| gastroesophageal reflux is a highly prevalent condition that usually requires long-term medical therapy. Although symptom management still remains satisfactory for the majority of patients, laparoscopic Nissen fundoplication is proving to be an effective alternative in treating complications of gastroesophageal reflux disease. ( info) |
2/625. 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. ( info) |
3/625. Total gastric replacement following gas bloat in a 21-month-old child. A 21-month-old child with a previously repaired left congenital diaphragmatic hernia underwent a 360 degrees 'loose-wrap' Nissen fundoplication for gastroesophageal reflux. Failure to replace the dislodged nasogastric tube on the 2nd night led to severe gas bloat and total gastric infarction. A 30-cm retrocolic, N-shaped, isoperistaltic jejunal pouch was constructed for gastric replacement. A pyloromyotomy ensured free emptying and a pouchostomy secured the pouch to the abdominal wall. At 8 months all nutrition was oral except for a biannual vitamin B12 injection, there was no dumping, and the pouchostomy was removed. By 18 months growth, originally along the 10th centile, was sustained at the 50th centile. Our early impression recommends a 30-cm retrocolic, isoperistaltic, N-shaped jejunal pouch similar to that of Hays and Clark as a safe and effective replacement for the stomach in children. ( info) |
4/625. Pseudo-steroid resistant asthma. BACKGROUND: Steroid resistant asthma (SRA) represents a small subgroup of those patients who have asthma and who are difficult to manage. Two patients with apparent SRA are described, and 12 additional cases who were admitted to the same hospital are reviewed. methods: The subjects were selected from a tertiary hospital setting by review of all asthma patients admitted over a two year period. Subjects were defined as those who failed to respond to high doses of bronchodilators and oral glucocorticosteroids, as judged by subjective assessment, audible wheeze on examination, and serial peak flow measurements. RESULTS: In 11 of the 14 patients identified there was little to substantiate the diagnosis of severe or steroid resistant asthma apart from symptoms and upper respiratory wheeze. Useful tests to differentiate this group of patients from those with severe asthma appear to be: the inability to perform reproducible forced expiratory manoeuvres, normal airway resistance, and a concentration of histamine causing a 20% fall in the forced expiratory volume (FEV1) being within the range for normal subjects (PC20). Of the 14 subjects, four were health care staff and two reported childhood sexual abuse. CONCLUSION: Such patients are important to identify as they require supportive treatment which should not consist of high doses of glucocorticosteroids and beta2 adrenergic agonists. Diagnoses other than asthma, such as gastro-oesophageal reflux, hyperventilation, vocal cord dysfunction and sleep apnoea, should be sought as these may be a cause of glucocorticosteroid treatment failure and pseudo-SRA, and may respond to alternative treatment. ( info) |
5/625. 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. ( info) |
6/625. 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. ( info) |
| OBJECTIVE: To describe a case of esophageal ulcer associated with the use of alendronate. CASE REPORT: This is the fifth case ever described in the literature according to our bibliographic review. In our patient, the association between the drug and the esophageal lesions was masked by the presence of a hiatal hernia, potentially a cause of the esophageal lesion. The persistence of the lesions despite high doses of anti-reflux therapy called attention to the possibility of the relationship. The esophageal lesion healed soon after suspension of alendronate. DISCUSSION: The authors present a review of the literature and point to the need for diagnostic investigation, to suspend such a drug from patients who experience dyspeptic symptoms while using it. ( info) |
8/625. Peptic esophageal stricture in children. INTRODUCTION: Peptic esophageal stricture as a complication of gastroesophageal reflux disease (GERD) occurs in 5% of the affected children. MATERIAL AND methods: Case histories of 6 children treated successfully in the Department of pediatrics and Clinic of Pediatric Surgery were studied. The diagnosis in each case was based on clinical symptoms (vomiting leading to hypothrophy, hematemesis, and anemia), and esophagoscopy, esophageal pH-metry (according to ESPGAN recommendations), and contrast X-ray examination. After evaluation medical treatment was applied in 3 and bougienage with a hard bougie in 6 patients. Because of failure of this treatment Nissen fundoplication and postoperative bougienage were performed in all patients. RESULTS: In all surgically treated patients complete recovery without postoperative complications was achieved. DISCUSSION: The authors give interpretation of the pathogenesis and outline the primary symptoms of the disease. Terms of performance and reliability of the instrumental methods of diagnosing are discussed. The experience in treatment of peptic esophageal stricture in children is presented. CONCLUSIONS: Medical treatment combined with bougienage yields poor results in peptic esophageal stricture and Nissen fundoplication appears to be the treatment of choice. ( info) |
9/625. Fixed drug eruption in hands caused by omeprazole. OBJECTIVE: omeprazole is one of the most widely prescribed gastric antisecretory drugs. It is generally well tolerated and significant adverse reactions occur rarely. The objective of this report is to describe a case of fixed drug eruption that occurred during omeprazole treatment. CASE REPORT: A 37-year-old white female patient admitted with epigastric pain and heartburn symptoms. An upper gastrointestinal endoscopy revealed reflux esophagitis and the patient was given 20 mg b.i.d. omeprazole. She developed dark-red coloration on her hands, at the fourth day of treatment, which has been defined as fixed drug eruption. These lesions were attributed to treatment and recurred soon after a rechallenge with omeprazole. CONCLUSION: Fixed drug eruption is associated with many drugs but this is the first such report with omeprazole. We suggest being aware of such reactions during omeprazole usage. ( info) |
10/625. Primary anastomosis in esophageal atresia type I without a gap. This paper reports the case of an infant born with type I esophageal atresia (EA) associated with duodenal atresia (DA). The critical condition of the patient necessitated an exploratory laparotomy, which revealed severe dilatation of the stomach and duodenum. The routine procedure for repairing type I EA is a delayed primary anastomosis after 10 weeks of age because of the long gap between the two esophageal segments. In our case, due to the concomitant DA, the lower pouch was long enough to allow primary neonatal anastomosis. A radiograph taken with a Hegar dilator in the lower segment via the gastrostomy confirmed this suspicion, and the baby underwent a thoracotomy and primary anastomosis between the esophageal pouches. The authors propose the possibility of primary esophageal anastomosis in similar cases. ( info) |