflux disease and without other diagnostic tools treatment could be introduced. Helpful diagnostic test is a test with proton pump inhibitors. Endoscopic assessment should be performed at least once in every patient with chronic gastroesophageal reflux disease in order to eliminate complications (Barrett disease). Main impedance advantage is possibility of reflux diagnosis disregarding ph value. Continuous monitoring of impedance in many segments of esophagus can help to establish direction of reflux and its characteristics and extent establishment. (liquid, gaseous, mixed). The main role in pharmacological gastroesophageal reflux disease treatment plays drugs decreasing acid output, proton pump inhibitors (PPI). Dosage of chronic use should be assess individually. The Basic rule is the use of possibly minimal therapeutic dose of PPI. In this paper authors presented basics of gastroesophageal reflux disease diagnosing, monitoring and treatment.

Barrett's esophagus: chemoprevention.

The clinical applicability of the experimental data discussed previously remains questionable, and results of clinical studies on chemoprevention in Barrett's esophagus are needed. The utility of selectively targeting acid exposure, ODC, and COX-2 is not clear, and elucidation of that role will be facilitated by a better understanding of the contribution of these factors in the development of Barrett's cancers. The insights already gained into the basic mechanisms of acid exposure, ODC, and COX-2 in the pathogenesis of Barrett's esophagus and esophageal adenocarcinoma hold promise for the development of future therapies aimed at these molecular targets and their signaling pathways. In preclinical studies, the ability of COX-2 selective NSAIDs and DFMO to inhibit carcinogenesis is encouraging. Results of well-designed, prospective clinical studies, however, are still needed to establish the efficacy of potent acid suppression, COX-2 inhibitors, and DFMO in the prevention of this malignancy.

Importance of duodeno-gastro-esophageal reflux in the medical outpatient practice.

BACKGROUND/AIMS: The role of acid and duodeno-gastro-esophageal reflux (DGER), also termed bile reflux, in esophageal mucosal injury is controversial. Several recent developments, especially availability of the recent bilirubin monitoring device (Bilitec), have resulted in clarifications in this area. In order to better understand the role of acid and DGER in esophageal mucosal injury, we summarized the recent publications in this area. METHODOLOGY: Review of published medical literature (MEDLINE) on the clinical consequence of esophageal exposure to gastric acid or DGER. RESULTS: Recent data suggest that esophageal pH monitoring and pH > 7 is a poor marker for reflux of duodenal contents into the esophagus. DGER in non-acidic environments (i.e., partial gastrectomy patients) may cause symptoms but does not cause esophageal mucosal injury. Acid and duodenal contents usually reflux into the esophagus simultaneously, and may be contributing to the development of Barrett's metaplasia and possibly adenocarcinoma. Proton pump inhibitors decrease acid and DGER by reducing intragastric volume available for reflux and raising intragastric pH. The promotility agent cisapride decreases DGER by increasing LES pressure and improving gastric emptying. CONCLUSIONS: 1) The term "alkaline reflux" is a misnormer and should no longer be used in referring to reflux of duodenal contents. 2) Bilitec is the method of choice in detecting DGER and should always be used simultaneously with esophageal pH-monitoring for acid reflux. 3) DGER alone is not injurious to esophageal mucosa, but can result in significant esophageal mucosal injury when combined with acid reflux. 4) Therefore, controlling esophageal exposure to acid reflux by using proton pump inhibitors also eliminates the potentially damaging effect of DGER.

Laparoscopic transgastric esophageal mucosal resection for high-grade dysplasia.

BACKGROUND: High-grade dysplasia of the esophageal mucosa has been shown to be a precursor to adenocarcinoma. In addition to esophagectomy, multiple ablative endoscopic techniques have evolved for the management of this condition. As a surgical alternative to esophagectomy, we describe for the first time a new option in the treatment of high-grade dysplasia. MATERIALS AND METHODS: Two patients with a history of gastroesophageal reflux disease (GERD) underwent upper gastrointestinal endoscopy which demonstrated high-grade dysplasia of the distal esophagus. The first patient had a short segment (0.5-1.0 cm), and the second patient had a longer (2 cm) segment of dysplasia. The patient is placed in the modified lithotomy position. Five trocars are placed as if to perform a fundoplication. A complete circumferential mobilization of the esophagus is performed. The short gastric vessels are divided with the harmonic scalpel, to free up the fundus of the stomach. An anterior horizontal gastrotomy is performed three to four centimeters below the gastroesophageal junction. A solution of epinephrine and normal saline (1:100,000) is injected into the mucosa at the Z-line and, utilizing specially designed hook electrocautery, the mucosa is incised circumferentially around a lighted bougie. Using blunt dissection the mucosa is undermined, elevated, and excised in four quadrants. Three centimeters of the distal esophageal mucosa are resected. The gastrotomy is then closed using a linear stapler, and a 360 degrees fundoplication is performed around a 50 Fr bougie. RESULTS: High-grade dysplasia was identified in the specimens from both patients; however, neither patient was found to have carcinoma in situ or invasive esophageal cancer. Our first patient has been followed for twenty months, the second for ten months. Both patients underwent routine upper gastrointestinal endoscopy for surveillance of the healing process. At eight months, the mucosa of the first patient showed complete regeneration of squamous epithelium. Our most recent patient appears to be progressing without complications and has also demonstrated normal squamous epithelium at ten months postoperatively, without changes of Barrett's epithelium. CONCLUSION: The technique of laparoscopic transgastric esophageal mucosal resection is feasible and may be proven to be an alternative to esophagectomy for the management of high-grade dysplasia.

GERD management. Strategies recommended for primary care practice.

Primary care physicians are on the front lines in the treatment of gastroesophageal reflux disease. Therefore, they need the most current information available regarding how to achieve the best outcomes possible. Much clinical evidence indicates that when prescribed for initial and maintenance therapy, the proton pump inhibitors are effective for symptom relief and cost-effective in maintaining remission. In this article, Drs Kuritzky and Rodney discuss several step management strategies that could well be "just what the doctor ordered."

Gastro-oesophageal reflux disease--current concepts in management.

BACKGROUND: Gastro-oesophageal reflux disease (GORD) is defined as recurring symptoms or mucosal damage resulting from exposure of the distal oesophagus to reflux of gastric contents. In the past, GORD has been managed with a 'step up' approach beginning with antacids and progressing to H2 antagonists or proton pump inhibitors (PPI) as required. OBJECTIVE: This article presents a systematic approach to the management of GORD. DISCUSSION: Diagnosis of GORD is made on the basis of symptoms and the decision to treat is based on the symptom pattern. Endoscopy is reserved for cases where there are alarm symptoms, diagnostic uncertainty, poor response to treatment or clinical suspicion of a complication such as Barrett's oesophagus or stricture. A 'step down' approach to treatment involves treating with a PPI for 4-8 weeks. Aggressive therapy is then reduced to maintenance doses, intermittent therapy or in some cases, withdrawn. However, relapse occurs in about 70% of all patients within 6 months. A step down approach ensures more rapid resolution of symptoms, improved quality of life, reduced risk of complications, and overall lower cost.

Diet and esophageal disease.

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on macronutrients, dietary patterns, and risk of adenocarcinoma in Barrett's esophagus; micronutrients, trace elements, and risk of Barrett's esophagus and esophageal adenocarcinoma; the role of mate consumption in the development of squamous cell carcinoma; the relationship between energy excess and development of esophageal adenocarcinoma; and the nutritional management of the esophageal cancer patient.

"Mini" gastric bypass: systematic review of a controversial procedure.

Mini gastric bypass is being explored by many bariatric surgeons as a standalone bariatric procedure. Several surgeons from different parts of the world have now published their extensive experience with this procedure. It appears to be an effective bariatric procedure with acceptable weight loss, co-morbidity resolution, and complication rates in the short and medium term. Its proponents claim that it is safer and easier than the gold standard Roux-en-Y gastric bypass. However, concerns with regard to symptomatic gastric or oesophageal biliary reflux requiring revisional surgery and long-term risk of gastric and oesophageal cancers persist. This paper reviews the published experience to date with this procedure and examines the surrounding controversy.

Barrett's esophagus: a late complication of laparoscopic adjustable gastric banding.

Laparoscopic adjustable gastric banding has become a popular bariatric restrictive procedure in the USA. The increasing popularity of the laparoscopic adjustable gastric band procedure could, in part, be related to the lower cost and lower morbidity compared with laparoscopic gastric bypass. Although its placement is related to a lower number of perioperative complications compared with laparoscopic gastric bypass, its morbidity may be substantial. Barrett's esophagus or esophageal intestinal metaplasia is a known complication of chronic gastro-esophageal reflux disease that, in rare occasions, progresses to dysplasia and esophageal adenocarcinoma. Barrett's esophagus, after laparoscopic adjustable gastric banding placement, is a rare but not unexpected complication after gastric band placement. The incidence of Barrett's esophagus after adjustable gastric banding is not known. We present a case of Barrett's esophagus as a result of laparoscopic adjustable gastric banding placement due to a chronically and highly restrictive gastric band in a former morbidly obese patient.

Guía de práctica clínica para la enfermedad por reflujo gastroesofágico / Clinical practice guideline for disease caused by gastroesophageal reflux

Objetivo: brindar una guía de práctica clínica basada en la evidencia más reciente para el diagnóstico y tratamiento del reflujo gastroesofágico teniendo en cuenta la efectividad y seguridad de las intervenciones dirigidas a pacientes, personal asistencial, administrativo y entes gubernamentales de cualquier servicio de atención en Colombia. Materiales y métodos: esta guía fue desarrollada por un equipo multidisciplinario con apoyo de la Asociación Colombiana de Gastroenterología, el Grupo Cochrane ITS y el Instituto de Investigaciones Clínicas de la Universidad Nacional de Colombia. Se desarrollaron preguntas clínicas relevantes y se realizó la búsqueda de guías nacionales e internacionales en bases de datos especializadas. Las guías existentes fueron evaluadas en términos de calidad y aplicabilidad; 1 guía cumplió los criterios de adaptación, por lo que se decidió adaptar 3 preguntas clínicas. El Grupo Cochrane realizó la búsqueda sistemática de la literatura. Las tablas de evidencia y recomendaciones fueron realizadas con base en la metodología GRADE. Las recomendaciones de la guía fueron socializadas en una reunión de expertos con entes gubernamentales y pacientes. Resultados: se desarrolló una guía de práctica clínica basada en la evidencia para el diagnóstico y tratamiento de pacientes con reflujo gastroesofágico en Colombia. Conclusiones: el diagnóstico y manejo oportuno de los pacientes con ERGE contribuirá a disminuir la carga de la enfermedad en Colombia, así como de las enfermedades asociadas.

Objective: To provide a clinical practice guideline with the latest evidence for diagnosis and treatment of gastroesophageal reflux for patients, caregivers, administrative and government bodies at all levels of care in Colombia. Materials and Methods: This guide was developed by a multidisciplinary team with the support of the Colombian Association of Gastroenterology, Cochrane STI Group and Clinical Research Institute of the Universidad Nacional de Colombia. Relevant clinical questions were developed and the search for national and international guidelines in databases was performed. Existing guidelines were evaluated quality and applicability. One guideline met the criteria for adaptation, so the group decided to adapt 3 clinical questions. Systematic literature searches were conducted by the Cochrane Group. The tables of evidence and recommendations were made based on the GRADE methodology. The recommendations of the guide were socialized in a meeting of experts with government agencies and patients. Results: An evidence-based Clinical Practice Guidelines for the diagnosis and treatment of gastroesophageal reflux was developed for the Colombian context. Conclusions: The opportune detection and appropriate management of gastroesophageal reflux would contribute to the burden of the disease in Colombia and its associated diseases.