Anatomic and clinical data suggest that the gastroesophageal junction or cardia in patients with gastroesophageal reflux disease GERD) may be dilated. We hypothesized that anatomic dilatation of the cardia induces a lower esophageal sphincter dysfunction that may be corrected by narrowing the gastroesophageal junction (i.e., calibration of the cardia). We measured the perimeter of the cardia during surgery in control subjects and patients with GERD and Barrett's esophagus. We then tested our hypothesis in a mechanical model. The model was based on a pig gastroesophageal specimen with perpendicularly placed elastic bands around the cardia simulating the action of the "sling" and "clasp" fibers. "Dilatation" of the cardia was induced by displacing the sling band laterally and decreasing its tension. "Calibration" of the cardia was performed by reapproximation of the sling band toward the esophagus but maintaining the same tension as the dilated model. In the "basal," "dilated," and "calibrated" states, the perimeter of the cardia was noted and rapid mechanized pullback manometry with a water-perfused catheter was performed. The opening pressure was determined, and three-dimensional sphincter pressure images were analyzed. The average cardia perimeter was 6.3 cm in control subjects, 8.9 cm in GERD patients, and 13.8 cm in patients with Barrett's esophagus. The arrangement of the bands in the experimental model generated a manometric high-pressure zone similar to that in the human lower esophageal sphincter. Dilatation of the cardia resulted in a decrease in the resting pressure, length, and vector volume of the high -pressure zone, and reduced the opening pressure. Calibration restored the resting and opening pressure, and normalized the three-dimensional pressure image. In patients with GERD and Barrett's esophagus, the cardia is dilated. Our model supports the hypothesis that lower esophageal sphincter function is compromised by anatomic dilatation of the cardia and can be restored by approximation of the "sling" fibers toward the lesser curvature "clasp" fibers). This provides evidence for a correlation between gastroesophageal sphincter dysfunction in reflux disease and its correction by antireflux surgery.

Adult↗

PubMedDate not supplied

Prevalence of common bile duct stones according to the increasing number of risk factors present. A prospective study employing routinely intraoperative cholangiography in 477 cases.

BACKGROUND/AIMS: To determine if the use of Intraoperative choliangiography (IOC) should be routinely performed and, if not, which criteria should be used to select patients requiring IOC during open or laparoscopic cholecystectomy. METHODOLOGY: 495 Patients with 1 or more gallstones were included in a two-year study. Twelve clinical, laboratory, ultrasonographic and intraoperative factors were chosen and evaluated in all cases. Prior to cholecystectomy, IOC was performed after having identified the common bile duct (CBD) and cystic duct. The majority of the patients were operated on by the same surgeon to avoid differences in criteria and techniques. Statistical evaluation made use of the exact Fisher test and chi square test and, a p-value less than 0.05 was considered as significant. RESULTS: IOC could be performed in 479 out of the 495 cases. IOC resulted in a normal CBD in 76.0%, had a false positive in 2.7%, a false negative in 0.48%, and a presence of 1 or more stones in the CBD in 20.9%. The study revealed that when none of the 12 risk factors were present, there were no cases with CBD stones. As the number of risk factors increased, so did the number of cases presenting with CBD stones. CONCLUSION: Not all 12 risk factors show the same index of predictability; only 5 in particular (jaundice, ultrasound diameter CBD 7 mm, bilirubin over 26 umol/it, cystic duct > 4 mm and CBI, diameter over 9 mm) showed a high rate of predictability. However, when careful measurement and evaluation of risk factors for CBD stones are undertaken, it is possible to avoid the routine use of IOC.

Adolescent↗