A gastrointestinal(GI) transmural defect is defined as total rupture of the GI wall,and these defects can be divided into three categories: perforations,leaks,and fistulas. Surgical management of these defects is usua...A gastrointestinal(GI) transmural defect is defined as total rupture of the GI wall,and these defects can be divided into three categories: perforations,leaks,and fistulas. Surgical management of these defects is usually challenging and may be associated with high morbidity and mortality rates. Recently,several novel endoscopic techniques have been developed,and endoscopy has become a firstline approach for therapy of these conditions. The use of endoscopic vacuum therapy(EVT) is increasing with favorable results. This technique involves endoscopic placement of a sponge connected to a nasogastric tube into the defect cavity or lumen. This promotes healing via five mechanisms,including macrodeformation,microdeformation,changes in perfusion,exudate control,and bacterial clearance,which is similar to the mechanisms in which skin wounds are treated with commonly employed wound vacuums. EVT can be used in the upper GI tract,small bowel,biliopancreatic regions,and lower GI tract,with variable success rates and a satisfactory safety profile. In this article,we review and discuss the mechanism of action,materials,techniques,efficacy,and safety of EVT in the management of patients with GI transmural defects.展开更多
Lung transplantation is one of the highest risk solid organ transplant modalities. Recent studies have demonstrated a relationship between gastroesophageal reflux disease(GERD) and lung transplant outcomes, including ...Lung transplantation is one of the highest risk solid organ transplant modalities. Recent studies have demonstrated a relationship between gastroesophageal reflux disease(GERD) and lung transplant outcomes, including acute and chronic rejection. The aim of this review is to discuss the pathophysiology, evaluation, and management of GERD in lung transplantation, as informed by the most recent publications in the field. The pathophysiology of reflux-induced lung injury includes the effects of aspiration and local immunomodulation in the development of pulmonary decline and histologic rejection, as reflective of allograft injury. Modalities of reflux and esophageal assessment, including ambulatory p H testing, impedance, and esophageal manometry, are discussed, as well as timing of these evaluations relative to transplantation. Finally, antireflux treatments are reviewed, including medical acid suppression and surgical fundoplication, as well as the safety, efficacy, and timing of such treatments relative to transplantation. Our review of the data supports an association between GERD and allograft injury, encouraging a strategy of early diagnosis and aggressive reflux management in lung transplant recipients to improve transplant outcomes. Further studies are needed to explore additional objective measures of reflux and aspiration, better compare medical and surgical antireflux treatment options, extend followup times to capture longer-term clinical outcomes, and investigate newer interventions including minimally invasive surgery and advanced endoscopic techniques.展开更多
文摘A gastrointestinal(GI) transmural defect is defined as total rupture of the GI wall,and these defects can be divided into three categories: perforations,leaks,and fistulas. Surgical management of these defects is usually challenging and may be associated with high morbidity and mortality rates. Recently,several novel endoscopic techniques have been developed,and endoscopy has become a firstline approach for therapy of these conditions. The use of endoscopic vacuum therapy(EVT) is increasing with favorable results. This technique involves endoscopic placement of a sponge connected to a nasogastric tube into the defect cavity or lumen. This promotes healing via five mechanisms,including macrodeformation,microdeformation,changes in perfusion,exudate control,and bacterial clearance,which is similar to the mechanisms in which skin wounds are treated with commonly employed wound vacuums. EVT can be used in the upper GI tract,small bowel,biliopancreatic regions,and lower GI tract,with variable success rates and a satisfactory safety profile. In this article,we review and discuss the mechanism of action,materials,techniques,efficacy,and safety of EVT in the management of patients with GI transmural defects.
文摘Lung transplantation is one of the highest risk solid organ transplant modalities. Recent studies have demonstrated a relationship between gastroesophageal reflux disease(GERD) and lung transplant outcomes, including acute and chronic rejection. The aim of this review is to discuss the pathophysiology, evaluation, and management of GERD in lung transplantation, as informed by the most recent publications in the field. The pathophysiology of reflux-induced lung injury includes the effects of aspiration and local immunomodulation in the development of pulmonary decline and histologic rejection, as reflective of allograft injury. Modalities of reflux and esophageal assessment, including ambulatory p H testing, impedance, and esophageal manometry, are discussed, as well as timing of these evaluations relative to transplantation. Finally, antireflux treatments are reviewed, including medical acid suppression and surgical fundoplication, as well as the safety, efficacy, and timing of such treatments relative to transplantation. Our review of the data supports an association between GERD and allograft injury, encouraging a strategy of early diagnosis and aggressive reflux management in lung transplant recipients to improve transplant outcomes. Further studies are needed to explore additional objective measures of reflux and aspiration, better compare medical and surgical antireflux treatment options, extend followup times to capture longer-term clinical outcomes, and investigate newer interventions including minimally invasive surgery and advanced endoscopic techniques.
