1,721,124 research outputs found
Refractoriness to Treatment Suggests That Clinical Evaluation Should Go Beyond the Diagnosis of Reflux Disease
No full textNo abstrac
Symptom analysis improves GERD diagnosis and may be helpful to define a successful surgical approach.
No full textTo the editor,
We read with interest the article by Koch et al. that randomly allocated 125 patients with documented chronic gastroesophageal reflux disease (GERD) to either laparoscopic floppy Nissen fundoplication (n = 62) or laparoscopic Toupet fundoplication (n = 63). Both procedures proved to be equally effective in improving quality of life and both typical and atypical reflux-related symptoms. The
authors also indicated that laparoscopic Toupet fundoplication was characterized to have a high ability to belch and a reduced rate of postoperative dysphagia. The authors opted to use the current gold standard for GERD diagnosis (i.e., impedance-pH testing), and thus, they carefully and objectively defined the inclusion criteria for undergoing surgical fundoplication. Indeed, they considered patients for surgery who had a total number of refluxes higher than 73 per 24 h, a DeMeester score higher that 14.7, or a positive association between symptoms and reflux events by means of the symptom index (SI). One-year postsurgery impedance-pH studies clearly showed a marked decrease of reflux episodes (total, acid, proximal, upright, and recumbent refluxes) and a DeMeester score that paralleled the large improvement of GERD symptoms and quality of life, thus supporting the usefulness of impedance-pH testing in selecting GERD patients for surgery. However, even though this study provides relevant novel data on the potential application of impedance-pH
technology for the surgical management of GERD patients, we believe that the interpretation of their findings would be improved if the results of symptom association analysis after surgery were also reported. Few data are reported about SI (i.e., only preoperative information, and without describing whether the association was positive for acid and/or nonacid reflux episodes), and no data are provided for symptom association probability (SAP), which is considered by several authors to be the best index demonstrating
an association between symptoms and reflux events. Indeed, SAP is based on statistical parameters, is not generated by chance, and clearly explores the relationship between symptoms and refluxes. Although SI has the advantage of being easy to calculate, it does not
take into account the total number of reflux episodes with the likelihood risk that a symptom is found to be associated with reflux by chance. Therefore, because impedancepH permits the measurement of all types of reflux and correlates them to symptoms, it increases the diagnostic yield by using a symptom association analysis mode such as SI or SAP. In fact, previous studies have shown that GERD patients, particularly those found to have no mucosal injuries at upper endoscopy, frequently have a normal distal acid exposure time and therefore a low acidrelated DeMeester score. Using these parameters, it has been observed that GERD patients have symptoms associated not only with acid reflux but also with weakly acidic reflux; this may explain the increased proton pump inhibitor failure observed in endoscopy-negative patients, thus supporting the use of alternative surgical or endoscopic therapies in this patient population. So far, data concerning the SI and SAP for acidic and weakly acidic reflux should be reported in order to know whether surgical procedures are effective in relieving symptoms associated with weakly acidic reflux. Furthermore, the authors recorded quality-of-life information and grouped symptoms in typical, atypical, gasbloated, and bowel dysfunction. However, few data have been provided about their impact and relation to GERD. For instance, very little information has been provided regarding the functional and atypical symptoms associated with GERD before surgery and how these symptoms changed after surgery. Previous studies demonstrated an important overlap between functional dyspepsia, irritable bowel syndrome, or atypical symptoms and GERD. Moreover, these studies hypothesized an important impact of these overlapping entities in determining the medical therapeutic failure in refractory patients. It is important to know whether surgery was able to modify the atypical symptoms, gas bloat, and bowel dysfunction and their relation with GERD, thus supporting the major impact of surgery rather than medical treatment in the management of patients with overlapping entities.
In conclusion, Koch et al. provided encouraging data about the efficacy of surgery in impedance-pH-proven GERD, but we believe that more information about symptom–reflux correlation and more details on extraesophageal symptoms and their relation with GERD would improve their results
Interstitial lung disease in systemic sclerosis patients may benefit more from anti-reflux therapies than from immunosuppressants.
No full textEditorial: post-reflux swallow-induced peristaltic wave in eosinophilic oesophagitis—more questions than answers? Authors' reply
No full textAcque meteoriche nei depuratori: effetti sul carico organico e azotato
No full textIn questo lavoro è stato studiato l’effetto delle acque
meteoriche sui carichi di sostanza organica e azoto in ingresso
all’impianto di depurazione di Udine, prendendo come
riferimento i valori di un giorno di tempo secco. In un
giorno con 23 mm di pioggia l’impianto ha trattato una portata
superiore del 79%, un carico organico superiore del 7%
e un carico azotato inferiore del 9% rispetto al giorno secco;
in un giorno con 46 mm di pioggia l’impianto ha trattato una
portata superiore del 187%, un carico organico superiore del
43% e un carico azotato inferiore del 40%. In tutti i casi
l’impianto in tempo di pioggia ha rispettato i limiti allo scarico
nonostante i minori tempi di residenza rispetto al tempo
secco
Esperienza di gestione del bulking filamentoso causato da Microthrix particella in un impianto a biomassa sospesa
No full textSleeve Gastrectomy, GERD, and Barrett’s Esophagus: It Is Time for Objective Testing
No full textDear Editor,
We have read with great interest the article published by Sebastianelli et al. [1] who reported the rate of Barrett’s esophagus (BE) 5 years after sleeve gastrectomy (SG). In this multicenter study, the authors followed-up 90 consecutive obese patients who underwent SG. All of them underwent upper endoscopy, clinical assessment for the presence of gastroesophageal reflux disease (GERD) symptoms, and recording of proton pump inhibitors (PPI) use before and after surgery. At baseline, BE was present in none of the obese patients, whereas 9 of them had esophagitis; 20 subjects, all assuming PPI before intervention, were classified as affected by GERD. After 5 years of follow-up, endoscopic examination showed newly diagnosed short BE, without evidence of dysplasia, in 18.8% of the cases. Interestingly, at univariate analysis, BE presence was linked to a failure of weight loss. Finally, the prevalence of GERD symptoms increased from 21 to 76%, with a consequent increase of PPI usage (52%), and esophagitis rate increased from 10 to 41% (with 19% of them being asymptomatic). Authors concluded that in SG patients, a systematic endoscopy should be performed in order to identify the pre-neoplastic lesion and preventing future complications.
This study provides very interesting data on a controversial issue, related to that is the prevalence of GERD and its complications after SG. Although some studies account for a reduction of GERD symptoms after SG, which could probably be related to the weight loss, other studies found a worsening of such symptoms or “de novo” development of this condition [2, 3]. The authors of the present study deserve commendation for exploring the incidence of GERD symptoms and related complications in patients with and without pre-operative symptoms and signs of pathological reflux. On the other hand, we believe that the interpretation of their findings would have greatly improved if the results of objective testing (high-resolution manometry, HRM, and impedance-pH monitoring) before and after SG were also reported. In fact, even if patients complaining of GERD symptoms and those with pre-operative esophagitis were included, no data on their real reflux burden can be extrapolated. Indeed, previous studies demonstrated that obese patients were hyposensitive to reflux occurrence [4]. In particular, two recent studies [5, 6] have showed that obese patients may have pathological exposure to reflux even in absence of symptoms and signs. Moreover, some Authors [7] showed that in obese subjects without pre-operative objective pathological reflux, SG increased the total number of reflux events, the esophageal pH < 4 exposure and the esophageal clearance time. A subsequent multicenter study [8] found that the most common mechanism of reflux genesis after SG is the increased intragastric pressure in the reduced stomach, because the lacking of fundus that in normal subject can maintain the stomach in an isobaric condition. Actually, GERD pathophysiology is complex and we should no more discuss about this phenomenon only considering symptoms or signs. The recent guidelines on GERD diagnosis and management [9, 10] clearly state that clinical features and mild esophagitis alone (grades A and B) are not sufficient to estimate the reflux burden. Furthermore, because of a high prevalence of non-erosive reflux disease [11] in the GERD spectrum, sometimes also with normal acid exposure but abnormal number of reflux events and positive reflux-related symptoms, impedance-pH monitoring is mandatory. This technique, in fact, allows to measure all kinds of reflux events, thus increasing the diagnostic yield of traditional reflux monitoring (pH-metry) [12]. Moreover, recent data suggests a further promising role of HRM in GERD pathophysiology; this technique allows to establish not only the motility of esophageal body, but actually can provide important data about esophagogastric junction morphology [13] and on the esophagogastric junction barrier effect [14]; the impairment of these two parameters is strongly linked to GERD presence.
Thus, providing objective testing with HRM and MII-pH before and after SG may be useful to understand whether a particular group of patients should be treated with alternative bariatric procedure in which there is a sure reduction of GERD, e.g., gastric bypass. So far, data obtained by HRM and MII-pH, together with those obtained by endoscopy, should be collected and reported before and after surgery in all studies evaluating the effect of any bariatric procedure in obese patients. This would allow to a better pre-operative selection for the best “tailored” bariatric surgery
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