Endoscopic treatment of vesicoureteral reflux in the previously reimplanted ureter: technical aspects and results / Tratamiento endoscópico del reflujo vesicoureteral en el uréter previamente reimplantado: aspectos técnicos y resultados

Objectives: To assess the feasibility and results of the endoscopic treatment of vesicoureteral reflux (VUR) after a failed ureteral reimplantation. Methods: From January 1996 to October 2006, 28 patients underwent endoscopic treatment for VUR grade II to V persisting after open ureteral reimplantation. VUR was bilateral in 11 patients, for a total of 39 ureteral units (UU) treated. The endoscopic treatment was performed 1 to 7 years after surgery (average 2.5 years). Dextranomer/Hyaluronic acid Copolymer (Dx/HA) was used as injectable material. The amount of injected material ranged from 0.5 to 2.8 ml (average: 1.2 ml). Some technical refinements were required to increase the success of the procedures. Patients were followed up from 2.5 to 17 years. Voiding cystourethrogram (VCUG) was performed at 6 months and MAG3 renal scan with voiding phase at 24 months. Results were compared with the outcome of the endoscopic treatment in patients treated by the same surgeons for primary VUR, matched for grade (control group). Results: All treatments were performed as one-day procedure. No complications were observed. Success was achieved in 22/28 patients (78.5%) and in 30/39 UU (76.9 %) after failed ureteral reimplantation. No significant difference in success rate was found from the control group (p= ns). Conclusions: Endoscopic treatment of VUR after a failed reimplantion can be a challenging procedure, for a skilled endoscopists. Nonetheless it can achieve successful results in a high percentage of patients with minimal morbidity and a minimal invasiveness; it should thus be recommended for these patients (AU)

Objetivo: Evaluar la viabilidad y resultados del tratamiento endoscópico del reflujo vesicoureteral (RVU) después del fracaso del reimplante ureteral. Métodos: Entre enero de 1996 y octubre del 2006, 28 pacientes fueron sometidos a tratamiento endoscópico del RVU persistente grados II a V después de reimplante ureteral. El RVU era bilateral en 11 pacientes, con un total de 39 uréteres tratados. El tratamiento endoscópico se realizó entre 1 y 7 años después de la cirugía (media 2,5 años). Como material inyectable se utilizó copolímero de ácido hialurónico/dextranomero. La cantidad de material inyectado varió entre 0,5 y 2,8 ml (media 1,2 ml). Fue necesaria alguna finura técnica para aumentar el éxito de los procedimientos. Los pacientes fueron seguidos entre 2,5 y 17 años. Se realizó cistouretrografía miccional seriada (CUMS) a los seis meses y gammagrafía renal MAG3 con fase miccional a los 24 meses. Los resultados se compararon con los de un grupo control de tratamiento endoscópico en pacientes con RVU primario tratados por los mismos cirujanos, emparejados según el grado. Resultados: Todos los tratamientos fueron realizados de forma ambulatoria. No se observaron complicaciones. Se obtuvo el éxito en 22/28 pacientes (78 .5%) y en 30/39 uréteres (76. 9%) después de un reimplante fallido. No hubo diferencias significativas en las tasas de éxitos comparando con el grupo control (p =ns). Conclusiones: El tratamiento endoscópico del RVU después del fracaso de un reimplante puede ser un desafío para un endoscopista experto. Sin embargo puede conseguir resultados exitosos en un alto porcentaje de pacientes con mínima morbilidad en pasividad. Por tanto, debería recomendarse en estos pacientes (AU)

[Biliary reflux in a reflux disorder of the oesophagus]. / Biliární reflux u refluxní nemoci jícnu.

This study assesses complications of a combined duodenogastric reflux disorder of the oesophagus. It has been proved that a degree of morphological affections of the mucosa is higher with an alcalic biliary reflux and can be assessed histologicaly. Primarily, the biliary portion of the reflux was assessed. Qualitative reflux parametres were assessed using a spectrophotometric examination. The examination can replace an expensive (and, therefore, generally unavailable) Bilitec 2000 system. In 21 subjects out of the total of 64 oesophageal reflux patients examined in the 2000-2003 period, complications of the disorder were confirmed. The biliary reflux was expected in 9 patients, however, using the spectrophotometry, it was confirmed in 3 patients. In this patient group, a more severe deterioration of the oseophageal mucosa by the alcalic reflux was confirmed, resulting in higher incidences of the disorder complications. The complications included strictures of the oesophagus, developement of a Barret's oesophagus and an adenocarcinoma of the oesophagus. Therefore, in order to prevent complications in this patient group, surgical management is preferred to conservative therapy.

[Duodenogastric and gastroesophageal bile reflux]. / Le reflux biliaire duodéno-gastrique et gastro-oesophagien.

This study reviews current data regarding duodenogastric and gastroesophageal bile reflux-pathophysiology, clinical presentation, methods of diagnosis (namely, 24-hour intraluminal bile monitoring) and therapeutic management. Duodenogastric reflux (DGR) consists of retrograde passage of alkaline duodenal contents into the stomach; it may occur due to antroduodenal motility disorder (primary DGR) or may arise following surgical alteration of gastoduodenal anatomy or because of biliary pathology (secondary DGR). Pathologic DGR may generate symptoms of epigastric pain, nausea, and bilious vomiting. In patients with concomitant gastroesophageal reflux, the backwash of duodenal content into the lower esophagus can cause mixed (alkaline and acid) reflux esophagitis, and lead, in turn, to esophageal mucosal damage such as Barrett's metaplasia and adenocarcinoma. The treatment of DGR is difficult, non-specific, and relatively ineffective in controlling symptoms. Proton pump inhibitors decrease the upstream effects of DGR on the esophagus by decreasing the volume of secretions; promotility agents diminish gastric exposure to duodenal secretions by improving gastric emptying. In patients with severe reflux resistant to medical therapy, a duodenal diversion operation such as the duodenal switch procedure may be indicated.

[Combined use of electric sleep and hofitol in the treatment of primary chronic gastroduodenitis]. / Kompleksnoe primenenie élektrosna i khofitola v lechenii pervichnogo khronicheskogo gastroduodenita.

Primary chronic gastroduodenitis (PCGD) accounts for 60-85% of the diseases of the gastroduodenal zone. In our study 90 patients with PCGD were divided into three groups getting one of the following therapies: electric sleep, hofitol, electric sleep plus hofitol. The effects of the treatments were assessed with updated techniques including computed pH-metry. Hofitol showed a good effect on dyspepsia, enhanced the alkalizing ability of the duodenal bulb. Electric sleep relieved pain and asthenoneurotic syndromes, decreased high acidity of the gastric juice in the body of the stomach. Electric sleep in combination with hofitol normalized macroscopic picture of the upper gastrointestinal tract and corrected imbalanced immunity.

[Complex treatment of patients with pylorobulbar ulcers in combination with duodenogastric reflux]. / Kompleksnoe lechenie bol'nykh s pilorobul'barnymi iazvami, sochetaiushchimisia s duodenogastral'nym refliuksom.

The complex approach to therapy of pylorobulbar ulcers combined with duodenogastral reflux was developed and introduced into the clinical practice. The treatment stipulates the elements of functional surgery and eradicative antiinflammatory and antisecretory therapy. The use of this complex method permits to obtain the good results providing the food passage close to physiologic one, to prevent the ulcer recurrence, development of gastric mucosa pathology caused by duodenogastral reflux and persistence of Helicobacter pylori infection. As the result the patients' life quality significantly improves.

Duodenogastroesophageal reflux and methods to monitor nonacidic reflux.

The role of duodenogastroesophageal reflux (DGER), once erroneously termed "bile reflux," in causing esophageal mucosal damage has been an area of interest in both animal and human studies. However, because of the lack of appropriate techniques to accurately measure DGER, extrapolation of findings from animal studies to humans has been difficult to make. The recent advent of the Bilitec system (Metronics Instruments, Minneapolis, MN), an ambulatory bilirubin monitoring device, is increasing our knowledge of the specific role of DGER in esophageal diseases. Studies suggest that DGER without acid reflux may result in symptoms, but unless acid reflux is present simultaneously, it does not cause esophagitis. Therefore, therapies should aim at reducing both DGER and acid reflux. Studies show that this may be accomplished by antireflux surgery or the use of proton pump inhibitors, which by reducing gastric volume, decrease the damaging potential of both acid and DGER.

Duodenogastro-oesophageal reflux.

The role of duodenogastro-oesophageal reflux (DGOR), once erroneously termed 'bile reflux', in causing oesophageal mucosal damage has been an area of interest in both animal and human studies. However, due to the lack of appropriate techniques for accurately measuring DGOR, extrapolation of findings from animal studies to humans was difficult to make. The recent advent of the Bilitec system, an ambulatory bilirubin monitoring device, is increasing our knowledge of the specific role of DGOR in oesophageal diseases. Studies suggest that the DGOR without acid reflux may result in symptoms but unless acid reflux is present simultaneously, it does not cause oesophagitis. Therefore, our therapies should aim at reducing both DGOR and acid reflux. Studies show that this may be accomplished by anti-reflux surgery or the use of proton pump inhibitors, which, by reducing gastric volume, decrease the damaging potential of both acid and DGOR.

[Therapeutic complex in therapy of patients with complicated course of pylorobulbar ulcers]. / Kompleks lechebnykh meropriiatii v terapii bol'nykh s oslozhnennym techeniem pilorobul'barnykh iazv.

Combined treatment of pylorobulbar ulcers associated with duodenogastric reflux incorporated surgery, antiinflammatory and antisecretory therapy. The treatment provides preventing ulcer recurrence, gastric mucosa affection caused by duodenogastric reflux and infection Helicobacter pylori. Finally, this led to improved quality of life.

Significance of duodenogastric reflux in patients with erosive esophagitis.

The role of duodenogastric reflux (DGR) in producing esophageal mucosal injury across the spectrum of GERD is still controversial. Our objective was to assess the role of DGR in the genesis and evolution of erosive esophagitis. Forty patients are presented who meet the criteria for the diagnosis of erosive esophagitis. Symptom scoring, endoscopy and mucosal biopsy with patohistologic classification of erosive esophagitis and a quantification of DGR, using scintigraphic imaging after intravenous injection of 99mTc-labeled HIDA, was performed. DGR was demonstrated in half of the patients. Both groups of patients (with and without DGR) were treated with life style changes, cisapride and nizatidine for a period of six weeks. After this period, symptom scoring, endoscopy and biopsy were performed again in both groups. There has been a significant decrease in the level of symptom scoring and endoscopic inflammation after the therapy, but without statistically significant difference between these two groups. Patohistologic finding after the medical treatment showed a marked difference between the two groups concerning the presence of DGR, indicating that the level of inflammation is statistically significantly higher in the group with DGR. This study showed that even if symptom scoring and endoscopy revealed improvement after the therapy in both groups of patients, patohistologic mucosal damage in patients with erosive esophagitis is greatly dependent of the presence of DGR. We conclude that alkaline component of GERD should be considered in the evaluation of patients with erosive esophagitis so that appropriate surgical therapy can be instituted.

Importance of duodenogastric reflux in the surgical outpatient practice.

To the surgeon, the importance of duodeno-gastro-esophageal reflux is related firstly to the injurious effects it has on the mucosa of the stomach and the esophagus, and secondly to the underlying pathophysiology causing the regulation of duodenal contents into the stomach and subsequently into the esophagus. Normally, the reflux of duodenal contents into the stomach rarely causes symptoms and consequently is usually not a primary disease. The symptoms develop after operations that distort or remove the pylorus. Consequently, in most situations the disease is iatrogenic in etiology. In contrast, the reflux of duodenal and gastric contents into the esophagus occurs very commonly as a primary disease entity. In such patients, a dysfunctional lower esophageal sphincter is the cause of the increased esophageal exposure and is of key importance to the surgeon. Surgery is the only treatment modality, which is able to specifically address and correct a structurally defective and dysfunctional lower esophageal sphincter. For patients with excessive duodenal reflux into the stomach, surgical diversion of the offending refluxate by means of a Roux-en-Y procedure is the only truly effective modality of treatment.

[Duodenogastric reflux in patients with irritable bowel syndrome treated with wheat bran]. / Zarzucanie dwunastniczo-zoladkowe u chorych z zespolem jelita nadwrazliwego leczonych pszennymi otrebami.

The aim of this study was to estimate the influence wheat bran enriched diet on incidence of duodenogastric reflux and symptoms in patients suffering from irritable bowel syndrome with predominant constipation. Duodenogastric reflux was examined in 31 patients by means of the cholangioscintigraphy. The results of this investigation were compared with the symptom score before and after 12 weeks of treatment with wheat bran. The incidence of duodenogastric reflux was not decreased post bran consumption. Bowel dysfunction symptom score was significantly lower in both subgroups-with and without duodenogastric reflux. However dyspeptic symptom score was not significantly lower in these groups.

Duodenogastric reflux causes growth stimulation of foregut mucosa potentiated by gastric acid blockade.

We investigated whether duodenogastric reflux (DGR) together with gastroesophageal reflux causes growth stimulation of the foregut mucosa and if additional gastric acid suppression enhances the effect of DGR. DGR was induced in rats using a split gastroenterostomy. A cardiomyotomy was performed across the gastroeophageal junction in order to enhance reflux into the esophagus. DGR rats were divided into six subgroups: DGR, DGR + truncal vagotomy, DGR + omeprazole, DGR + gastrin receptor blockade, DGR + omeprazole + gastrin receptor blockade, and DGR + gastrin. Two sham groups, one with and one without omeprazole treatment, served as controls. DGR significantly increased the weight and DNA content of the esophageal and gastric mucosa, which was further enhanced by vagotomy or omeprazole. Histology revealed foveolar hyperplasia in the stomach and esophageal mucosal hyperplasia in these groups. In addition, severe esophagitis was found in the DGR group receiving omeprazole. Omeprazole without DGR had no growth-stimulating effect on the foregut mucosa. DGR-induced growth stimulation was accompanied by hypergastrinemia. Increased growth in the stomach but not the esophagus was inhibited by gastrin receptor blockade. Gastrin administration did not result in enhancement of DGR-induced growth stimulation of the foregut mucosa. It is concluded that DGR, often present in severe reflux esophagitis, causes mucosal growth of the foregut of rats. This trophic response may explain why severe reflux esophagitis is associated with an increased risk of esophageal adenocarcinoma. DGR-induced growth stimulation of the foregut is potentiated by gastric acid suppression, suggesting that chronic antisecretory medication in gastroesophageal reflux may not always be advisable. Omeprazole + DGR caused severe esophageal damage, which may explain why antisecretory medication may fail to heal severe reflux esophagitis.

Reflujo alcalino: alcances fisiopatológicos y terapeúticos / Alkaline reflux: phisiopathological and therapeutical implications

Se analizan la clínica y fisiopatología del reflujo alcalino. Se establecen sus causas primarias y secundarias. Entre los íntomas más relevantes destacan la epigastralgia sin ritmo ulceroso y el vómito bilioso matinal. El diagnóstico se apoya en la demostración de reflujo biliar El tratamiento médico es de escaso rendimiento pero existen algunas técnicas quirúrgicas, entre las cuales la de mejor rendimiento es el asa disfuncionalizada al bolsilo gástrico en las secundarias y al duodeno (switch duodenal) en las primeras

[Diagnosis, prevention and treatment of postoperative reflux gastritis]. / Diagnostika, profilaktika i lechenie posleoperatsionnogo refliuks-gastrita.

Postoperative reflux gastritis in persons who were operated on for peptic ulcer occurs much more frequently after resection of the stomach (68.6%) than after organ-preserving operations on the stomach (39.4%). The incidence of reflux gastritis after gastric resection depends on the type of gastroenteroanastomosis. It is encountered much less frequently after Roux' operation (9.2%). The pronounced character and frequency of reflux gastritis after organ-preserving operations on the stomach are determined by the type of stomach-draining operations, the localization of the ulcer before the operation, whether in the stomach or the duodenum, the existence of duodenogastric reflux (DGR) before the operation. Measures for the prevention of postoperative reflux gastritis in the management of peptic ulcer are as follows: (a) wide introduction of organ-preserving operations, preferably SPV by itself or in combination with duodenoplasty; (b) formation of Roux' gastroenteroanastomosis when resection of the stomach is indicated. Reflux gastritis must be treated by nonoperative methods, including medicinal, dietetic, and spa therapy. Surgery is indicated in reflux gastritis combined with other diseases of a stomach which had been operated on, for which an operation is necessary, and in occasional cases of erosive reflux gastritis.

[Features of the correction of duodenogastric reflux in peptic ulcer]. / Osobennosti korrektsii duodenogastral'nogo refliuksa pri iazvennoi bolezni.

In 131 patients with the duodenal ulcer disease the dependence of duodenogastric reflux frequency and intensity from the periodic motor gastric and duodenal activity was determined with the help of balloonographic method. Various mechanism of the origin were elucidated, and the correction schemes of the duodenogastric reflux are proposed.

[Diagnostic and therapeutic update on primary duodenogastric reflux]. / Attualità diagnostiche e terapeutiche nella patologia da reflusso duodenogastrico primitivo.

The authors, after some remarks on the pathophysiology of primary alkaline gastritis, analyze the main methods, available at present, for diagnosis; they particularly consider the importance of endoscopy and histology, gastroesophageal 24-hours pH-metry and 99mTc HIDA scintigraphy. Successively, they present the criteria for the identification of patients who will predictably benefit from surgical treatment, and examine advantages and limits of the two main corrective surgical techniques for the duodenogastric reflux in patients not previously operated on the gastrointestinal tract: duodenal extramucosal myotomy according to Mattioli, relatively easy to perform, and the "duodenal switch" according to De Meester, technically more complex, but pathophysiologically more acceptable, completely eliminating the duodenogastric reflux.

[Postoperative gastritis due to alkaline reflux. Our results]. / Gastritis postquirúrgica por reflujo alcalino. Nuestros resultados.

We present the results of a retrospective study carried out on 23 patients with alkaline gastric reflux (AGR) verified through endoscopy, biopsies and Tc99m HIDA, which were operated on in our department with Y of Roux, Braun, Henley as the correction techniques of this pathology. The criteria of surgical indications were evaluated in these patients as also the results obtained in reference to residual symptoms and changes in the histologic and gammagraphic patterns.