Gastroesophageal and pharyngeal reflux detection using impedance and 24-hour pH monitoring in asymptomatic subjects: defining the normal environment

Airway symptoms are often caused by aspiration of refluxed materials into the larynx. In this study we sought to define the frequency, character, and proximal extent of refluxed contents - including nonacid reflux-in normal subjects using intraluminal impedance to improve our understanding of the relationship between reflux and aspiration. Ten subjects, who had no symptoms of gastroesophageal reflux disease or airway disease, underwent impedance/pH monitoring with a catheter that allowed simultaneous esophageal and pharyngeal monitoring. Impedance detected 496 gastroesophageal reflux episodes in the 10 subjects during 240 hours of study. The majority, 399 (81% of the total) were acid reflux episodes (pH < 4). Ninety-seven were nonacid (pH > 4). Most reflux episodes (348 of 496) reached the mid esophagus (9 cm above lower esophageal sphincter). There were 51 reflux episodes that reached the pharynx (PR). Only 13 (25%) of PR were acidic (pH < 4), while 38 were nonacid. Twenty-six PR episodes were liquid and 25 were mixed (liquid and gas). The median number of PR episodes measured with impedance was 5 (0-10). In asymptomatic subjects, most episodes of gastroesophageal reflux are acidic and reach the midesophagus. Reflux into the PR appears to be more common than previously believed, and most of these episodes are not acidic. Thus, traditional 24-hour pH monitoring may underestimate the presence of pharyngeal reflux. The combination of impedance with pH monitoring markedly enhances our ability to accurately detect potential microaspiration.

Patch esophagoplasty using AlloDerm as a tissue scaffold

BACKGROUND/PURPOSE

Anastomotic leak and stricture are common causes of morbidity after esophageal repair. The authors describe a technique of patch esophagoplasty using decellularized human skin.

METHODS

Twelve conditioned dogs underwent a cervical 2.0- x 1.0-cm esophagoplasty with AlloDerm. A gastrostomy tube was used for feedings until an esophagram was performed on the 10th to 14th postoperative day. Dogs were then given oral chow and followed up for leak and dysphagia. Animals were killed at 1-, 2-, and 3-month intervals and evaluated for stricture, diverticula formation, and patch histology.

RESULTS

All animals survived, and none had sepsis or dysphagia. All esophagrams were without evidence of leak or stricture. At death there were no strictures or diverticula. Histologic examination of 1-month specimens showed partial reepithelialization of the patch with neovascularization. Control staining of AlloDerm was strongly positive for elastin. This was decreased in the region of the patch at 1 month. Two-month specimens showed intact epithelium and an increase in the caliber of new blood vessels. Three-month specimens showed no significant variation from 2-month animals.

CONCLUSION

Decellularized human skin (AlloDerm) provides a temporary collagen framework on which esophageal healing can occur and function can be maintained.

The development of gastroesophageal reflux after percutaneous endoscopic gastrostomy

The relationship between percutaneous endoscopic gastrostomy (PEG) and subsequent development of gastroesophageal reflux (GER) is complex and not well understood. The authors retrospectively reviewed 82 children over a 5-year period who underwent PEG tube (n = 64) or PEG button (n = 18) placement. Children were evaluated preoperatively for clinical evidence of GER (C-GER) or radiographic GER (R-GER) with upper gastrointestinal contrast study or Tc99m gastric scinitiscan. Seventy-five patients were evaluated for clinical evidence of postoperative GER by direct family contact. Eleven of 39 (28%) patients with no GER preoperatively developed GER postoperatively, eight (20%) of whom required Nissen fundoplication (NF) or gastrojejunostomy (GJ) tube. Ten of 19 (53%) with preoperative C-GER but no R-GER continued to have GER after PEG, but only three required NF or GJ. Only one of nine children who had R-GER only developed clinical GER after PEG placement. Of the eight children with both C-GER and R-GER, only two (25%) required NF or GJ and two (25%) had no postoperative GER. The authors conclude that PEG tubes are useful in infants and children and are associated with a relatively low incidence of postoperative GER. If C-GER is absent, a PEG is a reasonable procedure to consider even in the presence of R-GER.