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Liver transplant fortune telling
2816
What’s New in GI
that endless numbers of tests are not fruitlessly pursued by these patients. David R. Mack, M.D.
Medical and Surgical Treatment of GERD— The Long and Short of It Spechler SJ, Lee E, Ahnen D, et al. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: Follow-up of a randomized controlled trial. JAMA 2001;285:2331– 8. Spechler and colleagues conducted a long term follow-up study of a Veterans Affairs cooperative trial that prospectively compared medical and surgical treatments in patients with severe gastroesophageal reflux disease (GERD). Two hundred thirtynine of the original 247 participants were located; 129 (91 in the medical group and 38 in the surgery group) of the 160 survivors agreed to participate in the follow-up. The median durations of follow-up were 7.3 yr for medical patients and 6.3 yr for surgical patients. Ninety-two percent of the medical patients and 62% of the surgical patients reported ongoing use of medications for control of GERD symptoms. Although GERD symptoms were significantly less severe in the surgery patients when drug therapy was discontinued, there was no difference when the patients were allowed to continue their usual GERD medications. Patients in both groups were equally likely to develop esophageal strictures or adenocarcinoma. No significant differences between the groups were seen for overall mental and physical well-being as measured by Short Form 36 scores. Similarly, no difference in overall satisfaction between the groups was found. The annual incidence rate of esophageal adenocarcinoma in patients with Barrett’s esophagus at baseline was 0.4%, relative to 0.07% in patients without Barrett’s at base-
AJG – Vol. 96, No. 10, 2001
line. Interestingly, although there were no antireflux surgery-related deaths, mortality was higher in the surgery group (40% vs 28%, p ⫽ 0.047), largely due to an excess of cardiac-related deaths. It remains unclear how this is linked to antireflux surgery. On the basis of these data, the authors conclude that antireflux surgery should not be advised with the expectation that the GERD patients will no longer need to take GERD medications or that the procedure will prevent esophageal adenocarcinoma. Additionally, they suggest that, given the low rates of cancer development and mortality due to GERD found in this study, the current screening and surveillance guidelines for Barrett’s esophagus should be re-evaluated. This study has the most complete, longest term data available comparing medical and surgical GERD therapies and challenges the arguments supporting antireflux surgery: replaces antireflux medications, has a longlasting effect, and prevents cancer. In the process, it helps to refine the appropriate place that surgery holds in the management of GERD and raises important questions about the appropriateness of current practices in patients with Barrett’s esophagus. J. K. DiBaise, M.D.
Liver Transplant Fortune-Telling Bathgate A, Dollinger M, Plevris J, et al. Contact sensitization pretransplantation predicts acute hepatic allograft rejection. Hepatology 2001; 33:1043– 6. Acute cellular rejection after liver transplant is common but, in patients without hepatitis C, does not decrease graft survival but may increase patient morbidity. Investigators from the Scottish Liver Transplant Unit studied the pretransplant contact skin hypersensitivity T-cell–mediated response to 0.1% diphenylcyclopropenone. These patients were then observed for 1 yr to
evaluate the relationship of skin responders to acute allograft rejection. Forty-one patients were studied; 19 of 41 (46%) were skin responders to the contact neoantigen. Twelve of 19 responders had rejection, and one of 19 nonresponders had rejection. On univariate analysis skin test response, donor age (younger), recipient ages (younger), and immunosuppression (csa ⬎ fk) had more acute rejections. On multivariate analysis, skin test response was the only independent factor associated with acute rejection. Protocol (7 day) biopsies were included in the study (which may increase overall reported rejection), and surprisingly, 12 of 19 responders had moderate/severe rejection. Not unexpectedly, primary sclerosing cholangitis had the most rejection and alcohol the least. Interestingly, the patient with the highest skin test response developed chronic rejection. This novel study was able to predict rejection with confidence, which may allow physicians in the future to either reduce immunosuppression more rapidly or monitor those at highest risk more closely. Of concern are the low numbers of patients in the “traditionally” high risk groups of primary sclerosing cholangitis and autoimmune hepatitis. The study needs to be conducted with larger numbers of patients, but is provocative in its early results. T. McCashland, M.D.
Depressing News About Flat Adenomas Saitoh Y, Waxman I, West B, et al. Prevalence and distinctive biological features of flat colorectal adenomas in a North American population. Gastroenterology 2001;120:1657– 65. Considerable controversy exists over the occurrence of flat and depressed (F&D) colorectal polyps in the West. These small lesions (typically ⬍1 cm) have a high propensity for harboring dysplasia or carcinoma. F&D lesions are commonly reported in Japan but
What’s New in GI
that endless numbers of tests are not fruitlessly pursued by these patients. David R. Mack, M.D.
Medical and Surgical Treatment of GERD— The Long and Short of It Spechler SJ, Lee E, Ahnen D, et al. Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: Follow-up of a randomized controlled trial. JAMA 2001;285:2331– 8. Spechler and colleagues conducted a long term follow-up study of a Veterans Affairs cooperative trial that prospectively compared medical and surgical treatments in patients with severe gastroesophageal reflux disease (GERD). Two hundred thirtynine of the original 247 participants were located; 129 (91 in the medical group and 38 in the surgery group) of the 160 survivors agreed to participate in the follow-up. The median durations of follow-up were 7.3 yr for medical patients and 6.3 yr for surgical patients. Ninety-two percent of the medical patients and 62% of the surgical patients reported ongoing use of medications for control of GERD symptoms. Although GERD symptoms were significantly less severe in the surgery patients when drug therapy was discontinued, there was no difference when the patients were allowed to continue their usual GERD medications. Patients in both groups were equally likely to develop esophageal strictures or adenocarcinoma. No significant differences between the groups were seen for overall mental and physical well-being as measured by Short Form 36 scores. Similarly, no difference in overall satisfaction between the groups was found. The annual incidence rate of esophageal adenocarcinoma in patients with Barrett’s esophagus at baseline was 0.4%, relative to 0.07% in patients without Barrett’s at base-
AJG – Vol. 96, No. 10, 2001
line. Interestingly, although there were no antireflux surgery-related deaths, mortality was higher in the surgery group (40% vs 28%, p ⫽ 0.047), largely due to an excess of cardiac-related deaths. It remains unclear how this is linked to antireflux surgery. On the basis of these data, the authors conclude that antireflux surgery should not be advised with the expectation that the GERD patients will no longer need to take GERD medications or that the procedure will prevent esophageal adenocarcinoma. Additionally, they suggest that, given the low rates of cancer development and mortality due to GERD found in this study, the current screening and surveillance guidelines for Barrett’s esophagus should be re-evaluated. This study has the most complete, longest term data available comparing medical and surgical GERD therapies and challenges the arguments supporting antireflux surgery: replaces antireflux medications, has a longlasting effect, and prevents cancer. In the process, it helps to refine the appropriate place that surgery holds in the management of GERD and raises important questions about the appropriateness of current practices in patients with Barrett’s esophagus. J. K. DiBaise, M.D.
Liver Transplant Fortune-Telling Bathgate A, Dollinger M, Plevris J, et al. Contact sensitization pretransplantation predicts acute hepatic allograft rejection. Hepatology 2001; 33:1043– 6. Acute cellular rejection after liver transplant is common but, in patients without hepatitis C, does not decrease graft survival but may increase patient morbidity. Investigators from the Scottish Liver Transplant Unit studied the pretransplant contact skin hypersensitivity T-cell–mediated response to 0.1% diphenylcyclopropenone. These patients were then observed for 1 yr to
evaluate the relationship of skin responders to acute allograft rejection. Forty-one patients were studied; 19 of 41 (46%) were skin responders to the contact neoantigen. Twelve of 19 responders had rejection, and one of 19 nonresponders had rejection. On univariate analysis skin test response, donor age (younger), recipient ages (younger), and immunosuppression (csa ⬎ fk) had more acute rejections. On multivariate analysis, skin test response was the only independent factor associated with acute rejection. Protocol (7 day) biopsies were included in the study (which may increase overall reported rejection), and surprisingly, 12 of 19 responders had moderate/severe rejection. Not unexpectedly, primary sclerosing cholangitis had the most rejection and alcohol the least. Interestingly, the patient with the highest skin test response developed chronic rejection. This novel study was able to predict rejection with confidence, which may allow physicians in the future to either reduce immunosuppression more rapidly or monitor those at highest risk more closely. Of concern are the low numbers of patients in the “traditionally” high risk groups of primary sclerosing cholangitis and autoimmune hepatitis. The study needs to be conducted with larger numbers of patients, but is provocative in its early results. T. McCashland, M.D.
Depressing News About Flat Adenomas Saitoh Y, Waxman I, West B, et al. Prevalence and distinctive biological features of flat colorectal adenomas in a North American population. Gastroenterology 2001;120:1657– 65. Considerable controversy exists over the occurrence of flat and depressed (F&D) colorectal polyps in the West. These small lesions (typically ⬍1 cm) have a high propensity for harboring dysplasia or carcinoma. F&D lesions are commonly reported in Japan but