New aspects in the pathomechanism and diagnosis of the laryngopharyngeal reflux-clinical impact of laryngeal proton pumps and pharyngeal p H metry in extraesophageal gastroesophageal reflux disease

AIM:To determine the laryngeal H+K+-ATPase and pharyngeal p H in patients with laryngopharyngeal reflux(LPR)-symptoms as well as to assess the symptom scores during PPI therapy.METHODS:Endoscopy was performed to exclude neoplasia and to collect biopsies from the posterior cricoid area(immunohistochemistry and PCR analysis).Immunohistochemical staining was performed with monoclonal mouse antibodies against human H+K+-ATPase.Quantitative real-time RT-PCR for each of the H+K+-ATPase subunits was performed.The p H values were assessed in the aerosolized environment of the oropharynx(Dxp H Catheter) and compared to a subsequently applied combined p H/MII measurement.RESULTS:Twenty patients with LPR symptoms were included.In only one patient,the laryngeal H+K+-ATPase was verified by immunohistochemical staining.In another patient,real-time RT-PCR for each H+K+-ATPase subunit was positive.Fourteen out of twenty patients had pathological results in Dxp H,and 6/20 patients had pathological results in p H/MII.Four patients had pathological results in both functional tests.Nine out of twenty patients responded to PPIs.CONCLUSION:The laryngeal H+K+-ATPase can only be sporadically detected in patients with LPR symptoms and is unlikely to cause the LPR symptoms.Alternative hypotheses for the pathomechanism are needed.The role of pharyngeal p H-metry remains unclearand its use can only be recommended for patients in a research study setting.

Endoscopic stent therapy in patients with chronic pancreatitis:A 5-year follow-up study

AIM:This study analyzed clinical long-term outcomes after endoscopic therapy,including the incidence and treatment of relapse. METHODS:This study included 19 consecutive patients(12 male,7 female,median age 54 years)with obstructive chronic pancreatitis who were admitted to the 2nd Medical Department of the Technical University of Munich.All patients presented severe chronic pancreatitis(stageⅢ°)according to the Cambridge classification.The majority of the patients suffered intermittent pain attacks.6 of 19 patients had strictures of the pancreatic duct;13 of 19 patients had strictures and stones.The first endoscopic retrograde pancreatography(ERP)included an endoscopic sphincterotomy, dilatation of the pancreatic duct,and stent placement.The first control ERP was performed 4 wk after the initial intervention,and the subsequent control ERP was performed after 3 mo to re-evaluate the clinical and morphological conditions.Clinical follow-up was performed annually to document the course of pain and the management of relapse.The course of pain was assessed by a pain scale from 0 to 10.The date and choice of the therapeutic procedure were documented in case of relapse. RESULTS:Initial endoscopic intervention was successfully completed in 17 of 19 patients.All 17 patients reported partial or complete pain relief after endoscopic intervention.Endoscopic therapy failed in 2 patients. Both patients were excluded from further analysis.One failed patient underwent surgery,and the other patient was treated conservatively with pain medication.Seventeen of 19 patients were followed after the successful completion of endoscopic stent therapy.Three of 17 patients were lost to follow-up.One patient was not avail-able for interviews after the 1st year of follow-up.Two patients died during the 3rd year of follow-up.In both patients chronic pancreatitis was excluded as the cause of death.One patient died of myocardial infarction, and one patient succumbed to pneumonia.All three patients were excluded from follow-up analysis.Followup was successfully completed in 14 of 17 patients.4 patients at time point 3,2 patients at time point 4,3 patients at time point 5 and 2 patients at time point 6 and time point 7 used continuous pain medication after endoscopic therapy.No relapse occurred in 57%(8/14) of patients.All 8 patients exhibited significantly reduced or no pain complaints during the 5-year follow-up.Seven of 8 patients were completely pain free 5 years after endoscopic therapy.Only 1 patient reported continuous moderate pain.In contrast,7 relapses occurred in 6 of the 14 patients.Two relapses were observed during the 1st year,2 relapses occurred during the 2nd year,one relapse was observed during the 3rd year,one relapse occurred during the 4th year,and one relapse occurred during the 5th follow-up year.Four of these six patients received conservative treatment with endoscopic therapy or analgesics.Relapse was conservatively treated using repeated stent therapy in 2 patients.Analgesic treatment was successful in the other 2 patients. CONCLUSION:57%of patients exhibited long-term benefits after endoscopic therapy.Therefore,endoscopic therapy should be the treatment of choice in patients being inoperable or refusing surgical treatment.

Management of occluded self-expanding biliary metal stents in malignant biliary disease

Background: Occlusion of self-expanding metal stents(SEMS) in malignant biliary obstruction occurs in up to 40% of patients. This study aimed to compare the different techniques to resolve stent occlusion in our collective of patients.Methods: Patients with malignant biliary obstruction and occlusion of biliary metal stent at a tertiary referral endoscopic center were retrospectively identified between April 1, 1994 and May 31, 2014. The clinical records were further analyzed regarding the characteristics of patients, malignant strictures, SEMS,management strategies, stent patency, subsequent interventions, survival time and case charges.Results: A total of 108 patients with biliary metal stent occlusion were identified. Seventy-nine of these patients were eligible for further analysis. Favored management was plastic stent insertion in 73.4% patients. Second SEMS were inserted in 12.7% patients. Percutaneous transhepatic biliary drainage and mechanical cleansing were conducted in a minority of patients. Further analysis showed no statistically significant difference in median overall secondary stent patency(88 vs. 143 days, P = 0.069), median survival time(95 vs. 192 days, P = 0.116), median subsequent intervention rate(53.4% vs. 40.0%, P = 0.501)and median case charge(€5145 vs. €3473, P = 0.803) for the treatment with a second metal stent insertion compared to plastic stent insertion. In patients with survival time of more than three months,significantly more patients treated with plastic stents needed re-interventions than patients treated with second SEMS(93.3% vs. 57.1%, P = 0.037).Conclusions: In malignant biliary strictures, both plastic and metal stent insertions are feasible strategies for the treatment of occluded SEMS. Our data suggest that in palliative biliary stenting, patients especially those with longer expected survival might benefit from second SEMS insertion. Careful patient selection is important to ensure a proper decision for either management strategy.

Positive predictors for gastroesophageal reflux disease and the therapeutic response to proton-pump inhibitors

AIM:To identify objective and subjective predictors for the reliable diagnosis of gastroesophageal reflux disease(GERD)and the response to proton pump inhibitor(PPI)therapy.METHODS:Retrospectively,683 consecutive patients suspected for GERD who underwent pH-metry/impedance measurement(pH/MII)were analyzed.All patients had previously undergone standard PPI treatment(e.g.,pantoprazole 40 mg/d or comparable).Four hundred sixty patients were at least 10 d off PPIs(group A),whereas 223 patients were analyzed during their ongoing PPI therapy(group B).In addition,all patients completed a standardized symptom-and lifestyle-based questionnaire,including the therapeutic response to previous PPI trials on a 10-point scale.Uniand multivariance analyses were performed to identify criteria associated with positive therapeutic response to PPIs.RESULTS:In group A,positive predictors(PPs)for response in empirical PPI trials were typical GERD symptoms(heartburn and regurgitation),a positive symptom index(SI)and pathological results in pH/MII,along with atypical symptoms,including hoarseness and fullness.In group B,regular alcohol consumption was associated with the therapeutic response.The PPs for pathological results in pH/MII in group A included positive SI,male gender,obesity,heartburn and regurgitation.In group B,the PPs were positive SI and vomiting.Analyzing for positive SI,the PPs were pathological pH and/or MII,heartburn regurgitation,fullness,nausea and vomiting in group A and pathological pH and/or MII in group B.CONCLUSION:Anamnestic parameters(gender,obesity,alcohol)can predict PPI responses.In non-obese,female patients with non-typical reflux symptoms,pH/MII should be considered instead of empirical PPIs.