Gastroesophageal reflux disease(GERD)is present in up to 75%of patients with chronic refractory ear,nose,and throat(ENT)symptoms,and proton pump inhibitor(PPI)therapy induces symptom relief in the majority of these pa...Gastroesophageal reflux disease(GERD)is present in up to 75%of patients with chronic refractory ear,nose,and throat(ENT)symptoms,and proton pump inhibitor(PPI)therapy induces symptom relief in the majority of these patients.It has been suggested that endoscopic findings and quantification of esophageal acid exposure may help to predict the long-term outcome of medical therapy,but prospective studies that confirm this hypothesis are lacking.The aim of the present study was to investigate the relationship of endoscopic findings and quantification of reflux with long-term outcome in patients with reflux-related ENT symptoms.One hundred six consecutive patients with chronic refractory unexplained ENT symptoms underwent upper GI endoscopy,24-hr dual-channel esophageal pH and Bilitec(n = 35)monitoring,and esophageal manometry.Subsequently,all were treated with omeprazole,20 mg b.i.d.,and patients were followed at 2-week intervals until symptom relief.Four weeks later,omeprazole therapy was gradually decreased and the lowest effective omeprazole maintenance dose,if any,was determined.Eighty-one patients(49 men;mean age,50)experienced a clear or excellent therapeutic response after,on average,4 weeks of omeprazole,20 mg b.i.d.In 36 patients(44%;group A),PPI treatment could be stopped completely,27 patients(33%;group B)required a maintenance dose of omeprazole,20 mg/day,and 18 patients(22%;group C)required maintenance with omeprazole,40 mg/day.The prevalence of reflux esophagitis was significantly lower in group A patients,who also had significantly lower distal esophageal acid exposure,proximal esophageal acid exposure,and esophageal duodenogastroesophageal reflux exposure compared to groups B and C.Multivariate analysis identified the presence of esophagitis and pathological distal esophageal acid exposure as risk factors for the need of maintenance therapy.In patients with reflux-related ENT symptoms,initial findings on upper GI endoscopy and 24-hr pH-metry help to predict the need for maintenance therapy.展开更多
Background and Study Aims: Endoscopic mucosal resection and photodynamic therapy are exciting, minimally invasive curative techniques that represent an alternative to surgery in patients with Barrett’s esophagus and ...Background and Study Aims: Endoscopic mucosal resection and photodynamic therapy are exciting, minimally invasive curative techniques that represent an alternative to surgery in patients with Barrett’s esophagus and high-grade dysplasia or intramucosal adenocarcinoma. However, there is lack of uniformity regarding which staging method should be used prior to therapy, and some investigators even question whether staging is required prior to ablation. We report our experience with a protocol of conventional endoscopic ultrasound staging prior to endoscopic therapy. Patients and Methods: A total of 25 consecutive patients with a diagnosis of high-grade dysplasia or intramucosal adenocarcinoma in Barrett’s esophagus who had been referred to the University of Chicago for staging in preparation for endoscopic therapy between March 2002 and November 2004 were included in the study. All 25 patients underwent repeat diagnostic endoscopy and conventional endosonography with a radial echo endoscope. Any suspicious lymph nodes that were detected were sampled using endoscopic ultrasound-guided fine-needle aspiration. Results: Baseline pathology in the 25 patients (mean age 70, range 49- 85) revealed high-grade dysplasia in 12 patients and intramucosal carcinoma in 13 patients. Five patients were found to have submucosal invasion on conventional endosonography. Seven patients had suspicious adenopathy, six regional (N1) and one metastatic to the celiac axis (M1a). Fine-needle aspiration confirmed malignancy in five of these seven patients. Based on these results, five patients (20% ) were deemed to be unsuitable candidates for endoscopic therapy. Conclusions: By detecting unsuspected malignant lymphadenopathy, conventional endosonography and endoscopic ultrasound with fine-needle aspiration dramatically changed the course of management in 20% of patients referred for endoscopic therapy of Barrett’s esophagus with high-grade dysplasia or intramucosal carcinoma. Based on our results, we believe that conventional endosonography and endoscopic ultrasound with fine-needle aspiration when nodal disease is present should be performed routinely in all patients referred for endoscopic therapy in this setting.展开更多
Background and Study Aims: The incidence of oesophageal adenocarcinoma has increased significantly in recent years. While surveillance of people with Barrett’s oesophagus, its usual precursor, has been advocated in o...Background and Study Aims: The incidence of oesophageal adenocarcinoma has increased significantly in recent years. While surveillance of people with Barrett’s oesophagus, its usual precursor, has been advocated in order to detect dysplasia and early cancer in those considered to be at greatest risk, the impact of such a strategy on survival from oesophageal adenocarcinoma is unclear. This study aimed to determine the effect of surveillance on mortality from oesophageal adenocarcinoma in a group of patients considered to be at high risk of developing Barrett’s oesophagus and adenocarcinoma. Patients and Methods: After performing a Medline search of the literature published between 1985 and 2004 for studies on gastro-oesophageal reflux disease, Barrett’s oesophagus and adenocarcinoma, we examined the impact of surveillance on mortality from oesophageal adenocarcinoma in a hypothetical sample of 100 high-risk patients (men aged over 50 with Barrett’s oesophagus but without high-grade dysplasia at entry). Results: Four patients in this high-risk group developed adenocarcinoma during surveillance, with survival rates of 78.9% (95% CI 64.9% - 88.5% ) at 2 years and 78.6% (95% CI 62.8% - 89.2% ) at 5 years. Meanwhile, between 515 and 2060 patients with Barrett s oesophagus were not detected or surveyed by this strategy and between 16 and 61 of these developed adenocarcinoma, with much lower survival rates of 37.1% (95% CI 25.4% - 50.3% ) at 2 years and 16.7% (95% CI 9% - 28.3% ) at 5 years. Although surveillance in the high-risk group resulted in the long-term survival of three patients who would not otherwise have survived, this gain was dramatically offset by the 13 to 51 patients, excluded from surveillance by this strategy, who died from oesophageal adenocarcinoma. Conclusions: A surveillance programme based on current concepts of risk cannot have an impact on mortality from oesophageal adenocarcinoma. To be effective, it will be necessary for surveillance programmes to utilise more precise methods for the identification of those who are most at risk of progression to adenocarcinoma.展开更多
文摘Gastroesophageal reflux disease(GERD)is present in up to 75%of patients with chronic refractory ear,nose,and throat(ENT)symptoms,and proton pump inhibitor(PPI)therapy induces symptom relief in the majority of these patients.It has been suggested that endoscopic findings and quantification of esophageal acid exposure may help to predict the long-term outcome of medical therapy,but prospective studies that confirm this hypothesis are lacking.The aim of the present study was to investigate the relationship of endoscopic findings and quantification of reflux with long-term outcome in patients with reflux-related ENT symptoms.One hundred six consecutive patients with chronic refractory unexplained ENT symptoms underwent upper GI endoscopy,24-hr dual-channel esophageal pH and Bilitec(n = 35)monitoring,and esophageal manometry.Subsequently,all were treated with omeprazole,20 mg b.i.d.,and patients were followed at 2-week intervals until symptom relief.Four weeks later,omeprazole therapy was gradually decreased and the lowest effective omeprazole maintenance dose,if any,was determined.Eighty-one patients(49 men;mean age,50)experienced a clear or excellent therapeutic response after,on average,4 weeks of omeprazole,20 mg b.i.d.In 36 patients(44%;group A),PPI treatment could be stopped completely,27 patients(33%;group B)required a maintenance dose of omeprazole,20 mg/day,and 18 patients(22%;group C)required maintenance with omeprazole,40 mg/day.The prevalence of reflux esophagitis was significantly lower in group A patients,who also had significantly lower distal esophageal acid exposure,proximal esophageal acid exposure,and esophageal duodenogastroesophageal reflux exposure compared to groups B and C.Multivariate analysis identified the presence of esophagitis and pathological distal esophageal acid exposure as risk factors for the need of maintenance therapy.In patients with reflux-related ENT symptoms,initial findings on upper GI endoscopy and 24-hr pH-metry help to predict the need for maintenance therapy.
文摘Background and Study Aims: Endoscopic mucosal resection and photodynamic therapy are exciting, minimally invasive curative techniques that represent an alternative to surgery in patients with Barrett’s esophagus and high-grade dysplasia or intramucosal adenocarcinoma. However, there is lack of uniformity regarding which staging method should be used prior to therapy, and some investigators even question whether staging is required prior to ablation. We report our experience with a protocol of conventional endoscopic ultrasound staging prior to endoscopic therapy. Patients and Methods: A total of 25 consecutive patients with a diagnosis of high-grade dysplasia or intramucosal adenocarcinoma in Barrett’s esophagus who had been referred to the University of Chicago for staging in preparation for endoscopic therapy between March 2002 and November 2004 were included in the study. All 25 patients underwent repeat diagnostic endoscopy and conventional endosonography with a radial echo endoscope. Any suspicious lymph nodes that were detected were sampled using endoscopic ultrasound-guided fine-needle aspiration. Results: Baseline pathology in the 25 patients (mean age 70, range 49- 85) revealed high-grade dysplasia in 12 patients and intramucosal carcinoma in 13 patients. Five patients were found to have submucosal invasion on conventional endosonography. Seven patients had suspicious adenopathy, six regional (N1) and one metastatic to the celiac axis (M1a). Fine-needle aspiration confirmed malignancy in five of these seven patients. Based on these results, five patients (20% ) were deemed to be unsuitable candidates for endoscopic therapy. Conclusions: By detecting unsuspected malignant lymphadenopathy, conventional endosonography and endoscopic ultrasound with fine-needle aspiration dramatically changed the course of management in 20% of patients referred for endoscopic therapy of Barrett’s esophagus with high-grade dysplasia or intramucosal carcinoma. Based on our results, we believe that conventional endosonography and endoscopic ultrasound with fine-needle aspiration when nodal disease is present should be performed routinely in all patients referred for endoscopic therapy in this setting.
文摘Background and Study Aims: The incidence of oesophageal adenocarcinoma has increased significantly in recent years. While surveillance of people with Barrett’s oesophagus, its usual precursor, has been advocated in order to detect dysplasia and early cancer in those considered to be at greatest risk, the impact of such a strategy on survival from oesophageal adenocarcinoma is unclear. This study aimed to determine the effect of surveillance on mortality from oesophageal adenocarcinoma in a group of patients considered to be at high risk of developing Barrett’s oesophagus and adenocarcinoma. Patients and Methods: After performing a Medline search of the literature published between 1985 and 2004 for studies on gastro-oesophageal reflux disease, Barrett’s oesophagus and adenocarcinoma, we examined the impact of surveillance on mortality from oesophageal adenocarcinoma in a hypothetical sample of 100 high-risk patients (men aged over 50 with Barrett’s oesophagus but without high-grade dysplasia at entry). Results: Four patients in this high-risk group developed adenocarcinoma during surveillance, with survival rates of 78.9% (95% CI 64.9% - 88.5% ) at 2 years and 78.6% (95% CI 62.8% - 89.2% ) at 5 years. Meanwhile, between 515 and 2060 patients with Barrett s oesophagus were not detected or surveyed by this strategy and between 16 and 61 of these developed adenocarcinoma, with much lower survival rates of 37.1% (95% CI 25.4% - 50.3% ) at 2 years and 16.7% (95% CI 9% - 28.3% ) at 5 years. Although surveillance in the high-risk group resulted in the long-term survival of three patients who would not otherwise have survived, this gain was dramatically offset by the 13 to 51 patients, excluded from surveillance by this strategy, who died from oesophageal adenocarcinoma. Conclusions: A surveillance programme based on current concepts of risk cannot have an impact on mortality from oesophageal adenocarcinoma. To be effective, it will be necessary for surveillance programmes to utilise more precise methods for the identification of those who are most at risk of progression to adenocarcinoma.
