The role of a defective lower esophageal sphincter in the clinical outcome of treatment for gastroesophageal reflux disease

OBJECTIVE

To evaluate the clinical role of a defective lower esophageal sphincter in the long-term outcome of medical and surgical treatment for gastroesophageal reflux disease.

DESIGN

Nonrandomized control study (median follow-up, 33 months).

SETTING

Referred care.

PATIENTS

Fifty-five patients with gastroesophageal reflux disease were prospectively evaluated using a symptom questionnaire, upper endoscopy, esophageal manometry, and 24-hour pH monitoring. Patients were classified into three groups: (1) those with a manometrically defective lower esophageal sphincter, treated surgically; (2) those with a manometrically defective lower esophageal sphincter, treated medically; and (3) those with a manometrically normal lower esophageal sphincter, treated medically.

INTERVENTION

Nissen antireflux procedure and medical therapy with H2-blockers and/or omeprazole.

MAIN OUTCOME MEASURES

Symptomatic improvement after treatment and need for continuous medication.

RESULTS

After therapy, symptoms improved significantly in all three groups (P < .05), but least in the patients who declined surgery. Among patients with a defective lower esophageal sphincter, medical therapy could be discontinued in 13 of 14 patients who had surgery compared with one of 14 who declined surgery. Of the 27 patients with a normal lower esophageal sphincter who were treated medically, medical therapy could be discontinued in 12.

CONCLUSIONS

In patients with gastroesophageal reflux disease who have a defective lower esophageal sphincter, surgery can ensure durable symptom control. Patients with a defective sphincter who decline surgery are destined for lifelong therapy, whereas in approximately half of those with a normal sphincter, medical therapy can eventually be discontinued.

Sequential intraluminal endoscopic and laparoscopic treatment for bile duct stones associated with gallstones

BACKGROUND

On the basis of a flowchart including prior or current jaundice or pancreatitis, abnormal liver function, ultrasound or IV cholangiography, bile duct (BD) stones were suspected in 71/593 patients referred for gallstones.

METHODS

When endoscopic retrograde cholangiography detected BD stones, endoscopic sphincterotomy (ES) and endoscopic BD clearance were attempted, followed by laparoscopic cholecystectomy (LC). BD stones were found in 44/71 patients. The sensitivity values of preoperative conditions were: 92% for IV cholangiography, 88% for abnormal liver function, 50% for ultrasound, and 37% for jaundice at admission.

RESULTS

Endoscopic clearance succeeded in 37 patients and LC was completed in 33 patients. Conversion to open surgery (9%) was comparable with the rate in patients without BD stones. The median hospital stay for the sequential endoscopic and laparoscopic treatments was 13 days (range 4-54) or 22 days if open surgery was used.

CONCLUSIONS

In conclusion, BD stones can be endoscopically cleared preoperatively in most patients without interfering with LC.

Modified Sujura operation: long-term results

From January 1980 to January 1986 a total of 93 patients with portal hypertension (59 males, 34 females; average age 51.5 years) underwent the modified Sujura's operation. All patients presented with esophageal varices during the preoperative endoscopic workup. Child's risk category was A in 6 patients and B in the remaining 87. Our technique consisted of: (1) devascularization of the upper half of the gastric corpus and fundus; (2) devascularization of the last 10 to 12 cm of the thoracic esophagus; (3) pyloric divulsion; (4) resection and anastomosis at the esophagogastric junction; and (5) antireflux fundoplication. In the presence of severe hypersplenism we added splenectomy. The surgical approach was through a xiphoumbilical laparotomy, extended to the left side when splenectomy was anticipated. We observed 19.8% early mortality (10% with elective procedures and 27.2% with emergency operations) and two cases of early rebleeding from acute mucosal lesions. Long-term follow-up of 82 patients revealed 30 cases of rebleeding (36.6%). Ruptured esophageal varices occurred in 12 patients (11 were treated with endoscopic sclerotherapy), whereas in 11 patients the cause of bleeding was a hemorrhagic gastritis. Of the remaining patients, two had rebleeding from a gastric ulcer, one from gastric varices, one from duodenal varices; in three patients the source of the hemorrhage remains unknown. The survival for elective procedure patients was 59.2% at 5 years and 40.7% at 10 years.

Chronic recurrent pancreatitis in pregnancy

This report describes a case of chronic recurrent pancreatitis due to gallstones arising in the first trimester of pregnancy. Total parental nutrition produced a normalization of pancreatic enzymes and a rapid regression of symptoms. Following another relapse of acute pancreatitis, a laparoscopic cholecystectomy was performed. The pregnancy continued normally and the patient had a spontaneous delivery at the 37th week.

Outpatient surgery of varices of the lower limbs: experience of 2,568 cases at four universities

Outpatient surgery of varices of the lower limbs is currently considered a viable alternative to traditional surgery with hospitalization. This paper reports the experience of 4 university groups (Padua, Modena, Verona, Milan), where outpatient treatment has been used since 1987. From June 1987 to June 1992, 2,568 lower limb varices were treated in this way. Different techniques of anaesthesia were used (local infiltration, combined local and general, general, subarachnoid). In all cases, crossectomy was combined with short or long saphenous stripping. There were no intra- or perioperative deaths, and only limited morbidity. Postoperative hospitalization was required in only 2 cases: for hemorrhaging of the inguinal wound in one case, and headache 2 days after spinal anaesthesia in the other. In 2 separate samples of 100 patients, 88 and 89 indicated satisfaction with the surgical treatment. In conclusion, outpatient surgery of varices can be based on the same techniques as in-patients treatment. The risks of surgery and anaesthesia in specialised centres are very limited, with scope for a variety of anaesthetic techniques according to facilities available. Patients satisfaction is high.

p53 overexpression in the multistep process of esophageal carcinogenesis

The timing of p53 mutation in the multistep process of esophageal carcinogenesis is still under debate. We tested p53 expression in 16 samples of low-grade and 29 samples of high-grade esophageal dysplasia (ED) coexisting with esophageal squamous cancer (ESC) in 31 patients who underwent total esophagectomy. In normal mucosa, a positive immunoreaction was detected in 10 of 31 cases, always restricted to the lower half of the epithelial thickness. We detected p53-positive nuclei in 11 of 16, 23 of 29, and 23 of 31 samples of low-grade ED, high-grade ED, and ESC, respectively. Cases exhibiting positive staining in dysplastic samples also demonstrated positive immunoreaction in the carcinomatous tissue. Immunoreactivity in cancer cells was never found in the absence of positive dysplastic nuclei. A significantly higher score of immunoreactive nuclei was detected in high-grade versus low-grade and in low-grade compared with normal mucosa. These data suggest that p53 mutation may represent an early event in esophageal oncogenesis.

Onset of oesophageal peristalsis after surgery for idiopathic achalasia

Twenty-seven patients were treated with a Heller myotomy and Dor fundoplication; some peristaltic contractions occurred in seven after operation. When clinical, radiological and manometric data in the seven patients developing peristalsis were compared with findings in the other 20, there were no differences in symptoms, lower oesophageal sphincter pressures and lengths, relief of dysphagia or oesophageal calibre reduction. Oesophageal resting pressure was lower and oesophageal contraction amplitudes were statistically higher in patients with restored peristalsis, which correlated only with the amplitude of contractions 5 cm above the lower oesophageal sphincter (P < 0.05, 95 percent confidence interval). Peristaltic contractions probably exist before treatment, but are concealed by the dilated oesophagus and the common cavity phenomenon. Achalasia is not necessarily associated with complete aperistalsis. No difference was found in the outcome of surgical treatment, and the return to peristalsis appears to be clinically relevant.

Laparoscopic treatment of gastro-esophageal reflux disease: indications and results

This paper deals with the indications, techniques and results of laparoscopic total or partial posterior fundoplications (Nissen and Toupet procedures, respectively) performed in 41 patients with gastroesophageal reflux disease (GERD) failing to respond to medical treatment. Stationary manometry and 24-hour esophageal pH monitoring established the indications for surgery. Laparoscopy was attempted in all patients, even when giant mixed or para-esophageal herniations were present. The rate of conversion to laparotomy amounted to 12.2%. There were no intraoperative complications. Major complications were observed in 3 patients (8%) and included 2 cases of slipped Nissen and 1 of pneumonia. Four patients had persistent postoperative dysphagia; two of them were re-operated and two were treated with pneumatic dilatation. Reflux only recurred in 1 patient. Functional follow-p demonstrated an overall increase in LES resting pressure and length, with no abnormal gastro-esophageal reflux episodes, findings which tended to persist in the long term.

[Myotomy of the esophageal body]

Extramucosal myotomy involving the external longitudinal and internal circular layers of the musculature of the esophagus represent the surgical therapy in patients with dysphagia and regurgitation or with angina-like chest pain secondary to functional abnormalities of the musculature of the esophagel body and sphincters. Surgery has a palliative function, because cures symptoms and complication such a diverticula, but not the disease. Modern surgical techniques also prevent recurrence of symptoms and complications are minimal with better long-term results than conservative therapy. Myotomy of the lower esophageal sphincter extended to the distal part of the esophageal body (Heller's operation) is performed as first choice or following insucces of dilatation in patients with primary achalasia of the esophagus, using a trans-abdominal or a trans-thoracic approach. Myotomy of the upper esophageal sphincter is indicated in patients with Zenker's diverticulum following diverticulectomy or diverticulopessy. Segmental myotomies are performed after diverticulectomy in patients with epiphrenic pulsion diverticula. Trans-thoracic "long" esophageal myotomy performed from the thoracic portion of the lower esophageal sphincter to the aortic arch is indicated in patients with diffuse esophageal spasm and nutcracker esophagus and sometimes in patients with aspecific abnormalities of the esophageal motor function associated with diverticula. Circular miotomies limited to the external longitudinal layer of the esophageal musculature can be performed at the level of anastomosis in order to gain tissue and reduce tissutal tension. The recent introduction of the endoscopic surgery allowed some of these operations to be performed through minimally invasive approaches. Therefore laparoscopic and thoracoscopic Heller's myotomy is feasible with clinical and functional results similar to those obtained with traditional open approach and with less postoperative discomfort and shorter hospital stay. This paper deals with the indications and surgical techniques of myotomies of the esophageal body both limited and extended to the lower esophageal sphincter.

Esophageal achalasia: laparoscopic versus conventional open Heller-Dor operation

BACKGROUND

The laparoscopic treatment of esophageal achalasia has recently been introduced, and the occasional reports in the literature seem to indicate considerable advantages for patients in terms of surgical trauma, postoperative discomfort, and appearance. As yet, however, no studies have directly analyzed the benefits and shortcomings of the new surgical technique by comparison with the conventional open procedure. The objective of our study was to review recent experience with the laparoscopic Heller-Dor operation (LAP-HD) at the Department of Surgery of Padua University and compare it with the traditional open Heller-Dor procedure (OPEN-HD) to assess early effectiveness in patients with primary esophageal achalasia.

PATIENTS AND METHODS

The records of 17 patients who had LAP-HD and a matched group of 17 patients who had OPEN-HD were retrospectively reviewed. The duration of procedures, morbidity, several aspects of the postoperative course, and hospital costs were recorded and compared. Results of clinical follow-up and of manometric and pH-monitoring studies performed 6 months postoperatively were also evaluated in both patient groups.

RESULTS

LAP-HD took longer than OPEN-HD (mean 178 versus 125 minutes). There was no mortality or major morbidity in either group. Postoperative pain and ileus and need for IV nutrition lasted a shorter time for LAP-HD patients (P < 0.0001). Consequently, the median postoperative hospital stay and the median interval before returning to normal activity were also shorter (4 and 14 days for the LAP-HD group versus 10 and 30 days for the OPEN-HD group, P < 0.0001). During follow-up, dysphagia recurred in 1 patient of the LAP-HD group and gastroesophageal reflux was registered in 1 patient of the OPEN-HD group. Lower esophageal sphincter pressure decreased significantly after both procedures.

CONCLUSIONS

Laparoscopic management of achalasia leads to short-term results comparable to those of the well-established open technique. In view of the less severe surgical trauma and lower hospital cost, the laparoscopic approach is preferable, but long-term studies are needed.

[Surgical treatment of acid gastroesophageal reflux]

Recently, it has been demonstrated that the surgical treatment of gastro-esophageal reflux disease is superior to the medical treatment. Further, the surgical treatment gained new popularity because of the introduction and diffusion of laparoscopic techniques. A careful definition of gastro-esophageal reflux disease, based on the underlying pathophysiological abnormality (i.e.: an increased exposure of the distal esophagus to the refluxed acid juice), and a proper selection of patients candidate to surgery must however be maintained, together with a proper surgical technique, in order to achieve satisfactory results. In this paper, the authors outline in this paper the general principles of anti-reflux surgery and review the most recent results obtained with Nissen fundoplication as well as with other antireflux procedures. They describe in detail the surgical technique of the Nissen fundoplication ("Floppy" Nissen) by a laparoscopic approach. They review their experience in this with 15 operations performed since June 1992, and report the results of an Italian multicentric survey study on laparoscopic surgery for gastro-esophageal reflux disease. Recent series appeared in Literature are also reviewed. In conclusion, the authors underline the need for careful prospective studies and long-term clinical and functional follow-up of patients undergoing laparoscopic anti-reflux surgery before drawing definitive conclusions on its efficacy. However, early results seem to be really promising.

Epidermal growth-factor receptors and erbb2 protein expression in esophageal cancer and normal mucosa

The epidermal growth factor receptor (EGFr) and the erbB2 protein (p185) concentrations were assessed in 31 esophageal cancer specimens and in the corresponding normal mucosa, in order to investigate the possible links with the main clinical and pathological parameters. Detectable and high affinity EGFr was found in 27/31 cancer and in 18/31 normal tissue samples. EGFr concentrations were not significantly different between cancer and normal tissue, although a trend toward higher levels in cancer was found. No relationships were found with histologic type, tumor bulk, lymph node status, pathologic stage, ploidy and type of surgical resection. A significant negative correlation between EGFr levels and overall survival was found. Detectable levels of p185 were found in all the tissues examined, but the expression was higher in adenocarcinoma than in squamous cell carcinoma samples. The EGFr role in malignant transformation still has to be established, but the determination could be of clinical use. As for p185, its role in the onset of esophageal cancer could be confined to the subgroup of the adenocarcinomas.

[Echo-sclerotherapy in the management of varices of the lower extremities]

Sclerotherapy has been used with satisfactory results, for several years in the treatment of varicose veins. Nevertheless sometimes sclerosis can be incomplete because of the morphology of lower limbs or because the varicose disease is not clinically evident. In addition, sclerotherapy can give rise to severe complications due to intrarterial or extraluminal injections. In order to exceed this limits, some authors suggested to use a new technique, the echosclerotherapy, which was presented for the first time in Strasburg 1989 by Knight and Vin. Echosclerotherapy is a good help for traditional sclerotherapy, especially when it is applied in the sclerosis of the short saphenous veins, of perforating veins or in unfavourable anatomical situations. From May to November 1993 at the Second Surgical Department of Padua University, 31 patients, 29 women and 3 men, have been treated by echosclerotherapy. 25 patients had great saphenous varicose veins; 3 patients had varices due to perforating veins of the popliteal fossa and 3 patients varices due to Hunter perforating veins. In 48.4% of cases we obtained a complete sclerosis of the vessel; in 38.7% a stump remained near the sapheno-femoral junction of about two centimeters; in one case the treatment was not completed and in one case remained a stump of ten centimeters. Only in two cases Echosclerotherapy was not able to obtain sclerosis. None of the patients had major complications and nobody had deep vein thrombosis. If we consider our results altogether we can say that in 87% of cases we had good results.(ABSTRACT TRUNCATED AT 250 WORDS)

[Laparoscopic cholecystectomy in pregnancy]

After appendicectomy, cholecystectomy is the most frequently nongynecological operation performed in pregnant women. Pregnancy has been stated to be a contraindication to laparoscopic cholecystectomy (LC) because of the unknown effects of a prolonged CO2 pneumoperitoneum on the fetus. Between September 1990 and December 1993 451 patients underwent LC at the 2nd Surgical Department of the University of Padova-Italy. Two patients were operated during the second trimester of pregnancy. LC without cholangiograms was successful in both patients and uncomplicated term delivery occurred. The Authors conclude that pregnancy is not a contraindication to LC; it can be performed safely during pregnancy and should be scheduled during the second trimester.

Excessive competence of the lower oesophageal sphincter after Nissen fundoplication: evaluation by three-dimensional computerised imaging

OBJECTIVE

To compare the competence of the lower oesophageal sphincter after Nissen fundoplication with that in a control group of healthy volunteers using a new computerized manometric device that integrates the pressure and length of the entire sphincter into one measurement, called the vector volume.

DESIGN

Open study.

SETTING

University hospital, Italy.

SUBJECTS

18 patients, 6-52 months (mean 10 months) after they had undergone Nissen fundoplication for gastro-oesophageal reflux, and 14 healthy volunteers.

INTERVENTIONS

Oesophageal computerised manometric system comprising a catheter with eight side holes radially oriented to each other at 45 degrees on one level and 24-hour oesophageal pH monitoring.

MAIN OUTCOME MEASURES

Differences in percentage time of oesophageal acid exposure, number of episodes of gastro-oesophageal reflux, and lower oesophageal sphincter vector volume.

RESULTS

The pH of the oesophagus was returned to the normal range in all patients after the Nissen fundoplication. There was a significant reduction in both the percentage time of acid exposure and the number of episodes of gastro-oesophageal reflux compared with the control group (p < 0.001). The vector volume of the intra-abdominal part of the lower oesophageal sphincter was significantly increased compared with the control group (p < 0.04). Lower oesophageal sphincter pressure measured at the respiratory inversion point, and lower oesophageal length, both increased after fundoplication to become similar to control values. When sphincter pressure was measured as a mean of the sphincter pressure curve there was a clear difference postoperatively compared with controls (p < 0.02).

CONCLUSIONS

Nissen fundoplication corrects abnormal gastro-oesophageal reflux but abolishes normal physiological postprandial reflux; this is caused by the gastric fundus that encircling the intra-abdominal oesophagus, restores sphincter pressure and length, and modifies its shape.

Laparoscopic versus conventional surgery for suspected appendicitis in women

The diagnosis of appendicitis remains uncertain in female patients and laparoscopy has been suggested as a valid diagnostic tool. The laparoscopic approach has recently also been proposed for the treatment of acute appendicitis, though its real value is still under debate. A clinical and economic prospective evaluation of laparoscopic surgery over a 1-year period in female patients is reported. The study involved 38 patients presenting with signs of appendicitis and assigned to open (18) or laparoscopic surgery (20). The two groups were comparable as regards age and clinical presentation of the disease. The duration of the procedures was similar (60 min). Morbidity was comparable (3 vs 2). The ratio of negative appendectomy (50% vs 44%) was also similar, but the laparoscopic approach enabled a higher number of certain diagnoses (9/10 vs 3/8 p > 0.05). No significant differences were observed in the median postoperative stay (3 days for laparoscopy and 4 for surgery) or in the days needed to return to normal activity (15 vs 18). The cosmetic satisfaction was higher for the laparoscopic patients. The cost of the laparoscopic approach, however, was much higher than for conventional surgery. Our results suggest that laparoscopy is a useful diagnostic tool in female patients, but that laparoscopic appendectomy should be considered with some caution in times of restricted financial resources.

Functional and morphological effects of defibrotide on renal ischemia

Defibrotide (Df) has been reported to protect various organs from ischemic damage. The aim of this study was to evaluate the effect of Df on renal function and morphology after warm kidney ischemia. Divided into two groups, 14 pigs underwent bilateral renal clamping for 90 min. One group (7 pigs) was treated with Df (32 mg/kg per h) for 6 h, whereas the control group received 5000 IU of heparin. Serum levels of blood urea nitrogen (BUN) and creatinine measured for 6 days were significantly higher in the control group (peak 26.8 +/- 16.7 vs 11.0 +/- 2.9 mmol/l and 501.2 +/- 351.4 vs 230.2 +/- 68.0 mumol/l P < 0.05). Renal biopsy evidenced a lesser extent of tubular and endothelial damage in Df-treated animals. In conclusion, Df provided relevant protection against renal ischemic injury.

Heller laparoscopic cardiomyotomy with antireflux anterior fundoplication (Dor) in the treatment of esophageal achalasia

The technique of Heller laparoscopic myotomy with associated Dor anterior fundoplication for the treatment of esophageal achalasia is described. This operation was performed on three patients with clinical, radiologic, and manometric diagnoses of achalasia. Complete relief of dysphagia and modifications of radiological and manometric patterns were achieved in all patients 1 month after surgery. Laparoscopic treatment of achalasia is technically feasible, reduces surgical trauma, and may be considered a valid alternative to open surgery.

[The use of totally implantable systems (TIS) for long-term endovenous therapy]

The availability of a long-term central venous access for the management of neoplastic and chronic patients is extremely important in order to achieve an easy and safe infusion of chemotherapeutic drugs, blood components, and parenteral nutrition. The authors evaluated 26 adult patients (25 with malignant tumors and 1 with severe asthma) in whom implantable catheter systems were placed subcutaneously between February 1989 and March 1992. Catheters were inserted through the cephalic vein in 13 cases, the subclavia vein in 8 cases and jugular vein in 5 cases. The mean function time was 262 days in deceased patients and 155 in alive ones. There were no infective or thromboembolic complications. The authors, in agreement with the literature, confirm that TIS represent a safe and easy access for a long term i.v. therapy, with a very low complication rate. Furthermore, comfort of the patients is substantially improved and nursing care is greatly facilitated.

Altered esophageal pain threshold in irritable bowel syndrome

Gut motility disorders and altered pain perception were reported in patients with irritable bowel syndrome (IBS). To verify foregut involvement in IBS, we studied 30 patients using esophageal manometry and 24-hr pH monitoring of the distal esophagus. Two subgroups of patients underwent esophageal provocative tests (bethanechol 50 micrograms/kg subcutaneously and esophageal balloon distension test). Twelve healthy volunteers formed a control group. A pain threshold on esophageal distension significantly lower than in healthy subjects (11.5 +/- 1 ml vs 22.2 +/- 1.7 ml, P < 0.01) was found in IBS patients. On the other hand, no differences between patients and controls were detected in lower esophageal sphincter pressure and length, esophageal body motility, or GER pattern; furthermore, bethanechol stimulation elicited similar esophageal body motility changes. Our study could confirm no detectable basal or bethanechol-induced esophageal motility disorders in IBS patients, nor enhanced GER. Esophageal involvement in IBS consists of a lower pain threshold on esophageal distension, possibly reflecting an altered visceral receptor sensitivity or modulation throughout the gut.

Transplantation of warm ischemia damaged kidneys: an experimental study in pigs

This study evaluated renal function and histological and oxidative injury in transplanted kidneys harvested after prolonged warm ischemia in pigs. In 8 donor pigs, kidneys were perfused in situ 120 min after cardiac arrest. One of each pair of kidneys was used for histological and biochemical studies while the other was transplanted into a recipient undergoing bilateral nephrectomy. In 6 cases, renal function was satisfactory 14 days after transplantation. Histologically, a reversible acute tubular necrosis was observed with partial recovery at the 14th postoperative day. A moderate oxidation was revealed by decreased glutathione and increased malondialdehyde levels. In spite of this ischemic injury, these findings suggest that kidneys harvested after prolonged warm ischemia can still recover after transplantation, and that non-heart-beating donors may be considered as an alternative organ source for kidney transplantation.

The safety and feasibility of laparoscopic cholecystectomy

This study analyzes data from 100 consecutive patients with gallstone disease who underwent laparoscopic cholecystectomy (LC), a surgical technique rapidly emerging as the treatment of choice for this disease. LC has two major advantages: reduction of postoperative pain and a shortened hospital stay. LC was successfully completed in 88 patients, the main cause of conversion to open cholecystectomy being acute or chronic inflammation of the gallbladder. Analysis of risk factors showed that age, obesity, episodes of jaundice, pancreatitis, and acute or chronic cholecystitis are not absolute contraindications to LC. Mortality was absent and the intraoperative morbidity rate was 2%. No lesion of the main bile duct occurred. Seven minor post-operative complications that did not prolong hospital stay were also observed. These figures compare well with the mortality and morbidity of open cholecystectomy, and demonstrate that the significant benefits in terms of patient welfare and hospital costs of LC are not obtained at the expense of increased surgical risk.