J. Maroske

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.

Importance of duodenogastric reflux in gastro‐oesophageal reflux disease

Bile in the oesophagus occurs frequently in patients with gastro‐oesophageal reflux disease (GORD) and has been linked to Barretts metaplasia and cancer. Although duodenogastric reflux is a prerequisite for bile in the oesophagus, little is known about its importance in GORD.

Sonographic appearances of the abdominal manifestations of hereditary angioedema.

Abstract Hereditary angioedema (HAE) is the autosomal dominant deficiency of C1-esterase inhibitor. There have hitherto been no reports on the US appearances of HAE. The unique case of a 12-year-old girl with recurrent abdominal pain is reported, in whom HAE was diagnosed by US and family history of paroxysmal dyspnoea, cutaneous swelling and attacks of abdominal pain. Pertinent US features were intestinal oedema and ascites. Sonographic evidence of intestinal swelling was only seen on the initial day of an episode of abdominal pain. Oedema, as demonstrated by MRI the following day, regressed rapidly, whereas ascites persisted for at least 3 days. It is therefore important to perform imaging in the acute phase to demonstrate the massive intestinal oedema, which is characteristic for the disease.

Laparoscopic Nissen repair: indications, techniques and long-term benefits

BackgroundThe Nissen fundoplication or total 360° fundoplication is probably the most frequently used anti-reflux procedure throughout the world. With the advent of laparoscopic surgery the popularity among surgeons to perform a laparoscopic Nissen fundoplication has even increased.AimThe purpose of this paper is to provide an overview of the experience of laparoscopic Nissen fundoplication over the past 15 years.MethodWe performed an extensive review of the literature in order to ascertain the representative papers. In addition, available consensus papers, especially with regard to indication and technique, were assessed. Indication for a laparoscopic Nissen fundoplication should depend on documentation of the presence of disease as well as objective testing of the functional disorders and the complications. The technique of Nissen fundoplication is discussed controversially. Consensus exists with regard to floppiness of the wrap, necessary closure of the crurae and the use of a calibration method during the performance of the wrap.ResultsThe laparoscopic technique creates a learning curve, which needs to be respected. Large prospective series in recent years have shown a complication rate between 5% and 10%, depending on the definition of the complication. In these last prospective series good and excellent results have been reported, of between 85% and 95%. Reflux recurrence is reported as between 1% and 8.5%, with a concomitant dysphagia rate of 0%–10%.ConclusionsThe Nissen fundoplication is currently performed throughout the world, most frequently in a minimally invasive technique. Several randomized trials that have been performed in the past years document that the Nissen fundoplication is an effective procedure for the treatment of pathological gastro-oesophageal reflux disease when a critical indication is used for well-defined patients.

Familial gastrointestinal stromal tumors caused by the novel KIT exon 17 germline mutation N822Y.

Gastrointestinal stromal tumors (GISTs) are most often associated with oncogenic mutations of the KIT gene resulting in activation of the tyrosine kinase receptor KIT. Familial GIST syndrome based on a hereditary predisposition to develop GIST owing to a germline mutation is exceedingly rare. We describe a kindred with familial GIST displaying a novel germline mutation in exon 17. Three siblings (2 females, 1 male; 42 to 49 y) underwent surgery for multiple intra-abdominal tumors within a 3-year period. Their father had been operated on for gastric and jejunal tumors 20 years previously. The GIST was confirmed by immunohistochemistry in each sibling. Tumor and blood samples of the family members were analyzed for mutations in KIT and platelet-derived growth factor receptor (PDGFRα) genes. All examined lesions were of spindle cell type with expression of CD117. The tumor material exhibited a novel point mutation in codon 822 in exon 17 resulting in the replacement of asparagine by tyrosine (N822Y). The same mutation was detected in the fathers blood sample. One healthy brother of the 3 siblings showed a wild-type sequence of the KIT gene. The germline mutation in exon 17 of the KIT gene identified in this kindred is very different from previously reported mutations of the KIT gene in familial GIST. Although the penetrance of KIT mutations is as yet unknown, assessment of the unaffected kindred of GIST patients for the presence of this mutation could help to distinguish individuals at high risk from those at virtually no risk.

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.

Technik und Langzeitergebnisse der laparoskopischen Fundoplicatio nach Nissen

Technique and Long-Term Results of Laparoscopic Nissen Fundoplication Thirty-five years after the first fundoplication by Nissen, this operative technique was performed laparoscopically for the first time in 1991. The available data on long-term results prove that the standards for security and quality of this operative method were held constant since introduction of the minimally invasive technique. Increasing knowledge on pathophysiology as well as a differentiated patient selection are factors contributing to the fact that Nissen fundoplication currently worldwide represents the standard method of operative treatment in gastroesophageal reflux disease.

Schweißdrüsencarcinom im Axillabereich

Abstract. The sweat gland carcinoma is a rare tumor, representing in approximately 1 % of primary skin lesions. In the literature 220 cases of sweat gland carcinomas have been presented over the last three decades. The medium age is 57 years, with an equal male-to-female distribution. Topographically, the tumor is located at the lower limbs (32.9 %), the upper extremities (28 %), and the head (26 %). Involvement of the trunk is rare. Diagnosis can be complicated as the carcinoma is a rare entity, with no correlation of its histologic classification and biologic presentation. This can only implicate the difficulties in treatment.Zusammenfassung. Das Schweißdrüsencarcinom präsentiert sich als ein seltener maligner Hautadnextumor, der an jeder Stelle des Körpers auftreten kann. Bezogen auf alle malignen Hauttumoren zeigt sich eine Incidenz von 0,005–0,01. In den vergangenen 30 Jahren wurden in der Literatur über 220 Fälle berichtet. Ein bevorzugtes Geschlechtsverhalten ist nicht zu beobachten. Das Durchschnittsalter beträgt 57 Jahre. In 32,9 % der Fälle ist der Tumor an den unteren Extremitäten lokalisiert. Weitere häufige Lokalisationen sind die obere Extremität (28 %) sowie der Kopf (26 %). Nur selten ist ein Auftreten im Bereich des Abdomens zu beobachten. Die Diagnosestellung wird nicht nur durch die Seltenheit des Carcinoms erschwert, sondern auch durch die fehlende Korrelation zwischen histologischer Klassifizierung und biologischem Verhalten. Dies impliziert die Schwierigkeit des Behandlungsregimes.

Indication for Antireflux Surgery

It is an understandable request of gastroenterologists and surgeons in clinical practice to have a precise list of indications for antireflux surgery. This is rather difficult because it is in contrast to the multifactorial aspects that should be summarized in such a list of indications in order to respond to the different needs in a differentiated therapeutic spectrum to individualize antireflux therapy. Currently there is a remarkable number of randomized trials available focusing on technical aspects of antireflux surgery [1]–[5]. However, there is very little evidence based information to justify certain factors for the indication of antireflux surgery. This chapter reflects all the different aspects which are part of the management of gastroesophageal reflux disease and play a role in the indication for surgery. The following factors are major issues in the discussion about the indication for laparoscopic antireflux surgery: