[Novel endoscopic antireflux procedures - time for critical appraisal]. / Dags för kritisk bedömning av nya minimalinvasiva antirefluxtekniker.

GERD is the most prevalent gastrointestinal disorder in the Western world and the extent of anatomic alterations underlying the mechanisms of GERD can be viewed upon as a spectrum from a single anatomic alteration (e.g.  incompetent lower esophageal sphincter) to multiple anatomic alterations, such as diaphragmatic hiatal hernia. The degree of anatomic aberrations also seem to correlate with the complications of GERD. Since GERD is a heterogenous disease, it can be argued that its treatment should be individualized. The medical and surgical therapies have been the mainstay of long-term treatment of GERD, but during recent decades several Food and Drug Administration (FDA)-approved devices have become available for endoscopic treatment of GERD, thus potentially filling the alleged therapeutic gap between medication and surgery. Endoscopic treatment options are now considered appropriate treatment in particular in patients early in the GERD spectrum. However, serious methodological concerns can be raised regarding the scientific documentation behind all of these devices, despite the fact that they are vigorously marketed. This article outlines the basic principles and guidelines for the current and future documentations of such devices, which might be helpful for the clinician in selecting the most accurate long-term therapeutic alternative for patients with chronic GERD.

[Management of patients with gastroesophageal reflux disease can be optimized]. / Gastroesofageal refluxsjukdom ­ gammal bekant med nya ansikten.

Gastroesophageal reflux disease (GERD) often requires lifelong treatment to return to and maintain a normal quality of life. Proton pump inhibitors (PPIs) offer effective medical treatment and can be used for a long time with good safety margins. The diagnostic criteria for GERD must be strictly based on current guidelines and the need for maintained treatment must be regularly evaluated. When medical treatment fails (> 20%), the patient should be offered a consultation with a specialist in the field. Too many patients who are currently treated with PPI for suspected GERD ultimately require treatment with a completely different diagnosis in focus. The investigation and treatment options are several and well-defined in the event of PPI failure in patients with well documented GERD. The indications for surgical treatment are well established, but this treatment option is likely underused today.

[Significant over- and misuse of PPIs]. / Stor överförskrivning och ökat bruk av protonpumpshämmare.

PPIs (Proton-pump inhibitors) offers the best treatment for acid related diseases. The predominant indications for PPI prescription are: GERD eradication of H. pylori-infection in combination with antibiotics H. pylori-negative peptic ulcer  healing of and prophylaxis against NSAID/COXIB--induced gastroduodenal lesions  acid hypersecretory states such as Zollinger-Ellisons syndrome. The market for PPIs continues to expand in most countries. A significant over- and misuse of PPIs prevails in hospital care as well as in general practice. The predominant reasons for and mechanisms behind the over- and misuse of PPIs are well recognised. The most important consequences of this overprescription of PPIs are increasing medical costs and risk for long-term adverse side effects. Continued education and dedicated information are key factors to guide physicians, medical personnel and patients to adopt to generally accepted principles for and balanced use of PPIs.

Laparoscopic Heller myotomy or pneumatic dilatation in achalasia: results of a prospective, randomized study with at least a decade of follow-up.

BACKGROUND AND OBJECTIVES: The most efficient long-term treatment strategy for achalasia has yet to be established. This study compared the long-term results (≥ 10 years) after either pneumatic dilatations or laparoscopic myotomy using treatment failure as the primary outcome. Secondary objectives were; the frequency and degree of dysphagia and effects on health-related quality of life (QoL). PATIENTS AND METHODS: Out of the 53 patients with achalasia who were initially randomized to either laparoscopic myotomy with a posterior partial fundoplication (LM) or repetitive pneumatic dilatation (PD), 43 remained for scrutiny after a median observation period of 170 months (LM; n = 20 and PD; n = 23). RESULTS: At the follow-up of 60 months, 10 patients (36%) in the PD group and two patients (8%) in the LM group were classified as treatment failures (p = 0.016). At the latest follow-up time point (≥ 10 years), the corresponding numbers were 13 (57%) and 4 (20%), respectively. The Kaplan-Meier analysis of the cumulative incidence of treatment failure revealed a significant advantage of LM over the dilatation strategy (p = 0.036)). QoL assessed by the generic instrument PGWB and the more disease-specific instrument GSRS revealed scores which were similar in the two study groups with no obvious changes over time. Reflux was better controlled in the LM group (p = 0.02 regarding PPI consumption). CONCLUSIONS: After more than a decade of follow-up, laparoscopic myotomy reinforces its superiority over repetitive pneumatic dilatation treatment strategy in the management of newly diagnosed achalasia.