Advanced endoscopy and endosurgical procedures: do we need a new subspecialty?

On the horizon is a new paradigm in minimally invasive therapy called natural orifice transluminal endoscopic surgery (NOTES). This new approach will most certainly disrupt both those living in the gut lumen with flexible endoscopes as well as those living in the peritoneal cavity using laparoscopes to perform surgical procedures. The question is what changes will need to occur in training and practice to accommodate this new paradigm? Those of us who consider ourselves to be gastrointestinal interventionalists are in a unique and exciting position because the answers to the question about training and practice in NOTES will unfold before us in the coming decade.

Nutritional assessment.

Hospital-based malnutrition continues to be an important comorbidity affecting clinical outcomes. Knowledge of performing an appropriate nutrition assessment and implementing a rational nutrition therapy should be part of any patient's hospital plan of care. Familiarity with nutrition assessment scoring systems and nutrition assessment tools should be part of any gastroenterologist's expertise.

Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicentre study using combined ambulatory impedance-pH monitoring.

Background And Aims: Empiric proton pump inhibitor (PPI) trials have become increasingly popular leading to gastroenterologists frequently evaluating gastro-oesophageal reflux disease (GORD) patients only after they have "failed" PPI therapy. Combined multichannel intraluminal impedance and pH (MII-pH) monitoring has the ability to detect gastro-oesophageal reflux (GOR) episodes independent of their pH and evaluate the relationship between symptoms and all types of GOR. Using this technique, we aimed to characterise the frequency of acid and non-acid reflux (NAR) and their relationship to typical and atypical GOR symptoms in patients on PPI therapy.

Fundoplication eliminates chronic cough due to non-acid reflux identified by impedance pH monitoring.

The symptoms of extra-oesophageal gastro-oesophageal reflux disease (GORD) (such as chronic cough and hoarseness) are traditionally more difficult to treat than typical GORD symptoms (heartburn and regurgitation). Patients with extra-oesophageal manifestations may require longer and higher doses of acid suppressive therapy. In patients not responding to acid suppressive therapy the physician faces a dilemma as to whether the symptoms are due to ongoing acid reflux, non-acid reflux, or not associated with reflux.

Gastroesophageal Reflux Disease.

Lifestyle modifications should be discussed with every patient with symptoms of chronic gastroesophageal reflux disease (GERD). Proton pump inhibitors are the most efficacious medical therapy for GERD. H(2) receptor antagonists are likely to be effective in patients with mild to moderate GERD and for occasional symptoms.