Gastroparesis is a condition in which a human stomach cannot empty itself of food in a normal manner. Gastroparesis disorder is also known as delayed gastric emptying.
Dr Pravin John and Dr John Thanakumar, Anurag Hospital, Coimbatore present the differences between metabolic and obesity surgery - dept of advanced laparoscopy and obesity
GERD is most common gastric problem in community affecting large number of people. Diagnosis and management is very simple with understanding.
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
https://drdhavalmangukiya.com/
Surgical management of gastroesophageal reflux disease (GERD) and hiatal hernia is an approach used when conservative treatments fail to provide adequate relief or in cases where complications arise. GERD is a condition characterized by the backward flow of stomach acid and contents into the esophagus, leading to symptoms such as heartburn, regurgitation, and chest pain. Hiatal hernia, on the other hand, occurs when a portion of the stomach protrudes through the diaphragm into the chest cavity.
The surgical treatment of GERD and hiatal hernia aims to reinforce the lower esophageal sphincter (LES) and repair the anatomical defect in the diaphragm. This is typically achieved through a procedure called fundoplication, which involves wrapping a portion of the upper stomach (fundus) around the lower esophagus to create a new valve-like mechanism. This reinforces the LES and helps prevent the backflow of stomach acid into the esophagus.
There are different surgical techniques available for fundoplication, including open surgery and minimally invasive procedures such as laparoscopic or robotic-assisted surgery. Laparoscopic surgery involves making small incisions in the abdomen and using specialized instruments and a tiny camera to perform the procedure. Robotic-assisted surgery utilizes robotic arms controlled by the surgeon to perform precise movements during the operation.
The advantages of minimally invasive techniques over traditional open surgery include smaller incisions, reduced postoperative pain, faster recovery, and shorter hospital stays. However, the choice of surgical approach depends on various factors, including the patient's overall health, the size of the hiatal hernia, and the surgeon's expertise.
Surgical management of GERD and hiatal hernia can provide long-term relief from symptoms and improve the quality of life for many patients. However, as with any surgery, there are potential risks and complications involved, such as infection, bleeding, difficulty swallowing, and gas-related discomfort. It is important for patients to discuss the potential benefits and risks with their healthcare provider and undergo a thorough evaluation before considering surgical intervention.
Overall, surgical management plays a crucial role in the treatment of GERD and hiatal hernia, particularly for individuals who do not respond well to medication or lifestyle modifications. It offers an effective solution to restore the normal functioning of the lower esophageal sphincter and repair the anatomical defect, providing relief from symptoms and reducing the risk of complications associated with these conditions.
Gastroparesis is a condition in which a human stomach cannot empty itself of food in a normal manner. Gastroparesis disorder is also known as delayed gastric emptying.
Dr Pravin John and Dr John Thanakumar, Anurag Hospital, Coimbatore present the differences between metabolic and obesity surgery - dept of advanced laparoscopy and obesity
GERD is most common gastric problem in community affecting large number of people. Diagnosis and management is very simple with understanding.
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
https://drdhavalmangukiya.com/
Surgical management of gastroesophageal reflux disease (GERD) and hiatal hernia is an approach used when conservative treatments fail to provide adequate relief or in cases where complications arise. GERD is a condition characterized by the backward flow of stomach acid and contents into the esophagus, leading to symptoms such as heartburn, regurgitation, and chest pain. Hiatal hernia, on the other hand, occurs when a portion of the stomach protrudes through the diaphragm into the chest cavity.
The surgical treatment of GERD and hiatal hernia aims to reinforce the lower esophageal sphincter (LES) and repair the anatomical defect in the diaphragm. This is typically achieved through a procedure called fundoplication, which involves wrapping a portion of the upper stomach (fundus) around the lower esophagus to create a new valve-like mechanism. This reinforces the LES and helps prevent the backflow of stomach acid into the esophagus.
There are different surgical techniques available for fundoplication, including open surgery and minimally invasive procedures such as laparoscopic or robotic-assisted surgery. Laparoscopic surgery involves making small incisions in the abdomen and using specialized instruments and a tiny camera to perform the procedure. Robotic-assisted surgery utilizes robotic arms controlled by the surgeon to perform precise movements during the operation.
The advantages of minimally invasive techniques over traditional open surgery include smaller incisions, reduced postoperative pain, faster recovery, and shorter hospital stays. However, the choice of surgical approach depends on various factors, including the patient's overall health, the size of the hiatal hernia, and the surgeon's expertise.
Surgical management of GERD and hiatal hernia can provide long-term relief from symptoms and improve the quality of life for many patients. However, as with any surgery, there are potential risks and complications involved, such as infection, bleeding, difficulty swallowing, and gas-related discomfort. It is important for patients to discuss the potential benefits and risks with their healthcare provider and undergo a thorough evaluation before considering surgical intervention.
Overall, surgical management plays a crucial role in the treatment of GERD and hiatal hernia, particularly for individuals who do not respond well to medication or lifestyle modifications. It offers an effective solution to restore the normal functioning of the lower esophageal sphincter and repair the anatomical defect, providing relief from symptoms and reducing the risk of complications associated with these conditions.
I meccanismi del danno gastrico e la patologia H. Pylori correlataASMaD
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Ph impedenziometria nella MRGE: quando, come e perchèASMaD
Presentazione a cura della Dottoressa Francesca Galeazzi - "Malattia da reflussogastroesofageo e infezione da Helicobacter Pylori: old topics?" - Roma 11/05/2019
Presentazione a cura del Professor Enrico Corazziari - "Malattia da reflussogastroesofageo e infezione da Helicobacter Pylori: old topics?" - Roma 11/05/2019
Cambiamenti di popolazione e flussi migratori: cambiano anche le malattie met...ASMaD
Presentazione a cura della Dottoressa Migneco Maria Giuseppina - "Incontri endocrinologici AME LAzio - L'endocrinologia nel SSN: prospettive e nuove problematiche" - Roma 17/12/2018
Tiroide: chi decide quale intervento e per chi?ASMaD
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Tiroide: Integrazione tra elementi nutriacetici e farmacologia: utile o inutile?ASMaD
Presentazione a cura del Dottor Roberto Cesareo - "Incontri endocrinologici AME LAzio - L'endocrinologia nel SSN: prospettive e nuove problematiche" - Roma 17/12/2018
L'ecografia tiroidea: strumento cruciale nella gestione clinica?ASMaD
Presentazione a cura del Dottor Guglielmi Rinaldo - "Incontri endocrinologici AME LAzio - L'endocrinologia nel SSN: prospettive e nuove problematiche" - Roma 17/12/2018
Il chirurgo e la tiroide oggi un rapporto in crisi?ASMaD
Presentazione a cura del Dottor Luca Piantoni e del Dottor Francesco Pedicini - "TIROIDE 2018 Nuovi approcci diagnostici e terapeutici" - Roma 24/11/2018
Presentazione a cura della Dottoressa Rosella Pasqualoni e del dottor Gregorio Reda - "TIROIDE 2018 Nuovi approcci diagnostici e terapeutici" - Roma 24/11/2018
1. Endoscopia nella
MRGE: quando,
come e perché
Marco Ferrara
UOSD di Gastroenterologia ed
Endoscopia Digestiva
Ospedale Fatebenefratelli, Isola
Tiberina - Roma
2. Scientific Society guidelines on
Gastroesophageal Reflux in adults
World Gastroenterology Organisation (WGO): Global guidelines on GERD – Global perspective on gastroesophageal reflux disease (2017)
Canada
Choosing Wisely Canada: Don't maintain long term Proton Pump Inhibitor (PPI) therapy for gastrointestinal symptoms without an attempt to stop/reduce PPI at least once per
year in most patients (2017)
Canadian Association of Gastroenterology (CAG): Canadian consensus conference on the management of gastroesophageal reflux disease in adults, update (2004)
United States
American College of Gastroenterology (ACG): Guidelines for the diagnosis and management of gastroesophageal reflux disease (2013)
Choosing Wisely: For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump
inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals (2012)
Society of American Gastrointestinal and Endoscopic Surgeons (SAGES): Guidelines for surgical treatment of gastroesophageal reflux disease (GERD) (2010)
American Gastroenterological Association (AGA): Medical position statement on the management of gastroesophageal reflux disease (2008)
Europe
European Association of Endoscopic Surgery (EAES): Recommendations for the management of gastroesophageal reflux disease (2014)
United Kingdom
National Institute for Health and Care Excellence (NICE): Clinical guideline on gastro-oesophageal reflux disease and dyspepsia in adults – Investigation and
management (2014)
Australia
Gastroenterological Society of Australia (GESA): Gastro-oesophageal reflux disease in adults, clinical update (2017)
Choosing Wisely Australia: Don't use proton pump inhibitors (PPIs) long term in patients with uncomplicated disease without regular attempts at reducing dose or
ceasing (2016)
Choosing Wisely Australia: Do not continue prescribing long term proton pump inhibitor (PPI) medication to patients without attempting to reduce the medication down to
the lowest effective dose or cease the therapy altogether (2016)
Japan
Japanese Society of Gastroenterology (JSGE): Evidence-based clinical practice guidelines for GERD, 2nd edition (2015)
3. Dati epidemiologici e appropriatezza
MRGE Esofago di Barrett (EB)
Definizione: presenza di pirosi o
rigurgito almeno 2 vv /sett.
Prevalenza 10-20 % nel mondo
occidentale (5% in Asia)
Incidenza 0.5% /anno
Pirosi nel 22%, rigurgito nel 16%
nell’ultimo mese, rispettivamente
significativo (> 2 vv /sett.) nel 6 e
3%
Prevalenza EB nella popolazione con
MRGE stimata 5-15%
Prevalenza EB nella popol. gen. difficile
da stimare, dati disponibili 1.3 e 1.6 %
I numeri non autorizzano le autorità
sanitarie a programmare uno screening
di popolazione per identificare
precocemente l’EB
(BOB CAT: A large-scale review and Delphi consensus for management of
Barrett’s esophagus with no dysplasia, indefinite for, or low-grade dysplasia,
Bennett C et al., Am J Gastroenterol 2015)
Epidemiology of gastro-oesophageal reflux disease:
a systematic review - Dent J, Gut. 2005
The Montreal definition and classification of GERD:
a global evidence-based consensus -Vakil N et al.,Am J Gastroenterol. 2006
Prevalence of precancerous and other metaplasia in the distal
oesophagus and g-oe junction, Johansson J.,Scand J Gastroenterol 2005
Gastro-oesophageal reflux symptoms, oesophagitis and Barrett’s
oesophagus in the general population: the Loiano–Monghidoro study.
Zagari R et al., Gut 2008
High prevalence of gastroesophageal reflux symptoms and esophagitis
with or without symptoms in the general adult Swedish population:
a Kalixanda study report. Ronkainen J, et al.,Scand J Gastroenterol 2005
4. Da Sikkema M, de Jonge PJ, Steyerberg EW et al. Risk of esophageal adenocarcinoma and mortality in patients with Barrett's esophagus:
a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2010
Cause di morte in pz con EB
5. Rischio di adenoca esofageo
Yearly risk among pz > 50 ys with heartburn 0.04%
Shaheen N, JAMA 2002
Cancer incidence as a function of age
Rubenstein JH, Am J Gastroenterol 2011
Upper Endoscopy for Gastroesophageal Reflux Disease: Best Practice Advice From
the Clinical Guidelines Committee of the American College of Physicians
Ann Intern Med 2012
6. EGDs: quando
“Upper endoscopy is not required in the presence of
typical GERD symptoms of heartburn or regurgitation
We recommend an upper endoscopy if the diagnosis of
GERD is unclear and to evaluate alarm features or
abnormal imaging if not performed within the last
three months.
Upper endoscopy should also be performed to screen
for Barrett’s esophagus in patients with risk factors”.
Guidelines for the diagnosis and management of gastroesophageal reflux disease
Katz, Am J Gastroenterol. 2013
7. Indicazioni ad EGDs nella MRGE
Sintomi d’allarme Fattori di rischio per EB
Nuovi sintomi in età ≥ 50 aa
Sospetta emorragia digestiva
(ematemesi, melena)
Anemia sideropenica
Anoressia
Calo ponderale
Disfagia
Odinofagia
Vomito persistente
Familiarità neopl. spec. di 1°
Sintomi da RGE da oltre 5-10 aa
Età > 50
Sesso maschile
Razza bianca
Ernia gj
Obesità
Reflusso notturno
Tabagismo
Familiarità di 1° per EB o
adenoca esofageo
8. EGDs nella MRGE: quando
Sempre in caso di: “if the diagnosis of GERD is
unclear …” :
sintomi d’allarme
fattori di rischio per EB
controllo esofagite severa
(LA classe C e D)
sorveglianza esofago di
Barrett e complicanze
prima e dopo chirurgia anti-
reflusso
sintomi refrattari (20-40%)
sintomi anche atipici, sosp.
reflusso non acido (5%),
persistenti o ricorrenti,
prima di altre indagini
(DD con NERD, pirosi funzionale,
esofago ipersensibile, discinesie)
sospetta esofagite eosinofila
11. Approccio diagnostico:
valutare la complessità
Limiti della sintomatologia anche tipica (riferita da 1/3
dei pz con dispepsia funzionale, specie EPS)
Limiti dell’esame endoscopico nella MRGE:
specifico, non sensibile (NERD nel 70-80%)
Importanza dei sintomi non tipici (spesso neanche
associati a quelli tipici, persistenti e ricorrenti)
Ruolo dei farmaci, sintomi e danni iatrogeni
Il 32.8% dei soggetti con esofagite ed il 46.2% di
quelli con EB non hanno sintomi da reflusso
Gastro-oesophageal reflux symptoms, oesophagitis and Barrett's oesophagus in
the general population: the Loiano-Monghidoro study, Zagari et al, Gut. 2008
12. Sintomi refrattari alla terapia
Assenza di risposta terapeutica dopo 6-8 sett di IPP a dose standard (o
a doppia dose in caso di sintomi atipici)
Da Richter JE. Review article: extraoesophageal manifestations of gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2005
13. Laringite da
reflusso
quadro laringoscopico aspecifico
genesi spesso multifattoriale
EGDs poco sensibile, in genere
non indicata in assenza di sintomi
tipici o d’allarme
terapia con IPP poco efficace,
soprattutto in assenza di sintomi
tipici ed in presenza di tosse o
raucedine
la pH impedenzometria
(e la pH metria faringea - Restech)
indicate in presenza di sintomi
refrattari o ricorrenti , ma spesso
non dirimenti e di limitata
disponibilità a fronte della
diffusione del fenomeno
Laryngeal signs and symptoms and
gastroesophageal reflux disease (GERD):
a critical assessment of cause and effect
association.
Vaezi et al., Clin Gastroenterol Hepatol 2003
Reflux finding score.
The validity and reliability of the reflux
finding score (RFS). Belafsky PC
Laryngoscope 2001
Proton Pump Inhibitor Therapy for the
Treatment of Laryngopharyngeal Reflux.
A Meta-Analysis of Randomized Controlled Trials.
Guo H et al., J Clin Gastroenterol 2016
14. Abuso diagnostico e spesa sanitaria
nella sintomatologia atipica
Impegno economico in miliardi di dollari in USA (stima) correlato al management diagnostico-
terapeutico di pazienti con sintomi tipici di MRGE, cancro, reflusso extra-esofageo (EER) o
cardiopatia. Da Ates F, Vaezi MF. Approach to the patient with presumed extraoesophageal GERD. Best Pract Res Clin Gastroenterol 2013
15. Esofagite Eosinofila (EoE)
Prevalenza nella popolazione generale: 0.4-4/1000, 43-52/100.000
Prevalenza nei pz sintomatici (TDS) 5-16%
Si presenta nel 10% dei casi con sintomi da RGE refrattari a terapia
Fattori di rischio: sesso maschile, giovane età, diatesi
allergica/atopica, disfagia ricorrente
Prevalence of oesophageal eosinophils and eosinophilic oesophagitis in adults: the population based Kalixanda study.
Ronkainen J, et al Gut 2007
Diagnosis and Management of Eosinophilic Esophagitis. Dellon ES et al., Clin Gastroenterol Hep 2012;
Prevalence of eosinophilic esophagitis in an adult population undergoing upper endoscopy: a prospective study.
Veerappan GR et al., Clin Gastroenterol Hepatol 2009;
Eosinophilic esophagitis in patients with refractory gastroesophageal reflux disease.
Foroutan M et l.,Dig Dis Sci 2010
16. 1 EGDs “life-time”
nella MRGE “long-standing”?
Nel pz adulto-anziano i sintomi tendono a ridursi mentre può aumenta re la severità
dell’esofagite
Prevale l’opinione che la MRGE abbia un modesto tasso di progressività dalle forme
non erosive verso quelle erosive , per lo più di tipo lieve (16% a 5 aa, anche in
trattamento)
La maggior parte delle diagnosi di adenoca esofageo sono effettuate su pz che non
avevano mai subito un esame endoscopico
Receipt of previous diagnoses and endoscopy and outcome from esophageal adenocarcinoma:
a population-based study with temporal trends – Cooper GS et al., Am J Gastroenterol 2009
Heartburn severity underestimates erosive esophagitis severity in elderly patients with gastroesophageal
reflux disease - Johnson DA et al., Gastroenterology 2004
Gastroesophageal reflux disease is a progressive disease – PaceF et al., Dig Liv Dis 2007
Evolution of gastro-oesophageal reflux disease over 5 years under routine medical care – the
ProGERD study. - Malfertheiner P et al.,Aliment Pharmacol Ther 2012
17. EGDs nella MRGE: come
Sospensione IPP 2-4 sett prima (migliora la sensibilità)
Classificazioni delle lesioni: LA, Parigi, Praga, dopo
corretta identificazione di giunzione EG, linea “z”, jatus diaframmatico
AGA technical review on the management of Barrett’s esophagus. Spechler SJ et al.,Gastroenterology 2011
20. Campionamento bioptico
rinviare biopsie per EB
dopo terapia in presenza di
esofagite
protocollo di Seattle per EB
biopsie distinte in esofago sup. ed
inf. per EoE
biopsie G per Hp sempre o in
pz selezionati?
AGA technical review on the management of Barrett’s esophagus. Spechler SJ et al.,Gastroenterology 2011
Endoscopic mucosal tissue sampling, ASGE GL 2013
22. L’ernia gastrica
jatale
• La diagnosi endoscopica è sovrastimata
• “Scivolamenti” della giunzione squamo-colonnare sopra l’impronta
diaframmatica < 2 cm. NON consentono la diagnosi
• Solo ernie di grosse dimensioni sono correlate alla presenza dell’esofagite
• La maggior parte delle ernie “piccole “ è asintomatica
• L’uso delle classificazioni di Hill e ZAP può aiutare a porre diagnosi
corretta di ernia ed ipotizzare la presenza di metaplasia
Hill classification is superior to the axial length of a hiatal hernia for
assessment of the mechanical antireflux barrier at the gastroesophageal
junction, Hansdotter et al., Endoscopy Open Int 2016
Endoscopic assessment of the “Z-line” (squamocolumnar junction)
appearance: reproducibility of the ZAP classification among
endoscopists – Wallner B et al., GIE 2002
23. EGDs nella MRGE: perché
Confermare la diagnosi (ERD) nei soggetti a rischio
Selezionati i pz a rischio (EB, esofagite severa), programmarne la
sorveglianza
Valutare eventuali complicanze (ed il relativo trattamento)
Ipotizzare patologia di esclusione nei pz refrattari o con sintomi
ricorrenti: NERD, pirosi funzionale, EoE, esofago “ipersensibile”,
reflusso “non acido”, con indicazione ad eventuali diverse indagini
Orientare e calibrare la terapia con IPP (step-up o step down, in
presenza o meno di esofagite) la sua durata, l’utilizzo di farmaci
alternativi
Systematic review: persistent reflux symptoms on proton pump inhibitor therapy in primary care
and community studies - El-Serag H et al., Aliment Pharmacol Ther. 2010
24. Conclusioni:
L’appropriatezza dell’EGDs è necessaria per un corretto utilizzo delle
risorse (costi sanitari e sociali), per i potenziali rischi della procedura
(non trascurabili su grandi numeri) non bilanciati da reali benefici per i
pz, per il rischio di sovrastimare l’EB inducendo altre indagini, per una
razionale gestione delle liste d’attesa (1/3 del carico di lavoro previsto)
L’appropriatezza diagnostica favorisce l’appropriatzza prescrittiva,
consentendo di personalizzare il trattamento ed evitare farmaci inutili o
protrarre terapie oltre il necessario (con potenziali effetti collaterali ed
incremento della spesa sanitaria)
La selezione dei soggetti realmente a rischio consente di prevenire le
complicanze e diagnosticare in fase precoce la patologia neoplastica