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2
REFERENCES
American
Society
of
Clinical
Oncology.
Recommended
breast
cancer
surveil-
lance
guidelines.
J
Clin
Oncol
1997;
15:2149-2156
Edelman
MJ,
Meyers
FJ,
Siegel
D.
The
utility
of
follow-up
testing
after
cura-
tive
cancer
therapy:
A
critical
review
and
economic
analysis.
J
Gen
Int
Med
1997;12:318-331
Torrey
MJ,
Poen
JC
and
Hoppe
RT.
Detection
of
relapse
in
early-stage
Hodgk-
in's
disease:
Role
of
routine
follow-up
studies.
J
Clin
Oncol
1997;15:1123-1130
Virgo
KS,
Vernava
AM,
Longo
WE,
McKirgan
LW,
Johnson
FE.
Cost
of
pa-
tient
follow-up
after
potentially
curative
colorectal
cancer
treatment.
JAMA
1995;
273:1837-41
Walsh
GI,
O'Connor
M,
Willis
KM
et
al.
Is
follow-up
of
lung
cancer
patients
after
resection
medically
indicated
and
cost
effective?
Ann
Thorac
Surg
1995;60:
1563-72
Noninvasive
Positive
Pressure
Mechanical
Ventilation
NONINVASIVE
MECHANICAL
VENTILATION
refers
to
the
tech-
nique
of
supporting
alveolar
ventilation
without
the
use
of
an
artificial
airway
in
the
trachea.
Although
mechani-
cal
ventilation
with
endotracheal
intubation
is
a
success-
ful
means
of
providing
ventilatory
support,
recent
advances
in
the
design
of
nasal
and
facial
masks,
togeth-
er
with
the
development
of
newer
styles
of
ventilators,
have
widened
the
options
available
to
patients
with
res-
piratory
failure.
Potential
advantages
to
avoiding
endo-
tracheal
tubes
include
improved
comfort,
preservation
of
speech
and
swallowing,
decreased
risk
of
infectious
complications
and
decreased
laryngeal
injury.
However,
not
all
patients
with
respiratory
failure
are
candidates
for
noninvasive
techniques.
Careful
selection
of
patients
and
equipment
is
necessary
for
success.
A
variety
of
types
and
sizes
of
nasal
and
facial
masks
are
now
available
for
use,
allowing
a
comfortable
fit
for
most
patients.
The
mask
should
fit
snugly,
while
avoid-
ing
excessive
pressure
on
the
skin;
small
air
leaks
around
the
mask
are
acceptable.
Nasal
masks
permit
speech,
eating
and
expectoration
without
removal
of
the
mask.
However,
patients
in
respiratory
distress
who
mouth
breathe
may
need
a
full
face
mask.
Gastric
dis-
tention
is
rarely
a
problem
when
the
applied
pressure
is
less
than
25
cm
H20.
A
nasogastric
tube
for
gastric
decompression
need
not
be
placed
routinely.
Noninvasive
positive
pressure
ventilation
(NPPV)
can
be
provided
by
standard
volume-cycled
or
pressure-
controlled
ventilators
or
bilevel
positive
airway
pressure
ventilators
(bilevel
PAP).
Advantages
of
standard
venti-
lators
include
a
broader
range
of
ventilation
capacity,
the
ability
to
deliver
higher
oxygen
concentrations,
and
the
presence
of
sophisticated
monitoring
devices
and
alarms.
Pressure-support
and
pressure-controlled
modes
appear
to
be
the
most
successful
settings
when
used
for
NPPV.
However,
standard
ventilators
are
expensive,
complex
and
need
a
high-pressure
gas
source
(50
psi),
which
limits
their
use
outside
the
intensive
care
unit.
For
these
reasons,
bilevel
PAP
has
become
a
popular
means
of
delivering
noninvasive
ventilation.
These
less
expen-
sive
machines
cycle
between
different
positive
inspira-
tory
and
expiratory
pressures,
either
in
response
to
a
patient's
respiratory
efforts,
or
at
fixed
rate
set
by
the
clinician.
Disadvantages
of
the
currently
available
bilevel
PAP
machines
include
their
inability
to
provide
high
oxygen
concentrations
and
limited
monitoring
and
alarm
capabilities.
NPPV
appears
to
benefit
over
50%
of
patients
with
acute
respiratory
failure
who
are
cooperative,
hemody-
namically
stable,
not
severely
hypoxemic,
can
protect
their
airway
and
are
able
to
tolerate
a
nasal
or
facial
mask.
Patients
suffering
from
exacerbations
of
chronic
obstructive
pulmonary
disease
(COPD)
appear
particu-
larly
well-suited
for
NPPV,
with
studies
suggesting
a
substantially
decreased
need
for
endotracheal
intuba-
tion.
Noninvasive
ventilatory
techniques
have
been
very
successful
for
many
patients
with
chronic
respiratory
failure
due
to
restrictive
chest
wall
diseases,
certain
neu-
romuscular
diseases
and
hypoventilation
syndromes.
Some
patients
with
chronic
hypercapnea
due
to
COPD
also
appear
to
benefit.
For
many
patients
with
chronic
respiratory
failure,
intermittent
NPPV,
often
for
only
a
few
hours
each
night,
can
improve
daytime
gas
exchange.
Possible
reasons
for
the
benefit
in
these
patients
include
intermittent
respiratory
muscle
rest,
improvement
of
respiratory
compliance
by
correction
of
microatelectasis,
or
resetting
of
the
respiratory
center's
sensitivity
to
CO2.
In
summary,
NPPV
is
a
useful
modality
for
selected
patients
with
acute
or
chronic
respiratory
failure.
This
technique
can
provide
ventilatory
support
while
avoid-
ing
many
of
the
disadvantages
of
endotracheal
tubes
and
tracheotomies.
However,
time
may
be
wasted
if
NPPV
is
begun
in
inappropriate
patients
rather
than
proceeding
directly
to
mechanical
ventilation
using
endotracheal
intubation.
JANICE
M.
LIEBLER,
MD
Portland,
Oregon
REFERENCES
Hillberg
RE,
Johnson
DC.
Noninvasive
ventilation.
N
Engl
J
Med
1997;
337:1746-1752
Meduri
GU.
Noninvasive
positive-pressure
ventilation
in
patients
with
acute
respiratory
failure.
Clin
Chest
Med
1996;
17:513-553
Treatment
of
Gastroesophageal
Reflux
Disease-1
998
THE
GOALS
OF
THERAPY
for
gastroesophageal
reflux
dis-
ease
(GERD)
are
to
relieve
symptoms,
heal
damaged
esophageal
mucosa,
prevent
complications,
and
main-
tain
remission.
Effective
medical
therapy
can
now
achieve
all
of
these
goals
in
the
vast
majority
of
patients.
Additionally,
the
introduction
of
laparoscopic
fundopli-
cation
has
renewed
the
interest
in
surgery
as
a
way
to
achieve
these
goals,
and
is
an
option
for
patients
who
prefer
an
alternative
to
medication.
Most
GERD
patients
have
intermittent
reflux
symp-
toms,
do
not
have
significant
esophagitis,
and
are
unlikely
to
develop
complications.
For
these
patients
lifestyle
modifications
such
as
dietary
changes,
eleva-
tion
of
the
head
of
the
bed,
avoidance
of
early
recum-
WJM,
June
1998-Vol
168,
No.
6
Epitomes-internal
Medicine
529
Epitomes-Internal
Medicine
bency
after
meals,
and
discontinuation
of
smoking,
alco-
hol
and
irritant
medications
may
be
the
only
therapy
that
is
necessary.
Antacids
may
be
helpful,
but
they
are
nei-
ther
effective
nor
cost-effective
in
patients
with
daily
symptoms
or
significant
endoscopic
esophagitis.
For
patients
with
more
severe
or
more
frequent
symptoms
of
reflux,
H2
receptor
antagonists
may
be
added
to
lifestyle
modifications.
Therapy
for
6
to
12
weeks
effectively
relieves
symptoms
of
reflux
and
heals
esophagitis
in
about
50%
of
patients,
and
maintains
remission
in
about
25%
of
patients.
For
severe
esophagitis,
it
is
generally
more
cost
effective
to
add
another
agent
or
to
switch
to
a
proton
pump
inhibitor
instead.
Promotility
agents
may
also
be
used
to
manage
GERD.
Cisapride
effectively
relieves
nocturnal
heart-
burn
in
up
to
50%
of
patients
and
is
as
effective
as
rani-
tidine
in
healing
mild-to-moderate
esophagitis.
Metoclo-
pramide
may
improve
symptoms
of
reflux,
but
does
not
heal
esophagitis,
and
should
seldom
be
used
because
of
its
significant
side
effects.
Proton
pump
inhibitors
are
far
more
effective
than
H2
receptor
antagonists
at
suppressing
acid
secretion.
In
patients
with
mild
to
moderate
esophagitis,
omeprazole
or
lansoprazole
control
GERD-related
symptoms
more
effectively
than
H2
receptor
antagonists
and
achieve
healing
rates
of
80%
to
100%
within
8
weeks.
Severe
cases
may
require
higher
doses.
Aggressive
acid
sup-
pression
with
proton
pump
inhibitors
also
improves
reflux-related
dysphagia
and
may
prevent
or
delay
stric-
ture
formation.
Significant
side
effects
are
uncommon.
Most
patients
with
significant
esophagitis
will
relapse
when
therapy
is
discontinued,
and
maintenance
therapy
with
proton
pump
inhibitors
may
be
indicated.
In
a
recent
large
prospective
study
highest
remission
rates
were
found
in
patients
on
combined
omeprazole
and
cis-
apride
(89%),
followed
by
omeprazole
(80%),
ranitidine
plus
cisapride
(66%),
cisapride
(54%)
and
finally,
raniti-
dine
(51%).
Helicobacter
pylori
infection
itself
is
not
thought
to
be
an
important
cause
of
GERD,
and
eradica-
tion
of
this
infection,
if
present,
is
not
necessary
in
the
treatment
of
GERD.
Ironically,
during
the
same
time
that
proton
pump
inhibitors
came
into
common
use,
surgery
for
GERD
also
increased
due
to
the
introduction
of
laparoscopic
fundoplication.
First
performed
in
the
early
1990s,
the
procedure
is
now
commonly
performed
at
many
medical
centers
throughout
the
country.
Laparoscopic
fundoplication
closely
approximates
the
procedure
performed
over
many
years
by
laparot-
omy
or
thoracotomy.
Both
a
"complete"
fundoplication,
sometimes
referred
to
as
"Nissen
fundoplication,"
as
well
as
a
"partial"
fundoplication,
may
be
performed
laparoscopically.
Partial
fundoplications
augment
lower
esophageal
sphincter
pressure
less
than
complete
fundo-
plications
and
may
be
preferred
in
patients
with
signifi-
cant
impairment
of
esophageal
peristalsis.
More
com-
plex
operations,
in
which
the
length
of
the
esophagus
is
augmented
by
dividing
a
portion
of
the
stomach,
may
also
be
performed,
but
wide
experience
with
these
is
lacking.
Patients
being
considered
for
surgery
for
GERD
should
undergo
endoscopy
with
biopsies,
24
hour
pH
monitoring,
and
esophageal
manometry.
Endoscopy
with
biopsy
is
necessary
to
look
for
esophagitis
or
the
premalignant
condition
of
Barrett's
esophagus.
Biop-
sies
should
be
performed
because
short
segments
of
Barrett's
esophagus
may
not
always
be
grossly
appar-
ent.
A
24
hr
pH
is
performed
to
confirm
that
symptoms
are
caused
by
reflux
of
gastric
contents
and
to
docu-
ment
pathologic
reflux
in
patients
with
atypical
symp-
toms.
Manometry
is
performed
to
assess
esophageal
motor
function.
Patients
with
impaired
peristalsis
are
at
increased
risk
for
the
development
of
dysphagia
if
a
complete
fundoplication
is
performed,
and
in
these
patients
a
partial
fundoplication
may
be
preferred.
Occasionally,
manometric
findings
may
suggest
an
underlying
collagen
vascular
disease
(eg,
scleroderma),
and
in
some
instances
the
manometric
findings
may
contraindicate
an
antireflux
operation.
Some
patients
with
early
achalasia,
for
example,
may
complain
of
heartburn,
and
an
antireflux
procedure
would
be
inap-
propriate.
A
barium
swallow
is
expected
by
many,
but
not
all
surgeons,
to
assess
the
size
of
a
hiatal
hernia
and
to
exclude
anatomic
surprises,
such
as
diverticulae
or
esophageal
shortening.
Long
term
follow-up
with
laparoscopic
fundoplications
is
not
yet
available,
but
it
is
reasonable
to
expect
good
or
excellent
results
in
90%
of
patients
at
ten
years.
Previous
studies
have
demonstrated
the
superiority
of
antireflux
surgery
performed
by
laparotomy
to
that
of
medical
management
with
H2
blockers.
To
date,
however,
there
is
no
direct
comparison
of
the
results
of
laparoscopic
fundoplications
with
proton
pump
inhibitors
nor
are
there
any
good
cost
data
to
compare
the
two
approaches.
Indications
for
surgery,
therefore,
are
not
well
defined.
Complications
of
GERD
are
sel-
dom
fatal,
and
in
most
patients
they
may
be
prevented
and
symptoms
much
improved
with
medications.
Indeed,
symptoms
that
are
not
significantly
improved
by
aggressive
medical
management
may
not
actually
be
from
gastroesophageal
reflux,
and
may
not
be
relieved
by
surgery.
Most
patients
are
referred
for
surgery
because
of
their
desire
not
to
be
medication-dependent.
Long-term
follow-up
studies
will
be
necessary
to
deter-
mine
the
role
of
laparoscopic
surgery
in
the
modern-day
management
of
GERD.
MARK
A.
VIERRA,
MD
GEORGE
TRIADAFILOPOULOS,
MD
Stanford,
California
REFERENCES
Horgan
S,
Pellegrini
CA.
Surgical
treatment
of
gastroesophageal
reflux
dis-
ease.
Surg
Clin
North
Am
1997;77:1063-1082
Hinder
RA,
Perdikis
G,
Klinger
PJ,
De
Vault
KR.
The
surgical
option
for
gas-
troesophageal
reflux
disease.
Am
J
Med
1997;103:144S-148S
Lambert
R.
Review
article:
current
practice
and
future
perspectives
in
the
man-
agement
of
gastro-oesophageal
reflux
disease.
Aliment
Pharmacol
Ther
1997;
11:651-662
530
WJM,
June
1998-Vol
168,
No.
6
Epitomes-internal
Medicine
