Letteratura scientifica selezionata sul tema "Gastrointestinal system – Motility; Gastroesophageal reflux; Gastroesophageal reflux – Surgery"

Background: Gastroesophageal reflux disease (GERD) is one of the most common upper gastrointestinal diseases that affects 10% to 20% of the general population worldwide.Current Concepts: Proton pump inhibitors (PPIs), the main treatment for this disease, is used to control symptoms. In most cases, PPI is prescribed empirically, and may be ineffective in 30% to 40% of patients. Even in cases with a precise diagnosis of GERD following objective tests, PPI becomes less effective as the disease progresses over a long time period. Laparoscopic anti-reflux surgery can be a good option when PPI therapy becomes ineffective and dose increases are required. This surgery effectively abolishes all kinds of reflux by constructing a mechanical anti-reflux valve at the gastroesophageal junction. Before surgery, a precise diagnosis should be made following several objective tests, including esophagogastroduodenoscopy, pH monitoring, manometry, and esophagram. The degree of fundoplication should be tailored according to esophageal motility and disease severity.Discussion and Conclusion: Laparoscopic anti-reflux surgery may be particularly effective for GERD patients with hiatal hernia, mechanically defective lower esophageal sphincter, or weak acidic/nonacidic reflux.

The esophagus is the centerpiece of the digestive system of individuals and plays an essential role in transporting swallowed nutrients to the stomach. Diseases of the esophagus can alter this mechanism either by causing anatomical damage that obstructs the lumen of the organ (e.g., peptic, or eosinophilic stricture) or by generating severe motility disorders that impair the progression of the alimentary bolus (e.g., severe dysphagia of neurological origin or achalasia). In all cases, nutrient assimilation may be compromised. In some cases (e.g., ingestion of corrosive agents), a hypercatabolic state is generated, which increases resting energy expenditure. This manuscript reviews current clinical guidelines on the dietary and nutritional management of esophageal disorders such as severe oropharyngeal dysphagia, achalasia, eosinophilic esophagitis, lesions by caustics, and gastroesophageal reflux disease and its complications (Barrett’s esophagus and adenocarcinoma). The importance of nutritional support in improving outcomes is also highlighted.

AbstractThe Endoluminal Functional Imaging Probe (EndoFLIP, Medtronic, Minneapolis, MN) impedance planimetry system provides real-time three-dimensional images of gastrointestinal sphincters of interest, particularly the esophagogastric junction. This allows for real-time objective measurements during the surgical management of foregut diseases such as gastroesophageal reflux and achalasia. Literature continues to grow on how to best utilize this recent technology to improve patient outcomes. This outlines the intraoperative utilization of EndoFLIP.

Abstract Background Laparoscopic fundoplication (LF) is considered as standard surgical antireflux therapy. However, even if performed in specialized centers, the procedure can be followed by long-term side effects dysphagia, gas bloating or inability to belch. Especially patients with motility disorders (IEM) and concurrent GERD are prone to postoperative dysphagia after LF. The aim of this study is the evaluation of electrical stimulation (EST) of the lower esophageal sphincter (LES) in patients with IEM and GERD and its impact on procedure-related gastrointestinal side effects such as dysphagia. Methods This is a prospective, open-label, non-randomized single-center study. All variables are depicted as median and interquartile range (IQR) or 95% confidence intervals (CIs) or mean with standard deviation (SD). Ineffective esophageal motility (IEM) was defined as a Distal Contractile Integral (DCI) below 450 mmHg-s-cm in ≥ 5 of out 10 swallows. Differences in GERD health-related quality of life (HRQL) scores before and after treatment were compared with paired t-test due to a normal distribution. P-values < 0.05 were considered significant. Results Between 05/2015 and 10/2017 twenty patients were treated with LES-stimulation for GERD. Thirteen patients (61.9%) presented with IEM in esophageal manometry before surgery and were included in this analysis. DCI was 91 (IQR 30.5–331.5) mmHg-s-cm. Median 24-hours esophageal pH at baseline was 10.2% (IQR 4.4–21.5). Fifty-seven percent of patients were treated with PPI at time of surgery. Nine patients (69.2%) presented with typical GERD symptoms whereas 6 patients (46.2%) also presented with atypical GERD symptoms. BMI was 26.1 (SD 4.9). Eight patients (61.5%) showed a hiatal hernia at the time of surgery and underwent also hiatal repair. Operating time was 59 minutes (IQR 34.5–70.25). HRQL for heartburn at baseline was 21.1 (SD 5.4) and improved to 7.3 after surgery (SD 6.7) at follow up of one month (mean difference 13.8 (CI 12.5–15.1) P < 0.001). HRQL for regurgitation at baseline was 18.69 (SD 6.9) and improved to 3.84 (SD 2.4) (mean difference 14.9 (CI 13.95–15.76) P < 0.001). No patients showed any clinical signs of dysphagia nor impaired findings in postoperative contrast swallow. Gastrointestinal side effects such as the inability to belch or bloating were not seen in any patients. There were no severe adverse events related to the procedure, but one patient need re-do surgery and re-implantation of the LES-stimulation due to a breaking of the lead close to the implanted pulse generator after one year. Conclusion LES-EST was introduced as a potential alternative technique to avoid side effects of LF. It was demonstrated that LES-EST significantly raises the LES pressure and improved GERD symptoms such as heartburn and regurgitation. The advantage of this procedure is that the anatomy of the esophageal-gastric junction is not altered dramatically. Disclosure All authors have declared no conflicts of interest.

Systemic sclerosis (SSc) is a disease that affects the gastrointestinal tract resulting in its atrophy and fibrosis of smooth muscles. Approximately 80% of SSc patients develop both gastroesophageal reflux disease (GERD) and dysphagia. The nocturnal GERD can cause regurgitation and aspiration, which can further aggravate the pulmonary fibrosis from SSc. Also, their dysphagia is further worsened by performing standard Nissen fundoplication. Therefore, we aimed to investigate whether Dor fundoplication (a 180° anterior wrap) can reduce nocturnal heartburn and regurgitation without worsening dysphagia in patients with SSc and severe GERD. Five SSc patients with drug-refractory severe GERD underwent a Dor fundoplication procedure with a median follow-up of 2 years (range: 1-5 years). In all 5 patients, the preoperative high-resolution manometry showed significant impairment of esophageal motility. Patients were interviewed postoperatively to assess for nocturnal and diurnal GERD symptoms, treatment response, the status of dysphagia, and adverse effects of surgery. The average age of 5 patients was 50 years and all were females. Four of the 5 patients (80%) reported 90% improvement in both diurnal and nocturnal GERD symptoms since surgery, with no nocturnal reflux, heartburn, or regurgitation, and reports to sleep at night without requiring any more pillows or wedges. About 50% of patients reported a decrease in their proton pump inhibitor dosage after surgery compared to before surgery. No surgical complication was reported and specifically, no worsening of dysphagia. The Dor fundoplication performed for refractory GERD in SSc patients substantially decreases heartburn and regurgitation, primarily nocturnal, without affecting dysphagia, thus improving the quality of life.

Objective: to assess the quality of life of patients and the state of the hepatopancreatobiliary system before and after cholecystectomy in the long-term period. Materials and methods: at the first stage, 107 people were examined after emergency, planned cholecystectomy (with symptomatic and asymptomatic course of GI). At the second stage, 90 people at different times after cholecystectomy for a more detailed examination of the external secretory function of the pancreas was performed. Results: the majority of patients, regardless of the type of surgery, had symptoms of dyspepsia associated with the development of functional disorders of the gastrointestinal tract (gastroesophageal reflux, duodenogastric reflux, sphincter Oddi dysfunction). A decrease in the external secretory function of the pancreas was shown regardless of the period after cholecystectomy. Conclusion: after cholecystectomy, functional disorders of the digestive system predominate in the long-term period due to loss of the physiological function of the gallbladder.

Laparoscopic repair for gastroesophageal reflux disease is now an accepted therapy. However, controversy exists with regard to the choice of operation between complete 360-degree Nissen fundoplication versus partial 270-degree Toupe fundoplication. In addition there is some controversy with regard to the proper choice of operation in patients with poor esophageal motility. Another class of hiatal hernia patients are those patients with paraesophageal herniation. Questions regarding the approach to these patients include whether or not to use a reflux procedure at the time of repair and the role of mesh in repair of these large hernias. This retrospective study was undertaken to compare the results of laparoscopic Nissen fundoplication and Toupe fundoplication in patients with both normal and abnormal esophageal motility. In addition the subset of patients with paraesophageal herniation was studied in an effort to ascertain the best surgical approach in these patients. In this study a retrospective analysis was performed on 188 consecutive patients during the period 1995 to 2001. All patients who presented with hiatal hernia surgical problems during this period were included. Endoscopy was performed in all patients with esophageal reflux. Manometry was performed in all patients except those presenting as emergency incarcerations. pH probe testing was performed in those patients in whom it was deemed necessary to establish the diagnosis. Upper gastrointestinal radiographs were used to define anatomy in paraesophageal hernia patients when possible. All patients with esophageal reflux were first treated with a trial of medical therapy. Patients with esophageal reflux and normal esophageal motility underwent 360-degree Nissen fundoplication. Those patients with poor esophageal motility (less than 65 mm of mercury) underwent laparoscopic 270-degree Toupe fundoplication. Patients presenting with paraesophageal herniation underwent laparoscopic repair. When possible esophageal manometry was performed on these patients preoperatively and if normal peristalsis was documented a Nissen fundoplication was performed. If poor esophageal motility was documented before surgery a Toupe fundoplication was performed. Mesh reinforcement of the diaphragmatic hiatus was used if necessary to complete a repair without tension. Patients were followed both by their primary gastroenterologist and their surgeon. Follow-up studies including endoscopy, pH probe, and upper gastrointestinal series were used as necessary in the postoperative period to document any problems as they occurred. Of the 188 patients in the study 141 patients underwent Nissen fundoplication, 21 patients underwent Nissen fundoplication and repair of paraesophageal hernia, 15 underwent Toupe fundoplication, seven underwent Toupe and paraesophageal hernia repair, and four paraesophageal hernia repair alone. One hundred eighty-three patients underwent a laparoscopic operation. Five patients of the 188 underwent an initial open operation—two of these patients because of the size of their paraesophageal hernia. Three of these patients had reoperations of remote operations done years before at other institutions. Twenty-two patients with poor esophageal motility (11.7 %) were included in the study. Fifteen patients required Toupe fundoplication whereas seven patients required Toupe fundoplication and repair of paraesophageal hernias. Mesh repair of paraesophageal hernias was accomplished in ten patients. Patients undergoing Toupe fundoplication had a 13 per cent dysphagia rate less than 4 weeks postoperatively and a 0% dysphagia rate greater than four weeks postoperatively. Patients undergoing Nissen fundoplication had a 16 per cent dysphagia rate less than 4 weeks postoperatively, 2 per cent dysphagia rate greater than 4 weeks postoperatively and no dysphagia at 6 weeks postoperatively. Recurrent symptomatic reflux occurred in 1.4 per cent of Nissen fundoplications and 6.7 per cent of Toupe fundoplications. Of Nissen and paraesophageal repairs 14.2 per cent had reflux and 14.3 per cent of Toupe and paraesophageal repairs had recurrent symptomatic reflux. Overall, complication rate was low. Use of mesh to repair large paraesophageal hernias resulted in a recurrence rate of 0 per cent. There was no instance of infection or bowel fistulization related to the use of mesh. We conclude that laparoscopic Nissen fundoplication in patients with normal esophageal motility is associated with a low rate of dysphagia and a low rate of recurrent reflux. Toupe fundoplication when used in reflux patients with poor esophageal motility is associated with a low rate of dysphagia and an acceptable rate of recurrent reflux. Laparoscopic repair of large paraesophageal herniation when combined with an appropriate antireflux procedure and mesh when needed is an effective treatment with low recurrence rate.

Currently, the global prevalence of obesity among the worlds adult population is about 650 million people, which makes it possible to consider this chronic metabolic disease as a non-infectious pandemic of the 21st century. It has been proven that obesity is associated with several gastroenterological diseases, while the mechanisms of these associations are extremely heterogeneous and multifactorial. Hypertrophy and hyperplasia of adipocytes in obesity lead to a change in the profile of adipokine production (a decrease in adiponectin, an increase in leptin), an increase in the production of pro-inflammatory cytokines (interleukin-1, 6, 8, tumor necrosis factor ), C-reactive protein, free fatty acids, as well as active forms of oxygen (superoxide radicals, H2O2). All the above induces the development of chronic slowly progressive inflammation, oxidative stress, and insulin resistance. In addition, peptides secreted by adipocytes (adiponectin, leptin, nesfatin-1 and apelin) can modulate gastrointestinal motility, acting both centrally and peripherally. The qualitative and quantitative changes in the intestinal microbiota observed in obese patients (increased Firmicutes and decreased Bacteroidetes) lead to a decrease in the production of short-chain fatty acids and an increase in the intestinal permeability due to disruption of intercellular tight junctions, which leads to increased translocation of bacteria and endotoxins into the systemic circulation. Numerous studies have demonstrated the association of obesity with diseases of the esophagus (gastroesophageal reflux disease, Barretts esophagus, esophageal adenocarcinoma, esophageal motility disorders), stomach (functional dyspepsia, stomach cancer), gallbladder (cholelithiasis, gallbladder cancer), pancreas (acute pancreatitis, pancreatic cancer), liver (non-alcoholic fatty liver disease, hepatocellular carcinoma), intestine (diverticular disease, irritable bowel syndrome, colorectal cancer).

We aimed to evaluate the frequency of the need for proton pump inhibitor treatment following laparoscopic Nissen fundoplication (LNF) for gastroesophageal reflux disease (GERD). A total of 162 patients with GERD were treated surgically with LNF from October 2006 to March 2010 in our surgery department. Diagnoses were made by using upper gastrointestinal system (GIS) endoscopy and 24-hour pH monitoring, and all the patients underwent routine LNF surgery. The patients were questioned regarding complaints and proton pump inhibitor (PPI) usage during the postoperative period, and 40 patients who had postoperative GIS symptoms were included. Upper GIS endoscopy with antral biopsy for Helicobacter pylori (HP) identification and multichannel intraluminal impedance pH (MII-pH) monitoring were applied, and all the data were evaluated. The median postoperative follow-up time was 1.84 ± 0.850 (0.29–3.48) years. PPI treatment frequency was 37.5% (15 patients) in the 40 symptomatic patients, or 9.26% in all 162 patients who were operated on. The reason for PPI usage in 3 patients (7.5%) was regarded as recurrence. HP positivity was 67.5% in the symptomatic patients and 73.3% in the PPI treated group; 40% (6 patients) recovery was achieved in the HP (+) patients by using an HP eradication treatment protocol. The operated patients displayed statistically significant results in increased quality of life (P = 0.001) and lowered DeMeester scores (P = 0.000) during the postoperative period when compared with the preoperative period. LNF treatment for GERD prevents pathologic reflux in the long term and maintains symptomatic control, which leads to increased and better quality of life. PPI treatment alone during the postoperative period does not indicate “recurrence.” One of the most important reasons for recurrence is antral gastritis secondary to HP infection; PPI usage diminishes remarkably with an HP eradication protocol. MII-pH monitoring is an effective method of determining recurrences due to reflux and their types in postoperative symptomatic patients.

Main RecommendationsESGE suggests flexible endoscopic treatment over open surgical treatment as first-line therapy for patients with a symptomatic Zenker’s diverticulum of any size.Weak recommendation, low quality of evidence, level of agreement 100 %.ESGE recommends that emerging treatments for Zenker’s diverticulum, such as Zenker’s peroral endoscopic myotomy (Z-POEM) and tunneling, be considered as experimental; these treatments should be offered in a research setting only.Strong recommendation, low quality of evidence, level of agreement 100 %.ESGE recommends against the widespread clinical use of transoral incisionless fundoplication (TIF) as an alternative to proton pump inhibitor (PPI) therapy or antireflux surgery in the treatment of gastroesophageal reflux disease (GERD), because of the lack of data on the long-term outcomes, the inferiority of TIF to fundoplication, and its modest efficacy in only highly selected patients. TIF may have a role for patients with mild GERD who are not willing to take PPIs or undergo antireflux surgery.Strong recommendation, moderate quality of evidence, level of agreement 92.8 %.ESGE recommends against the use of the Medigus ultrasonic surgical endostapler (MUSE) in clinical practice because of insufficient data showing its effectiveness and safety in patients with GERD. MUSE should be used in clinical trials only.Strong recommendation, low quality evidence, level of agreement 100 %.ESGE recommends against the use of antireflux mucosectomy (ARMS) in routine clinical practice in the treatment of GERD because of the lack of data and its potential complications.Strong recommendation, low quality evidence, level of agreement 100 %.ESGE recommends endoscopic cecostomy only after conservative management with medical therapies or retrograde lavage has failed.Strong recommendation, low quality evidence, level of agreement 93.3 %.ESGE recommends fixing the cecum to the abdominal wall at three points (using T-anchors, a double-needle suturing device, or laparoscopic fixation) to prevent leaks and infectious adverse events, whatever percutaneous endoscopic cecostomy method is used.Strong recommendation, very low quality evidence, level of agreement 86.7 %.ESGE recommends considering endoscopic decompression of the colon in patients with Ogilvie’s syndrome that is not improving with conservative treatment.Strong recommendation, low quality evidence, level of agreement 93.8 %.ESGE recommends prompt endoscopic decompression if the cecal diameter is > 12 cm and if the Ogilvie’s syndrome exists for a duration of longer than 4 – 6 days.Strong recommendation, low quality evidence, level of agreement 87.5 %.

Part 1 reviews the major portions of the gastrointestinal system (esophagus, stomach, small intestine, colon, and pancreas), their function (motility, acid production, enzymatic function, and absorption), and various disorders associated with them (dysmotility, ulceration, malabsorption, inflammation, and dysplasia). Symptoms, diagnostic testing, and treatment of common gastrointestinal conditions, such as gastroesophageal reflux disease, peptic ulcer disease, diarrhea, constipation, inflammatory bowel disease, and pancreatitis, are reviewed.