1/23. A practical approach to heartburn. heartburn and other symptoms of gastroesophageal reflux disease can be a lifelong problem, affecting millions of Americans each year. Fortunately, treatment has improved dramatically over the past decade. Medications currently available are remarkably safe and, with proper selection, almost universally effective. When indicated, surgical treatment is also highly effective. ( info) |
2/23. Nonerosive reflux disease. Until recently, the finding of erosive esophagitis in patients with chronic heartburn was thought to indicate more severe gastroesophageal reflux disease. However, recent data suggests that this is not necessarily true. Seventy-five percent of patient's chronic heartburn have moderate to severe symptoms, regardless of the presence or absence of esophagitis. Nonerosive reflux disease (NERD) is characterized by heartburn symptoms for at least 3 months with no evidence of esophagitis. patients with NERD are similar to patients with esophagitis in symptom severity, quality of life scores, and response to anti-reflux therapy. There are probably 3 distinct groups of NERD patients, those with pathologic reflux, those with a heightened sensitivity to physiologic reflux and those with other medical problems mistaken for reflux. This article discusses the 3 clinical scenarios. ( info) |
3/23. Laparoscopic adjustable gastric banding: complications and side effects responsible for the poor long-term outcome. In a remarkably short time, Laparoscopic Adjustable Gastric Banding (LAGB) has become a common operation for morbid obesity in europe and elsewhere. More than 70,000 such procedures have been performed in recent years. We used LAGB as a routine treatment for morbid obesity in 90 patients between 1994 and 1996. We agree with other authors that LAGB is the least invasive of all gastric restrictive procedures, resulting in a low perioperative mortality and morbidity. The weight loss appears to be similar to that obtained by vertical banded gastroplasty (VBG). However, our long-term follow-up studies, including endoscopic examinations, as well as recent data in the literature also indicate a number of significant problems with LAGB. Patient discomfort occurs frequently in the postoperative course. When questioned according to a standardized protocol 2 years after surgery, every other patient in our series admitted heartburn and acid regurgitation. Regular endoscopic surveillance revealed a prevalence of erosive esophagitis of 44%. After a median follow-up of 7 years, 58% of the patients had been reoperated on, almost always with excision of the banding system and conversion to Roux-en-Y gastric bypass (RYGBP). The reasons for reoperation were esophagitis, band erosion, pouch dilatation, leakage from the balloon, and esophageal dilatation, complications that also have been described in several recent papers in the literature. Our prediction is that LAGB will not stand the test of time. ( info) |
4/23. Does chemoprevention of Barrett's esophagus using acid suppression and/or COX-2 inhibition prevent neoplastic progression? Barrett's esophagus--intestinal metaplasia within the tubular esophagus - is a premalignant histologic lesion and a marker of cancer risk. Strategies to prevent Barrett's-related esophageal cancer have focused on reversal of Barrett's using pharmacological or surgical antireflux therapies and endoscopically-induced injury. Currently, however, there is little compelling evidence to support the reversal of Barrett's through pharmacological or surgical therapy, and endoscopic reversal of Barrett's has not yet been validated. chemoprevention using intensive acid suppression and/or inhibition of cyclooxygenase-2 (COX-2) with nonsteroidal anti-inflammatory drugs remains a biologically plausible strategy that is supported by a rapidly growing body of scientific evidence. Data suggest that a combination of acid suppression with COX-2 inhibition might be the most effective chemopreventive strategy. Whether this approach is effective awaits the results of well-designed outcomes studies. ( info) |
5/23. Laparoscopic repair of a recurrent chronic traumatic diaphragmatic hernia. Traditionally the approach to a long-standing traumatic diaphragmatic hernia has been a closure of the diaphragmatic defect via a thoracotomy. The evolution of minimally invasive surgery has allowed surgeons to challenge many of the traditional approaches. Herein we describe the first reported case of laparoscopic repair of recurrent chronic traumatic diaphragmatic hernia as well as review the current literature on minimally invasive surgery for traumatic diaphragmatic hernia. With proper advanced laparoscopic skills and techniques laparoscopic diaphragmatic herniorrhaphy for a chronic and recurrent defect is a safe and viable option. ( info) |
6/23. Laparoscopic resection of a periampullary villous adenoma. BACKGROUND: Adenomas of the duodenal papilla are rare lesions. Because of their malignant potential, resection is mandatory. Options for resection include endoscopic resection, transduodenal local excision, and pancreaticoduodenectomy. This report details a case of periampullary villous adenoma diagnosed endoscopically and resected laparoscopically via a transduodenal approach. CASE REPORT: A healthy 75-year-old woman with heartburn underwent an upper endoscopy for vague right upper abdominal pain. A periampullary tumor was diagnosed. Endoscopic biopsy results were consistent with a villous adenoma, and endoscopic ultrasound showed distal bile duct involvement. The patient underwent laparoscopic transduodenal local excision of the tumor with biliary reconstruction. CONCLUSIONS: Laparoscopic transduodenal resection of periampullary lesions provides advantages similar to those of an endoscopic resection by removal of the tumor using minimally invasive techniques. In addition, laparoscopic surgery maintains the surgical tenents of open transduodenal resection with en bloc tumor resection including the adjacent duodenal wall and ductal structures as necessary. As noted in this case, laparoscopic techniques resect ampullary lesions involving the ductal structures as well. Laparoscopic transduodenal ampullectomy is a valuable treatment option for benign and selected premalignant ampullary lesions. ( info) |
| OBJECTIVE: To report a case of chronic, persistent cough induced by omeprazole therapy.CASE SUMMARY: A 42-year-old white woman presented with chronic, persistent cough after omeprazole initiation for treatment of postoperative heartburn. The cough was permanent, dry, and exhausting and worsened at night. omeprazole therapy was continued for 4 months because the persistent cough was thought to be related to gastroesophageal reflux disease (GERD). However, no cause of persistent, chronic cough was identified. After omeprazole discontinuation, the cough resolved. DISCUSSION: The most common causes of chronic cough in nonsmokers of all ages are postnasal drip syndrome, asthma, and GERD. However, persistent cough without bronchospasm or other pulmonary involvement may occur as a drug adverse effect. According to the US omeprazole package insert, cough is observed as an adverse reaction in 1.1% of patients, although this has not been mentioned in international drug information sources or medical literature. A medline search (1966-June 2003) using the terms cough, drug related, adverse effects, and omeprazole failed to find any data. In our patient, there was a temporal relationship between cough and medication use, suggesting a causal relationship. An objective causality assessment revealed that the adverse drug reaction was probable. The mechanism is unclear. CONCLUSIONS: Chronic, persistent cough may occur as an adverse effect of omeprazole therapy. Clinicians must be aware of this adverse effect to avoid useless and costly tests. ( info) |
8/23. air swallowing can be responsible for non-response of heartburn to high-dose proton pump inhibitor. Intraluminal electrical impedance is a novel technique, which is able for the first time to provide a qualitative assessment of refluxed material moving from the stomach to the oesophagus. In other words, the presence of air can be differentiated from that of liquid, because the former is characterised by high and the latter by low impedance compared with baseline. Moreover, the combined measurement of electrical impedance and pH-metry permits to distinguish acid from non-acid liquid reflux. One of the most important clinical applications of this method is to assess the reasons for poor response of GORD patients to high-dose proton pump inhibitors. This case report describes the results of impedance in the evaluation of a young woman, who did not respond to twice-daily doses of rabeprazole. She continued to complain of heartburn as major symptom and impedance allowed us to clarify that it was not related to acid or non-acid reflux, but to air swallowing. Therefore, this technique identified aerophagia to be responsible for persistent heartburn despite high-dose proton pump inhibitor and prevented the adoption of more aggressive, but probably unuseful therapies, such as the surgical one. ( info) |
9/23. An uncommon clinical presentation of retroperitoneal non-Hodgkin lymphoma successfully treated with chemotherapy: a case report. We report the case of a patient affected by an extra-nodal non-Hodgkin lymphoma presenting as a unique, large retroperitoneal mass with an unusual clinical presentation mimicking gastric peptic or neoplastic disease. The patient was successfully treated with a first generation therapy, CHOP modified regimen (cyclophosphamide 600 mg/m2 intravenously on d 1, epirubicin 55 mg/m2 intravenously on d 1, vincristine 1.2 mg/m2 intravenously on d 1, prednisone 60 mg/m2 on d 1-5), and a complete response was achieved. The (18)F-fluorodeoxyglucose positron emission tomography was used to assess the therapy outcome. A brief review of literature is provided. ( info) |
10/23. heartburn and multiple-site foregut perforations as primary manifestation of Crohn's disease. SUMMARY: Crohn's disease may affect any segment of the digestive tract, more commonly the distal ileum, colon and/or perianal region. There is an increasing number of reports dealing with foregut Crohn's disease. We present the case of a patient with a history of heartburn and multiple spontaneous perforations of the esophagus, duodenum and jejunum as a primary manifestation of Crohn's disease who required emergency surgical and endoscopic procedures. Early detection of Crohn's disease may decrease the incidence of acute life-threatening complications provided that appropriate medical treatment is administered and a multidisciplinary approach is offered to these patients. ( info) |