Gastroesophageal reflux patients' defective antioxidative capacity in the proximal esophageal mucosa before antireflux surgery and also after 4‐year follow‐up

Background. Oxidative stress has a role in the pathogenesis of gastroesophageal reflux disease (GERD).

Aim. To investigate the redox balance in proximal esophagus before and 6 and 48 months after antireflux surgery.

Methods. In 20 GERD patients and 9 controls oxidative stress by myeloperoxidase activity (MPO activity) and antioxidative capacity of esophageal mucosa by superoxide dismutase activity (SOD), and glutathione content (GSH) was measured from proximal esophageal samples.

Results. In proximal esophagus of GERD patients compared to controls', antioxidative capacity appearing as GSH level was significantly decreased (P<0.001) at all time points and as SOD levels preoperatively (P<0.001) and 4 years postoperatively (P = 0.01). MPO activity of patients was significantly lower than controls' preoperatively, and 6 months and 4 years postoperatively (P<0.05). MPO activity remained lower than that of the distal esophagus at 6 months and 4 years (P<0.01 for both).

Conclusions. In GERD patients, proximal esophageal mucosal antioxidative defense is defective before and after antireflux surgery. Antireflux surgery seems not to change the level of oxidative stress in proximal esophagus, suggesting that defective mucosal antioxidative capacity plays a role in development of oxidative damage to the esophageal mucosa in GERD.     

Long-term results of laparoscopic partial posterior fundoplication in patients with esophageal reflux and disorders of esophageal peristalsis

BACKGROUND: Gastrosophageal reflux disease (GERD) of long duration is frequently associated with impaired esophageal body motility. This condition has been considered unsuitable for antireflux surgery. METHODS: In order to investigate the outcome of antireflux surgery in the presence of impaired esophageal peristalsis, we studied 67 consecutive GERD patients with poor esophageal body function who underwent laparoscopic partial posterior fundoplication. A standardized questionnaire, upper GI endoscopy, esophageal manometry and 24-hour pH monitoring were performed preoperatively and at a median of 28 months (range, 6-54 months) postoperatively. Esophageal motility was analyzed for contraction amplitudes in the distal two thirds of the esophagus (level 3, 4, and 5), frequency of peristaltic, simultaneous and interrupted waves and total number of defective propagations. In addition, parameters defining the function of the lower esophageal sphincter (LES) were-evaluated. RESULTS: Following antireflux surgery 65 patients (97%) were free of heartburn and regurgitation and had no esophagitis on endoscopy, confirmed by histology. The rate of dysphagia was reduced from 49% preoperatively to 9% postoperatively (p < 0.001). There was significant improvement in esophageal peristalsis after the antireflux procedure. The median DeMeester reflux score was reduced from 33.3 to 1.1 (p < 0.001). Lower esophageal sphincter pressure and intra-abdominal length were normal after surgery. CONCLUSIONS: Partial posterior fundoplication provides an effective antireflux barrier in patients with impaired esophageal body motility in the long term. Postoperative dysphagia is avoided by improving esophageal body function.     

Prokinetic medication after surgical therapy of reflux patients with disorders of esophageal peristalsis: a randomized clinical study

BACKGROUND: Long-standing gastroesophageal reflux disease (GERD) is frequently associated with impaired esophageal body motility. Partial posterior fundoplication improves esophageal peristalsis. The aim of this prospective randomized study was to investigate whether administration of the prokinetic agent cisapride enhances this effect. METHODS: Forty consecutive GERD patients with impaired esophageal peristalsis entered the study and were randomized in two groups: group 1 with and group 2 without postoperative treatment with cisapride (6 months, 20 mg twice daily). Four patients had to be excluded during the study. Esophageal motility was analyzed preoperatively and 6 months after surgery by measuring contraction amplitudes in the distal two thirds of the esophagus, frequency of simultaneous and interrupted peristaltic waves and total number of defective propagations. RESULTS: In both groups esophageal peristalsis was improved significantly following partial posterior fundoplication (p < 0.05; Wilcoxon Test). However, this effect was significantly more pronounced in patients receiving cisapride medication postoperatively (p < 0.05; Mann-Whitney U test). Lower esophageal sphincter pressure, intra-abdominal sphincter length and the DeMeester reflux score were normalized in both groups following antireflux surgery. CONCLUSIONS: Partial posterior fundoplication combined with postoperative cisapride medication seems to be the therapy of choice in GERD patients with impaired esophageal body motility.     

Extension of squamous epithelium into the proximal stomach: a newly recognized mucosal abnormality

BACKGROUND AND STUDY AIMS: The presence of squamous epithelium in the stomach has been rarely noted in the past with only sporadic case reports of squamous cell carcinoma of the stomach and a variety of other pathological processes. We report the documentation, over a period of 9 months, of squamous epithelium extending beyond the esophagogastric junction and into the proximal stomach in 16 patients who underwent upper endoscopy. PATIENTS AND METHODS: This newly recognized mucosal abnormality was systematically identified by both antegrade and retrograde views of the esophagogastric junction during routine upper endoscopy. Other associated mucosal abnormalities were also evaluated (Barrett's esophagus, erosive esophagitis, etc.). Biopsies were obtained from the distal esophagus, cardia, antrum and the squamous extension. Additionally, all patients underwent a detailed interview. RESULTS: Of the patients, 14 were Caucasian and two Hispanic; all were males, with a mean age 61.2+/-4.2. Indications for upper endoscopy included dysphagia, Barrett's esophagus surveillance, failure of antireflux treatment and anemia. Heartburn was reported by 12 patients (75%). None of the patients reported a history of corrosive injury, foreign body ingestion or surgery. A total of 12 patients had a solitary tongue of squamous cell extension, three had two tongues and in addition, two had squamous islands. Hiatal hernia was present in all patients, Barrett's esophagus in six (37.5 %), and esophageal stricture in four. CONCLUSION: Squamous cell extension into the proximal stomach is a newly recognized mucosal abnormality with presently unknown clinical significance. This mucosal abnormality may represent an esophageal mucosal response to proximal gastric injury.     

Reflux disease and Barrett's esophagus

Gastroesophageal reflux disease (GERD) is a common clinical problem. New information suggests that infection with Helicobacter pylori may protect patients from developing GERD and its complications. Endoscopy may be used by clinicians to tailor GERD therapy, but an empirical trial of a proton-pump inhibitor may be an alternative diagnostic approach. Studies continue to show that laparoscopic antireflux surgery is a cost-effective treatment option for patients requiring maintenance therapy with proton-pump inhibitors. However, the minimally invasive nature of the operation should not alter the indications for antireflux surgery, especially for patients with atypical symptoms. It remains unclear why some patients with GERD develop Barrett's esophagus, whereas others do not. Recent guidelines suggest that patients with long-standing GERD symptoms, especially white men over 50 years of age, should undergo endoscopy at least once to screen for Barrett's esophagus. Debate concerning short-segment Barrett's esophagus continues. Intestinal metaplasia at a normal-appearing gastroesophageal junction may be associated with intestinal metaplasia of the stomach and infection with H. pylori, whereas short tongues of intestinal metaplasia in the esophagus are associated with GERD. Cancer surveillance is indicated in short-segment Barrett's esophagus, as dysplasia may develop in these patients. Barrett's esophagus is the only known risk factor for the development of esophageal adenocarcinoma, but the incidence of adenocarcinoma may be lower than previously reported. New clinical guidelines for endoscopic surveillance suggest that the surveillance interval should be lengthened to every two years in patients without dysplasia. Newer treatment options, such as thermal ablation and photodynamic therapy, continue to show promise, but are not yet ready for routine clinical use.     

Oxidative stress, antioxidant status and DNA damage in patients with impaired glucose regulation and newly diagnosed Type 2 diabetes

Previous studies have postulated the association between oxidative stress and Type 2 diabetes. Considering the long pre-diabetic period with IGR (impaired glucose regulation) and its high risk of developing diabetes, to test this hypothesis, we have investigated oxidative stress pathways and DNA damage in patients with IGR and newly diagnosed Type 2 diabetes. The study population consisted of 92 subjects with NGT (normal glucose tolerance), 78 patients with IGR and 113 patients with newly diagnosed diabetes. Plasma MDA (malondialdehyde) and TAC (total antioxidative capacity) status, erythrocyte GSH content and SOD (superoxide dismutase) activity were determined. A comet assay was employed to evaluate DNA damage. Compared with subjects with NGT, patients with IGR had reduced erythrocyte SOD activity. Patients with diabetes had a higher plasma MDA concentration, but a lower plasma TAC level and erythrocyte SOD activity, than the NGT group. Correlation analysis revealed a strong positive association between IR (insulin resistance) and MDA concentration, but negative correlations with TAC status and SOD activity. With respect to beta-cell function, a positive association with TAC status and an inverse correlation with GSH respectively, were observed. The comet assay revealed slight DNA damage in patients with IGR, which was increased in patients with diabetes. Significant correlations were observed between DNA damage and hyperglycaemia, IR and beta-cell dysfunction. In conclusion, the results of the present study suggest that hyperglycaemia in an IGR state caused the predominance of oxidative stress over antioxidative defence systems, leading to oxidative DNA damage, which possibly contributed to pancreatic beta-cell dysfunction, IR and more pronounced hyperglycaemia. This vicious circle finally induced the deterioration to diabetes.     

高频腔内超声对胃食管反流患者食管运动功能的评价

目的 应用高频腔内超声与食管测压同步检测胃食管反流病(GERD)患者的食管运动功能异常情况,并尝试论证腔内超声评估食管运动功能异常的有效性和可行性,以及食管压力与食管壁肌层厚度之间的关系.方法 10例经内镜及24 h食管pH检测确诊为GERD的患者,5例正常志愿者作为对照.经鼻腔导入高频超声探头(频率20 MHz,直径1.9 mm)及四通道水灌注式测压导管,在观察静息及吞咽时食管压力变化的同时,同步记录食管的运动影像,并计算出下食管括约肌上端5 cm、10 cm、1 5 cm及20 cm处食管环形肌和纵形肌的收缩指数、收缩周期及食管截面积.同时,通过测压导管同步监测湿咽时食管的最大压力值,计算其与同一位置的食管最大肌层厚度之间的相关性.结果 10例GERD患者与正常对照组相比,食管各段环形肌、纵形肌收缩指数均明显缩小(P＜0.05);收缩周期有延长的趋势;而最大截面积与正常对照组差异无统计学意义(P＞0.05).食管各段的最大压力值与同一部位的最大肌层厚度之间存在正相关(r=0.552～0.736).结论 食管各部位的最大压力值与最大肌层厚度之间存在正相关;GERD患者存在食管运动功能的异常,食管壁的舒缩能力下降以及收缩周期延长可能影响食管的廓清力,从而与GERD的发病有直接关系;同时,高频腔内超声为功能性胃肠病的诊断及其临床研究提供了一种新的方法.     

Peripheral oxidative stress in relapsing-remitting multiple sclerosis

ObjectivesTo evaluate levels of oxidative stress in blood samples in patients with relapsing–remitting MS (RR-MS).Design and methodsPeripheral blood samples were collected from 24 RR-MS patients and 15 healthy controls. Levels of the following were measured: carbonylated proteins, 8-hydroxy-2′deoxyguanosine (8OHdG), total glutathione, reduced glutathione (GSH), oxidized glutathione (GSSG), GSH/GSSG ratio, superoxide dismutase (SOD), glutathione peroxidase (GPx), glutathione reductase (GRd), glutathione-S-transferase (GST), myeloperoxidase (MPO), antioxidant gap, total antioxidant capacity (PAO), global oxidative stress (GOS), serum vascular cell adhesion molecule-1 (sVCAM-1) and serum inter-cellular adhesion molecule 1 (sICAM-1).ResultsValues for carbonylated proteins, 8OHdG, total glutathione, GSH, GSH/GSSG ratio, SOD, GRd and GOS were significantly higher in RR-MS patients than in healthy controls. By contrast, PAO, GSSG, GPx and GST were lower in RR-MS patients.ConclusionOxidative stress plays a major role in MS, and is observed prior to relapse.     

Prevalence, pathophysiology, and treatment of patients with asthma and gastroesophageal reflux disease

About one third of the US adult population experiences symptoms of gastroesophageal reflux on a monthly basis. Asthma is present in about 5% of the same population. This article reviews and summarizes the literature in the following areas: (1) prevalence of gastroesophageal reflux disease (GERD) in asthmatic patients based on clinical symptoms, endoscopic esophagitis, and 24-hour ambulatory esophageal pH recordings; (2) proposed pathophysiologic mechanisms linking the 2 diseases; and (3) medical and surgical treatment trial results of antireflux therapy for asthmatic patients. Asthmatic patients appear to have an increased prevalence of GERD symptoms and 24-hour esophageal acid exposure. The clinical management of these patients remains controversial. Common management approaches to GERD in asthmatic patients include medical therapy with a proton pump inhibitor and/or antireflux surgery, which improve asthma symptoms in many patients but minimally affect pulmonary function.     

Reflux disease and Barrett's esophagus

Gastroesophageal reflux disease (GERD) is one of the most prevalent gastrointestinal disorders. The key feature of GERD is reflux of gastric contents into the esophagus. Medical treatment with proton-pump inhibitors (PPIs) is well established and is considered the standard treatment. Given the high prevalence of the condition and the excellent response to medical therapy, antireflux surgery is an option for patients with volume reflux that is not properly controlled by medical therapy. Adenocarcinoma is a rare but life-threatening complication of GERD. The only known precursor lesion for esophageal adenocarcinoma is Barrett's esophagus. In recent years, a clearer understanding of the development of Barrett's and of its progression toward invasive cancer has developed. Genetic factors almost certainly determine the individual risk. The length of the Barrett's esophagus segment and the size of a hiatal hernia are associated with the risk of developing high-grade dysplasia and esophageal adenocarcinoma.With regard to the clinical management of GERD patients with Barrett's, endoscopic surveillance at 3-year intervals is now considered appropriate in the absence of dysplasia. In patients with high-grade dyspepsia, the situation is more difficult. While a considerable proportion of these patients may already have invasive cancers, there is also the possibility that there is only focal dysplasia. For this reason, it is justifiable to carry out curative endoscopic resection. Mucosal ablation procedures may also be appropriate, but these still need to be properly investigated in clinical trials.     

Inflammation and oxidative stress in gastroesophageal reflux disease

The etiology of esophageal mucosal injury is complex, since it may involve the reflux of gastric acid, bile acid, and pancreatic juice, external factors such as drugs and alcohol, or functional factors such as esophagogastric motility. The mechanism of esophageal mucosal injury has gradually been understood at the molecular biological level. It is particularly important that pro-inflammatory factors, such as inflammatory cytokines (interleukin-6 and -8), leukocytes and oxidative stress, have been demonstrated to be involved in the development of gastroesophageal reflux disease (GERD) including nonerosive reflux disease (NERD). In addition, nociceptors such as acid-sensitive vanilloid receptors, protease-activated receptors and substance P have also been implicated in the pathogenesis of neurogenic inflammation in NERD patients with esophageal hypersensitivity. The development of new therapy with anti-inflammatory and anti-oxidant effects is expected to assist in the treatment of intractable NERD/GERD and the prevention of carcinogenesis.     

难治性胃食管反流病的反流危险因素调查

目的：收集胃食管反流病（gastroesophageaf reflux disease,GERD）患者的临床信息、胃镜表现以及24 h食管pH-阻抗监测结果,比较难治性GERD和非难治性GERD的反流特点,探讨难治性GERD的预测因素,为临床处理提供依据.方法：入选2008年10月-2012年12月因反酸、烧心、非心源性胸痛、咽痛等症状在复旦大学附属中山医院消化科疑诊为GERD的74例患者.记录患者的年龄、性别、身高、体质量、胃镜结果等.监测患者的食管下段pH和食管阻抗变化.难治性GERD诊断：符合GERD诊断标准,同时经过质子泵抑制剂（PPI）治疗4周（每天至少1次）无效或者deMeester评分下降少于50％;非难治性GERD诊断：符合GERD诊断标准,同时经过PPI治疗4周（每天至少1次）症状改善明显;非GERD诊断：内镜检查未见食管黏膜损害,且24 h食管pH-阻抗监测反流次数和deMeester评分不足以诊断GERD.计数资料正态分布者用r±s表示,菲正态分布者用中位数和百分位数（25th,75th）表示.采用SPSS 17.0软件进行统计学处理.按是否为GERD、是否为难治性GERD分组,比较患者的一般资料和反流特征性因素.结果：（1）难治性GERD患者与非难治性GERD患者的酸反流次数、总反流次数差异无统计学意义;难治性GERD患者的deMeester评分较非难活性GERD患者高,长酸反流次数较非难治GERD患者多（P=0.032,P=0.008）;（2）经Logistic多因素分析发现,难治性GERD与长酸反流次数、非糜烂性胃食管反流病（NERD）呈正相关（P值分别为0.01和0.045）.长酸反流次数增加1次,发生难治性GERD的危险增加36％;NERD患者发生难治性GERD的危险是反流性食管炎患者的4.54倍;（3）不同类型GERD的反流特征：NERD患者的近端反流次数大于反流性食管炎和Barrett食管患者,而近端反流百分比显著大于反流性食管炎患者和Barrett食管患者（P=0.006）.结论：（1）长酸反流次数多和NERD是难治性GERD的独立危险因素;（2）NERD患者比糜烂食管炎患者更容易发展为难治性GERD.NERD患者的近端反流百分比的升高可能与其对PPI的反应差有关.     

Increased postoperative myeloperoxidase concentration associated with low baseline antioxidant capacity as the risk factor of delirium after cardiac surgery

BackgroundThough risk factors of postoperative delirium are well described, its pathophysiology is still undiscovered. The primary objective of the current study is to assess whether increased pre- and postoperative myeloperoxidase (MPO) levels are associated with postoperative delirium in the population of cardiac surgery patients. The secondary objective is to evaluate the correlation between MPO levels and serum antioxidant capacity (AC).MethodsThe patients’ cognitive status was assessed one day preoperatively with the use of the Mini-Mental State Examination Test and the Clock Drawing Test. A diagnosis of major depressive disorder and anxiety disorders was established based on DSM-5 criteria. Blood samples for MPO and AC levels were collected both pre- and postoperatively. The Confusion Assessment Method for the Intensive Care Unit was used to screen for a diagnosis of delirium.ResultsDelirium occurred in 34% (61 of 177) of patients. Multivariable logistic regression analysis revealed that increased postoperative MPO concentration was independently associated with postoperative delirium development, and negatively correlated with lower baseline serum AC.ConclusionsCardiac surgery patients with less efficient antioxidative mechanisms experience a higher postoperative peak of serum MPO, which in turn may predispose to postoperative delirium development.

KEY MESSAGES

• MPO is a lysosomal enzyme with strong pro-oxidative and pro-inflammatory properties.
• Cardiac surgery patients who have increased concentration of postoperative MPO are at significantly higher risk of postoperative delirium development.
• This higher level of postoperative MPO is negatively correlated with baseline antioxidant capacity (AC).
• It can be hypothesized that individuals with decreased baseline AC experience a higher peak of MPO post-surgery due to less efficient antioxidative mechanisms, which in turn contributes to postoperative delirium development.

     

慢性阻塞性肺疾病患者气道局部氧化应激与体重指数及肺功能下降的关系

目的：研究慢性阻塞性肺疾病（COPD）患者气道局部氧化应激水平的变化及其与体重指数（BMI）、肺功能下降的相关性。方法：对70例COPD患者（A组）、30例健康对照（B组）进行痰诱导及肺功能、BMI测定,并测定诱导痰中丙二醛（MDA）、还原型谷胱甘肽（GSH）含量,超氧化物歧化酶（SOD）、谷胱甘肽过氧化物酶（GSH-PX）活性。结果：COPD患者诱导痰MDA含量较健康对照高,P〈0.05;而诱导痰GSH含量、SOD、GSH-PX活性较健康对照下降,P〈0.05;BMI与痰SOD、痰MDA、GSH、GSH-PX的相关系数分别为0.751、-0.694、0.685、0.701,P〈0.05;3.FEV1与痰SOD、痰MDA、GSH、GSH-PX的相关系数分别为0.874、-0.826、0.853、0.809,P〈0.05。结论：COPD患者气道局部均存在氧化/抗氧化失衡;气道局部氧化应激是导致COPD患者BMI及肺功能水平下降的原因之一。     

Improved antioxidative protection in winter swimmers.

Adaptation to oxidative stress is an improved ability to resist the damaging effects of reactive oxygen species, resulting from pre-exposure to a lower dose. Changes in uric acid and glutathione levels during ice-bathing suggest that the intensive voluntary short-term cold exposure of winter swimming produces oxidative stress. We investigated whether the repeated oxidative stress in winter swimmers results in improved antioxidative adaptation. We obtained venous blood samples from winter swimmers and determined important components of the antioxidative defense system in the erythrocytes or blood plasma: reduced and oxidized glutathione (GSH and GSSG), and the activities of superoxide dismutase (SOD), glutathione peroxidase (GPx) and catalase (Cat). The control group consisted of healthy people who had never participated in winter swimming. The baseline concentration of GSH and the activities of erythrocytic SOD and Cat, were higher in winter swimmers. We interpret this as an adaptative response to repeated oxidative stress, and postulate it as a new basic molecular mechanism of increased tolerance to environmental stress.     

Endoscopic examination including magnifying endoscopy for diagnosis of GERD

Symptoms of heartburn and regurgitation are the most important for diagnosis of gastroesophageal reflux disease (GERD) in the clinical field. Endoscopic examination is also widely used modality for Los Angeles classification of GERD according to endoscopic severity of esophageal mucosal breaks. However, about half of GERD patients reveal no abnormality under conventional endoscopy. These endoscopic negative GERD is called as non-erosive reflux disease (NERD). There is the possibility to underestimate a minute mucosal change of GERD by conventional endoscopy that has the limitation of visual ability. Magnifying endoscopic examination is able to get clear visualization of intrapapillary capillary loops(IPCL), which are usually shown as dot-like structures in esophageal mucosa by a conventional endoscopy. The changing of IPCLs is associated with inflammation and neoplasia of esophagus. Minute change of IPCLs such as a dilation and elongation with regular intervals were reported to be suggestive of inflammatory change in esophagus. Magnifying endoscopic observation of IPCLs is useful for diagnosis of NERD which cannot be visualized by conventional endoscopy.     

Surgical management of esophageal achalasia

Between 1970 and 1983, 46 patients were hospitalized in the Vanderbilt University Medical Center and the Metropolitan Nashville General Hospital for treatment of achalasia. All patients had been symptomatic for at least two years. Efforts were made initially to manage most of these patients (40) with periodic esophageal dilatation. This was successful in only six cases (15%). In four instances (10%), patients had esophageal perforation. Thirty patients have had esophagomyotomy (Heller procedure), and 14 of these had an associated antireflux procedure. Three had proximal gastric vagotomy for associated duodenal ulcer disease. Twenty-seven (90%) have had a good result, three died postoperatively, and two elderly patients had postoperative myocardial infarction. The other patient had sepsis after repair of a perforated esophagus. While periodic esophageal dilatation is necessary in patients who may not tolerate an operative procedure, most patients with achalasia are best treated with Heller esophagomyotomy.     

Cytokine expression in GERD

The mechanism of esophageal mucosal injury has gradually been understood at the microbiological level. It is particularly important that pro-inflammatory factors, such as inflammatory cytokines, leukocytes and oxidative stress, have been demonstrated to be involved in the development of gastroesophageal reflux disease (GERD) including nonerosive reflux disease (NERD). Our present study reveals that expression of IL-8 mRNA, a potent neutrophil chemotactic and activating peptide, is correlated with the endoscopic grade of esophagitis or with inflammatory cell infiltration. In addition, it has been shown that bile acids and trypsin can promote IL-8 production from human esophageal epithelial cells via NFkappaB-and AP-1-dependent mechanism. Nociceptors such as acid-sensitive vanilloid receptors, protease-activated receptors and neuropeptides such as substance P have also been implicated in the pathogenesis of neurogenic inflammation in NERD patients with esophageal hypersensitivity. The development of new therapy with antiinflammatory and anti-oxidant effects is expected to assist in the treatment of intractable NERD/GERD and the prevention of carcinogenesis.     

食管癌患者不同时间段营养状况与氧化应激水平的相关性研究

目的探讨食管癌患者术前1周、术后1周、术后2周机体营养状况与氧化应激水平的相关性,为临床食管癌患者术前、术后分阶段营养支持提供依据。方法对92例食管癌患者在术前1周、术后1周、术后2周分别进行体质指数、上臂中围、上臂肌围、肱三头肌皮褶厚度、总淋巴细胞计数、血清白蛋白营养不良指标监测,同时进行血清中总超氧化物歧化酶、总抗氧化能力、谷胱甘肽过氧化物酶、丙二醛实验室检测,采用Pearson分析患者营养状况与氧化应激水平的相关性。结果患者术前1周营养不良发生率为26.09%,术后1周营养不良的发生率升高至81.52%;术后1周较术前及术后2周营养指标都有变化(P0.05)。术前1周丙二醛与上臂中围、上臂肌围呈显著负相关(P0.01);术后1周丙二醛与体重指数、白蛋白呈负相关(P0.01);术后2周超氧化物歧化酶与体重指数、白蛋白呈正相关(P0.01)。结论食管癌患者术前1周即存在营养不良,术后1周是营养不良和氧化应激发生最为严重的时期,术后2周营养不良状况与氧化应激反应仍低于术前1周,护理工作者应通过积极、有效营养干预,改善患者术后营养状态氧化应激水平。     

Gastroesophageal reflux disease: natural history and long-term medical and surgical outcomes

Gastroesophageal reflux disease (GERD) is a chronic condition that affects a large proportion of the adult population. Persistent untreated GERD can lead to esophageal strictures, premalignant Barrett's esophagus, and an increased risk of adenocarcinoma of the esophagus. Currently, the most effective medical treatment targets gastric acid suppression, allowing healing of erosive/peptic lesions and controlling symptoms. Most patients take over-the-counter medication or are successfully treated by their primary care physician. Gastroenterologists and gastrointestinal surgeons see patients with complications, refractory symptoms despite acid-suppressive therapy, or atypical symptoms. For the medical management of GERD, proton pump inhibitors are potent acid suppressants with favorable side-effect profiles and long-term efficacy and safety. Medical therapy can heal 80% to 100% of patients with erosive esophagitis with 30% to 60% of patients reporting sustained resolution of heartburn. Surgery may be offered to patients with GERD as an alternative to long-term antireflux medication. Careful selection of appropriate surgical candidates is important, and the risk of developing new or recurrent symptoms requiring medication should be disclosed to patients contemplating the surgical alternative.