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Heartburn and Acid Reflux Cure Program

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Heartburn and Acid Reflux Cure Program Summary


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Author: Jeff Martin
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The Acid Reflux Strategy

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The Acid Reflux Strategy Summary

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Official Website: blueheronhealthnews.com
Price: $49.00

Case study 1 eradication of H pylori in nonulcer dyspepsia

Pylori Eradication

H. pylori is a bacterium that inhabits the stomach and has been linked to the development of peptic ulcer eradication of the bacterium with antibiotics is an effective cure for most ulcer disease. H. pylori is also considered to have a possible causal role in the development of non-ulcer dyspepsia. A meta-analysis of the five relevant trials reported a small reduction in dyspepsia rates 12 months after eradication, which was just statistically significant.19 The effect measure used in the published analysis was the relative risk of remaining dyspeptic 12 months after eradication. This was chosen as it was thought to be the most clinically relevant outcome and had been pre-stated in the review protocol. No alternative effect measures were considered. Eight alternative meta-analyses are presented in Table 16.3. Results are shown using fixed and random effects analyses for odds ratios, risk differences and the two risk ratios of dyspepsia recovery and remaining dyspeptic. (Estimates of...


Derived from Greek roots meaning difficult digestion, dyspepsia has long served as a synonym for indigestion, one of the most common - and etiologically varied - of human miseries. It has also been regularly employed to label symptoms of diverse organic disorders, with the result that some gastroenterologists find the word uselessly elastic. Most practitioners, however, have reached a consensus to use dyspepsia to denote either the ailment of functional indigestion or the symptoms of peptic ulcer.

Rodney J Mason Tom R Demeester

Functional disorders of the esophagus are such an abnormality. They can exist for a period of time without causing morphologic changes while causing considerable symptoms. Typical symptoms of functional esophageal disorders are heartburn, regurgitation, and dysphagia. Ascribing these symptoms to a specific esophageal abnormality in the absence of structural or histologic findings and without further investigation can lead to an error in diagnosis. This is because a variety of gastric, duodenal, cardiac, and pulmonary disorders can cause symptomatology similar to esophageal abnormalities, making it difficult to differentiate and discriminate them from the latter. Further, functional esophageal disorders can present with atypical symptoms, such as chest pain, chronic cough, or shortness of breath, which lead the investigator to suspect abnormalities of the heart or lung. Complicating matters even more, functional esophageal disorders can also occur concomitantly with gastroduodenal,...

Preoperative Evaluation

The goal of preoperative evaluation is to confirm the presence of GERD and to select the best treatment option for each individual based on clinical presentation and gastroesophageal function.1 Upper gastrointestinal endoscopy should be performed on all surgical candidates to assess for reflux complications and is best performed by the operating surgeon or an endoscopist with substantial experience in esophagoscopy and reflux disease. If possible, erosive esophagitis should be healed before surgery to reduce periesophageal inflammation. If Barrett's esophagus is present, thorough biopsies of the abnormal epitheliums are required, and the presence of dysplasia or adenocarcinoma requires specific further evaluation. Upper endoscopy can also be used to evaluate the size and type of hiatal hernia. The identification of a large ( 5 cm) sliding hernia, a paraesophageal hernia, or esophageal scarring is important. These findings may indicate the presence of esophageal shortening, which would...

Special Considerations

Nissen fundoplication is a proved and effective long-term therapy for GERD. Appropriate patient selection and attention to surgical technique are keys to obtaining satisfactory results. The minimally invasive approach appears to provide results comparable to those of open fundoplication, but long-term results continue to be assessed. 2. DeMeester, T.R., and Stein, H.J. Surgical treatment of gastroesophageal reflux disease. In Castell, D.O. (ed.). The Esophagus. Boston, Little, Brown, 1992, pp. 579-625. 3. Gallup Survey on Heartburn Across America. Princeton, NJ, The Gallup Organization, March 28, 1988. 4. Spechler, S.J. Epidemiology and natural history of gastro-esophageal reflux disease. Digestion, 51 24, 1992. 6. Stein, H.J., DeMeester, T.R., and Perry, R.P. The three-dimensional lower esophageal sphincter pressure profile in gastroesophageal reflux disease Effect of antireflux procedures. Ann. Surg., 216 35, 1992. 7. DeMeester, T.R., Bonavina, L., and Albertucci, M. Nissen...

Years after diagnosis

Figure 15-4 Thoracic esophagus and lesser curvature of stomach show multicentric (two) foci of invasive carcinoma in Barrett's esophagus. Progressive dysphagia to solids developed in the patient, a 59-year-old man with an anatomic sliding esophageal hiatal hernia who did not have a history of gastroesophageal reflux symptoms or alcohol or tobacco abuse. Subsequent radiography and endoscopy defined columnar epithelium-lined lower esophagus with squamocolumnar junction just above the aortic arch and more distal invasive cancer near the esophagogastric junction. Not until the specimen was opened was the second, higher-invasive cancer appreciated.

Inflammatory Bowel Disease IBD

Hypothyroidism slows down the rate at which food travels through the stomach and intestines. This can result in gastroesophageal reflux disease (heartburn) and constipation. On the other hand, thyrotoxicosis from untreated Graves' disease causes more frequent bowel movements consequent to an increased rate of movement of food through the intestines. These functional differences may be mistaken for primary intestinal diseases, including IBD.

Presenting Symptoms And Signs

Epigastric pain, diarrhea, persistent heartburn, and dysphagia ( Table 8-1 ). The majority of patients with ZES (approximately 90 ) are found to have peptic ulceration, with the proximal duodenum as the most commonly involved site. However, a minority of patients still have multiple peptic ulcers or ulcers in unusual locations, such as the distal duodenum (14 ) and jejunum (11 ), or even recurrent ulceration after 5 7 5

Timothy M Farrell John G Hunter

The appropriate role of minimally invasive surgery for diseases of the stomach and duodenum is emerging. The advent of contemporary medical and surgical therapies for the treatment of gastroesophageal reflux (GER) disease and peptic ulcer disease (PUD) has challenged the traditional application of these modalities. Although laparoscopic antireflux surgery has achieved a place in modern treatment algorithms for GER, elective surgical management of PUD remains subordinate to antisecretory and antibacterial strategies. However, patients who are refractory to standard medical regimens or experience complications of PUD such as bleeding or perforation may receive surgical therapy via a minimally invasive approach.

Management of Established Problems

Optimal management of cancer-related GI complications requires cooperation between the survivor's primary physician, gastroenterologist and surgeon. Conditions most often requiring intervention usually result from primary or secondary consequences of chronic inflammation or fibrosis of GI tissues. Esophagitis and gastritis are usually easily managed with a variety of pharmacologic agents, including H2 antagonists and proton pump inhibitors, which eliminate or reduce acid production by the parietal cells. Prokinetic agents are also helpful if acid reflux is contributing to chronic esophagitis. Adjunctive agents such as carafate, which binds to the proteins of denuded mucosa, may also be used as a physical barrier to mucosal irritation.

Chromosomal Anomalies

In addition to the typical phenotypic features of the syndrome, associated congenital cardiac and gastrointestinal abnormalities may be present. A third to a half of patients with Down's syndrome have congenital cardiac defects, of which one third are endocardial cushion defects, and the remainder are ventricular septal defects. Tetralogy of Fallot and atrial septal defects also occur, and there is an increased incidence of moyamoya disease. More than half of patients have bilateral hearing loss, of which many cases are attributable to anomalies of the inner and middle ear. Malformations of the gastrointestinal tract, including intestinal atresia and imperforate anus, occur in about 5 to 7 percent of patients, and there is a reported increased incidence of Hirschsprung's disease. Although abnormalities of T-lymphocyte function have been reported, no specific relationship of these to the infection rate has been established. Other associated abnormalities include gastroesophageal...

B lAryngotracheoesophageal cLEFT rEPAIR Daniel P Ryan MD

Laryngotracheoesophageal cleft is a rare, congenital anomaly that results from failure of separation of the trachea and esophagus (see Figure 6-4 in Chapter 6, Congenital and Acquired Tracheal Lesions in Children ).1,2 Early manifestations are related to the airway and feeding difficulties. Associated malformations should also be recognized. Many of these patients have foreshortened tracheas and most also have microgastria with severe gastroesophageal reflux. This description of technique for repair is limited to the most extensive clefts type III, which extends to the carina and type IV, in which the cleft extends into one or both mainstem bronchi. After securing the airway, the initial step in caring for these patients is to do a laparotomy and divide the stomach, placing a draining tube in the proximal aspect and a feeding tube in the distal part of the stomach. Because of the associated microgastria and the concurrent massive gastroesophageal reflux that these patients have, this...

Additional Information

99mTc-DTPA has been used for studies of gastroesophageal reflux and gastric emptying. In this case, scintigraphy is performed after oral administration of 99mTc-DTPA (10-20 MBq, 0.3-0.6 mCi) in a suitable liquid (300 ml), according to local practice. Sequential scintigraphy and static imaging may be performed. The patient's stomach is imaged at 5 and 10 min after drinking the liquid, and then every 5-15 min until the stomach activity has reached half the original value. The gastric emptying half-time is determined from a plot of percent activity versus time. Normal values are 10-15 min delayed emptying is observed with gastric ulcers, pyloric stenosis, vagotomy, and in the case of malignancy (Chadhuri 1974).

Methods of Diagnosis

The symptoms of pancreatic cancer are quite nonspecific (Table 11.4). Delays in diagnosis are not uncommon. Weight loss appears to be the most consistent finding. Despite a normal appetite, patients demonstrate a significant weight loss prior to other symptoms. Since more than 60 of pancreatic cancers appear in the head of the gland, jaundice is often a presenting symptom. Dark urine and light, clay-colored stools are associated with the jaundice and often, when the jaundice is quite profound, the patients complain of pruritus. Diarrhea due to biliary and or pancreatic duct obstruction can occur. Many patients also present early with vague abdominal pain and generalized dyspepsia.

The Timing of Technology Assessment

Not uncommonly, the rapid development of new technologies may antiquate the results of well-designed and performed clinical trials, even before completion or widespread diffusion of their results. This has been the case for medical treatments of cholelithiasis, such as extracorporeal shock wave lithotripsy, with the advent of laparoscopic cholecystectomy,47,48 and the assessment of gastroesophageal reflux disease drug therapy prior to the omeprazole era.49 Some groups have thus suggested a critical point at which the assessment of an emerging technology should be carried out50 with the ideal window alternately being determined as akin to the beginning of a feasibility study51 or the time at which opinion leaders of the innovating group

Posterior Glottic Stenosis

Tracheostomy Thyroid Cartilage

Posterior glottic stenosis is usually due to intubation, when an endotracheal tube lies in place too long or is too large a caliber, especially if the patient is awake and swallowing, because the natural point of maximum pressure of an oral endotracheal tube is at the posterior commissure of the larynx. Often, this problem is combined with a subglottic stenosis due to insertion of the too large endotracheal tube. From actual measurements done in anatomy laboratories, it has been shown that one should never use a larger than 6 mm endotracheal tube in a female patient. Many women can take larger than 6 mm, but a significant number have a cricoid lumen that will not permit larger than a 6 mm tube to pass atraumatically through it. Patients who have a prolonged intubation should be placed on medication to minimize gastric acid secretion, in case of gastroesophageal reflux. Reflux can lead to inflammatory changes that would add to those of intubation and help generate stenosis in the...

Ralph W Aye Lucius D Hill Stefan J M Kraemer

Gastroesophageal reflux disease (GERD) with its complications of heartburn, esophagitis, and pneumonitis is the most common abnormality of the upper gastrointestinal tract. Despite the high incidence of GERD, the pathophysiology of this disorder has been poorly understood until recently. Basically, gastroesophageal reflux occurs when the antireflux barrier fails. To understand the disorder as well as the principles of surgical correction, it is essential to understand the components of the antireflux barrier (ARB).

Anatomic Variation And Evaluation

Anus Squamocolumnar Junction

Esophageal reflux strictures tend to be one of three general varieties. Most reflux strictures are only 1 to 2 cm in Figure 13-1 Barium esophagograms demonstrating the most frequent type of esophageal reflux stricture a short, less than 2-cm stenosis (arrow) occurring at the esophagogastric junction just proximal to a sliding hiatal hernia. (From Orringer, M.B. Short esophagus and peptic stricture. In Sabiston, D.C., Jr., and Spencer, F.C. eds. Surgery of the Chest, 6th ed. Philadelphia, W.B. Saunders, 1995, p. 1059, with Figure 13-2 Barium esophagogram demonstrating an 8-cm-long esophageal reflux stricture that occurred after protracted vomiting. There is an associated sliding hiatal hernia. (From Orringer, M.B. Short esophagus and peptic stricture. In Sabiston, D.C., Jr., and Spencer, F.C. eds. Surgery of the Chest, 6th ed. Philadelphia, W.B. Saunders, 1995, p. 1060, with permission.) Regardless of which endoscopic grading system is used, such objectivity in describing the...

Mollie fancher Dailey 1894

Known as the Brooklyn Enigma, Mollie Fancher was alleged to have exhibited five distinct personalities. Around the age of fifteen, Fancher developed what her doctor labeled nervous indigestion. Doctors recommended horseback riding as a treatment. The therapy didn't work as intended in May 1864 Fancher was thrown off her horse. Her head hit the pavement and several of her ribs were broken. In spite of the blow to her head she appeared to recover. A year later, while climbing down from a streetcar, Fancher once again sustained a bad fall after being

Normal Pharyngeal Pressure

Upper Esophageal Sphincter Dysfunction

Figure 6-34 Sensitivity and specificity of diagnostic test for gastroesophageal reflux disease. (LES lower esophageal sphincter.) (From DeMeester, T.R , and Stein, H.J. Gastroesophageal reflux disease. In Moody, F.G., Jones, R.S., Kelly, K.A., et al. eds. Surgical Treatment of Digestive Disease, 2nd ed. Chicago, Year Book Medical Publishers, 1989, p. 67, with permission.) Figure 6-34 Sensitivity and specificity of diagnostic test for gastroesophageal reflux disease. (LES lower esophageal sphincter.) (From DeMeester, T.R , and Stein, H.J. Gastroesophageal reflux disease. In Moody, F.G., Jones, R.S., Kelly, K.A., et al. eds. Surgical Treatment of Digestive Disease, 2nd ed. Chicago, Year Book Medical Publishers, 1989, p. 67, with permission.)

Karen M Horton Bronwyn Jones Elliot K Fishman

Endoscopic studies are often considered the diagnostic modality of choice for the evaluation of esophageal pathology. However, radiologic studies continue to play a vital role in the diagnosis of many benign and malignant diseases of the esophagus. Although upper endoscopy can be used to evaluate the esophageal lumen and mucosa, it cannot be used to detect extrinsic disease and provides limited functional information. Contrast esophagography allows real-time visualization of esophageal peristalsis, thereby providing both functional and anatomic information. Nuclear scintigraphy allows evaluation and quantification of esophageal peristalsis and gastroesophageal reflux. Computed tomography (CT) is used to image the esophageal lumen and adjacent structures.

Research Unit for Plant Growth and Development Department of Botany University of Natal Pietermaritzburg Private Bag

S. africana-caerulea Used by European settlers as a remedy for coughs, colds and chest troubles, a tincture also for whooping cough and uterine troubles. An old household remedy for colic, diarrhoea, heartburn and indigestion prepared as a tea to which Epsom salt and lemon juice was added.

Hiram C Polk Jr Mark A Wilson

The discovery of the existence and pathophysiology of gastroesophageal reflux disease (GERD) proceeded in a sequential and orderly manner. Unfortunately, as a result of Allison's widely read and appreciated article, excessive emphasis was placed on the existence of a hiatal hernia, and insufficient emphasis was placed on the true underlying process of abnormal acid reflux. Not surprisingly, a large number of patients, often without significant acid reflux or esophagitis, underwent either transabdominal or transthoracic repair of hiatal hernias. Often the operations failed either anatomically or symptomatically because relatively few of the patients had symptoms that were related to the anatomic abnormalities described radiographically and discovered at operation. Many individuals in Western societies who are of middle or older age will have radiographically demonstrable hiatal hernias. Often, occasional heartburn may be present, but comparatively few patients have symptomatic reflux...

Indications For Esophagoscopy

Esophagoscopy should be performed when upper abdominal discomfort is associated with signs of organic disease, including anorexia or weight loss, or when it persists despite a trial of appropriate therapy. Dysphagia or odynophagia should always be evaluated endoscopically. Symptoms of gastroesophageal reflux disease that persist or progress in spite of proper therapy warrant endoscopic evaluation. Esophagoscopy is also indicated to confirm radiographic findings suggesting a neoplastic lesion, a gastric or esophageal ulcer, or an obstructing stricture or mass in the esophagus. Periodic esophagoscopy should be performed in all patients with Barrett's esophagus for surveillance for malignant degeneration and for follow-up of large ulcers on Barrett's esophagus to demonstrate healing. Esophagoscopy is used as the initial method of evaluation in most cases of acute gastrointestinal bleeding as an alternative to x-ray studies. Esophagoscopy is also indicated when surgical treatment of such...

Antisterility Vitamin In Human Beings

Among the gastrointestinal symptoms of thiamine deficiency are indigestion, severe constipation, anorexia, gastric atony, and hypochlorhydria. All these effects presumably result from failure of the smooth muscle and glands of the gastrointestinal tract to derive sufficient energy from carbohydrate metabolism.

Thomas R Eubanks Carlos A Pellegrini

Gastroesophageal reflux disease (GERD) is routinely treated through a laparoscopic approach. Paraesophageal hernias and esophageal dysmotility syndromes, especially achalasia, may be approached videoendoscopically but are less common clinical entities. Epiphrenic diverticula and benign soft tissue tumors are even less common, but experience with the laparoscopic approach is being reported. Esophagectomy for benign or malignant conditions can be accomplished with laparoscopic assistance but is practiced at very few centers. All of these procedures require advanced laparoscopic skills, including suturing, control of bleeding, and two-handed operative techniques. GASTROESOPHAGEAL REFLUX DISEASE Indications The indications for the laparoscopic treatment of GERD are the same as those for the open approach severe esophagitis, Barrett's esophagus, and incomplete resolution of symptoms or relapses while on medical therapy are the most common. The diagnosis of laryngeal or pharyngeal reflux...

Incidence And Importance Of The Hiatal Hernia Problem

Paraesophageal Hernia Anatomy

Although its exact prevalence in the normal population remains unknown, it is certain that hiatal hernia is the most common abnormality, reported on barium studies of the upper gastrointestinal tract. Women are more likely to be afflicted than men, the highest incidence occurring in the fifth and sixth decades of life. Skinner estimates that routine gastrointestinal series show hiatal hernia in 10 of the population, with 5 of this group having pathologic reflux. If these figures are correct, significant gastroesophageal reflux disease is present in more than 1 million Americans. To be sure, one may take issue with the fact that the radiologic examinations were presumably requested for upper gastrointestinal symptoms and that the reported frequency, therefore, is unnaturally high. Identification of the stomach above the hiatus, Figure 9-2 Pain patterns. The location of the discomfort from gastroesophageal reflux varies. Patients themselves shaded In the original sketches. 7. Belsey,...

Pure Cholinergic or Adrenergic Disorders

Its clinical features include insensitivity to pain and temperature, absence of tears, hypoactive corneal and tendon reflexes, and absence of fungiform papillae of the tongue. Patients with familial dysautonomia have poor suck and feeding responses, esophageal reflux with vomiting and aspiration, uncoordinated swallowing, episodic hyperhidrosis, vasomotor instability, postural hypotension, hypertensive crises, supersensitivity to cholinergic and adrenergic agents, and absent histamine flare. 39

Preface and acknowledgments

This atlas contains about 180 scanning electron microscopy (SEM) pictures, together with several explanatory figures, showing the essence of human cardiac development. Apart from serving a unique overview on cardiac development in the human embryo, this atlas enables the projection of experimental results in animals to the human situation. The material for this atlas is largely based on the collection of Prof. dr Gerd Steding, with additional material from the late Prof. dr Szabolcs Viragh. The differences in approaches and specific interests guarantee the diversity in images which is necessary to give a complete and extensive exposure of all spatial and temporal aspects of human cardiac development, as presented in this atlas.

Digestive Changes and Weight Gain

Because your system has slowed down, you'll suffer from constipation, hardening of stools, bloating (which may cause bad breath), poor appetite, and heartburn. The heartburn results because your food is not moving through the stomach as quickly, so acid reflux (where semidigested food comes back up the esophagus) may occur.

Therapy Options

Studies that compared medical and surgical therapy of symptomatic GERD have often suggested similar outcomes, although some indicate superior results for operative repair.1 Discussions of these issues continue and have been further stimulated by the TABLE 12-2 -- Non-operative Management of Gastroesophageal Reflux

Mark B Orringer

Esophageal reflux strictures result from the Inflammatory reaction that Is Induced In the esophagus by exposure to regurgitated gastric contents, both acid and alkaline.1 1 Why only some patients with gastroesophageal reflux develop strictures is unknown, but patients with reflux strictures tend to be older with a longer history of reflux and to have more reduced lower esophageal sphincter pressure and abnormal esophageal motility compared with reflux patients without strictures.1 Gastroesophageal reflux occurs independently of the presence of a hiatal hernia, and incompetence of the lower esophageal sphincter, not the size of the hernia, is the critical pathologic lesion. As a result of the esophageal epithelial burn caused by exposure to gastric contents, ulceration, submucosal edema, and inflammatory cellular infiltration occur. The inflammation may involve the muscular layers of the esophageal wall as well as periesophageal soft tissues. Surrounding mediastinal edema and...

Gastric Analysis

Refractory gastroesophageal reflux disease. The measurement of gastrin response to secretin injection, calcium infusion, and or a test meal has in large part replaced the more cumbersome gastric acid analysis.1 A formal gastric acid analysis requires a nasogastric or orogastric tube with continuous suction. The tube is placed in the dependent portion of the stomach under fluoroscopic guidance. The fluid collected during the first 15 minutes is discarded. During the next 60 minutes, aliquots are collected during four consecutive 15-minute intervals. Gastric contents are measured for volume and pH. BAO of less than 5 mEq hr confirms the absence of hypersecretion. Patient preparation includes discontinuation of H2 -receptor antagonists for 4 to 7 days and proton pump inhibitors for 7 days. Exceptions include patients with

General Principles

Most patients who present for reoperation on the stomach had the initial surgery for a benign condition, such as gastroesophageal reflux, morbid obesity, or peptic ulcer. Although each of these conditions can indubitably lead to death in a certain percentage of the population (e.g., from adenocarcinoma of the esophagus, heart disease, or upper gastrointestinal GI bleeding, respectively), the individual patient usually had the original surgery for symptomatic relief. It is therefore regrettable that for a portion of these patients, surgical therapy is destined to fail, or they will become disabled by an operation that was intended to improve their quality of life. This is sometimes due to an ill-conceived or improperly performed operation. Medical progress has led to new operations for certain patient groups (e.g., laparoscopic fundoplication for intractable gastroesophageal reflux disease), and fewer operations for others (e.g., intractable peptic ulcer). Young surgeons recently out...


Worldwide incidence varies widely, but 10 to 12 appears to be a reasonable estimate. I J The exact pathogenesis of postsclerotherapy-induced esophageal strictures remains unclear. The major determinant is thought to be tissue reaction to the sclerosant solutions, but other factors, including alterations in esophageal motility and acid reflux, may be contributory. Kochhar et al. evaluated 129 patients who underwent


Fig. 12.6 Oesophageal pH recording showing acid reflux in sleep. The oesophageal pH frequently falls below 4 at night, whereas it rarely does so during the day. The refluxed gastric acid may stay in contact with the oesophageal and pharyngeal mucosa for prolonged periods because of the infrequency of swallowing and reduced peristalsis after swallowing. This slow clearance of acid contributes to oesophagitis. Gastroesophageal reflux is common in obstructive sleep apnoeas, partly because of the association with obesity, but also because of the fluctuations in intrathoracic pressure during the apnoeas. If swallowing does occur more readily it may lead to sufficiently frequent arousals to cause excessive daytime sleepiness. Reflux can be diagnosed by continuous oesophageal pH recordings which show the duration as well as the extent of the fall in pH (Fig. 12.6). The frequency of episodes of reflux is usually taken as the number in which the pH remains less than 4 for at least 12 s. 1...

Belsey Gastroplasty

Operation Belsey

Figure 13-10 Combined Thal fundic patch operation and Nissen fundoplication for esophageal reflux stricture. Top panel A, Longitudinal incision of the stricture. B, Opened stricture. C, Transverse closure of the incision, which widens the area of stenosis but shortens the esophagus. Middle, A split-thickness skin graft has been sutured to the gastric fundus to provide epithelial continuity within the esophagus. Bottom panel A, The fundic path is sutured into the esophageal defect. B, A fundoplication is completed for reflux control. (From Thomas, H.F., Clarke, J.M., Rayl, J.E., et ah Results of the combined fundic patch-fundoplication operation in the treatment of reflux esophagitis with stricture. Surg. Gynecol. Obstet, 135 241, 1972, by permission of Surgery, Gynecology and Obstetrics.)

Clement A Hiebert

GASTROESOPHAGEAL REFLUX PERSPECTIVES ON THE HISTORY OF AN IDEA Ideas become fossilized in names. For the first half of the twentieth century, surgeons were mesmerized by the idea that something called a hernia, which looked like a hernia and caused pain in the area of the affliction, should be managed like a hernia. Nissen,1 prot g of the renowned Ferdinand Sauerbruch, recalled that his mentor at the turn of the century was so seduced by the implication of the diagnosis that he would actually section the hiatal rim of an ordinary sliding hiatal hernia to release the supposedly throttled stomach. For more than five decades, textbooks of surgery relegated hiatal hernia to chapters dealing with scrotal, umbilical, and other coelomic ruptures. Thoracic and abdominal surgeons, who had yet to learn about gastroesophageal reflux, knew threatened turf when they saw it and jousted over the advantages of pushing or pulling on their migrant quarry. Regardless of from which side of the...

Idiopathic Stenosis

Grillo Anastomosis

Cicatricial stenosis with a lesser inflammatory component, localized in the subglottic larynx and upper trachea, occurs without known cause.23,24 This process is labelled idiopathic laryngotracheal stenosis (Figure 14-9). None of these patients have been intubated for ventilation or have suffered external or internal trauma to the trachea. The lesions are not congenital. There are no findings in this group of patients of associated mediastinal fibrosis or lymph node involvement by any pathologic process. Few patients have histories or findings suggesting esophageal reflux and aspiration. None have had specific or nonspecific tracheal infections, nor did they later develop manifestations of systemic disease such as polychondritis, or amyloid. A few with stenosis due to Wegener's granulomatosis confined to the upper airway were initially misdiagnosed as idiopathic stenosis, prior to routine screening with an anti-neutrophil cytoplasmic antibody (ANCA) test. In a series of 73 patients,...


The ongoing extension of laparoscopic techniques to gastric surgery has not eliminated the risks of perforation. Veress needle insertion for establishing pneumoperitoneum may result in the perforation of any intra-abdominal organ. Laparoscopic fundoplication is now widely used for gastroesophageal reflux disease. Although morbidity rates are low, the procedure may perforate the esophagus or stomach, with the


Pilling Esophagoscope

Figure 13-5 Equipment needed for the initial evaluation of an esophageal reflux stricture a ruler for precise localization of the pathology (in centimeters from the incisor teeth) a biopsy forceps (and cytology brush, not shown) to exclude carcinoma with biopsies and brushings of the stricture and gum-tipped Jackson dilators, manipulated gently through the stricture, to assess the length and pliability of the obstruction. The No. 26 French dilator is the largest size that passes through the standard 45-cm rigid esophagoscope.

Physical Examination

A complete head and neck examination should be performed in the initial patient evaluation. The presence of lymphadenopathy may suggest sarcoidosis, chronic serous otitis media could be associated with Wegener's granulomatosis, or laryngeal findings of posterior glottic erythema and edema may reveal underlying gastroesophageal reflux.

Victor F Trastek

The initial explanation of this condition was that the aberrant mucosa was entirely congenital, but the frequent association of Barrett's esophagus with hiatal hernia, hypotensive lower esophageal sphincter, and symptomatic reflux with a positive acid reflux test result has overwhelmingly suggested that the condition is an acquired process that is a consequence of chronic gastroesophageal and duodenal content reflux. 9 17

Table 9 Continued

Alcohol and tobacco use poor diet (e.g. lacking fresh fruit and vegetables) chronic gastro-oesophageal reflux disease (GERD) for the cancer, as well as for Barrett oesophagus genetic syndrome (e.g. tylosis) Barrett oesophagus Patients at high risk of oesophageal cancer (e.g. GERD, smokers, geographic ethnic, such as Linxian, China) Abbreviations ASA, acetyisalicylic acid BCC, basal cell carcinoma BBI, Bowman-Birk protease inhibitor BCG, Bacillus Calmette Guerin CIN, cervical intraepithelial neoplasia COX, cyclooxygenase DCIS, (breast) ductal carcinoma In situ DFMO, 2-dimethylfluorornithine DHEA, dehydroepiandrosterone EGF, epidermal growth factor EGFR, epidermal growth factor receptor FAP, familial adenomatous polyposis GERD, gastro-oesophageal reflux disease GGT, 7-gluta-myltransaminase HBV, hepatitis B virus HCV, hepatitis C virus HNPCC, hereditary nonpolyposis colorectal cancer (syndrome) HPV, human papilloma virus IGF, insulin-like growth factor NOS, inducible nitric oxide...

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