Endoluminal Surgery

Initial endoscopic approaches to Barrett's esophagus have dealt with accurate diagnosis and staging of this condition. Early attempts at endoscopic ablation of Barrett's mucosa involved use of pinpoint thermal therapy and coagulation devices such as lasers, argon plasma coagulation, and bipolar probes. More recently pho-todynamic therapy has been utilized to destroy larger areas of abnormal mucosa. Attempts at endoscopic mucosal resection of larger areas of Barrett's mucosa have been accomplished and, as resection techniques become more refined, will undoubtedly replace ablation as the therapy of choice. The technique of endo-scopic mucosal resection has been widely employed in Japan, and the method is rapidly being adopted throughout the world. This method has been applied to to the treatment of premalignant and superficial malignant lesions.

Endoscopic approaches to the therapy of gastro-esophageal reflux are numerous and have led the way in recent innovative application of new endoscopic technology. Endoscopic suturing was first described by Paul Swain. Devices based on his original design have been employed to place sutures at or near the esoha-gogastric junction in order to enhance the integrity of the lower esophageal sphincter and reduce reflux. The first device, EndoCinch (Bard) was used in a variety of clinical studies and offered initial promise of symptomatic improvement and reduction of consumed medication. It used a suction capsule design to grasp a bit of gastric wall and place a stitch. The mechanism was slow, inefficient, and a bit difficult to standardize. Unfortunately, little change was seen in objective criteria of reflux such as 24-h pH and esophageal manometry [1]. Third party payors were hesitant to compensate physicians and hospitals for these procedures, and use of the method has declined. Other technologies have attempted to approximate more closely the Nissen fun-doplication by gathering tissue at the esophagogastric junction. The most visible of the latter is the Plicator device (NDO) [2]. The instrument is somewhat bulky and passed with an endoscope into the stomach. It is retroflexed and, under vision of the scope, gathers and sutures (full thickness) the tissue surrounding the gastric cardia. Although initial results are promising, no large series or long-term results are yet available for this procedure. It does, however, offer the durability of full-thickness gastric sutures with the promise of serosa to serosa healing.

Another developing endoluminal approach to gas-troesophageal reflux is the injection of biopolymers into the submucosa or muscle of the esophageal wall, just above the esophagogastric junction [3]. Again, while promising and apparently quite easily performed, there are little available data regarding results. Perhaps one of the most attractive and well-studied therapies has been the application of radiofrequency energy into the esophageal wall by means of small needles mounted on an esophageal balloon (Stretta procedure). Energy is applied at numerous sites at six to eight levels around the esophagogastric junction. Early results suggested excellent relief of symptoms and high patient satisfaction. However, as in those with other aforementioned procedures, there were initially little objective data to support improvement. However, more recent studies involving evaluation of 24-h pH and manometry as well as a sham study seem to demonstrate documented reduction in reflux [4].

The mechanism by which the radiofrequency energy may work is thought to be twofold. Scarring in the distal esophageal wall may act as a barrier to reflux. In addition, there is some suggestion that vagal afferent fibers to the esophagus, which may normally produce transient relaxation of the distal sphincter, may destroyed by the thermal energy.

How To Reduce Acne Scarring

How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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