Prevalence of bile reflux in gastroesophageal reflux disease patients not responsive to proton pump inhibitors

AIM:To determine the prevalence and characteristics of bile reflux in gastroesophageal reflux disease(GERD) patients with persistent symptoms who are non-responsive to medical therapy.METHODS:Sixty-five patients(40 male,25 female;mean age,50 ± 7.8 years) who continued to report symptoms after 8 wk of high-dose proton pump inhibitor(PPI) therapy,as well as 18 patients with Barrett's esophagus,were studied.All patients filled out symptom questionnaires and underwent endoscopy,manometry and combined pH-metry and bilimetry.RESULTS:There were 4 groups of patients:22(26.5%) without esophagitis,24(28.9%) grade A-B esophagitis,19(22.8%) grade C-D and 18(21.6%) Barrett's esophagus.Heartburn was present in 71 patients(85.5%) and regurgitation in 55(66.2%),with 44(53%) reporting simultaneous heartburn and regurgitation.The prevalence of pathologic acid reflux in the groups without esophagitis and with grades A-B and C-D esophagitis was 45.4%,66.6% and 73.6%,respectively.The prevalence of pathologic bilirubin exposure in these 3 groups was 53.3%,75% and 78.9%,respectively.The overall prevalence of bile reflux in non-responsive patients was 68.7%.Pathologic acid and bile reflux was observed in 22.7% and 58.1% of non-esophagitic patients and esophagitic patients,respectively.CONCLUSION:The high percentage of patients poorly responsive to PPI therapy may result from poor control of duodenogastroesophageal reflux.Many patients without esophagitis have simultaneous acid and bile reflux,which increases with increasing esophagitis grade.

Laparoscopic calibrated total vs partial fundoplication following Heller myotomy for oesophageal achalasia

AIM:To compare the mid-term outcomes of laparoscopic calibrated Nissen-Rossetti fundoplication with Dor fundoplication performed after Heller myotomy for oesophageal achalasia.METHODS:Fifty-six patients(26 men,30 women;mean age 42.8±14.7 years)presenting for minimally invasive surgery for oesophageal achalasia,were enrolled.All patients underwent laparoscopic Heller myotomy followed by a 180°anterior partial fundoplication in 30 cases(group 1)and calibrated NissenRossetti fundoplication in 26(group 2).Intraoperative endoscopy and manometry were used to calibrate the myotomy and fundoplication.A 6-mo follow-up period with symptomatic evaluation and barium swallow was undertaken.One and two years after surgery,the patients underwent symptom questionnaires,endoscopy,oesophageal manometry and 24 h oesophago-gastric pH monitoring.RESULTS:At the 2-year follow-up,no significant difference in the median symptom score was observed between the 2 groups(P=0.66;Mann-WhitneyU-test).The median percentage time with oesophageal pH< 4 was significantly higher in the Dor group compared to the Nissen-Rossetti group(2;range 0.8-10 vs 0.35;range 0-2)(P<0.0001;Mann-WhitneyU-test).CONCLUSION:Laparoscopic Dor and calibrated Nissen-Rossetti fundoplication achieved similar results in the resolution of dysphagia.Nissen-Rossetti fundoplication seems to be more effective in suppressing oesophageal acid exposure.

Adenocarcinoma of gastric cardia in the elderly: Surgical problems and prognostic factors

AIM: To analyze retrospectively, our results about patients who underwent surgical treatment for adenocarcinoma of the cardia in relation to age, in order to evaluate surgical problems and prognostic factors.METHODS: From January 1987 to March 2003, 140 patients with adenocarcinoma of the cardia underwent resection in the authors' institution. They were divided into three groups with regard to age. Patients <70 and >60 year old (31) were excluded; we also excluded 18 out of 109 patients with poor general status or systemic metastases. So, we compared 51 elderly (≥ 70 year old)and 58 younger patients (≤ 60 year old). The treatment was esophagectomy for type Ⅰ tumors, and extended gastrectomy and distal esophagectomy for type Ⅱ and Ⅲ lesions.RESULTS: Laparotomy was carried out in 91 patients (83.4%), 38 in the elderly (74.5%) and 53 in younger patients (91.3%, P＜0.05). Primary resection was performed in 811 cases (89%) without significant differences between the two groups. Postoperative death was higher in the elderly (12.1%) than the other group (4.1%, P＜0.05), while morbidity was similar in both groups. A curative resection (R0) was performed in 59 patients (72.8%), 69.6% in the elderly and 75% in the younger group (P＞0.05). The overall 3- and 5-year survival rates were 26.7% and 117.8% respectively for the elderly and 40.7% and 35.1% respectively for younger patients (P = 0.1544). Survival rates were significantly associated with R0 resection,pathological node-positive category and tumor differentiation in both groups.CONCLUSION: As the age of the general population increases, more elderly patients with gastric cardia cancer will be candidates for surgical resection. Age alone should not preclude surgical treatment in elderly patients with gastric cardia cancer and a tumor resection can be carried out safely. Certainly, we should take care in defining the surgical treatment in elderly patients, particularly as regarding the surgical approach; although the surgical approach does not influence the survival rate, the transhiatal way still remains the best one due, to the lower incidence of respiratory morbidity and thoracic pain.

Large symptomatic gastric diverticula:Two case reports and a brief review of literature

Gastric diverticula are rare and uncommon conditions.Most gastric diverticula are asymptomatic.When symptoms arise,they are most commonly upper abdominal pain,nausea and emesis,while dyspepsia and vomiting are less common.Occasionally,patients with gastric diverticula can have dramatic presentations related to massive bleeding or perforation.The diagnosis may be difficult,as symptoms can be caused by more common gastrointestinal pathologies and only aggravated by diverticula.The appropriate management of diverticula depends mainly on the symptom pattern and as well as diverticulum size.There is no specific therapeutic strategy for an asymptomatic diverticulum.Although some authors support conservative therapy with antacids,this provides only temporary symptom relief since it is not able to resolve the underlying pathology.Surgical resection is the mainstay of treatment when the diverticulum is large,symptomatic or complicated by bleeding,perforation or malignancy,with over two-thirds of patients remaining symptom-free after surgery,while laparoscopic resection,combined with intraoperative endoscopy,is a safe and feasible approach with excellent outcomes.Here,we present two cases of uncommon large symptomatic gastric diverticula with a discussion of the cornerstones in management and report a minimally invasive solution,with a brief review of the literature.

Strong Stability Preserving IMEX Methods for Partitioned Systems of Differential Equations

We investigate strong stability preserving(SSP)implicit-explicit(IMEX)methods for partitioned systems of differential equations with stiff and nonstiff subsystems.Conditions for order p and stage order q=p are derived,and characterization of SSP IMEX methods is provided following the recent work by Spijker.Stability properties of these methods with respect to the decoupled linear system with a complex parameter,and a coupled linear system with real parameters are also investigated.Examples of methods up to the order p=4 and stage order q—p are provided.Numerical examples on six partitioned test systems confirm that the derived methods achieve the expected order of convergence for large range of stepsizes of integration,and they are also suitable for preserving the accuracy in the stiff limit or preserving the positivity of the numerical solution for large stepsizes.

Preface to Focused Section on Efficient High-Order Time Discretization Methods for Partial Differential Equations

During May 8-10,2019,the International Workshop on Efficient High-Order Time Discretization Methods for Partial Differential Equations took place in Villa Orlandi,Anacapri,Italy,a Congress Center of the University of Naples Federico II.About 40 senior researchers,young scholars,and Ph.D.students attended this workshop.The purpose of this event was to explore recent trends and directions in the area of time discretization for the numerical solution of evolutionary partial differential equations with particular application to high-order methods for hyperbolic systems with source and advection-diffusion-reaction equations,and with special emphasis on efficient time-stepping methods such as implicit-explicit(IMEX),semi-implicit and strong stability preserving(SSP)time discretization.The present focused section entitled“Efficient High-Order Time Discretization Methods for Partial Differential Equations”in Communications on Applied Mathematics and Computation(CAMC)consists of five regularly reviewed manuscripts,which were selected from submissions of works presented during the workshop.We thank all the authors of these contributions,and hope that the readers are interested in the topics,techniques and methods,and results of these papers.We also want to thank the CAMC journal editorial staff as well as all the referees for their contributions during the review and publication processes of this focused section.