Harald Tigges

Combination of endoscopic argon plasma coagulation and antireflux surgery for treatment of Barrett's esophagus.

Columnar-lined epithelium with specialized intestinal metaplasia of the esophagus (i.e., Barrett’s esophagus) is a premalignant condition caused by chronic gastroesophageal reflux disease. Progression of intestinal metaplasia may be avoided by antirefiux surgery, whereas regeneration of esophageal mucosa could be achieved by endoscopic argon plasma coagulation (EAPC). The aim of this prospective study was to show the early results of a combination of EAPC and antireflux surgery. Thirty patients with Barrett’s esophagus were treated between August 1996 and December 1999. Regeneration of esophageal mucosa was achieved with several sessions of EAPC under general anesthesia. All patients were receiving a double dose of proton pump inhibitors. Endoscopic follow-up was performed 6 to 8 weeks after the last session. Antireflux surgery (Nissen [n = 26] or Toupet In = 4] fundoplication) followed complete regeneration of the squamous epithelium in the esophagus. One year after laparoscopic fundopfication and EAPC follow-up with endoscopy and quadrant biopsies of the esophagus, 24-h0ur pH monitoring and esophageal manonletry were performed. All 30 patients showed complete regeneration of the squamous epithelium after a median of two sessions (range 1 to 7) of EAPC. Twenty-two patients underwent 1-year follow-up studies. All showed endoscopically an intact fundic wrap. Recurrence of a 1 cm segment of Barrett’s epithelium without dysplasia was present in two patients, both of whom had recurrent acid reflux due to failure of their antireflux procedure. Our results indicate that the combination of EAPC and antireflux surgery is an effective treatment option in patients with Barrett’s esophagus with gastroesophageal reflux disease. Long-term follow-up of this therapy is necessary to evaluate its effect on cancer risk in Barrett’s esophagus.

Gastric bilirubin monitoring to assess duodenogastric reflux

Duodenogastric reflux (DGR) was assessed with 24-hour gastric bilirubin monitoring in 345 patients (219 men; 49 ± 13 years) with foregut symptoms and 41 healthy subjects (24 men, 28 ± 5 years). Bilirubin exposure was measured as percent time above absorbance level 0.25 and excessive DGR was defined above the 95th percentile of normal values (>24.8%). DGR was highest following Billroth II gastric resection (60 ± 24%, N = 15). Patients after cholecystectomy (28 ± 25%, N = 25), patients with gastroesophageal reflux disease (24 ± 24%, N = 199), and patients with nonulcer dyspepsia (23 ± 21%, N = 61) had a significantly higher exposure to DGR than healthy subjects (7 ± 8%, P < 0.0001). In conclusion, gastric bilirubin monitoring is useful for the assessment of DGR specifically in symptomatic patients following gastric resection. Increased amounts of DGR may further be of clinical importance in patients with reflux disease or nonulcer dyspepsia and following cholecystectomy.

Laparoscopic fundoplication--short- and long-term outcome.

Abstract. Gastroesophageal reflux disease is probably the most frequently occurring benign functional disorder in the Western industrial countries. With the increasing popularity of laparoscopic anti-reflux procedures, issues on the appropriate technique have been revitalized. The purpose of this study is to evaluate the short- and long-term outcomes of laparoscopic fundoplication and reflect on the perspective of an increasing frequency of performed operations. The data sampling is based on a literature review and a questionnaire. It can be summarized that reflux recurrence due to breakdown of the wrap or herniation of the wrap can also develop in later years after the primary surgery and amount up to 8%. Persistent dysphagia is a severe problem in the first post-operative year, but usually decreases with time and is limited to rates of 3–5% on the long-term follow-up. Other functional problems, such as gas-bloat, meteorism and epigastric pain – the cause often cannot be further detected or specified – limit the quality of life of patients after laparoscopic anti-reflux surgery in the long-term follow-up in up to 5% of cases. Side effects of laparoscopic antireflux procedures can be limited to 5 to 10%, but not totally avoided.

Pathophysiologie der gastroösophagealen Refluxkrankheit

In die Diagnostik und Therapie der gastroosophagealen Refluxkrankheit sind aufgrund der hohen Pravalenz und der Symptomatik der Erkrankung in westlichen Industrielandern viele Arzte auch verschiedener Fachdisziplinen involviert. Dies liegt am klinischen Erscheinungsbild der Erkrankung, die nicht nur durch die spezifischen Symptome, Sodbrennen und Regurgitation, sondern sehr haufig durch unspezifische Symptome, wie epigastrische Schmerzen, Nausea, retrosternaler Druck, Husten, chronische Bronchitiden, Heiserkeit und posteriore Laryngitis, auffallen kann [1, 2]. Das klassische Bild der Refluxkrankheit mit Sodbrennen und endoskopisch nachweisbarer Osophagitis bietet wenig diagnostische Schwierigkeiten und die Erkrankung liese sich mit den eben genannten Kriterien einfach definieren. Die Symptomvielfalt der Erkrankung ist jedoch eine Tatsache und mehrfach nachgewiesen worden, was eine klinische Definition der Erkrankung somit sehr problematisch macht [3, 4].

S3-Leitlinie «Chirurgie der Adipositas»: Kommentierte Kurzfassung

Hintergrund: Übergewicht und Adipositas haben in Deutschland endemische Ausmaße erreicht. Infolgedessen nimmt die Zahl der Adipositas-Operationen (bariatrische Chirurgie) rasant zu. Neue minimal invasive Operationsmethoden und die Zunahme wissenschaftlicher Evidenz tragen zur Erkenntnis bei, dass im multimodalen Behandlungskonzept der Adipositas und ihrer Folgeerkrankungen chirurgische Konzepte integriert werden müssen. Methoden: Systematische Literaturrecherche, Evidenzklassifikation, Entwicklung von graduierten Empfehlungen und interdisziplinäre Konsentierung. Ergebnisse: Adipositas-Operationen sind evidenzbasierte Behandlungsoptionen, die eine multidisziplinäre Evaluation und Vorbereitung, kompetente Durchführung und langfristige Nachsorge benötigen. Die Leitlinie bestätigt das traditionelle, BMI-basierte Indikationsspektrum (BMI > 40 kg/m2 oder > 35 kg/m2 mit Sekundärerkrankungen) und erweitert es durch Wegfall von Altersbegrenzungen und vielen Kontraindikationen. Voraussetzung zur Operation ist die Erschöpfung einer strukturierten konservativen Therapie über 6–12 Monate oder die Aussichtslosigkeit derselben. Diabetes mellitus Typ 2 wird als potenzielles Indikationskriterium bei einem BMI < 35 kg/m2 aufgenommen (metabolische Chirurgie). Die Verfahrenswahl ist individualisiert; Standardtechniken sind Magenband, Magen-Bypass, Schlauchmagen und biliopankreatische Diversion. Um spezifischen Mangelerscheinungen vorzubeugen, und weil die Adipositas als chronische Erkrankung verstanden werden sollte, muss auch nach Operationen die Nachsorge strukturiert und langfristig geplant werden. Schlussfolgerung: Die S3-Leitlinie beinhaltet evidenzbasierte Empfehlungen zur Indikation, Verfahrenswahl, Technik und Nachsorge. Die Implementierung der Leitlinie in Praxis und Klinik und deren Beachtung durch Kostenträger/MDK wird eine Optimierung der Patientenversorgung zur Folge haben.

Chirurgische Konzepte zu Prävention und Therapie von Präkanzerosen und Frühkarzinomen des Ösophagus

Surgical Concepts for Prevention and Therapy of Precanceroses and Early Carcinomas of the Esophagus Recently, precancerosis and early stage carcinoma of the esophagus and the cardia gained popularity. It is not only the epidemiology and diagnostic procedures which have changed, but also the therapeutic options and concepts. Meanwhile it is known that 5–10 years of pathologic exposition to toxic reflux are necessary to cause intestinal metaplasia. Basic thoughts for the development from intestinal metaplasia to carcinoma might be gall – and pancreatic juice refluxing into the esophagus. Gold treatment standard for the non-dysplastic Barrett’s esophagus is either medical by proton pump inhibitors or surgical by antireflux surgery. None of the named therapeutic concepts can prevent development from metaplasia into malignancy definitely. In the treatment of intraepithelial neoplasia, various alternatives, from modern endoscopic mucosa resection up to the radical subtotal esophageal resection followed by lymphadenectomy, are well described.

Variability in the composition of physiologic duodenogastric reflux

Duodenogastric reflux has long been associated with various diseases of the foregut. Even though bile is often used as a marker, duodenogastric reflux consists of other components such as pancreatic juice and duodenal secretions. The aim of this study was to investigate the occurrence of duodenogastric reflux, its components, and the variability of its composition in normal subjects. Twenty healthy volunteers (7 men and 13 women) whose median age was 24 years underwent combined 24-hour bilirubin and gastric pH monitoring and intraluminal gastric aspiration. All probes were placed at 5 cm below the lower border of the lower esophageal sphincter. Aspiration was performed hourly and at any time when bilirubin and/or pH monitoring showed signs of duodenogastric reflux. Elastase and amylase were measured in the aspirate. All volunteers had episodes of physiologic duodenogastric reflux. A total of 70 episodes of duodenogastric reflux were registered with a median of three episodes (range 1 to 8) per subject. Most bile reflux occurred separately from pancreatic enzyme reflux. Pancreatic enzyme aspirate was significantly more often associated with a rise in pH in comparison to bile reflux (P <0.01). Duodenogastric reflux is a physiologic event with varying composition. Both bile and pancreatic enzyme reflux frequently occur separately. These findings could explain the disagreement regarding assessment and interpretation of duodenogastric reflux in the past. Thus monitoring of duodenogastric reflux requires more than the detection of just one component.