Gerhard Schwab

Respiratory symptoms in patients with gastroesophageal reflux disease following medical therapy and following antireflux surgery.

BACKGROUND It is not known whether antireflux surgery is more effective than medical therapy to control respiratory symptoms (RS) in gastroesophageal reflux disease (GERD). METHODS In 21 GERD patients with RS, reflux was assessed by endoscopy, manometry, and pH monitoring. Patients had proton pump inhibitor therapy and cisapride for 6 months. After GERD relapsed following withdrawal of medical therapy, 7 patients with normal esophageal peristalsis had a laparoscopic Nissen fundoplication and 14 with impaired peristalsis a Toupet fundoplication. Respiratory symptoms were scored prior to treatment, at 6 months following medical therapy, and at 6 months after surgery. RESULTS Heartburn and esophagitis were effectively treated by medical and surgical therapy. Only surgery improved regurgitation. Respiratory symptoms improved in 18 patients (85.7%) following surgery and in only 3 patients (14.3%) following medical therapy (P <0.05). Esophageal peristalsis improved following the Toupet fundoplication. CONCLUSION Medical therapy fails to control reflux since it does not inhibit regurgitation. Surgery controls reflux and improves esophageal peristalsis, which contributes to its superiority over medical therapy in the treatment of RS associated with GERD.

Dieulafoy's disease of the large and small bowel.

The Dieulafoy lesion is a rare cause of severe gastrointestinal hemorrhage. The lesion is usually located in the stomach, although it may occur anywhere in the gastrointestinal tract. We describe four patients with extragastric Dieulafoys disease, in the duodenum (one), the proximal jejunum (two), and the left hemicolon (one). Diagnosis was made by endoscopy in all four and confirmed by histology in three. The pathology of the Dieulafoy lesion is essentially the same throughout the gastrointestinal tract. Endoscopic treatment by sclerotherapy combined with electrocoagulation was successful in the duodenal and colonic Dieulafoy lesions, but not in the jejunal lesions.

Significant weight loss after laparoscopic Nissen fundoplication

BackgroundLaparoscopic Nissen fundoplication (LNF) has evolved as a gold standard in antireflux surgery. However, the association between body weight and gastroesophageal reflux disease (GERD) is still unclear, and no data are available concerning the effect of fundoplication on body weight. We present the first report elucidating the impact of LNF on body weight in GERD patients with special emphasis on patients’ quality of life.MethodsFrom July 2000 to March 2003, LNF was carried out in 213 patients (85 women and 128 men) after thorough preoperative examination including clinical interview with standardized assessment of symptoms and quality of life (QoL), endosocopy, barium swallow, 24-h pH-metry, and manometry. Follow-up investigations were performed 3 and 12 months after LNF obtainable from 209 patients (98.1%) and 154 patients (72.3%), respectively.ResultsThe mean body mass index (BMI) decreased significantly after LNF (27.6 ± 5.6 kg/m2 before LNF vs 26.0 ± 3.8 kg/m2 after LNF, p < 0.001). Twelve months after LNF, neither a tendency toward a renewed increase nor a further decrease in BMI was observable. The average body weight loss was 3.9 kg. BMI reduction was higher in women than in men (p < 0.002), and obese patients lost more weight than lean patients (p < 0.001). There was no association between BMI reduction and dysphagia. Plasma cholesterol and triglyceride levels did not change after LNF. The mean general score of the Gastrointestinal Quality of Life Index markedly improved (90.1 ± 21.3 before LNF vs 118.0 ± 16.2 after LNF, p < 0.01), as did the GERD-Health Related Quality of Life Index (21.9 ± 6.4 before LNF vs 3.5 ± 2.7 after LNF, p < 0.001). However, there was no association between changes in BMI and QoL.ConclusionLNF leads to significant and persistent body weight loss.

Laparoscopic antireflux surgery provides excellent results and quality of life in gastroesophageal reflux disease patients with respiratory symptoms.

Medical and surgical treatment are able to improve symptoms in patients with gastroesophageal refiux disease(GERD).Theaim of this study was to evaluate the outcomefollowing laparoscopic antirefiux surgery in GERD patients with primary respiratory-related symptoms and to investigate the quality of life index before and after therapy. Three hundred thirty-eight consecutive patients underwent surgical treatment for GERD-induced symptoms. Of this group 126 patients had primary respiratory symptoms related to GERD. All patients were studied by means of a symptom questionnaire, endoscopy, esophageal manometry, 24-hour esophageal pH monitoring, and a barium esophagogram. In addition, the quality of life was measured by the means of the Gastrointestinal Quality of Life Index (GIQLI). All patients had medical therapy with proton pump inhibitors preoperatively. A laparoscopic fundoplication was performed in all patients. The outcome was assessed 3 and 12 months postoperatively. Following surgery, all respiratory symptoms were significantly improved. While GIQLI was highly impaired before surgical therapy, a significant improvement of quality of life was obtained. Because medical treatment is likely to fail in GERD patients with respiratory symptoms, the need for surgery arises and may be the only successful treatment in the long term. Quality of life was significantly improved by surgical treatment.

Methimazole-induced cholestatic liver injury, mimicking sclerosing cholangitis

Cholestatic jaundice caused by imidazole derivates is a rare complication of antithyroid therapy. Only 20 such cases have been reported in the literature since the introduction of methimazole in 1949 and of carbimazole in 1953. We present a further case of methimazole-induced cholestatic liver injury, mimicking sclerosing cholangitis, where the etiology has been proven by a clear chronological relationship and the lack of other causative factors.ZusammenfassungAls seltene Nebenwirkung einer Therapie der Hyperthyreose mit Imidazolabkömmlingen wurde das Auftreten einer mechanischen Cholestase beschrieben. 20 derartige Fälle wurden seit der Einführung von Methimazol 1949 und von Carbimazol 1953 publiziert. Wir berichten über den weiteren Fall einer mechanischen Cholestase unter Methimazoltherapie, die mit dem radiologischen Bild einer primär sklerosierenden Cholangitis einherging.

In Vivo Band Manometry: a New Access to Band Adjustment

Background: By application of a newly developed device for invasive pressure measurements, we have investigated band adjustments monitored by in vivo intraband pressures. With access to the port of the gastric banding device, pressures can be recorded inside the band system at rest and during bolus application with different adjustments of the band. Methods: 25 patients (mean age 38.7, mean BMI 45.1, 80% women) had intraband pressure measurements at the first band adjustment 8.2 weeks (range 6 to 17) postoperatively. For this purpose, we adapted a pressure monitoring system with the TruWave disposable pressure transducer of Edwards®. All patients underwent gastric banding using the Swedish adjustable gastric band (SAGB) by the pars flaccida technique. Results: In vivo intraband pressures differ from ex vivo intraband pressures. With increasing fill volume in vivo measurements show increasingly higher pressures than ex vivo measurements. This difference can mainly be attributed to the influence of the enclosed tissue. The in vivo intraband pressures correlate with the amount of outflow obstruction. Conclusion: Intraband pressure measurement is an encouraging new access to gastric banding. It appears to be a feasible method to control band adjustment without need for x-ray studies in low pressure bands. We expect physiologically exact adjustments to achieve good weight loss and to prevent esophageal problems in the long term.

Respiratory symptoms and dysphagia in patients with gastroesophageal reflux disease: a comparison of medical and surgical therapy

Abstract Background: Gastroesophageal reflux disease (GERD) is a common condition and may frequently lead to dysphagia and respiratory symptoms. The aim of this study was to investigate the effects of medical and surgical therapy to control these symptoms. Methods: Eighty GERD patients with either dysphagia or respiratory symptoms were studied by means of a detailed symptom questionnaire, upper gastrointestinal endoscopy, esophageal manometry, 24-h esophageal pH monitoring and a barium esophagogram. All patients had been receiving medical therapy with proton-pump inhibitors and cisapride for 6 months. After withdrawal of medical therapy and relapse of GERD, 62 patients decided to undergo anti-reflux surgery (laparoscopic Nissen fundoplication in 19 and laparoscopic partial posterior fundoplication in 43 patients). Symptoms were assessed prior to treatment, at 6 months following medical therapy and 6 months after surgery. Results: Heartburn and esophagitis were effectively treated by medical and surgical therapy. Dysphagia was improved in all patients following surgery but only in 27% of patients following medical therapy. Improvement of respiratory symptoms was found in 86% of patients following surgery but only in 14% following medical therapy. Improvement of regurgitation was registered only following surgical therapy. Conclusions: Since medical treatment is likely to fail in GERD patients with complex symptoms such as dysphagia, regurgitation and respiratory symptoms, the need for surgery arises in these patients and may be the only successful treatment in the long term.

Primary squamous cell carcinoma of the stomach in a seventeen-year-old boy

Primary squamous cell carcinoma (SCC) of the stomach is extremely rare and thought to arise from ectopic squamous epithelium, which in turn could either result from the squamous metaplasia of the gastric mucosa or be congenital in origin. We report herein a case of SCC of the stomach in a 17-year-old male, who died 1 year after undergoing a gastrectomy. To our knowledge, this is the youngest case of primary SCC of the stomach reported in the literature. Further speculative possibilities of the development of primary gastric SCC are discussed following the presentation of this case.

Is There a Dysplasia-Carcinoma Sequence in Rat Gastric Remnant?

Epithelial dysplasia in the gastric remnant isgenerally considered to have a positive predictive valuefor malignancy. Whether dysplasia progresses tocarcinoma or whether both just have a common origin, is still a matter of controversy. The aim ofthe present study in rats was to investigate the naturalhistory of epithelial lesions in the gastric remnant. Agastric resection was carried out in 50 male Wistar rats. Postoperatively the animalsreceived N-methyl-Nnitro-N′-nitrosoguanidineorally. Gastroscopy was carried out monthly and biopsieswere taken for histologic evaluation. The rats werekilled after 12 months or if gastric cancer was found ongastroscopy. Twenty-four rats died postoperatively andwere excluded from the study. A total of 228gastroscopies was performed in the remaining 26 animals;24 animals developed dysplastic lesions during thefollow-up period. The rate of development of gastriccancer within one month increased with the stage ofdysplasia at the previous examination (3% for mild, 48% for moderate, 100% for severe dysplasia).There was a strong correlation between the time periodfollowing gastric resection and grade of dysplasia andbetween the grade of dysplasia and development of cancer. Our study demonstrates that gastricstump cancer in rats develops from dysplastic lesions.A dysplasia-carcinoma sequence can therefore beassumed.

Gastroesophageal reflux disease in diabetic patients: a systematic review

ZusammenfassungGRUNDLAGEN: Diabetes mellitus (DM) und die Gastroösophageale Refluxkrankheit (GERD) sind in der westlichen Welt durch eine rasch steigende Inzidenz charakterisiert, die enorme Kosten verursachen. DM betrifft etwa 10% der Bevölkerung, während GERD-Symptome und Refluxösophagitis bei rund 40% bzw. 20% beschrieben wurden. METHODIK: Dieser Übersichtsartikel fasst den derzeitigen Wissensstand über GERD bei Diabetikern zusammen und legt ein besonderes Augenmerk auf Symptome, diagnostische Ergebnisse, pathophysiologische Zusammenhänge und Therapieoptionen. Der Evidenzgrad ist gering, da es sich bei den meisten Arbeiten um Fall-Kontrollstudien mit limitierter Patientenzahl (Evidenz-Level IIIb) und Fallserien (Evidenz-Level IV) handelt. ERGEBNISSE: Refluxsymptome werden bei rund 50% der Diabetiker beschrieben, wobei sie bei Patienten mit oraler antidiabetischer Therapie am stärksten ausgeprägt sind. Lang bestehende Krankheitsdauer, schlechte Blutzuckereinstellung mit erhöhten HbA1c-Werten und Übergewicht verstärken diese Beschwerden. Die erosive Ösophagitis betrifft mehr als 40% der Diabetiker mit einer höheren Prävalenz bei Vorliegen einer autonomen Neuropathie. PH-metrische Untersuchungen waren bei bis zu 90% symptomatischer Refluxpatienten pathologisch, während bislang widersprüchliche manometrische Ergebnisse beschrieben wurden. Vermehrte Magensäure-, verminderte Bikarbonat- und Speichelsekretion, gesteigertes Auftreten von transienten Sphinkterrelaxationen und ein verminderter Tonus des unteren Ösophagussphinkters sind an der Entstehung der Refluxkrankheit ebenso beteiligt wie verminderte Ösophagus- und Magenmotilität. Überdies ist die Heilung von Schleimhautverletzungen bei Diabetikern verzögert. Daten zur Therapie der GERD bei Diabetikern mittels Protonenpumpenihibitoren sind ebenso wenig verfügbar wie Studien über die interventionelle oder chirurgische Behandlung dieser Patienten. SCHLUSSFOLGERUNGEN: Es gibt einige Hinweise dafür, dass Diabetes, unabhängig von Adipositas, ein Risikofaktor für die Entstehung der GERD ist. Spezifische pathophysiologische Mechanismen sind für die Genese der GERD bei Diabetikern von Bedeutung, was die Notwendigkeit weiterer Studien unterstreicht.SummaryBACKGROUND: Diabetes mellitus (DM) and gastroesophageal reflux disease (GERD) are characterized by a rapidly increasing incidence within the Western World causing incredible costs. DM affects about 10% of the population, whereas GERD symptoms and GERD related esophagitis have been reported in 40% and 20%, respectively. METHODS: This systematic review deals with the current knowledge on GERD in diabetic patients with special reference to symptoms, diagnostic outcomes, pathophysiologic characteristics and treatment strategies. The evidence level is low, as most of the contributions are individual case-control studies with limited number of patients (evidence level IIIb) and case series (evidence level IV). RESULTS: GERD symptoms are found in about 50% of diabetics being most pronounced among those taking oral hypoglycaemic agents. Prolonged duration of diabetes, low glycaemic control with increased HbA1c levels and obesity intensify these complaints. Erosive esophagitis affects more than 40% of diabetics, with a higher prevalence for those suffering from autonomic neuropathy. PH-metric abnormalities have been documented in up to 90% of diabetics with symptomatic GERD, whereas manometric findings are conflicting. Altered gastric acid, bicarbonate and salivary secretion, increased rates of transient lower esophageal sphincter relaxations and a hypotensive lower esophageal sphincter contribute to the genesis of GERD besides impaired esophageal and gastric peristalsis. Moreover, diabetic conditions cause delayed healing of mucosal injury. No data have been available on the effects of proton pump inhibitors in diabetic GERD patients, and there are no studies dealing with interventional or surgical treatment of these patients. CONCLUSIONS: There is some evidence that diabetes is an independent risk factor for the development of GERD not directly associated with obesity. Distinct pathophysiologic mechanisms are of importance for the genesis of GERD in diabetics raising the need for further studies.