Laparoscopic conversion of omega loop gastric bypass to Roux-en-Y gastric bypass for Barrett's esophagus: case report.

BACKGROUND: The number of mini gastric bypass / one anastomosis bypass (MGB-OAGB) procedures in bariatric patients that have been performed world-wide has drastically increased during the past decade. Nevertheless, due to the risk of subsequent biliary reflux and development of ulcer and neoplastic (pre)lesions caused by long-time bile exposure, the procedure is still controversially discussed. In here presented case report, we could endoscopically demonstrate a transformation from reflux oesophagitis to Barrett's metaplasia most likely caused by bile reflux after mini-gastric bypass. To our knowledge, this is a first case study that shows development of Barrett's metaplasia after MGB-OAGB. CASE PRESENTATION: We present the case of a 50-year-old female which received a mini-gastric bypass due to morbid obesity (body mass index (BMI) 42.4 kg/m2). Because of history gastroesophageal reflux disease (GERD), a fundoplication had been performed earlier. Preoperative gastroscopy showed reflux esophagitis (Los Angeles classification grade B) with no signs of Barrett's metaplasia. Three months post mini-gastric bypass, the patient complained about severe bile reflux under 40 mg pantoprazole daily. Six months postoperative, Endoscopically Barrett's epithelium was detected and histopathologically confirmed (C1M0 after Prague classification). A conversion into Roux-en-Y gastric bypass was performed. The postoperative course was without complications. In a follow up after 6 months the patient denied reflux and showed no signs of malnutrition. CONCLUSIONS: The rapid progress from inflammatory changes of the distal esophagus towards Barrett's metaplasia under bile reflux in our case is most likely a result of previous reflux disease. Nevertheless, bile reflux appears to be a potential decisive factor. Study results regarding presence of bile reflux or development of endoscopically de-novo findings after MGB-OAGB are widely non-conclusive. Long-term prospective studies with regular endoscopic surveillance independent of clinical symptoms are needed.

[Dysphagia--differential diagnosis and therapy. What is behind a lump in the throat?]. / Dysphagie--Differenzialdiagnose und Therapie. Was steckt hinter dem Kloss im Hals?

Swallowing disorders are the symptom of numerous conditions. The diagnostics and therapy require the close interdisciplinary collaboration of different medical specialists.

Use of an endoscopic suturing device (the "ESD") to treat patients with gastroesophageal reflux disease, after unsuccessful EndoCinch endoluminal gastroplication: another failure.

BACKGROUND: Endoluminal gastroplication, using the EndoCinch procedure, has emerged as a potential endoscopic antireflux therapy. Although initial results have been promising, the long-term durability of the treatment is uncertain due to suture loss. A new endoscopic suturing device, the "ESD," has been developed that promises excellent visibility and endoscopic control. The aim of this study was to evaluate prospectively the feasibility and efficacy of the ESD method after EndoCinch failure. METHODS: The study involved 20 patients with gastroesophageal reflux disease (GERD), who had been initially treated with an EndoCinch procedure, but had relapsed after a median of 7.5 months, with lost or dysfunctional sutures and with reflux symptoms that required proton pump inhibitor (PPI) treatment. Using the ESD, at least three plications were created at the gastroesophageal junction. Patients underwent endoscopy, 24-hour pH monitoring and esophageal manometry before treatment and 6 months afterwards. In addition, reflux symptoms as well as quality-of-life scores were assessed (using the SF-6 and GERD-HRQL scales). RESULTS: The ESD procedure (median procedure time 45 min) was performed successfully in all patients without major complications. After 6 months only one patient (5 %) still had all sutures in situ, while no remaining sutures could be detected in 3/20 (15 %). No significant changes in reflux esophagitis; 24-hour pH monitoring results (median pH < 4/24 h9.9 % vs. 12.3 %; P = 0.60); manometry findings (median lower esophageal sphincter pressure 7.2 mm Hg vs. 9.9 mm Hg; P = 0.22); PPI use; or reflux esophagitis could be detected after 6 months. While reflux symptoms improved (heartburn severity score 30 vs. 48, P < 0,05), no changes in quality-of-life scores were detected. CONCLUSIONS: Endoluminal gastroplication using the ESD is an easy and safe, but unfortunately ineffective procedure for endoscopic GERD treatment. Endoluminal gastroplication techniques clearly need refinements before these therapies can evolve as a treatment option for GERD patients.

Long term failure of endoscopic gastroplication (EndoCinch).

INTRODUCTION: Endoluminal gastroplication (EndoCinch; Bard) has been introduced as an endoscopic treatment option in gastro-oesophageal reflux disease (GORD) patients with promising short term results. However, little is known about the long term efficacy of endoscopic suturing. The aim of this study was to evaluate prospectively the long term outcome after EndoCinch. PATIENTS AND METHODS: A total of 70 patients treated with EndoCinch at a single referral centre were studied prospectively. All patients were interviewed using a standardised questionnaire regarding their symptoms and medication prior to and 18 months after EndoCinch. In addition, follow up included endoscopy, 24 hour pH monitoring, and oesophageal manometry. RESULTS: The procedure was well tolerated without major short or long term complications. Eighteen months after EndoCinch, 56/70 patients (80%) were considered treatment failures as their heartburn symptoms did not improve or proton pump inhibitor medication exceeded 50% of the initial dose. Endoscopy showed all sutures in situ in 12/70 (17%) patients while no remaining sutures could be detected in 18/70 (26%). In 54 and 50 patients examined, respectively, no significant changes in 24 hour pH monitoring (median pH <4/24 hours, 9.1% v 8.5%; p = 0.82) or lower oesophageal sphincter (LOS) pressure (7.7 v 10.3 mm Hg; p = 0.051) were observed while median LOS length slightly increased (3.0 to 3.2 cm; p<0.05). CONCLUSION: Endoscopic gastroplication (EndoCinch) is a safe and minimally invasive endoscopic treatment for GORD with reasonable short term results. In contrast, long term outcome is disappointing, probably due to suture loss in the majority of patients. Therefore, technical improvements to ensure suture durability are mandatory before endoscopic suturing can evolve as a therapeutic option for GORD treatment.

Are endoscopic antireflux therapies cost-effective compared with laparoscopic fundoplication?

BACKGROUND AND STUDY AIMS: A number of endoscopic antireflux therapies (EATs) have emerged as potential nonmedical treatment options for patients with gastroesophageal reflux disease (GERD). Concerns about clinical efficacy and costs have given rise to debate about their role in GERD management. The costs of laparoscopic fundoplication (LF) were compared with the costs of EAT when used in a sequential strategy that reserves the option of LF for EAT failure. METHODS: A simple mathematical criterion of direct medical costs was applied. Published articles concerning EAT were reviewed to assess its effectiveness, durability and costs, in order to estimate the parameters of the model. The costs of EAT and LF were evaluated from the perspective of a German third-party payer. Only direct medical costs were considered. RESULTS: Assuming that EAT has no impact on potential LF later on, the outcome of both strategies (LF, or EAT first with LF in case of failure of EAT) is identical and preference is a simple question of costs. The sequential strategy in nonmedical GERD treatment would be preferable if the long-term relief rate with EAT exceeds the ratio of the cost of EAT to the cost of LF. Long-term success rates of EAT do not exceed 0.65. At current prices EAT is clearly not cost-effective in Germany. CONCLUSION: Our simple criterion indicates that EAT would only be cost-effective and beneficial in a sequential strategy if the costs of EAT were to be decreased to around 30 % of current retail prices. However, long-term studies and randomized controlled trials are necessary to finally determine the role of EAT in GERD treatment, and the preference may change in either direction.

Endoluminal gastroplication: what are the predictors of outcome?

BACKGROUND: Endoluminal gastroplication (EndoCinch) has emerged as an endoscopic anti-reflux therapy, but predictive factors for symptom relief have not been established. The aim of this study was to evaluate the major determinants to predict outcome in patients treated with EndoCinch. METHODS: A total of 53 consecutive patients, treated with EndoCinch at a single center were included in this prospective study. Inclusion criteria were symptoms of chronic heartburn, dependency on proton-pump inhibitors, documented pathological esophageal acid exposure, and a hiatal hernia smaller than 3 cm in length. All patients underwent endoscopy, 24-h pH monitoring, esophageal manometry, barium esophagram, and a detailed questionnaire regarding their symptoms before treatment. Patients were stratified into a responder and a non-responder group using a questionnaire at 3-month follow-up. A multivariate analysis was performed. RESULTS: The success rate was 64% (34/53 patients). Three variables weresignificantly predictive for successful endoscopic anti-reflux treatment at the multivariate level: presence of typical symptoms (P=0.01), complete symptom relief with acid suppressive therapy (P=0.01), and normal lower esophageal sphincter pressure (P = 0.04). Not predictive of outcome were age, body mass index, esophagitis, other manometric findings, hiatal hernia size, or pathological level of pH <4/24 h. Barium esophagram did not add any additional predictive information. CONCLUSIONS: Since no single factor can predict outcome after EndoCinch, a careful patient selection is mandatory to maximize the success rate. The ideal candidate for EndoCinch is a gastroesophageal (GERD) patient with a normal lower esophageal sphincter pressure, whose typical symptoms completely resolved with acid suppressive therapy.

Role of prostaglandins in regulation of pancreatic enzyme secretion by various diets.

We have demonstrated by the use of isolated rat pancreatic acini that exogenous prostaglandins of the E type inhibit secretagogue-stimulated amylase secretion. We here studied whether the pancreas is a source of prostaglandin synthesis and whether prostaglandins mediate regulation of pancreatic enzyme secretion by various diets. Prostaglandin E2 was measured by enzyme immunoassay in pancreatic acini from either normal animals or after 10 days of feeding with different diets. Acini were prepared by collagenase digestion. Amylase secretion was measured after stimulation with cholecystokinin in the presence or absence of indomethacin, an inhibitor of prostaglandin synthesis. Prostaglandin E2 concentration in pancreatic acini was comparable to other organs such as kidney and liver. Feeding a diet enriched in proteins caused an increase of cholecystokinin-stimulated maximal amylase secretion and a decrease of prostaglandin E2 concentration. Incubation of acini with indomethacin caused a decrease in prostaglandin E2 concentration and an increase in cholecystokinin stimulated amylase secretion. We conclude that regulation of pancreatic enzyme secretion by diets may be mediated by prostaglandins.

Cyclooxygenase-2 transcription is stimulated and amylase secretion is inhibited in pancreatic acinar cells after induction of acute pancreatitis.

Cyclooxygenases as the key enzymes of prostaglandin synthesis have an important role in regulation of inflammation. We describe that Cox-1 and Cox-2 are synthesized in rat pancreatic acinar cells. Upon induction of pancreatitis, Cox-2 mRNA increases while Cox-1 expression remains constant. However, the cyclooxygenase inhibitor indomethacin has no influence by a feed-back mechanism on the expression of the two isoforms. We have previously shown that prostaglandins of the E-type inhibit cholecytoskinin-stimulated amylase secretion. Consistent with this observation, we find here that pancreatitis inhibits CCK-stimulated amylase secretion from isolated acini. In agreement with this result, the effect is neutralized by indomethacin inhibition of prostaglandin synthesis. In summary, we have found that both cyclooxygenases are synthesized in pancreatic acinar cells and that their expression is differentially regulated which in turn influences amylase secretion.