Gastroesophageal reflux: the use of pH monitoring.
Explore the source record for details and available documents.
Chest Pain↗
Biomedical subjects
T R DeMeester
Publications and source records attributed to T R DeMeester.
A tailored approach to antireflux surgery.
Tailored surgical antireflux procedures were done in 104 patients during a 7-year period. Presenting symptoms included heartburn in 95 patients (91%), regurgitation in 83 patients (80%), and dysphagia in 61 patients (60%). Evaluation before operation included video barium esophagography, endoscopy, 24-hour esophageal pH monitoring, and esophageal motility studies. On the basis of anatomic and functional findings, the following procedures were performed: 15 laparoscopic and 49 open transabdominal Nissen fundoplications, 23 transthoracic Nissen fundoplications, seven Belsey partial fundoplications, and 10 Collis gastroplasty and Belsey partial fundoplications. The severity of symptoms was assessed before and after operation according to a previously published grading score. Eighty-five of the 104 patients (82%) were able to be contacted for a follow-up evaluation by means of a standardized questionnaire. Median length of follow-up was 4 years, with 40 patients having follow-up beyond 5 years. The tailored operation cured the symptoms of heartburn in 97%, regurgitation in 91%, and dysphagia in 92%. Ninety-eight percent of the patients reported that operation had cured their preoperative symptoms and 93% were satisfied with the outcome of the operation. To obtain optimal results, surgical treatment of gastroesophageal reflux disease should be tailored to the patient's anatomic and functional assessments. For early, uncomplicated disease a transabdominal Nissen fundoplication is done, laparoscopically when expertise exists. Patients with complicated disease should undergo an open antireflux procedure tailored to specific anatomic or functional abnormalities.
Adolescent↗
Pathologic duodenogastric reflux associated with persistence of symptoms after cholecystectomy.
BACKGROUND: The aim of this study was to determine whether increased duodenogastric reflux contributes to postcholecystectomy symptoms. METHODS: Gastric pH monitoring, hepatobiliary scintigraphy, gastric emptying scans, and gastric acid analysis were performed in asymptomatic (n = 10) and in symptomatic (n = 27) patients after cholecystectomy. Normal subjects (n = 20), patients with dyspepsia related to gastric acid hypersecretion (n = 20), patients with reflux gastritis after gastric surgery (n = 10), and patients with confirmed primary pathologic duodenogastric reflux (n = 10) were studied as controls. Symptomatic patients also underwent upper gastrointestinal endoscopy. RESULTS: Symptomatic patients had significantly increased interprandial gastric exposure to pH < 3 compared with asymptomatic subjects, which correlated well with a high incidence of hepatobiliary scans positive for abnormal duodenogastric reflux and chronic gastritis on endoscopy. Gastric alkaline exposure in symptomatic patients was similar to that seen in patients with primary pathologic duodenogastric reflux and patients with duodenogastric reflux related to gastric surgery. Gastric acid secretion and gastric emptying were not altered. Five patients tested before and after laparoscopic cholecystectomy showed that nocturnal gastric alkalization was enhanced after operation. CONCLUSIONS: This study suggests that excessive duodenogastric reflux may be responsible for persistence of symptoms after cholecystectomy.
Adult↗
Three-dimensional pressure image and muscular structure of the human lower esophageal sphincter.
BACKGROUND: The structural equivalent to the manometric high pressure zone separating the stomach from the esophagus is still a matter of dispute. We compared the three-dimensional (3D) manometric pressure image with muscular thickness and architecture at the human gastroesophageal junction. METHODS: Three-dimensional manometric images were obtained in 25 volunteers by using a stepwise pullback technique of a catheter with eight radially oriented pressure transducers. Muscle thickness was measured in four radial directions at 10 levels between the midesophagus and stomach in 37 specimens obtained from organ donors. Muscular architecture was assessed in specimens from 10 organ donors and 12 human cadavers and was related to muscle thickness. RESULTS: Manometric 3D images of the lower esophageal high pressure zone showed a marked radial and longitudinal asymmetry. Radial pressures peaked at the respiratory inversion point and were highest toward the left posterior direction. Anatomic evaluation showed an asymmetric thickening of the muscular layer at the gastroesophageal junction that mirrored the manometric image. Muscle thickness was highest toward the greater curvature side corresponding to the gastric "sling" fibers and toward the lesser curvature corresponding to the semicircular "clasp" fibers. CONCLUSIONS: The human lower esophageal sphincter is not a muscular ring. Rather, the perfect match between the manometric pressures and the arrangement of muscular structures at the gastroesophageal junction indicates that the gastric sling fibers and the semicircular clasps are the anatomic correlate of the manometric lower esophageal sphincter in human beings.
Adolescent↗
Mixed reflux of gastric and duodenal juices is more harmful to the esophagus than gastric juice alone. The need for surgical therapy re-emphasized.
OBJECTIVE: The author's goal was to determine the role of duodenal components in the development of complications of gastroesophageal reflux disease. SUMMARY AND BACKGROUND DATA: There is a disturbing increase in the prevalence of complications, specifically the development of Barrett's esophagus among patients with gastroesophageal reflux disease. Earlier studies using pH monitoring and aspiration techniques have shown that increased esophageal exposure to fluid with a pH above 7, that is, of potential duodenal origin, may be an important factor in this phenomenon. METHODS: The presence of duodenal content in the esophagus was studied in 53 patients with gastroesophageal reflux disease confirmed by 24-hour pH monitoring. A portable spectrophotometer (Bilitec 2000, Synectics, Inc.) with a fiberoptic probe was used to measure intraluminal bilirubin as a marker for duodenal juice in the esophagus. Normal values for bilirubin monitoring were established for 25 healthy subjects. In a subgroup of 22 patients, a custom-made program was used to correlate simultaneous pH and bilirubin absorbance readings. RESULTS: Fifty-eight percent of patients were found to have increased esophageal exposure to gastric and duodenal juices. The degree of mucosal damage increased when duodenal juice was refluxed into the esophagus, in that patients with Barrett's metaplasia (n = 27) had a significantly higher prevalence of abnormal esophageal bilirubin exposure than did those with erosive esophagitis (n = 10) or with no injury (n = 16). They also had a greater esophageal bilirubin exposure compared with patients without Barrett's changes, with or without esophagitis. The correlation of pH and bilirubin monitoring showed that the majority (87%) of esophageal bilirubin exposure occurred when the pH of the esophagus was between 4 and 7. CONCLUSIONS: Reflux of duodenal juice in gastroesophageal reflux disease is more common than pH studies alone would suggest. The combined reflux of gastric and duodenal juices causes severe esophageal mucosal damage. The vast majority of duodenal reflux occurs at a pH range of 4 to 7, at which bile acids, the major component of duodenal juice, are capable of damaging the esophageal mucosa.
Adult↗
Surgical management of Barrett's esophagus.
Barrett's esophagus is a premalignant metaplastic change in the lining of the distal esophagus. It represents a peculiar form of healing which can occur at any time in patients with reflux esophagitis. Ninety percent of patients with Barrett's esophagus have a mechanically defective lower esophageal sphincter and 93% have abnormal esophageal acid exposure on 24 hour esophageal pH monitoring. Barrett's esophagus should be considered in all patients undergoing endoscopy for symptoms of reflux disease and is confirmed when any biopsy shows the presence of specialized intestinal metaplasia, irrespective of the macroscopic appearances of the distal esophagus. An anti-reflux procedure is indicated for patients with Barrett's esophagus since it is highly effective in controlling reflux symptoms, healing the associated esophagitis, prevents repetitive injury of the Barrett's epithelium, and is more effective than medical therapy in the long term. Annual endoscopic surveillance with multiple biopsy sampling of the esophageal mucosa is indicated after the antireflux repair. Identification of high grade dysplasia heralds the development of invasive cancer and offers the surgeon an opportunity to intervene. Despite extensive endoscopic sampling of the esophageal mucosa the differentiation between high grade dysplasia and invasive adenocarcinoma is unreliable. Esophagectomy remains the treatment of choice for patients with high grade dysplasia. Barrett's adenocarcinoma can be cured by en bloc esophagectomy in selected patients with early disease.
Adenocarcinoma↗
Three-dimensional manometric imaging of the lower esophageal sphincter.
The lower esophageal sphincter provides a pressure barrier between the negative intrathoracic and positive intra-abdominal pressure environment. The resistance of the lower esophageal sphincter to reflux of gastric juice is determined by the integrated effects of radial pressures exerted over the entire length of the sphincter. This can be best quantitated by manometry with radially oriented pressure transducers and calculation of the SPVV (ie, the volume of the 3D sphincter pressure image). Validation studies have shown that the SPVV is superior to standard parameters of sphincter strength (ie, sphincter resting pressure, overall length, and abdominal length) and improves the identification of patients that will benefit from an anti-reflux procedure. This is particularly so in patients with subtle sphincter defects and patients with increased esophageal acid exposure and no mucosal injury on endoscopy. In addition, asymmetry of the sphincter that may contribute to incompetence of the cardia can only be detected by 3D manometric sphincter imaging. The effect of an anti-reflux procedure in controlling reflux is dependent on restoration of the defective 3D sphincter pressure image. Failure to do so is associated with recurrent or persistent reflux. 3D sphincter imaging can also illustrate the severely asymmetric and hypertensive sphincter in patients with achalasia and the effect of myotomy with or without a concomitant anti-reflux procedure on the sphincter pressure profile.
Diagnostic Imaging↗
Biopsy of upper gastrointestinal tract lesions. Indications and clinical significance.
Endoscopic biopsy is an integral part of the investigation of foregut disease. This article discusses the indications for obtaining biopsies in lesions of the esophagus and stomach and for interpretation of brush cytology, fine needle aspiration, and interoperative tissue biopsy in foregut malignancies. New concepts in the diagnosis of Barrett's esophagus are proposed and appropriate management strategies of this condition are examined in depth.
Adenocarcinoma↗
Clinical and physiologic comparison of laparoscopic and open Nissen fundoplication.
BACKGROUND: Although recent reports have documented the safety and efficacy of laparoscopic fundoplication, none have compared outcomes to that of open Nissen fundoplication. STUDY DESIGN: Eighty-one patients had either open (n = 47) or laparoscopic (n = 34) Nissen fundoplication. Relief of symptoms was measured by a standardized questionnaire and scored by a modified Visick-Index. Physiologic outcome was assessed by postoperative pH monitoring and manometry in a subset of both groups. RESULTS: Primary symptoms were heartburn in 55 percent of the patients, regurgitation in 9 percent, dysphagia in 11 percent, and atypical in 25 percent of patients. Twenty-seven (84 percent) of 32 patients in the laparoscopic group and 31 (84 percent) of 37 patients in the open group were cured or improved. Operative time was significantly longer in the laparoscopic group (218 compared to 168 minutes). The period of hospitalization was shorter for the laparoscopic group (4.7 compared to 9.2 days, p < 0.0001). Postoperative pressures in the lower esophageal sphincter (LES) were significantly higher in the laparoscopic group (20.9 compared to 12.1, p = 0.006). Augmentation of sphincter length was similar for both groups. More patients in the laparoscopic group failed to relax their LES completely after fundoplication (32 compared to 71 percent, p = 0.1). CONCLUSIONS: Symptomatic outcome after laparoscopic fundoplication is similar to that of open surgery. Physiologic studies reveal a greater augmentation of LES pressure and a low prevalence of sphincter relaxation after laparoscopic fundoplication.
Adolescent↗
Selection of patients for curative or palliative resection of esophageal cancer based on preoperative endoscopic ultrasonography.
OBJECTIVE: To assess the accuracy of pretreatment staging and the potential of using endosonographic findings to select patients for curative or palliative resection by comparing the preoperative endosonographic and computed tomographic (CT) findings with the histology of the surgical specimen. METHODS: Forty-two patients referred to our clinic with esophageal carcinoma underwent preoperative upper endoscopy with biopsy, endosonography, thoracic CT, and abdominal CT. Based on endoscopic ultrasonographic findings, patients with early-stage disease underwent en-bloc esophagogastrectomy, whereas those with advanced disease had a palliative transhiatal esophagectomy. Exceptions included patients with poor physiologic reserve who were treated by the transhiatal route. RESULTS: In eight patients, we were unable to pass the ultrasonographic endoscope. Seven of these eight had transmural tumors with nodal involvement on histologic study. Tumor length, based on endosonographic measurements, was correctly predicted in 34 patients (85%). Extent of wall penetration was accurately predicted in 26 (76%) of the 34, and regional lymph node status was accurately predicted in 28 (82%) of the 34. Of the patients with sonographic wall penetration, 80% had histologic evidence of one or more positive nodes. Using the WNM staging system, endoscopic ultrasonography correctly staged the cancer in 68% of the patients. Three patients were treated with an inappropriate procedure. CONCLUSION: Endosonography is a reliable method for the preoperative staging and selection of patients for curative or palliative resection. Endosonographic wall penetration appears to be a critical factor in determining tumor spread.
Adult↗
Is Barrett's metaplasia the source of adenocarcinomas of the cardia?
OBJECTIVE: To investigate the prevalence of Barrett's esophagus in patients with adenocarcinomas located at the gastroesophageal junction. DESIGN: A case series of patients who underwent esophagogastrectomy for adenocarcinoma was retrospectively reviewed. Tumors were grouped by location as esophageal, cardiac, and subcardiac, and the prevalence of specialized intestinal metaplasia in the histological specimens was determined. SETTING: A university department of surgery that specializes in esophageal diseases. PATIENTS: One hundred patients with adenocarcinoma of the esophagus, cardia, or proximal stomach. MAIN OUTCOME: Cardiac adenocarcinomas were associated with Barrett's esophagus in 42% of the patients. RESULTS: Specialized intestinal metaplasia was identified in the histological sections from the resected specimen in 42% (13/31) of cardiac adenocarcinomas and in 79% (38/48) of esophageal adenocarcinomas but in only 5% (1/21) of subcardiac adenocarcinomas. The preoperative endoscopic biopsy results concurred with the final diagnosis of Barrett's esophagus in 33 of the 38 esophageal tumors, six of the 13 cardiac tumors, and the one subcardiac tumor but failed to detect specialized intestinal metaplasia in 54% (7/13) of cardiac tumors. Cardiac tumors were associated with shorter lengths of Barrett's mucosa than esophageal tumors (2.7 +/- 1.8 cm vs 7.4 +/- 3.4 cm, P < .01). The Barrett's metaplasia was dysplastic in 36 of the 38 esophageal tumors, 10 of the 13 cardiac tumors, but not in the subcardiac tumor. CONCLUSIONS: Adenocarcinomas located at the gastroesophageal junction were associated with Barrett's metaplasia in nearly one half of the patients. The length of the Barrett segment tends to be short and may be missed during endoscopy. The presence of high-grade dysplasia within Barrett's mucosa supports a barrett's origin for half of the adenocarcinomas arising at this location.
Adenocarcinoma↗
Effect of gastroduodenal juice and dietary fat on the development of Barrett's esophagus and esophageal neoplasia: an experimental rat model.
BACKGROUND: Reflux of duodenal content into the lower esophagus of rats enhances the formation of nitrosamine-induced esophageal cancer and results in the induction of adenocarcinoma. We investigated the extent of the mucosal injury that was produced when the lower esophagus of rats was exposed to the reflux of gastroduodenal juice in the presence or absence of a carcinogen and tested the hypothesis that induction of esophageal cancer in this model would be influenced by the intake of dietary fat. METHODS: Esophagoduodenostomy with gastric preservation was performed in 165 Sprague-Dawley rats in order to expose the lower esophagus to the reflux of gastroduodenal juice. Postoperatively selected groups of rats were treated with the carcinogen methyl-n-amylnitrosamine (MNAN). Subsequently, rats were fed diets of differing fat and calorie content for 20 weeks until they were put to death. RESULTS: Refluxed gastroduodenal juice, in the absence of MNAN, induced esophageal inflammatory changes (diffuse papillomatosis and hyperkeratosis) in 38 of 39 rats (97%), specialized columnar metaplasia (Barrett's esophagus) in four of 39 (10%), dysplasia in three of 39 (8%), and squamous cell carcinoma in one of 39 (3%). Diet did not influence the incidence of neoplasia in the absence of MNAN treatment. In rats treated with MNAN, refluxed gastroduodenal juice induced inflammation in 110 of 111 rats (99%), columnar metaplasia in 14 of 111 (13%), and cancer in 63 of 111 (57%). Fifty-eight percent of esophageal tumors were squamous cell carcinoma and 42% were adenocarcinoma. The highest incidence of tumors was observed in rats fed the semipurified high-fat diet (24 of 29; 83%) compared with rats fed the semipurified control diet (13 of 29; 45%), semipurified, calorie-restricted diet (15 of 27; 55%), and chow diet (11 of 26; 42%), p < 0.05. CONCLUSIONS: Reflux of gastroduodenal content into the lower esophagus of rats can induce both Barrett's metaplasia and neoplasia. Addition of a carcinogen increases the tumor yield and results in a proportion of the lesions being adenocarcinoma. This carcinogenic process is promoted by a diet with a high fat content.
Adenocarcinoma↗
Alkaline gastroesophageal reflux: assessment by ambulatory esophageal aspiration and pH monitoring.
The pathophysiologic effect of duodenal contents in the refluxed gastric juice of patients with gastroesophageal reflux disease (GERD) is controversial. We evaluated the composition of the refluxed gastric juice in 43 normal volunteers and 52 patients with GERD using a newly developed device that allows ambulatory esophageal aspiration. The findings were correlated with the results of 24-hour esophageal pH monitoring and the presence of complications of GERD. Compared with bile concentrations in normal volunteers, the total bile acid concentration in the reflux aspirates was higher in patients with GERD (p < 0.01). There was a significant correlation between the bile acid concentration in the aspirates and the percentage of time the pH was above 7 on ambulatory 24-hour esophageal pH monitoring (r = 0.59, p = 0.006), and both were highest during the night (p < 0.01). The bile acid concentration and the percentage of time pH was greater than 7 were particularly increased in patients with strictures or Barrett's esophagus (p < 0.01). Both an increased bile acid concentration in aspirates and the percentage of time with pH greater than 7 on pH monitoring were observed primarily in patients with a destroyed gastroduodenal barrier [status post Billroth II resection (BII), Billroth I resection (BI), or pyloroplasty] or after cholecystectomy. An increased bile acid concentration also occurred in a substantial number of patients without previous foregut surgery, although this did not usually result in an increase in the time that pH was above 7. These data suggest that contamination of the refluxed gastric juice with bile acids predisposes the patient to the development of strictures and Barrett's esophagus. An increased time that pH is greater than 7 on esophageal pH monitoring indicates biliary reflux and occurs primarily after previous foregut surgery. A normal-time pH above 7 does, however, not exclude contamination of the refluxed gastric juice with duodenal contents.
Bile Acids and Salts↗
The Angelchik prosthesis: what have we learned in fifteen years?
Explore the source record for details and available documents.
Contraindications↗
Living-related donor lobectomy for bilateral lobar transplantation in patients with cystic fibrosis.
Donor lobectomy has been performed in 14 patients enabling 7 recipients with cystic fibrosis to undergo bilateral living-related lobar pulmonary transplantation. Donors included 11 patients, 2 brothers, and 1 uncle. Donor mean age was 43 years (range 24 to 55 years). Their mean height and weight was 170 cm (range, 169 to 180 cm) and 72.4 kg (range, 55 to 90 kg), respectively, compared with 161 cm (range, 140 to 175 cm) and 42.4 kg (range, 27 to 55 kg), respectively, in the recipient group. Donor pulmonary evaluation consisted of a history and physical examination, chest roentgenogram and computed tomographic scan, spirometry with arterial blood gas measurement, echocardiography, and perfusion scanning. From each pair of donors, one was selected for right lower lobectomy and the other for left lower lobectomy. Standard lobectomy techniques were modified to facilitate implantation and optimize preservation of the donor lobes. On the right side, the middle lobe was removed and discarded in the first three donors to provide an adequate cuff of pulmonary artery and bronchus for implantation. With increased experience, this has proved not to be necessary. There have been no deaths and no long-term complications in the donor group. Prolonged postoperative air leaks occurred in the 3 patients who underwent right lower and middle lobectomies. All donors have been able to resume their previous lifestyles. Living-related donor lobectomy provides an alternative to cadaveric organs in select patients in need of pulmonary transplantation.
Adolescent↗
Nodal metastasis and sites of recurrence after en bloc esophagectomy for adenocarcinoma.
The operative specimens from 43 patients undergoing en bloc esophagectomy for adenocarcinoma of the lower esophagus or cardia were analyzed. Depth of invasion of the tumor and extent and location of lymph node metastases were determined. Postoperative recurrence was identified from positive findings on successive 3-month computed tomographic scans. Positive nodes occurred in 33% (2/6) of intramucosal tumors, 67% (6/9) of intramural tumors, and 89% (25/28) of transmural tumors (p < 0.01). Commonly involved nodes were those in the lesser curve of the stomach (42%), parahiatal nodes (35%), paraesophageal nodes (28%), and celiac nodes (21%). Excluding perioperative deaths, follow-up was complete for 38 patients. Twenty patients had recurrence. Fifteen patients (40%, 15/38) had nodal recurrence: cervical, 7.9% (3/38); superior mediastinal, 21% (8/38); and abdominal, 24% (9/38) (retropancreatic in 7 and retrocrural in 2). Of 5 patients with nodal recurrence alone, 3 (60%) had recurrence at sites outside the margins of resection. Patients with four metastatic nodes or less had a survival advantage over those with more than four (p < 0.05). There was no difference in survival according to location of nodal metastases. Two (22.2%) of 9 patients with celiac node metastases survived longer than 4 years. Adenocarcinoma of the lower esophagus and cardia spreads widely to mediastinal and abdominal nodes, and death can occur from nodal disease. Rates of lymph node metastases increase with the depth of the primary tumor. Patients with lymphatic metastases can be cured particularly if there are fewer than four nodes involved. Curative surgical therapy necessitates wide lymph node resection to ensure removal of all metastatic nodes.
Adenocarcinoma↗
Dysplastic Barrett's: is continued surveillance appropriate?
Explore the source record for details and available documents.
Adenocarcinoma↗
Motility in the Hunt-Lawrence pouch after total gastrectomy.
PURPOSE: The aim of this study was to evaluate motility patterns of the Hunt-Lawrence pouch and the jejunal limb of patients reconstructed with a pouch after total gastrectomy, and to compare the findings in symptomatic patients to those without symptoms after the operation. PATIENTS AND METHODS: Thirty-three patients who had undergone post-gastrectomy pouch reconstruction were studied using a water-perfused motility system. In 21, the pouch was connected by a Roux-en-Y, and, in 12, by a jejunal interposition. Twenty-eight patients were asymptomatic, including 17 connected by a Roux-en-Y and 11 by a jejunal interposition. Five patients were by a jejunal interposition. Five patients were symptomatic, including 4 connected by Roux-en-Y Y and 1 by jejunal interposition. A control group consisted of 5 healthy volunteers who had not undergone operation. RESULTS: The motility phases in the pouch and jejunal limb of asymptomatic patients were of shorter duration than those of controls, and they followed a random sequence instead of a normal progression from phase I to II to III. Motility features were similar in the pouch and the jejunal limb. Orthograde propagation of phase III-like activity was reduced and may contribute to the pouch storage function. Four of the 5 symptomatic patients showed highly abnormal motility with hypomotile or obstructive patterns. The technique of connecting the pouch--jejunal interposition of Roux-en-Y--did not affect the motility findings. CONCLUSIONS: The altered motility occurs after a Hunt-Lawrence pouch reconstruction in asymptomatic patients. Symptoms after gastrectomy are associated with further disturbed motility that can be differentiated from the motility changes in asymptomatic patients.
Adult↗