Current opinion in gastroenterology
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Bariatric surgery today is the only effective therapy for morbid obesity. Commonly performed procedures include adjustable gastric banding and vertical banded gastroplasty, variations of the Roux-en-Y gastric bypass, biliopancreatic diversion or duodenal switch, and mixed procedures. This review discusses key issues in the surgical management of morbid obesity. ⋯ According to current opinion, gastric restrictive procedures (adjustable gastric banding, vertical banded gastroplasty) are generally considered safe and quick to perform, but the long-term outcome and quality of life have been questioned. By contrast, the long-term efficacy of adjustable gastric banding can be improved by the development of new band devices. More complex bariatric procedures, such as the Roux-en-Y gastric bypass or biliopancreatic diversion, have a greater potential for serious perioperative complications but are associated with good long-term outcome in terms of weight loss combined with less dietary restriction.
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Primary sclerosing cholangitis is a chronic cholestatic liver disease characterized by strictures of the biliary tree. It is immune mediated, although the precise cause remains unknown. Recent reports have shown a higher prevalence and burden of disease than was previously suspected. ⋯ Genetic heterogeneity among patients with primary sclerosing cholangitis is supported, and further gene polymorphisms associated with protection against primary sclerosing cholangitis have been elucidated. Bile duct injury seems to be a multistep process. Magnetic resonance cholangiopancreatography is a cost-effective and accurate way of diagnosing primary sclerosing cholangitis in comparison with endoscopic retrograde cholangiopancreatography. Ursodeoxycholic acid may have a role as a colorectal and hepatobiliary cancer chemopreventive agent. Liver transplantation remains the only treatment in end-stage disease. The 5-year and 10-year patient and graft survival rates are comparable with those in patients without primary sclerosing cholangitis, but there is a higher rate of retransplantation for primary sclerosing cholangitis in most centers. Hepatobiliary malignancy is found in a minority of patients at transplantation, although 5-year survival rates for these patients are still promising.
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Enteral nutrition is now widely used as the preferred route of nutritional support in malnourished and intensive care unit patients. Studies providing evidence for efficacy, techniques of administration, and outcome are appearing daily in the literature. This review presents evidenced-based studies in this field from December 2002 to the present and critically reviews them for the reader. In this way the reader can rapidly access important publication from the morass being published each year. ⋯ Enteral nutrition is an established modality of nutritional support that has received wide acceptance. It is not clear, however, for which conditions it improves patient outcome and the best way to optimize its delivery. In this review, articles addressing the outcome of patients and methods to optimize delivery of enteral nutrition are reviewed. Unfortunately, with few exceptions, most studies are based on few patients or do not have a placebo arm. An more important flaw in these studies is the nutritional status of the patient and need for support.
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To outline recent findings on the efficacy of immunonutrients in patients undergoing inflammatory stress due to surgery, infection and cancer. ⋯ Immunonutrition is effective in improving outcome in a wide range of patients when applied enterally, particularly in malnourished individuals. Parenteral immunonutrition carries a higher risk but can be efficacious in selected patient groups for whom enteral nutrition is problematic.
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Graft-versus-host disease (GVHD) is a common, potentially life-threatening complication of allogenic hematopoietic stem cell transplantation. Gastrointestinal GVHD frequently involves the colon and complicates management of these seriously ill patients. This review updates the diagnosis and management of colonic GVHD. ⋯ Although colonic GVHD is readily diagnosed, advances in management await greater understanding of pathogenesis and more specifically targeted therapies.