ABSTRACT
BACKGROUND: Vascular Ehlers-Danlos syndrome is a rare and severe genetic condition leading to spontaneous, potentially life-threatening arterial and digestive complications. Colonic ruptures are a common feature of the disease, but clear recommendations on their management are lacking. OBJECTIVE: This study aimed to identify surgery-related morbidity and 30-day postoperative mortality after colonic perforation. DESIGN: This was a retrospective review. SETTING: A large cohort of patients with vascular Ehlers-Danlos syndrome was followed in a tertiary referral center. PATIENTS: Between 2000 and 2016, the French National Reference Centre for Rare Vascular Diseases (HEGP, AP-HP, Paris, France) followed 148 patients with molecularly proven vascular Ehlers-Danlos syndrome. MAIN OUTCOME MEASURES: The primary outcomes measured were surgery-related morbidity and 30-day postoperative mortality. RESULTS: Of 133 patients with molecularly proven vascular Ehlers-Danlos syndrome, 30 (22%) had a history of colonic perforation and 15 (50%) were males. These subjects were diagnosed with vascular Ehlers-Danlos syndrome at a younger age than patients with a history of GI events without colonic perforation (p = 0.0007). There were 46 colonic perforations, median 1.0 event per patient (interquartile range, 1.0-2.0). Reperforations occurred in 14 (47%) patients, mostly males. Surgical management consisted of Hartmann procedures or subtotal abdominal colectomies, with a nonnegligible rate of reperforation following partial colonic resection (11 patients, 41%). LIMITATIONS: The main limitations of this work are its retrospective design and that the diagnosis of vascular Ehlers-Danlos syndrome was made after colonic perforations in a majority of patients. CONCLUSION: Colonic perforations seem more severe in males, with a high rate of reperforation after Hartmann procedure. Subtotal colectomy may reduce digestive morbidity, particularly in male patients. Additional studies are required to identify other predictors of reperforation. See Video Abstract at http://links.lww.com/DCR/A937.
Subject(s)
Colonic Diseases/etiology , Colonic Diseases/surgery , Ehlers-Danlos Syndrome/complications , Intestinal Perforation/etiology , Intestinal Perforation/surgery , Postoperative Complications/etiology , Adolescent , Adult , Child , Colectomy/adverse effects , Colectomy/mortality , Ehlers-Danlos Syndrome/diagnosis , Female , Humans , Male , Middle Aged , Molecular Diagnostic Techniques , Recurrence , Retrospective Studies , Young AdultABSTRACT
In the fine balance between tumor invasion and our defensive systems, the role played by the adaptive immune response at the tumor site is critical. Beyond the fact that all the immune components of the innate and adaptive response can be observed to varying degrees in the tumor microenvironment, it appears that a high density of T cytotoxic and memory lymphocytes, in a context of Th1 immune orientation in the tumor and its invasion front, provides a prognostic marker of paramount importance for colorectal cancer and more generally all solid tumors. The understanding of the role of immunity in cancer, tailored during one century of intensive research, has led to a complete paradigm shift.based on a sharp dissection In order to show the major impact of this conceptual revolution, we herein retrace through the example of colorectal cancer, how an effective immune test, namely the "Immunoscore", has been developed. We also provide up to date data demonstrating the capacity of the Immunoscore to prognosticate with a better accuracy than the TME classification clinical outcomes and to guide therapeutic strategies.
Subject(s)
Colonic Neoplasms/immunology , Health Status Indicators , Rectal Neoplasms/immunology , Tumor Microenvironment/immunology , Adaptive Immunity/immunology , Humans , Prognosis , Th1 Cells/immunology , Treatment OutcomeABSTRACT
PURPOSE: Gastric fistula is a severe complication following sleeve gastrectomy (SG). Chronic gastric fistula can progress to complex anatomical situations, such as esogastro-bronchial and/or esogastro-pleural (EGBP) fistulas. We decided to analyze the anatomical characteristics of these EGBP fistulas after SG. METHODS: Our work consisted of an analysis of the clinical, endoscopic, and radiological data of patients treated for EGBP fistulas after SG at the Georges Pompidou European Hospital from May 2009 to November 2017. RESULTS: A total of 11 patients were retrospectively included with available complete clinical, endoscopic, and radiological data. The origin of the fistula was mostly at the top of the staple line. The fistula's termination was pleural in 5 patients (45%) and bronchial in 6 (55%). In bronchial fistulas, 2 were proximal and 4 were distal, with the left pulmonary posterolateral segment (S10) being reached in each case. The trans-diaphragmatic passage was through the left cupola in 9 out of 11 patients (82%). In 2 patients, the passage was trans-hiatal (18%). Interestingly, the 2 eso-bronchial fistulas had a trans-hiatal passage with a termination in the proximal bronchus, while the 4 gastro-bronchial fistulas had a trans-diaphragmatic passage with a termination in the distal bronchus. All pleural fistulas were gastric with a trans-diaphragmatic passage. CONCLUSIONS: Esogastro-bronchial and gastro-pleural fistulas after SG originated mostly at the top of the staple line. Eso-bronchial fistulas had a trans-hiatal passage with a proximal bronchial termination, while gastro-bronchial fistulas had a trans-diaphragmatic passage with a distal bronchial termination.
Subject(s)
Bronchial Fistula , Gastrectomy/adverse effects , Gastric Fistula , Pleural Diseases , Postoperative Complications , Diaphragm/anatomy & histology , Humans , Lung/anatomy & histology , Pleura/anatomy & histology , Retrospective StudiesABSTRACT
INTRODUCTION: One anastomosis gastric bypass (OAGB) was suggested as an option in the management of weight loss failure after sleeve gastrectomy (SG). In parallel, the length of the biliopancreatic limb (BPL) is currently debated. OBJECTIVES: To evaluate morbidity and efficiency of the conversion of SG to OAGB using two lengths of BPL (150 cm versus 200 cm). METHODS: Retrospective analysis of a prospectively collected database on 72 patients operated on between 2007 and 2017: (200-cm BPL before 2014 versus 150-cm BPL since 2014). RESULTS: At revision, the mean body mass index (BMI) was 43.6 ± 7 kg/m2. Sixteen patients (20%) had type 2 diabetes (T2D) and 23 (29%) had obstructive sleep apnea (OSA). Early morbidity rate was 4.2% (n = 3). Mean BMI were 33.7 ± 6 and 34.8 ± 9 at 2 and 5 years, respectively. At 5 years, the rate of lost of follow-up was 34%. T2D and OSA improved in 80% (n = 12) and 70% (n = 16) of the patients, respectively. At revision, the mean BMI were 46 ± 8 kg/m2 and 41 ± 6 kg/m2 for patients with 200-cm BPL (n = 38) and 150-cm BPL (n = 34), respectively. Two years after conversion, the mean BMI were 34 ± 1 kg/m2 for 200-cm BPL and 32 ± 7 kg/m2 for 150-cm BPL. The rate of gastroesophageal reflux disease (GERD) and diarrhea was 13% and 5% in patients with 200-cm BPL versus 3% and 0% in patients with 150-cm BPL. CONCLUSION: This study shows that the conversion of SG to OAGB is feasible and safe allowing significant weight loss and improvement in comorbidities. Weight loss seems comparable between the 150-cm and 200-cm BPL.
Subject(s)
Gastrectomy/methods , Gastric Bypass/methods , Obesity, Morbid/surgery , Adult , Body Mass Index , Comorbidity , Databases, Factual , Diabetes Mellitus, Type 2/surgery , Diarrhea/etiology , Feasibility Studies , Female , Gastric Bypass/adverse effects , Gastroesophageal Reflux/etiology , Humans , Male , Middle Aged , Obesity, Morbid/physiopathology , Postoperative Complications , Reoperation/methods , Retrospective Studies , Sleep Apnea, Obstructive/surgery , Treatment Failure , Weight LossABSTRACT
BACKGROUND AND AIM: Vascular Ehlers-Danlos syndrome (vEDS) is a rare connective tissue disorder due to heterozygous mutations in the COL3A1 gene with a dominant negative effect. Spontaneous bowel perforation and intra-abdominal organ rupture are common complications of vEDS. Other gastrointestinal (GI) manifestations may occur but have not been extensively characterized. We herein describe the natural history of GI events and surgery-related complications in patients with vEDS. METHODS: A retrospective review of GI events in a large cohort of molecularly proven vEDS patients was conducted, after exclusion of mild forms of the disease. RESULTS: Of 133 patients, 41% had a history of GI manifestations with 112 events, mean 2.0 ± 1.3 events per patient. There was an earlier occurrence of GI events in men (P 0.008). Cumulative incidence was 58% for all patients, higher in men and in patients with splice-site variants. Recurrence of GI events was reported in more than 50% of patients. Colonic perforation was the first digestive event for 47% of patients. Of 85 GI surgeries, 37 (43%) were complicated with 43 events. Nine deaths were reported in this population. CONCLUSIONS: Vascular Ehlers-Danlos syndrome is characterized not only by bowel perforation but also by a wide variety of GI complications that occur in close to half (41%) of patients. The pattern of GI fragility seems more severe in males and splice-site variants. Complications of GI surgery are common and are related with tissue fragility/friability.
Subject(s)
Ehlers-Danlos Syndrome/complications , Intestinal Perforation/etiology , Adult , Collagen Type III/genetics , Ehlers-Danlos Syndrome/genetics , Female , Humans , Incidence , Intestinal Perforation/epidemiology , Male , Middle Aged , Mutation , Retrospective Studies , Sex Factors , Time Factors , Young AdultABSTRACT
BACKGROUND: Anastomotic leakage (AL) is a potential feared complication after colorectal resection, which is associated with an increased risk of postoperative mortality and frequently requires additional surgery. The aim of this study was to assess major independent risk factors for AL after elective colonic resection for cancer, including anastomotic location. METHODS: Among 1940 consecutive patients referred to our institution for colorectal adenocarcinoma, 1025 patients had elective colonic resection with intraperitoneal anastomosis without diverting stoma. Risk factors were assessed among preoperative, operative, and histological data. RESULTS: Clinical AL was observed in 36 patients (3.5%) with 24 patients requiring revisional surgery (67%). In multivariate analysis, endoscopic impassable tumor and colo-colic or ileo-colic anastomosis were independent risk factors for AL. The occurrence of AL was associated with poor overall (43.1 months vs. 146.4 months; p < 0.001) and disease-free survival (40.5 months vs. 137.3 months; p = 0.003). CONCLUSION: Anastomotic leakage occurs more frequently after colo-colic and ileo-colic anastomosis than after intraperitoneal colorectal anastomosis. The right colectomy appears to be at higher risk of AL, with a greater risk of surgical intervention than after an elective left colectomy. Ileo-colic anastomosis should be avoided in cases of suboptimal conditions.
Subject(s)
Adenocarcinoma/surgery , Anastomotic Leak/etiology , Colon/surgery , Colorectal Neoplasms/surgery , Ileum/surgery , Rectum/surgery , Adenocarcinoma/pathology , Aged , Anastomosis, Surgical/adverse effects , Colectomy/adverse effects , Colon, Ascending/surgery , Colon, Sigmoid/surgery , Colon, Transverse/surgery , Colorectal Neoplasms/pathology , Disease-Free Survival , Elective Surgical Procedures/adverse effects , Female , Humans , Male , Reoperation , Risk Factors , Survival RateABSTRACT
Complicated Meckel's diverticulum represents a common etiology of acute abdomen in children. However, this condition is less frequent in adults. We reviewed the records of adult patients who underwent the surgical removal of complicated Meckel's diverticulum between 2001 and 2017 at 2 tertiary French medical centers. We then analyzed the clinical characteristics, mode of presentation, and management for all patients.The Meckel's diverticulum was resected in 37 patients (24 males and 13 females). The mean patient age was 46.1â±â21.4 years. The most common clinical presentations of complicated Meckel's diverticulum were diverticulitis (35.1%, nâ=â13), small-bowel obstruction (35.1%, nâ=â13), and gastrointestinal bleeding (29.8%, nâ=â11) (anemia, nâ=â1; hematochezia, nâ=â10). Age distribution was significantly different (Pâ=â.02) according to the 3 Meckel's diverticulum complications: patients with diverticulitis (Pâ=â.02) were statistically more frequently over 40 (Pâ=â.05), significantly older than patients with gastrointestinal bleeding who were more frequently <40 (Pâ=â.05). There was a preoperative diagnosis available for 15 of the 37 patients (40%). An exploratory laparoscopy was necessary to determine the cause of disease for the other 22 patients (60%). An intestinal resection was performed in 33 patients (89%) and diverticulectomy was performed in 4 patients (11%). There was heterotopic tissue found in only 6 patients (16%). Postoperative complications were as follows: 1 death by cardiac failure in a 92-year-old patient and 2 patients with postoperative wound infections. The follow-up time was 3 to 12 months.The correct diagnosis of complicated Meckel's diverticulum in adults is difficult due to the lack of specific clinical presentation. As a result, exploratory laparoscopy appears to play a central role in cases of acute abdomen with uncertain diagnosis.
Subject(s)
Abdomen, Acute/diagnosis , Diverticulitis/etiology , Gastrointestinal Hemorrhage/etiology , Intestinal Obstruction/etiology , Laparoscopy/methods , Meckel Diverticulum/complications , Meckel Diverticulum/diagnosis , Abdomen, Acute/etiology , Abdomen, Acute/pathology , Adolescent , Adult , Age Factors , Aged , Aged, 80 and over , Female , Humans , Intestine, Small/pathology , Male , Meckel Diverticulum/pathology , Middle Aged , Retrospective Studies , Risk Factors , Young AdultABSTRACT
PURPOSE OF REVIEW: Morbid obesity and type-2 diabetes mellitus (T2DM) are both major public health problems. Bariatric surgery is a proven and effective treatment for these conditions; laparoscopic Roux-en-Y gastric bypass (RYGB) is currently the gold-standard treatment. One-anastomosis gastric bypass (OAGB) is described as a simpler, safer, and non-inferior alternative to RYGB to treat morbid obesity. Concerning T2DM, experts of the OAGB procedure report promising metabolic results with good long-term remission of T2DM; however, heterogeneity within the literature prompted us to analyze this issue. RECENT FINDINGS: OAGB has gained popularity given its safety and long-term efficacy. Concerning the effect of OAGB for the treatment of T2DM, most reports involve non-controlled single-arm studies with heterogeneous methodologies and a few randomized controlled trials. However, this available literature supports the efficacy of OAGB for remission of T2DM in obese and non-obese patients. Two years after OAGB, the T2DM remission and improvement rate increased from 67 to 100%. The results were improved and stable in the long term. The 5-year T2DM remission rate increased from 82 to 84.4%. OAGB is non-inferior compared with RYGB and even superior to other accepted bariatric procedures, such as sleeve gastrectomy and adjustable gastric banding. OAGB is an efficient, safe, simple, and reversible procedure to treat T2DM. The literature reveals interesting results for T2DM remission in non-obese patients. High-level comparative studies are required to support these data.
Subject(s)
Diabetes Mellitus, Type 2/surgery , Gastric Bypass/methods , Obesity, Morbid/surgery , Bariatric Surgery , HumansABSTRACT
Guidelines recommend suppression tests such as the saline infusion test (SIT) to ascertain the diagnosis of primary aldosteronism (PA) in patients with a high aldosterone:renin ratio. However, suppression tests have only been evaluated in small retrospective series, and some experts consider that they are not helpful for the diagnosis of PA. In this study, we evaluated whether low post-SIT aldosterone concentrations do exclude lateralized PA. Between February 2009 and December 2013, 199 patients diagnosed with PA on the basis of 2 elevated aldosterone:renin ratio results and a high basal plasma or urinary aldosterone level or high post-SIT aldosterone level had a selective adrenal venous sampling. We used a selectivity index of 2 and a lateralization index of 4 to interpret the adrenal venous sampling results. Baseline characteristics of the patients were the following (percent or median): men 63%, 48 years old, office blood pressure 142/88 mm Hg, serum potassium 3.4 mmol/L, aldosterone:renin ratio 113 pmol/mU, plasma aldosterone concentration 588 pmol/L. The proportion of patients with lateralized adrenal venous sampling was 12 of 41 (29%) among those with post-SIT aldosterone <139 pmol/L (5 ng/dL) and 38 of 104 (37%) among those with post-SIT aldosterone <277 pmol/L (10 ng/dL). Post-SIT aldosterone levels were not associated with the blood pressure outcome of adrenalectomy. A low post-SIT aldosterone level cannot rule out lateralized PA, even with a low threshold (139 pmol/L). Adrenal venous sampling should be considered for patients who are eligible for surgery with elevated basal aldosterone levels even if they have low aldosterone concentrations after recumbent saline suppression testing.
Subject(s)
Adrenalectomy/methods , Aldosterone/blood , Hyperaldosteronism/blood , Renin/blood , Sodium Chloride/administration & dosage , Adult , Cohort Studies , Diagnostic Techniques, Endocrine , Female , France , Humans , Hyperaldosteronism/diagnosis , Hyperaldosteronism/surgery , Infusions, Intravenous , Male , Middle Aged , Patient Selection , Preoperative Care/methods , Prognosis , Retrospective Studies , Treatment OutcomeABSTRACT
OBJECTIVE: This study was designed to identify factors associated with morbidity and mortality in patients older than 70 years who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC). BACKGROUND: Major surgery is associated with higher morbidity and mortality in elderly patients. For PC, CRS and HIPEC is the only current potential curative therapy, but the risks inherent to this patient population have called its benefits into question. METHODS: We retrospectively analyzed a multi-center database from 1989 to 2015. All patients who underwent CRS and HIPEC for PC were selected and patients older than 70 years were matched 1:4 with a younger cohort according to cancer origin, peritoneal cancer index (PCI), and completeness of cytoreduction. Major morbidity and mortality were analyzed. RESULTS: Of 2328 patients, 188 patients older than aged 70 years were matched with 704 younger patients. Patients older than aged 70 years demonstrated a higher American Society of Anesthesiologist score (≥ASA III 10.8 vs. 6.6 %, p = 0.008). There was no difference in overall 90-day morbidity (≥70: 45.7 % vs. <70: 44.5 %; p = 0.171); however, patients older than 70 years had significantly more cardiovascular complications (13.8 vs. 9.2 %, p = 0.044). Differences between the older and younger cohorts failed to reach significance for 90-day mortality (5.4 and 2.7 %, respectively; p = 0.052), and failure-to-rescue (11.6 and 6.1 %, respectively; p = 0.078). In multivariate analysis, PCI > 7 (95 % CI 1.051-5.798, p = 0.038) and HIPEC duration (95 % CI 1.106-6.235, p = 0.028) were independent factors associated with morbidity in elderly patients. CONCLUSIONS: CRS and HIPEC appear feasible for selected patients older than aged 70 years, albeit with a higher risk of medical complications associated with increased mortality.
Subject(s)
Antineoplastic Combined Chemotherapy Protocols/adverse effects , Cytoreduction Surgical Procedures/adverse effects , Hyperthermia, Induced/adverse effects , Peritoneal Neoplasms/therapy , Adolescent , Adult , Age Factors , Aged , Aged, 80 and over , Antineoplastic Combined Chemotherapy Protocols/administration & dosage , Cardiovascular Diseases/etiology , Case-Control Studies , Cause of Death , Combined Modality Therapy/adverse effects , Failure to Rescue, Health Care , Female , Health Status , Humans , Male , Middle Aged , Peritoneal Neoplasms/secondary , Retrospective Studies , Young AdultABSTRACT
BACKGROUND: Surgery appears to be the best treatment option for a chronic fistula after laparoscopic sleeve gastrectomy (LSG). Conservative procedures (conversion into a Roux-en-Y gastric bypass, Roux-limb placement) have proven their feasibility and efficacy, but an open total gastrectomy (TG) is sometimes required in challenging situations. OBJECTIVES: To assess outcomes from 12 consecutive patients who underwent surgery for a post-sleeve gastrectomy chronic fistula (PSGCF) between January 2004 and February 2012. SETTING: University public hospital, France. METHODS: Patients with a PSGCF who underwent surgery were included in this retrospective study. Mortality, morbidity (i.e., Clavien-Dindo score), weight loss, and nutritional status were assessed. RESULTS: Twelve of 57 patients (21%) with a post-LSG leak developed a PSGCF. There were 3 men (25%). Mean age was 39±9 years and mean preoperative body mass index was 35±5 kg/m2. All 12 patients underwent an open total gastrectomy with an esojejunostomy (TG). Conservative procedures were considered but not possible. The mean follow-up period was 38±11 months. The mean delay between LSG and TG was 12±6 months. Intraoperative discovery of multiple (>2) gastric fistulas was reported in 9 patients (75%). There were no deaths, but morbidity rate was 50%. Early postoperative fistula occurred in 3 patients (anastomosis n = 1, duodenal stump n = 2). None of these patients required further surgery. The median healing time of the fistula was 37 days (range 24-53). Promising results from weight loss and nutritional status were found at the end of the follow-up. CONCLUSION: A salvage open TG is a well-tolerated and reproducible salvage procedure for cases of a PSGCF, when conservative procedures are not possible.
Subject(s)
Cutaneous Fistula/surgery , Gastrectomy/adverse effects , Gastric Fistula/surgery , Obesity, Morbid/surgery , Acute Disease , Adult , Anastomotic Leak/etiology , Chronic Disease , Cutaneous Fistula/etiology , Drainage/methods , Emergency Treatment/statistics & numerical data , Female , Gastrectomy/methods , Gastric Fistula/etiology , Gastroscopy/statistics & numerical data , Humans , Laparoscopy/statistics & numerical data , Male , Postoperative Complications/etiology , Postoperative Complications/surgery , Reoperation , Retrospective Studies , Treatment OutcomeABSTRACT
Treatment of primary aldosteronism (PA) aims at preventing or correcting hypertension, hypokalemia and target organ damage. Patients with lateralized PA and candidates for surgery may be managed by laparoscopic adrenalectomy. Partial adrenalectomy and non-surgical ablation have no proven advantage over total adrenalectomy. Intraoperative morbidity and mortality are low in reference centers, and day-surgery is warranted in selected cases. Spironolactone administered during the weeks preceding surgery controls hypertension and hypokalemia and may prevent postoperative hypoaldosteronism. In most cases, surgery corrects hypokalemia, improves control of hypertension and reduces the burden of pharmacologic treatment; in about 40% of cases, it resolves hypertension. However, success in controlling hypertension and reversing target organ damage is comparable with mineralocorticoid receptor antagonists. Informed patient preference with regard to surgery is thus an important factor in therapeutic decision-making.
Subject(s)
Adrenalectomy , Hyperaldosteronism/surgery , Adrenalectomy/adverse effects , Adrenalectomy/methods , France , Humans , Hyperaldosteronism/drug therapy , Hypertension/drug therapy , Hypertension/surgery , Hypokalemia/drug therapy , Hypokalemia/surgery , Intraoperative Complications , Laparoscopy , Mineralocorticoid Receptor Antagonists/therapeutic use , Postoperative Complications , Spironolactone/therapeutic use , Treatment OutcomeABSTRACT
The French Endocrinology Society (SFE) French Hypertension Society (SFHTA) and Francophone Endocrine Surgery Association (AFCE) have drawn up recommendations for the management of primary aldosteronism (PA), based on an analysis of the literature by 27 experts in 7 work-groups. PA is suspected in case of hypertension associated with one of the following characteristics: severity, resistance, associated hypokalemia, disproportionate target organ lesions, or adrenal incidentaloma with hypertension or hypokalemia. Diagnosis is founded on aldosterone/renin ratio (ARR) measured under standardized conditions. Diagnostic thresholds are expressed according to the measurement units employed. Diagnosis is established for suprathreshold ARR associated with aldosterone concentrations >550pmol/L (200pg/mL) on 2 measurements, and rejected for aldosterone concentration<240pmol/L (90pg/mL) and/or subthreshold ARR. The diagnostic threshold applied is different if certain medication cannot be interrupted. In intermediate situations, dynamic testing is performed. Genetic forms of PA are screened for in young subjects and/or in case of familial history. The patient should be informed of the results expected from medical and surgical treatment of PA before exploration for lateralization is proposed. Lateralization is explored by adrenal vein sampling (AVS), except in patients under 35 years of age with unilateral adenoma on imaging. If PA proves to be lateralized, unilateral adrenalectomy may be performed, with adaptation of medical treatment pre- and postoperatively. If PA is non-lateralized or the patient refuses surgery, spironolactone is administered as first-line treatment, replaced by amiloride, eplerenone or calcium-channel blockers if insufficiently effective or poorly tolerated.
Subject(s)
Hyperaldosteronism , Hypertension , Adrenal Gland Neoplasms , Adrenalectomy , Adult , Aldosterone/blood , Calcium Channel Blockers/therapeutic use , France , Humans , Hyperaldosteronism/diagnosis , Hyperaldosteronism/therapy , Hypokalemia , Mineralocorticoid Receptor Antagonists/therapeutic use , Renin/blood , Spironolactone/therapeutic useABSTRACT
Diagnosis management of gastroesophageal reflux disease in adults. Gastroesophageal reflux (GERD) is a common disease that can however impair quality of life. A diagnostic algorithm was established by the French societies of gastroenterology based on clinical manifestations. In the absence of warning signs, the diagnosis of GERD is based on patient's history of a typical symptomatology. In other cases, an upper digestive endoscopy has to be performed, associated or not with a 24-hours pH monitoring. Concerning proton pump inhibitors resistant reflux, impedance pH monitoring is the exam of choice to highlight non acid reflux. A baseline esophageal manometry is recommended in the preoperative assessment for GERD surgery.
Stratégie diagnostique du reflux gastro-oesophagien chez l'adulte. Le reflux gastro-oesophagien est une affection très répandue qui peut être très invalidante au quotidien et altérer la qualité de vie. En fonction de la symptomatologie clinique, une stratégie diagnostique a été mise en place par les sociétés savantes françaises de gastro- entérologie. Le diagnostic du reflux gastro-oesophagien est fondé sur l'interrogatoire du patient quand il s'agit d'une symptomatologie typique et en l'absence de signes d'alarme. Dans le cas contraire, une endoscopie digestive haute est réalisée en première intention, associée ou non à une pH-métrie de 24 heures. Concernant les reflux résistants aux inhibiteurs de la pompe à protons, l'impédancemétrie est l'examen de choix pour objectiver un reflux non acide. Dans le cadre d'un bilan préopératoire d'une chirurgie de reflux, une manométrie oesophagienne de référence est préconisée.
Subject(s)
Esophageal pH Monitoring , Gastroesophageal Reflux , Adult , Gastroesophageal Reflux/diagnosis , Gastroesophageal Reflux/drug therapy , Humans , Manometry , Proton Pump Inhibitors/therapeutic use , Quality of LifeABSTRACT
Treatment of gastroesophageal reflux disease in adults. The high frequency of gastroesophageal reflux disease (GERD) and the symptoms variability should lead to propose graduate treatments that have in common lifestyle modifications and postural measures. First-line drugs are antacids and it is only in case of inefficiency that in second- line anti-secretory treatment is used. This therapeutic strategy is effective in over 90% of cases. In case of treatment failure additional tests and higher doses of proton-pump inhibitor must be discussed. These treatments do not change the volume of reflux but only its wounding power. Surgical approach for laparoscopic fundoplication is discussed in case of significant anatomical abnormalities or regurgitations. Endoscopic treatment is restricted to clinical trials.
Traitement du reflux gastro-oesophagien chez l'adulte. La fréquence du reflux gastro-oesophagien et la variabilité de l'importance des symptômes doivent conduire à proposer des traitements gradués qui tous ont en commun la mise en place de mesures hygiéno-diététiques et posturales. En première intention des médicaments antiacides sont prescrits et ce n'est qu'en cas d'inefficacité qu'en seconde intention on peut recourir à des traitements antisécrétoires. Cette stratégie thérapeutique est efficace dans plus de 90 % des cas. Les échecs du traitement doivent faire discuter des examens complémentaires et une réadaptation des doses d'inhibiteurs de la pompe à protons. Ce traitement ne modifie pas le volume du reflux mais son pouvoir vulnérant. Ce n'est qu'en cas d'anomalies anatomiques significatives ou de régurgitations importantes qu'une fundoplicature chirurgicale peut être discutée. Les traitements endoscopiques ne peuvent être proposés en dehors d'essais cliniques.