Ruxandra Ciovica

Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis.

Background:Although rare, esophageal achalasia is the best described primary esophageal motility disorder. Commonly used treatments are endoscopic botulin toxin injection (EBTI), endoscopic balloon dilation (EBD), and surgical myotomy with or without a fundoplication; however, reported outcomes mostly come from cohort studies. Objective:To summarize and compare the safety and efficacy of endoscopic and surgical treatments for esophageal achalasia. Methods:A systematic electronic Medline literature search of articles on esophageal achalasia. Treatment options reviewed included EBTI, EBD, and surgical myotomy using open and minimally invasive techniques. Main outcome measures were frequency of symptom relief, prevalence of post-treatment gastroesophageal reflux (GER), and complications. Outcome probability was estimated using weighted averages of the sample prevalence in each study, with weights equal to the number of patients. Outcomes, within or across studies, were compared using meta-analysis and meta-regression, respectively. Results:A total of 105 articles reporting on 7855 patients were selected, tabulated and reviewed. Symptom relief after EBD was better than after EBTI (68.2% vs. 40.6%; OR 3.4; 95% CI, 1.2–9.8; P = 0.02), and the need for additional therapy was greater for patients receiving EBTI (46.6% vs. 25%; OR, 2.6; 95% CI, 1.05–6.5; P = 0.04). Laparoscopic myotomy, when combined with an antireflux procedure, provided better symptom relief (90%) than all endoscopic and other surgical approaches and a low complication rate (6.3%). The incidence of postoperative GER was lower when a fundoplication was added to a laparoscopic myotomy (31.5% without a fundoplication vs. 8.8% with; OR, 6.3; 95% CI, 2.0–19.4; P = 0.003). Conclusions:EBD is superior to EBTI. Laparoscopic myotomy with fundoplication was the most effective surgical technique and can be considered the operative procedure of choice.

A clinical scoring system for predicting nonalcoholic steatohepatitis in morbidly obese patients.

Nonalcoholic steatohepatitis (NASH) is common in morbidly obese persons. Liver biopsy is diagnostic but technically challenging in such individuals. This study was undertaken to develop a clinically useful scoring system to predict the probability of NASH in morbidly obese persons, thus assisting in the decision to perform liver biopsy. Consecutive subjects undergoing bariatric surgery without evidence of other liver disease underwent intraoperative liver biopsy. The outcome was pathologic diagnosis of NASH. Predictors evaluated were demographic, clinical, and laboratory variables. A clinical scoring system was constructed by rounding the estimated regression coefficients for the independent predictors in a multivariate logistic model for the diagnosis of NASH. Of 200 subjects studied, 64 (32%) had NASH. Median body mass index was 48 kg/m2 (interquartile range, 43‐55). Multivariate analysis identified six predictive factors for NASH: the diagnosis of hypertension (odds ratio [OR], 2.4; 95% confidence interval [CI], 1‐5.6), type 2 diabetes (OR, 2.6; 95% CI, 1.1‐6.3), sleep apnea (OR, 4.0; 95% CI, 1.3‐12.2), AST > 27 IU/L (OR, 2.9; 95% CI, 1.2‐7.0), alanine aminotransferase (ALT) > 27 IU/L (OR, 3.3; 95% CI, 1.4‐8.0), and non‐Black race (OR, 8.4; 95% CI, 1.9‐37.1). A NASH Clinical Scoring System for Morbid Obesity was derived to predict the probability of NASH in four categories (low, intermediate, high, and very high). Conclusion: The proposed clinical scoring can predict NASH in morbidly obese persons with sufficient accuracy to be considered for clinical use, identifying a very high‐risk group in whom liver biopsy would be very likely to detect NASH, as well as a low‐risk group in whom biopsy can be safely delayed or avoided. (HEPATOLOGY 2008.)

Laparoscopic bariatric surgery improves candidacy in morbidly obese patients awaiting transplantation

BACKGROUND To evaluate, at a university tertiary referral center, the safety and efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients with end-stage renal disease (ESRD) and laparoscopic sleeve gastrectomy (LSG) in patients with cirrhosis or end-stage lung disease (ESLD); and to determine whether these procedures help patients become better candidates for transplantation. METHODS A retrospective review was performed of selected patients with end-stage organ failure who were not eligible for transplantation because of morbid obesity who underwent LRYGB or LSG. The prospectively collected data included demographics, operative details, complications, percentage of excess weight loss, postoperative laboratory data, and status of transplant candidacy. RESULTS Of the 15 patients, 7 with ESRD underwent LRYGB and 6 with cirrhosis and 2 with ESLD underwent LSG. Complications developed in 2 patients (both with cirrhosis); no patient died. The mean follow-up was 12.4 months, and the mean percentage of excess weight loss at > or =9 months was 61% (ESRD), 33% (cirrhosis), and 61.5% (ESLD). Obesity-associated co-morbidities improved or resolved in all patients. Serum albumin and other nutritional parameters at > or =9 months after surgery were similar to the preoperative levels in all 3 groups. At the most recent follow-up visit, 14 (93%) of 15 patients had reached our institutions body mass index limit for transplantation and were awaiting transplantation; 1 patient with ESLD underwent successful lung transplant. CONCLUSION The results of this pilot study have provided preliminary evidence that LRYGB in patients with ESRD and LSG in patients with cirrhosis or ESLD is safe, well-tolerated, and improves their candidacy for transplantation.

Quality of life in GERD patients: Medical treatment versus antireflux surgery

Medical and surgical treatments are able to improve symptoms in patients with gastroesophageal reflux disease (GERD). The aim of this study was to evaluate the outcome in GERD patients without therapy, under continuous medical treatment, and after laparoscopic antireflux surgery. Five hundred seventy-nine consecutive patients underwent medical or surgical treatment for GERD-induced symptoms. Patients were studied in detail before and after treatment by means of a symptom questionnaire, endoscopy, esophageal manometry, 24-hour esophageal pH monitoring, and a barium esophagogram. In addition, quality of life was measured by the means of the Gastrointestinal Quality of Life Index (GIQLI) and the Health-Related Quality of Life (HRQL) questionnaire. Surgery was indicated and performed in 351 patients with persistent or recurrent GERD symptoms and/or complications, and in patients preferring surgery to medical treatment, despite the use of an adequate medication. The remaining 228 patients were treated with proton pump inhibitors (PPI) in the standard dose, or if required, the double dose. The outcome was assessed 3 and 12 months after treatment. While symptoms and quality of life were highly impaired in GERD patients without therapy compared with normal people, a significant improvement was obtained by PPI therapy. Following surgery, quality of life was normalized in all subsections and was significantly higher compared with the medically treated group. These results stayed constant in short-term and intermediate follow-up. Medical and surgical therapies are both able to improve symptoms and quality of life in GERD patients. Nevertheless, the outcome is significantly better following surgery. It can be suggested that surgical treatment may be the more successful therapy in the long-term.

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.

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.

A controversy that has been tough to swallow: is the treatment of achalasia now digested?

Esophageal achalasia is a rare neurodegenerative disease of the esophagus and the lower esophageal sphincter that presents within a spectrum of disease severity related to progressive pathological changes, most commonly resulting in dysphagia. The pathophysiology of achalasia is still incompletely understood, but recent evidence suggests that degeneration of the postganglionic inhibitory nerves of the myenteric plexus could be due to an infectious or autoimmune mechanism, and nitric oxide is the neurotransmitter affected. Current treatment of achalasia is directed at palliation of symptoms. Therapies include pharmacological therapy, endoscopic injection of botulinum toxin, endoscopic dilation, and surgery. Until the late 1980s, endoscopic dilation was the first line of therapy. The advent of safe and effective minimally invasive surgical techniques in the early 1990s paved the way for the introduction of laparoscopic myotomy. This review will discuss the most up-to-date information regarding the pathophysiology, diagnosis, and treatment of achalasia, including a historical perspective. The laparoscopic Heller myotomy with partial fundoplication performed at an experienced center is currently the first line of therapy because it offers a low complication rate, the most durable symptom relief, and the lowest incidence of postoperative gastroesophageal reflux.

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.