Jejunal interposition for recurrent gastroesophageal reflux in children

There is limited experience with surgical treatment for recurrent gastroesophageal reflux after an antireflux procedure. In four pediatric patients with recurrent reflux after surgical therapy, interposition of an isoperistaltic segment of jejunum produced excellent short-term results. Further follow-up is needed as experience broadens. At the present time, this procedure merits consideration in patients with recurrent gastroesophageal reflux.     

Endoscopic intraluminal suture plication of the gastric pouch and stoma in postoperative Roux-en-Y gastric bypass patients

BACKGROUND: Endoscopic intraluminal suturing is currently used to treat gastroesophageal reflux disease. This new field of intraluminal gastric surgery may benefit postoperative Roux-en-Y gastric bypass patients. While gastric bypass is highly successful in the majority of patients, significant weight regain can occur over time due to stretching of the gastric pouch and stoma. METHODS: Between November 2002 and January 2003, four patients who previously underwent gastric bypass (GBP) surgery presented with dilated gastrojejunostomy (GJ) anastomosis and weight regain. They gave their consent and were taken to the operating room for upper endoscopy, where they were placed under general anesthesia. Using a flexible endoscopic suturing device with a standard 11-mm endoscope, the dilated GJ anastomosis was plicated to reduce its size, and in two of the patients the gastric pouch was also plicated. RESULTS: Successful stomal plication was performed on all four patients to narrow their dilated stomas that measured > 2 cm preoperatively to < 15 mm postoperatively. Patients were told to go on a puree diet for 4 weeks. One patient had a repeat procedure due to rupture of one suture after eating solid food two weeks after the surgery. The stoma was then plicated with 3 sutures. Two patients had their gastric pouch plicated near the stoma. All patients to date report feeling full earlier with decrease caloric consumption and subsequent weight loss. CONCLUSION: Upper endoscopic intraluminal suturing represents a new field of emerging technology that will certainly find its role in the postoperative bariatric patient. Both the gastric pouch and stoma are within reach for endoscopic intraluminal therapy. How it can aid our patients is currently being studied.     

The cost-effectiveness of endoscopic injection of dextranomer/hyaluronic acid copolymer for vesicoureteral reflux

PURPOSE: Vesicoureteral reflux is a risk factor for progressive renal damage associated with urinary tract infection. Mild to moderate reflux is routinely treated with long-term antibiotic prophylaxis to prevent recurrent infections and open surgical reimplantation for breakthrough infections despite antibiotic therapy. Endoscopic subureteral injection of implant material is a therapeutic alternative to long-term prophylaxis and open surgery but its widespread use in the United States has been prevented by the lack of a stable implant material. Dextranomer/hyaluronic acid copolymer has been shown to be a safe, effective and durable implant material and was recently approved in the United States. We estimate the effect on costs and cure rates of introducing endoscopic injection with dextranomer/hyaluronic acid copolymer as a treatment alternative in the United States. MATERIALS AND METHODS: We constructed a model that mimics current clinical practice of vesicoureteral reflux treatment for 6 years, and incorporates spontaneous resolution and surgical intervention rates obtained from 2 long-term followup studies. The treatment algorithm was established using medical data from the literature, and clinical management practices from a Delphi survey of 27 pediatric urologists and nephrologists across the United States. Endoscopic injection was introduced into the model as replacement to surgery or alternative to long-term antibiotic prophylaxis. The effectiveness of dextranomer/hyaluronic acid copolymer was calculated from 140 patients (208 ureters) with grade III reflux treated in a clinical study of 221 children in Sweden. RESULTS: With current practice, the average cost per patient in 6 years was 6,640 US dollars and 23.5% of patients continued to have reflux. Replacing open surgery with endoscopic injection led to similar cure rates (22.2% failures) but costs were reduced to 5,522 US dollars. When injection was performed after 1 year of antibiotic therapy failure rates were reduced to 8.5% but costs increased to 7,644 US dollars. CONCLUSIONS: Our results show that a persistent approach to endoscopic surgery can be expected to result in overall success that equals or exceeds open surgery at a lower cost. This finding is particularly true if open reimplant is reserved for patients with high grade or persistent vesicoureteral reflux.     

Evaluating outcomes of endoscopic full-thickness plication for gastroesophageal reflux disease (GERD) with impedance monitoring

Background  

Endoscopic full-thickness plication allows transmural suturing at the gastroesophageal junction to recreate the antireflux barrier. Multichannel intraluminal impedance monitoring (MII) can be used to detect nonacid or weakly acidic reflux, acidic swallows, and esophageal clearance time. This study used MII to evaluate the outcome of endoscopic full-thickness plication.     

Endoscopic full-thickness plication versus laparoscopic fundoplication: a prospective study on quality of life and symptom control

Background  

Endoscopic antireflux techniques have emerged as alternative therapies for gastroesophageal reflux disease (GERD). Endoscopic plication receives continuing interest as an effective and safe procedure. This treatment option has not been the subject of comparison with well-established operative therapies to date. The present study aimed at comparatively evaluating the effectiveness of endoscopic plication and laparoscopic fundoplication in terms of quality of life and symptom control.     

Pediatric gastroesophageal reflux: Age-specific indications for operation

Pediatric gastroesophageal reflux is common and its complications may be serious. The diagnosis is being suspected and confirmed with increasing frequency in children because of heightened awareness of the symptoms peculiar to pediatric patients. Thirty-one children who underwent Nissen fundoplication for gastroesophageal reflux are reviewed. Diagnosis was obtained by barium meal, isotope scanning, esophagoscopy and pH monitoring. Failure to thrive, recurrent pneumonia, apnea, feeding difficulty and esophageal stricture unresponsive to medical management were the indications for operation. Children with brain damage or previous repair of esophageal atresia are at high risk for gastroesophageal reflux and its complications. A protective fundoplication is a desirable adjunct to feeding gastrostomy in brain-damaged children. Fundoplication eliminated reflux in 30 of 31 patients, relieved symptoms in 28 and improved symptoms in 2. Nissen fundoplication is a safe and effective surgical procedure for correction of gastroesophageal reflux in children.     

Case-control comparison of endoscopic gastroplication with laparoscopic fundoplication in the management of gastroesophageal reflux disease: early symptomatic outcomes

Endoscopic gastroplication is a new technique in the management of gastroesophageal reflux disease. No comparisons of this technique with laparoscopic fundoplication have been done. Twenty-seven patients with symptoms of reflux disease were evaluated with upper endoscopy, esophageal manometry, and 24-hour esophageal pH monitoring, as well as a symptom severity questionnaire. Patients then underwent endoscopic gastroplication with use of the Bard Interventional Endoscopic Suturing System. Patients completed the symptom severity questionnaire 6 weeks after the procedure. These 27 patients were matched for age, gender, and pre-procedure symptom score with patients in a prospectively gathered database of laparoscopic antireflux operations. Twenty-one patients (78%) in the endoscopic gastroplication group were satisfied with their symptomatic outcome, 2 (7%) were neutral, and 4 (15%) were dissatisfied. In comparison, there were 26 satisfied patients (96%) in the laparoscopic group ( < 0.01). Median symptom scores improved similarly in both groups, with no statistically significant difference. The patients who were dissatisfied had a mean improvement in symptom score of 10, compared with 27 for the satisfied patients ( < 0.01). Endoscopic gastroplication is a viable alternative to laparoscopic fundoplication in selected patients. Nevertheless, approximately one quarter of patients will have no improvement, which is much more than those undergoing laparoscopic fundoplication.     

Endoscopic therapy for gastroesophageal reflux disease: can it replace antireflux surgery?

This article addresses emergent endoluminal technologies currently available for the treatment of gastroesophageal reflux disease (GERD) and compares it to the laparoscopic Nissen fundoplication. To date the mainstay of GERD therapy has been achieved with either open or laparoscopic fundoplication or life-long medical treatment. Endoluminal treatment modalities attempt to augment the gastroesophageal junction (GEJ) function by various techniques. We searched the Medline database from 1980 to 2004 for studies on endoscopic GERD techniques and laparoscopic fundoplications. Product investigators were contacted for data presented in abstract form only. Endoluminal management of GERD include using radiofrequency energy, injection of biocompatible polymers and endoluminal sutures to alter the GEJ and reduce reflux. Early results while encouraging, should be evaluated thoroughly and with caution before widespread use can be advocated. Endoscopic treatment of GERD has future promise, however, more experience and perhaps further refinement in techniques and technology must occur before widespread clinical application can be encouraged.     

Endoscopic chromoscopy in diagnosing and treatment of complicated gastroesophageal reflux disease

The authors describe the results of examination and endoscopic treatment of 278 patients with clinical symptoms of gastroesophageal reflux disease. The method of fibroesophagoduodenoscopy with 3% Lugol aqueous solution chromoscopy was introduced in medical-diagnostic algorithm of the patients. Inclusion of chromoendoscopy in the program of examination and treatment of patients with gastroesophageal reflux disease allowed higher detection of severe epithelial dysplasia (to 10.3%), leukoplakia (to 62.1%) and esophagus cancer (to 3.5%) and improvement of the results of endoscopic treatment.     

Management of severe gastroesophageal reflux in children

To evaluate response to fundoplication, clinical results for 66 consecutive pediatric patients operated on for gastroesophageal reflux were retrospectively reviewed. Indications for operation were gastroesophageal reflux with apnea, repeated emesis, recurrent pneumonia, failure to thrive, stricture, and esophagitis. All patients had preoperative documentation of significant gastroesophageal reflux by either cinefluoroscopic reflux esophagogram or reflux nuclear scan. Fundoplication was effective in 56 (87%) of 64 patients. None of the patients considered to be operative failures had persistent gastroesophageal reflux. Operative failures occurred primarily in patients with gastroesophageal reflux and apnea or recurrent pneumonia. More advanced diagnostic tests, such as pH monitoring, may help to select patients whose symptoms of apnea and recurrent pneumonia are truly due to reflux. Gastroesophageal reflux produces significant morbidity in pediatric patients and is well treated operatively by fundoplication.     

胃食管反流病的治疗进展

胃食管反流病是由胃内容物反流引起的症状或并发症,是一种常见的消化系统疾病。随着饮食结构的变化,胃食管反流病的发病率近年来呈上升趋势。目前,胃食管反流的治疗手段主要包括心理干预、药物治疗、内镜下治疗和外科手术。新技术的出现,为食管反流病的治疗带来更多的希望。     

Computerized 24-hour ambulatory esophageal pH monitoring and esophagogastroduodenoscopy in the reflux patient. A comparative study.

Ambulatory 24-hour esophageal pH monitoring and esophagogastroduodenoscopy were performed in 72 patients with symptoms suggestive of gastroesophageal reflux. Additionally, 22 asymptomatic healthy volunteers underwent pH monitoring. In patients with classic reflux symptoms and endoscopic esophagitis, a mean of 5.41 minutes/hour of reflux below pH 4 was found compared to 0.70 minutes/hour in controls (p less than 0.0001). The mean number and duration of reflux events in this group were 1.51 events/hour and 4.0 minutes/event, compared with 0.31 events/hour and 2.26 minutes/event in volunteers (p less than 0.001, p less than 0.01). A new system for ambulatory esophageal pH monitoring is presented using a pH-sensitive radiotelemetry pill or a pH probe and computerized methods for ambulatory data collection, analysis, and storage. An overall sensitivity of 76% was obtained with a 91% selectivity for detection of acid reflux in 51 patients having classic symptoms of gastroesophageal reflux. Ambulatory pH monitoring was positive for acid reflux in seven of 11 patients with normal endoscopic findings. Conversely, eight of 12 patients with normal pH monitoring had endoscopic esophagitis. In 19 patients presenting with atypical symptoms or previous gastric surgery, endoscopic findings were normal in 15. Nine of these 15 were identified as acid refluxers by pH monitoring. A combined approach using both pH monitoring and endoscopy is warranted for maximal detection and quantification of disease. A clear clinical role for pH monitoring is seen in the early diagnosis of acid reflux, particularly in patients having normal endoscopic findings with nonspecific gastrointestinal complaints or previous gastric operations.     

Subureteric polydimethylsiloxane injection in the treatment of vesico-ureteric reflux

Endoscopic treatment of vesico-ureteric reflux is a viable alternative to open surgery. We evaluated the effectiveness of polydimethylsiloxane in the endoscopic treatment of vesico-ureteric reflux. In the period between September 1994 and March 1996, 30 ureteral units of 20 children with vesico-ureteric reflux were treated by means of subureteric polydimethylsiloxane injection. Median age was 8 years in the group including 8 female and 12 male patients. Of the 30 ureteral units, 26 had no reflux at the end of the first injection. Two of the remaining four units were not refluxing after the second injection procedure. Contralateral reflux was observed postoperatively in two of the eleven patients who were treated for unilateral disease. It seems that endoscopic polydimethylsiloxane injection is an effective procedure in the treatment of vesicoureteric reflux.     

Techniques and outcomes of laparoscopic surgery in gastroesophageal reflux disease

BACKGROUND: The purpose of this study is to report personal experience in laparoscopic antireflux surgery and to analyze the clinical and functional outcomes of this procedure, also in relation to the different techniques used. METHODS: From 1996 to 2000, 20 patients with gastroesophageal reflux disease associated with hiatal hernia underwent laparoscopic surgery. The indication for surgery was failure of long-term medical therapy. All patients had severe acid reflux on 24 hrs-pH monitoring, endoscopic evidence of esophagitis and hiatal hernia, and defective lower esophageal sphincter. A Nissen fundoplication was performed in 13 patients with normal esophageal body motility, and a 270 degrees posterior fundoplication in seven patients with low esophageal motility. RESULTS: Mortality and conversion rate were 0. Mean operative time was 135 min and mean postoperative hospital stay 5 days. Operative morbidity was 15%. All the patients were completely cured of reflux symptoms; transient mild postoperative dysphagia occurred in two patients (10%). There was a significantly improvement of the results in postoperative esophageal manometry and 24 hrs-pH monitoring. CONCLUSIONS: This preliminary experience suggests that laparoscopic surgery represents a safe and effective procedure for the treatment of gastroesophageal reflux disease. Precise selection of patients and adequate surgical technique are essential.     

Role of conservative therapy and surgical treatment in disease caused by gastroesophageal reflux

A series of 82 subjects affected with reflux esophagitis is presented. Gastroesophageal reflux and peptic esophagitis were discovered and staged by contrast meal and endoscopy with biopsy. All patients underwent medical therapy based on drugs affecting gastroesophageal motility and acidity of gastric content: this therapy was administered for three months, then was performed a control endoscopic examination. Endoscopic recovery of esophagitis allowed a long term maintenance therapy, endoscopically controlled every year. When esophagitis persisted, cycles of medical attack therapy, were repeated. surgical operation was performed in 15 cases in which either three cycles of medical therapy failed to improve esophageal lesions, or when endoscopy showed worsening esophagitis.     

Endoskopische Therapiemöglichkeiten der gastroösophagealen Refluxkrankheit

Gastroesophageal reflux disease (GERD) is prevalent in 10% of the population. In addition to the established therapy, endoscopic antireflux procedures have been developed to improve the gastroesophageal reflux barrier. This can achieved by endoscopically placed sutures, application of radio frequency energy, or injection of biocompatible materials. These new techniques might be effective in some patients with GERD. To date, there are limited data on the effectiveness and safety of these methods. During a follow-up of 1-2 years, subjective parameters improved in 70-75% of the test patients such that no antisecretory treatment was required. Further, randomized, placebo-controlled studies are needed for objective evaluation of these promising new methods.     

New alternatives in the management of gastroesophageal reflux disease

BACKGROUND: To date the mainstay of surgical treatment for gastroesophageal reflux disease (GERD) has been achieved with either open or laparoscopic fundoplication. Several new treatment modalities are attempting to augment the gastroesophageal (GE) junction function by various endoscopic means. METHODS: The Medline database from 1980 to 2002 was searched for studies on endoscopic techniques for antireflux procedures. Product investigators were contacted for data presented in abstract form only. RESULTS: Recent improvements in equipment and technique with excellent long-term follow-up have made laparoscopic Nissen fundoplication the gold standard in antireflux surgery. New techniques include using radiofrequency energy, injection of silicon type polymer and using endoluminal sutures to narrow the gastroesophageal junction. Early results have encouraging aspects, but should be evaluated thoroughly and with caution before widespread use. CONCLUSIONS: Endoscopic treatment of gastroesophageal reflux has future promise. However, more experience and perhaps further improvement in techniques and technology must occur before wide application can be encouraged.     

A current assessment of endoluminal approaches to the treatment of gastroesophageal reflux disease

Over the past decade, a number of endoscopic techniques have been developed as alternatives to medical and surgical treatment of gastroesophageal reflux disease (GERD). The driving force was to provide an outpatient transoral, endoscopic procedure effective in controlling reflux in a portion of patients with GERD. Three major technologies emerged, although each use different approaches to augment the barrier function of the lower esophageal sphincter, mechanisms may be similar. These include Endocinch which tightens the gastroesophageal junction via a set of suture plications around the lower esophageal sphincter, Stretta, which delivers radiofrequency energy at the cardia, and Enteryx, which is an inert polymer injected into the muscle layer of the gastroesophageal junction. To date, the underlying mechanism of action of these procedures has not been completely elucidated, although each alters the compliance of the GEJ and thus its ability to respond to a "refluxogenic stress". The target population currently consists of proton pump inhibitor-dependent GERD patients, with little or no hiatal hernia and without severe esophagitis or Barrett's. The Stretta procedure is the only procedure to date to be subjected to a sham-controlled trial. Registries of complications suggest that these techniques are relatively safe, but serious morbidity including rare mortality have been reported. All can be performed on an outpatient basis. Future comparative studies with predetermined end points, validated outcome measures, prolonged follow-up, and complete complication registries are needed to determine the role of endoscopic procedures in the clinical practice of patients with GERD. Evolution of the current technologies will almost certainly occur, and a commonly performed, efficacious endoscopic antireflux procedure is likely to emerge.     

Strategien zur Behandlung der gastroösophagealen Refluxkrankheit

Gastroesophageal reflux disease (GERD) is a very common disorder. Therapeutic options include lifestyle modifications, medical therapy, laparoscopic antireflux surgery, and three more recent options—injection therapy to the lower esophageal sphincter, endoscopic sewing procedures, and radio frequency ablation therapy. Medical therapy is effective in most patients but not always successful with advanced disease. Up to 70% of subjects do not have adequate nocturnal control of gastric acid secretion with 20 mg of omeprazole given twice per day. Patients who do not tolerate medical therapy, who respond inadequately, or who want to avoid life-long drug therapy are candidates for alternate treatments. Studies on endoscopic procedures such as polymethylmethacrylate (PMMA) injection, the Stretta procedure,and endoscopic suturing techniques all suffer from having small study groups for each procedure,unknown durability, short follow-up, and the absence of randomized, controlled procedures. Limitations on endoscopic techniques are esophageal motility disorders, severe esophagitis, and larger hiatal hernias. Laparoscopic antireflux surgery remains a well-established, durable alternative to long-term medical therapy. It has the benefits of convenience, safety, minimal complications, improved quality of life, and low cost. Alternative methods will have to earn their place against this gold standard.     

Treatment strategies for gastroesophageal reflux disease]

Gastroesophageal reflux disease (GERD) is a very common disorder. Therapeutic options include lifestyle modifications, medical therapy, laparoscopic antireflux surgery, and three more recent options-injection therapy to the lower esophageal sphincter, endoscopic sewing procedures, and radio frequency ablation therapy. Medical therapy is effective in most patients but not always successful with advanced disease. Up to 70% of subjects do not have adequate nocturnal control of gastric acid secretion with 20 mg of omeprazole given twice per day. Patients who do not tolerate medical therapy, who respond inadequately, or who want to avoid life-long drug therapy are candidates for alternate treatments. Studies on endoscopic procedures such as polymethylmethacrylate (PMMA) injection, the Stretta procedure,and endoscopic suturing techniques all suffer from having small study groups for each procedure,unknown durability, short follow-up, and the absence of randomized, controlled procedures. Limitations on endoscopic techniques are esophageal motility disorders, severe esophagitis, and larger hiatal hernias. Laparoscopic antireflux surgery remains a well-established, durable alternative to long-term medical therapy. It has the benefits of convenience, safety, minimal complications, improved quality of life, and low cost. Alternative methods will have to earn their place against this gold standard.