A potential simple endoscopic antireflux method, "the Ripple Procedure" to reduce distensibility at the esophagogastric junction in a porcine model.

BACKGROUND AND AIMS: Currently available endoscopic or minimally invasive antireflux modalities are not widely accepted due to high procedure cost or inconsistent results. Therefore, a simpler and less technically demanding method is required. We evaluated the feasibility and efficacy of new endoscopic antireflux method (the Ripple Procedure) using functional lumen imaging probe (FLIP). METHODS: This 5-week survival study included 10 domestic pigs (control, n = 4; experimental [Ripple], n = 6). The procedure includes the following steps: (i) semicircular marking along the lesser curvature of the cardia; (ii) submucosal injection; and (iii) semicircular mucosal incision along the marking. Endoscopic and FLIP evaluations were performed preoperatively and on postoperative days (PODs) 14 and 35. Technical feasibility was evaluated, and FLIP parameters, including the distensibility index (DI) at the esophagogastric junction (EGJ) and histopathological findings, were compared between groups. RESULTS: The median procedure time was 28 (23.5-33.8) min. There was no significant difference in dysphagia score and body weight between groups. On POD 35, the Ripple group showed significantly lower EGJ DI at 30 mL [2.0 (1.3-2.5) vs 4.9 (2.7-5.0), P = 0.037]. The EGJ DI was significantly reduced at 30 mL, compared with that at the baseline level [- 59.0% (- 68.8% to - 32.1%) vs 27.8% (- 26.3% to 83.1%), P = 0.033]. Histologic evaluation revealed submucosal granulation tissues near the mucosal incision site, with increased intervening fibrosis between lower esophageal sphincter fibers in the Ripple group. CONCLUSION: The EGJ DI significantly decreased after the Ripple Procedure; hence, the procedure appears to be feasible and effective in this porcine model.

Vocal process granulomas: a systematic review of treatment.

OBJECTIVES: Vocal process granulomas (VPGs) are benign laryngeal lesions with controversial treatment and a tendency to recur. There are several treatment options with unpredictable results, high recurrence rates, and disappointing long-term outcome. The aims of this article are to focus on evidence-based current treatment strategies for primary lesions and recurrences. DATA SOURCES: The data came from a systematic review of the literature. METHODS: Main outcome measures were recurrence rate, reduction, and/or complete resolution. Inclusion criteria included English literature, randomized and nonrandomized trials, prospective and retrospective studies, and primary and recurrent cases. Exclusion criteria included case reports, teaching reviews, and papers not focusing on treatment. RESULTS: The time frame of the included studies was from 1997 to 2012. There are 6 different treatment options (single or combined) for VPG. Antireflux medication is the mainstay treatment and when combined with lifestyle changes and voice therapy results in the lowest recurrence rate. "Bloodless" in-office or in-theater laser techniques appear to have lower recurrence rates when compared to traditional cold steel microlaryngoscopy techniques, especially for recurrences. CONCLUSIONS: There is level 2A evidence that antireflux treatment is the main treatment strategy for vocal process granulomas with surgery reserved only for failures of medical treatment or airway obstruction or when diagnosis is in doubt.

Arytenoid granuloma: a single-institution experience of management of 62 cases.

OBJECTIVE: This retrospective study was undertaken to assess the outcome of the medical and/or surgical management of patients presenting with clinical features of arytenoid granuloma. METHODS: The records of 53 males and 9 females were reviewed for predisposing factors, types of treatment received and recurrence following the treatment. RESULTS: Most of the patients (48 out of 62, 77.4 per cent) were treated conservatively with medical management and voice therapy, which resulted in complete resolution of arytenoid granuloma in over two-thirds of the patients treated (32 out of 48, 66.6 per cent). Overall, 28 patients (out of 62, 45.1 per cent) required surgery (14 failed medical treatment cases and 14 surgery as first-line treatment cases). Of these, five patients (out of 28, 17.9 per cent) had recurrence, and were managed with revision surgery and concurrent local injection of Botox. CONCLUSION: Anti-reflux medication and voice therapy are effective first-line management options. Pre- and post-surgery adjuvant treatment improves the results of surgery. Local injection of Botox was successful in the treatment of failed surgical cases.

[EndoStim® treatment-a new minimally invasive technology in antireflux surgery]. / EndoStim®-Therapie ­ eine neue minimal-invasive Technologie in der Antirefluxchirurgie.

BACKGROUND: The symptoms of gastroesophageal reflux disease (GERD) are very common. Despite the fact that 40% of patients continue to suffer under conservative treatment, only approximately 1% of affected patients are operated on in Germany. Until recently, antireflux surgery was performed nearly exclusively in the form of a Nissen fundoplication or a Toupet hemifundoplication. These methods are still considered the gold standard. A new surgical minimally invasive procedure is described which treats reflux symptoms through electrical neuromodulation of the lower esophageal sphincter (LES). METHOD: An electrical neuromodulator for the LES (EndoStim®, EndoStim BV, Nijmegen, The Netherlands) is implanted into the abdominal wall as a pulse generator (IPG) and connected via an electrode cable to a pair of electrodes on the lower esophageal sphincter. In our own setting, patients are selected for this procedure after extensive functional diagnostics in the context of an interdisciplinary expert conference. The patient selection, patient education, required surgical training, surgical technique, postoperative phase as well as the results, complications and side effects are described. CONCLUSION: Electrical neuromodulation is a technique that successfully provides patients with GERD with control of their reflux symptoms. The technique requires interdisciplinary patient selection, comprehensive patient education, and comprehensive surgical training. The method is not free of postoperative problems. The electrical neuromodulation of the LES should therefore be used especially in centers with high expertise in reflux therapy.

Efficacy of sequential three-step empirical therapy for chronic cough.

BACKGROUND: Empirical three-step therapy has been proved in just one hospital. This study aimed to demonstrate applicability of the sequential empirical three-step therapy for chronic cough in different clinical settings. METHODS: Sequential empirical three-step therapy was given to patients with chronic cough in one tertiary and three secondary care respiratory clinics. Recruiters were initially treated with methoxyphenamine compound as the first-step therapy, followed by corticosteroids as the second-step therapy and the combination of a proton-pump inhibitor and a prokinetic agent as the third-step therapy. The efficacy of the therapy was verified according to the changes in cough symptom score between pre- and post-treatment, and compared among the different clinics. RESULTS: In total 155 patients in one tertiary clinic and 193 patients in secondary care clinics were recruited. The total dropout ratio is significantly higher in the secondary care clinics than that in the tertiary clinic (9.3% versus 3.2%, p = 0.023). The therapeutic success rate for cough was 38.7% at first-step therapy, 32.3% at second-step therapy and 20.0% at third-step therapy in the tertiary clinic, and comparable to corresponding 49.7%, 31.1% and 4.1% in secondary care clinics. Furthermore, the overall cough resolution rate was not significantly different (91.0% versus 85.0%, p = 0.091). However, the efficacy of the third-step therapy is much higher (20.0% versus 4.1%, p = 0.001) in the tertiary clinic than in the secondary care clinics. CONCLUSIONS: Sequential empirical three-step therapy is universally efficacious and useful for management of chronic cough in different clinical settings.