Tailored or Routine Addition of an Antireflux Fundoplication in Laparoscopic Large Hiatal Hernia Repair: A Comparative Cohort Study

Contains fulltext : 98394.pdf (publisher's version ) (Open Access)BACKGROUND: There is controversy about the tailored or routine addition of an antireflux fundoplication in large hiatal hernia (type II-IV) repair. We investigated the strategy of selective addition of a fundoplication in patients with a large hiatal hernia and concomitant gastroesophageal reflux disease. METHODS: Between 2002 and 2008, 60 patients with a large hiatal hernia were evaluated preoperatively and 12 months after surgery by reflux-related symptoms, upper endoscopy, and esophageal 24-h pH monitoring. In patients with preoperatively documented gastroesophageal reflux disease, an antireflux fundoplication was added during hiatal hernia repair. RESULTS: An antireflux procedure was added in 35 patients and 25 patients underwent hiatal hernia repair only. Preoperative symptoms were improved or resolved in 31 patients (88.6%) in the group who had fundoplication and in 20 patients (87.0%) in the group who did not have fundoplication. In patients with fundoplication, esophagitis was present in 6 patients (22.2%) after surgery and abnormal esophageal acid exposure persisted in 11 (39.3%). Seven patients (38.9%) with hernia repair only developed abnormal esophageal acid exposure, and esophagitis was postoperatively generated in five (27.8%). In neither group did patients have new onset of daily heartburn or dysphagia. CONCLUSIONS: In patients with a large hiatal hernia associated with gastroesophageal reflux disease, addition of a fundoplication during hernia repair yields acceptable reduction of symptoms and does not generate symptomatic side effects. Objective control of reflux, however, is only moderate. Omission of an antireflux procedure in the absence of gastroesophageal reflux disease induced esophagitis in 28% and abnormal esophageal acid exposure in 39% of patients. Therefore, routine addition of an antireflux fundoplication should be recommended

Large expert-curated database for benchmarking document similarity detection in biomedical literature search

Document recommendation systems for locating relevant literature have mostly relied on methods developed a decade ago. This is largely due to the lack of a large offline gold-standard benchmark of relevant documents that cover a variety of research fields such that newly developed literature search techniques can be compared, improved and translated into practice. To overcome this bottleneck, we have established the RElevant LIterature SearcH consortium consisting of more than 1500 scientists from 84 countries, who have collectively annotated the relevance of over 180 000 PubMed-listed articles with regard to their respective seed (input) article/s. The majority of annotations were contributed by highly experienced, original authors of the seed articles. The collected data cover 76% of all unique PubMed Medical Subject Headings descriptors. No systematic biases were observed across different experience levels, research fields or time spent on annotations. More importantly, annotations of the same document pairs contributed by different scientists were highly concordant. We further show that the three representative baseline methods used to generate recommended articles for evaluation (Okapi Best Matching 25, Term Frequency-Inverse Document Frequency and PubMed Related Articles) had similar overall performances. Additionally, we found that these methods each tend to produce distinct collections of recommended articles, suggesting that a hybrid method may be required to completely capture all relevant articles. The established database server located at https://relishdb.ict.griffith.edu.au is freely available for the downloading of annotation data and the blind testing of new methods. We expect that this benchmark will be useful for stimulating the development of new powerful techniques for title and title/abstract-based search engines for relevant articles in biomedical research.Peer reviewe

pH testing - The basics

Esophageal pH testing, first described more than 3 decades ago, has become incorporated in the diagnostic armamentarium of most gastroenterologists. Using commercially available sophisticated equipment and software, the procedure is easy to perform and the analysis of the signals is automated. Nevertheless, users of esophageal pH testing must remain aware of the technical pitfalls that may stand in the way of the acquisition of meaningful results. Esophageal pH monitoring provides quantitative information about the exposure of the distal esophagus to acid. The technique makes it also possible, however, to quantify the correlation between symptom episodes and reflux events. In clinical practice, the latter is often more relevant than information on esophageal acid exposur

Advances in esophageal motor disorders

Purpose of review Esophageal motor disorders, often leading to dysphagia and chest pain, continue to pose diagnostic and therapeutic problems. In the past 12 months important new information regarding esophageal motor disorders was published. This information will be reviewed in this paper. Recent findings A number of studies have addressed the issue of heterogeneity in achalasia, the best defined esophageal motility disorder. The spastic esophageal motility disorders nutcracker esophagus and diffuse esophageal spasm may coexist with gastroesophageal reflux disease, which has consequences for the management of patients with these disorders. The entity labelled ineffective esophageal motility is associated with reflux esophagitis, but also with morbid obesity. For the detection of disordered transit caused by ineffective esophageal motility, application of intraluminal impedance monitoring in conjunction with manometry leads to improved diagnosis. New data on the effect of Nissen fundoplication on esophageal motility were published during the last year. Summary Recent knowledge on the heterogeneity of achalasia and the association of spastic esophageal motor disorders and ineffective motility with reflux disease will help the clinician in the management of patients with these disorders

Management of the patient with incomplete response to PPI therapy

Proton pump inhibitors (PPIs) remove most of the acid from the gastroesophageal refluxate. However, PPIs do not eliminate reflux and the response of specific GERD symptoms to PPI therapy depends on the degree to which acid drives those symptoms. PPIs are progressively less effective for heartburn, regurgitation, chest pain and extra-oesophageal symptoms. Hence, with an incomplete PPI response, obtaining an accurate history, detailing which symptoms are 'refractory' and exactly what evidence exists linking these symptoms to GERD is paramount. Reflux can continue to cause symptoms despite PPI therapy because of persistent acid reflux or weakly acidic reflux. Given these possibilities, diagnostic testing (pH or pH-impedance monitoring) becomes essential. Antireflux surgery is an alternative in patients if a clear relationship is established between persistent symptoms, particularly regurgitation, and reflux. Treating visceral hypersensitivity may also benefit the subset of GERD patients whose symptoms are driven by this mechanis

Reproducibility of multichannel intraluminal electrical impedance monitoring of gastroesophageal reflux

OBJECTIVE: Esophageal impedance measurement is a novel method for gastroesophageal reflux monitoring. Reproducibility is an important aspect of every biomedical test. The aim of this study was therefore to asses the reproducibility of gastroesophageal reflux monitoring using impedance measurements. METHODS: Impedance and pH signals were recorded in 20 healthy volunteers during 90-min postprandial periods on two separate days. Hourly rates of gas, liquid, and mixed gas-liquid reflux episodes were measured in each recording period as well as percentage of time with pH < 4 and rate of acid reflux episodes. As a quantitative description of inter- and intraindividual variation for each variable, the mean percentage of covariation (100 x SD/mean: %COV) was calculated. As a second measure for reproducibility, Kendall's coefficients of concordance (W values) were calculated. RESULTS: For all variables, interindividual %COV was at least 50% higher than intraindividual %COV. Statistically significant concordances were found for gas reflux (W = 0.81, p= 0.04) and mixed reflux (W = 0.85, p= 0.03) while concordance for liquid reflux tended to be significant (W = 0.75, p= 0.08). This was comparable to the reproducibility of the number of acid reflux episodes and percentage of time with pH < 4 (W = 0.78, p= 0.05 and W = 0.88, p= 0.02, respectively). CONCLUSIONS: Postprandial gastroesophageal reflux data assessed with impedance monitoring are as reproducible as assessed with pH monitorin

Aerophagia:Excessive Air Swallowing Demonstrated by Esophageal Impedance Monitoring

BACKGROUND & AIMS: Patients with aerophagia suffer from the presence of an excessive volume of intestinal gas, which is thought to result from excessive air ingestion. However, this has not been shown thus far. The aim of this study was therefore to assess swallowing and air swallowing frequencies in patients with Suspected aerophagia. METHODS: Ambulatory 24-hour pH-impedance monitoring was performed in patients in whom excessive amounts of intestinal gas were visualized on plain abdominal radiograms. All patients had symptoms of bloating, abdominal distention, flatulence, or excessive belching. Reflux parameters and the number of swallows and air swallows were assessed. RESULTS: The most common symptoms were bloating, abdominal distention, and constipation. Only 3 patients reported excessive belching and 1 patient reported flatulence as their predominant symptom. During the 24-hour measurement, patients showed high incidences of air swallows (521 +/- 63) and gastric belches (126 +/- 37). Patients had normal swallowing frequency (741 +/- 71). CONCLUSIONS: This study presents objective parameters that confirm the existence of excessive air swallowing or aerophagia using esophageal impedance monitoring