Cases reported "Gastroesophageal Reflux"

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1/132. Gastrojejunal interposition for esophageal replacement.

    The main considerations in replacing the esophagus are to avoid postoperative necrosis of all or part of the graft, leakage or stenosis of the anastomoses, and complications related to acid-peptic or alkaline reflux. A 5-year-old boy, after two unsuccessful thoracic operations for atresia and then stenosis of the esophagus, underwent resection of the esophagus because of duodeno-gastroesophageal reflux. The continuity of the alimentary tract was restored by gastrojejunal interposition. We recommend this method of reconstruction when the esophago-gastrostoma is created in the chest, and the possibility of alkaline reflux must be considered.
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2/132. Importance of duodeno-gastro-esophageal reflux in the medical outpatient practice.

    BACKGROUND/AIMS: The role of acid and duodeno-gastro-esophageal reflux (DGER), also termed bile reflux, in esophageal mucosal injury is controversial. Several recent developments, especially availability of the recent bilirubin monitoring device (Bilitec), have resulted in clarifications in this area. In order to better understand the role of acid and DGER in esophageal mucosal injury, we summarized the recent publications in this area. METHODOLOGY: review of published medical literature (medline) on the clinical consequence of esophageal exposure to gastric acid or DGER. RESULTS: Recent data suggest that esophageal ph monitoring and pH > 7 is a poor marker for reflux of duodenal contents into the esophagus. DGER in non-acidic environments (i.e., partial gastrectomy patients) may cause symptoms but does not cause esophageal mucosal injury. Acid and duodenal contents usually reflux into the esophagus simultaneously, and may be contributing to the development of Barrett's metaplasia and possibly adenocarcinoma. proton pump inhibitors decrease acid and DGER by reducing intragastric volume available for reflux and raising intragastric pH. The promotility agent cisapride decreases DGER by increasing LES pressure and improving gastric emptying. CONCLUSIONS: 1) The term "alkaline reflux" is a misnormer and should no longer be used in referring to reflux of duodenal contents. 2) Bilitec is the method of choice in detecting DGER and should always be used simultaneously with esophageal pH-monitoring for acid reflux. 3) DGER alone is not injurious to esophageal mucosa, but can result in significant esophageal mucosal injury when combined with acid reflux. 4) Therefore, controlling esophageal exposure to acid reflux by using proton pump inhibitors also eliminates the potentially damaging effect of DGER.
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3/132. Laparoscopic removal of an Angelchik prosthesis.

    The use of Angelchik prosthetic rings for the surgical treatment of gastroesophageal reflux disease has been associated with frequent complications, including dysphagia and migration, erosion, or disruption of the ring. Although reports of the laparoscopic insertion of Angelchik rings have been published, there have been no descriptions of the laparoscopic removal of rings inserted at open laparotomy. Our group recently removed an Angelchik ring laparoscopically in an 80-year-old woman with progressive, refractory dysphagia and esophageal narrowing due to an Angelchik ring originally placed in 1981 via an upper midline incision at open operation. Upper endoscopy and dilatation had failed to provide symptom relief. An extensive adhesiolysis was performed laparoscopically, and the Angelchik ring was dissected free from the proximal stomach, diaphragm, and liver. The fibrous pseudocapsule enclosing the ring was divided, and the prosthesis was removed from around the esophagus and abdominal cavity. Intraoperative upper endoscopy confirmed resolution of the esophageal stricture. There were no intraoperative complications, and the patient was discharged home on the 3rd postoperative day tolerating a regular diet. Postoperatively, she experienced resolution of her dysphagia and complained only of mild reflux symptoms, which were easily controlled with famotidine and antireflux precautions. This case suggests that laparoscopic removal of Angelchik prosthetic rings is feasible for surgeons familiar with advanced laparoscopic procedures of the esophageal hiatus and should be considered for symptomatic patients, even if the ring was inserted via an open operation.
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4/132. Transient left vocal cord paralysis during laparoscopic surgery for an oesophageal hiatus hernia.

    A 45-year-old male, with symptoms of many years standing of gastro-oesophageal reflux disease, was subjected, under general anaesthesia, to laparoscopic fundoplication. Tracheal intubation yielded no problems but great difficulties were encountered during tube insertion into the oesophagus. After surgery, aphonia developed. Laryngological examination demonstrated paralysis of the left vocal cord. voice strength returned to the pre-operative status after 3 months, and laryngological examination confirmed normal mobility of both cords. The possible cause of the complication was damage to the left recurrent laryngeal nerve which occurred during insertion of the tube into the oesophagus. Gastro-oesophageal reflux disease causing 'acid laryngitis' can create conditions favouring this type of complication.
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5/132. Neuromotor disorders of the esophagus.

    Esophageal motility studies are helpful in diagnosing hypertensive and hypotensive disorders of the esophagus and its sphincters, including the exact measurement of the strength of contraction, temporal sequence and duration of the pathophysiology involved. In addition, the assessment of the extent of neuromotor involvement may be of great help to the surgeon in planning a myotomy. PH metering is probably the most accurate way to assess reflux in hypotonic states.
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6/132. Interposition of a jejunal segment between esophagus and pylorus for treatment of multirecurrent gastroesophageal reflux.

    Here the authors report the clinical experience with placement of an isolated jejunal segment between the esophagus and pylorus for treatment of multirecurrent gastroesophageal reflux (GER) in a child. A 6-year-old neurologically normal girl experienced severe symptomatic GER after 3 previous well-constructed Nissen fundoplications that failed over a 4-year period. The gastric cardia was closed, and a 16-cm isolated segment of proximal jejunum was placed in an isoperistaltic direction between the distal esophagus and an incision through the pylorus, extending onto both the antrum and duodenum. A gastrostomy was used for 3 months. The patient recovered from the operation without complications and has been completely relieved of reflux symptoms during the 15 months postoperation. She has gained over 6.5 kg in weight and 3.2 cm in height during this period and has not experienced difficulty swallowing solid foods. Esophagogastric dissociation with placement of an isolated jejunal segment between the esophagus and pylorus may have a useful role in the surgical management of multirecurrent symptomatic GER as a "rescue procedure" with low risk compared with other options.
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7/132. Supraesophageal complications of gastroesophageal reflux.

    Supraesophageal complications of GERD have become more commonly recognized or suspected by physicians. However, the direct association between these complications and GERD has often been difficult, if not impossible, to establish. Furthermore, the majority of patients with suspected supraesophageal complications of GERD do not have either the characteristic symptoms of heartburn and regurgitation or the definitive findings of esophageal inflammation, which would help reinforce the suspicion of a connection between the supraesophageal complications and GERD. Frequent acid reflux has been shown in patients with various bron-chopulmonary, laryngopharyngeal, or oral cavity disorders. GERD is one of the most common gastrointestinal complaints in the population. It is possible that the supraesophageal problems and acid reflux are mutually independent disorders that occur in the same person. The suspected mechanisms of GERD-related supraesophageal complications appear to be directed through two pathways: by a vagal reflex between the esophagus and tracheobronchial tree triggered by acid reflux or by microaspiration that causes contact damage to mucosal surfaces. The most useful diagnostic modality available to the clinician to aid in the diagnosis of supraesophageal GERD complications is the ambulatory pH recording technique. However, the sensitivity and specificity of this test for recording esophageal or pharyngeal acid reflux events has been critically challenged. Despite the many clinical studies that support the theory that GER has a role in suspected supraesophageal complications, only 1 long-term prospective controlled study of a large group of patients with asthma has shown the positive effects of the elimination of acid reflux. With the focus now on "outcomes medicine," there is a serious need for appropriately designed, controlled studies to answer the many questions surrounding a cause-and-effect association between acid reflux and supraesophageal disorders. Because of the lack of convincing proof between acid reflux and suspected supraesophageal complications, the physician must resort to an intent-to-treat strategy as both a primary therapy and a diagnostic trial. High-dose PPI therapy for prolonged periods is the recognized conservative therapy. Operative therapy (i.e., fundoplication operation) is the procedure of choice when overt regurgitation occurs or when medical therapy, although successful, is not practical for long periods. Controlled, well-designed clinical trials and more sophisticated techniques to measure and quantify acid reflux are crucial in the future to help determine which patients with suspected supraesophageal complications actually have acid reflux as a primary cause. The medical community needs to be alerted to the possibility of an association between GERD and supra-esophageal complications so that patients with a GERD-related complication will be recognized and effectively treated.
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8/132. Barrett's esophagus in a child with de lange syndrome: report of one case.

    Barrett's esophagus, a premalignant condition, is recognized as stratified squamous epithelium of the esophagus substituted by columnar epithelium. The risk factors for development of Barrett's esophagus include frequent gastroesophageal reflux, esophageal stricture, male sex and mental retardation, but there is no report of Barrett's esophagus in children with de lange syndrome. We report a 7-year-old boy who was diagnosed as de lange syndrome shortly after birth and had gastroesophageal reflux since early infancy. Upper gastrointestinal endoscopic examination revealed a cauliflower-like mass and a pink-red velvety mass over the lower third of the esophagus. biopsy showed goblet cells metaplasia, confirming Barrett's esophagus. We suggest surveillance of Barrett's esophagus could be done ahead of schedule in children with long-standing gastroesophageal reflux or with de lange syndrome.
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9/132. Oesophageal surgery.

    A wide variety of benign conditions affecting the oesophagus which have long been recognized in association with hiatus hernia are now known to be attributable to reflux oesophagitis. The development of modern methods of treatment of these conditions is described with reference to a number of illustrative cases.
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10/132. Esophageal cast: a manifestation of graft-versus-host disease.

    Diffuse involvement of the gastrointestinal tract by graft-versus-host disease (GVHD) is a common complication of bone marrow transplantation. The esophageal involvement in this disease tends to be a vesiculobullous, ulcerative or desquamative process. To our knowledge, esophageal cast has not been described in the context of GVHD. However, it has been described as a result of trauma to the esophagus or in association with bullous disease of the skin. We present a case of esophageal cast in a patient with chronic GVHD following bone marrow transplant.
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