Biomedical subjects

V Felice

Publications and source records attributed to V Felice.

13 recordsLinked to original sources

PubMed1998

Clinical and surgical relevance of the progressive phases of intrathoracic migration of the gastroesophageal junction in gastroesophageal reflux disease.

OBJECTIVE: The pathophysiologic influence of progressive intrathoracic migration of the gastroesophageal junction axial to the esophagus on gastroesophageal reflux disease was investigated. METHODS: A radiologic-manometric study was performed on hiatal insufficiency, concentric hiatus hernia, and short esophagus, the three radiologic steps of intrathoracic gastroesophageal junction migration, and on healthy volunteers. The distances between inferior and superior margins of the lower esophageal sphincter and the diaphragm were measured. Endoscopic, manometric, and pH-metric evaluations were performed after barium swallow in 38 patients with severe gastroesophageal reflux disease and sliding hiatus hernia with intraabdominally reducible gastroesophageal junction, in 35 patients with hiatal insufficiency, in 40 with concentric hiatus hernia, and in 19 with short esophagus. RESULTS: The distance from the lower esophageal sphincter inferior margin to the diaphragm was different in healthy volunteers (-2.6 +/- 0.9 cm [standard deviation]) versus that in patients with hiatal insufficiency (-1.0 +/- 0.7 cm; p = 0.02), concentric hiatus hernia (-0.8 +/- 1.0 cm; p = 0.02), and short esophagus (4.0 +/- 2.5 cm; p = 0.0002), and in patients with short esophagus versus hiatal insufficiency (p = 0.0002) and concentric hiatus hernia (p = 0.0002). Lower esophageal sphincter tone was reduced between healthy volunteers (19 +/- 9.1 mm Hg [standard deviation]) and patients with sliding hiatus hernia (12 +/- 7.2 mm Hg;p = 0.02), hiatal insufficiency (10 +/- 5.9 mm Hg; p = 0.0001), concentric hiatus hernia (7 +/- 3.1 mm Hg; p = 0.00002), and short esophagus (7 +/- 3.7 mm Hg; p = 0.00003) and between concentric hiatus hernia versus sliding hiatus hernia (p = 0.007). Acid gastroesophageal reflux total time percent was increased between healthy volunteers (2.4% +/- 1.8% [standard deviation]) and patients with sliding hiatus hernia (12.8% +/- 7.8%;p = 0.02), hiatal insufficiency (17.2% +/- 15.8%; p = 0.0001), concentric hiatus hernia (24.0% +/- 19.6%;p = 0.00002), and short esophagus (26.1% +/- 19.6%;p = 0.00002) and between sliding hiatus hernia versus concentric hiatus hernia (p = 0.002) and short esophagus (p = 0.01). CONCLUSIONS: Permanent gastroesophageal junction orad migration axial to the esophagus has greater pathophysiologic relevance on gastroesophageal reflux disease than sliding hiatus hernia with an intraabdominally reducible gastroesophgeal junction. Hiatal insufficiency, concentric hiatus hernia, and short esophagus are markers of progressively increasing irreversible cardial incontinence and therefore indications for surgical therapy.

Adult↗

PubMed1996

Onset timing of delayed complications and criteria of follow-up after operation for esophageal achalasia.

BACKGROUND: The purpose of this study was to define the length of follow-up necessary to obtain definitive results of the Heller myotomy for the therapy of esophageal achalasia and the modalities of long-term follow-up. Insufficient myotomy, periesophageal scarring, and gastroesophageal reflux esophagitis are the most common late complications of operation for achalasia. Columnar-lined esophagus with or without dysplasia and cancer can further complicate postoperative reflux esophagitis. Because progressive worsening of results with time has been reported, we assessed the timing of appearance of these complications. METHODS: Since 1973, 129 patients submitted to Heller myotomy were clinically and objectively followed up. Mean follow-up was 97.4 months (range, 12 to 268 months). Of 129 patients, 42 were followed up for less than 5 years (17 voluntary drop outs, 10 reoperations, 3 deaths, 12 in follow-up), 47 more than 5 years, 26 more than 10 years, 12 more than 15 years, and 2 more than 20 years. The timing of onset of symptoms and complications related to the myotomy were evaluated as was the development of dysplasia and cancer. RESULTS: In 11 patients, severe dysphagia due to insufficient myotomy reappeared a mean of 12.4 months after the operation (range, 3 to 30 months). In 7 patients with periesophageal scarring, dysphagia recurred a mean of 18.8 months (range, 6 to 28 months) after the operation. Postoperative reflux esophagitis appeared in 22 patients a mean of 76.5 months (range 21 to 168 months) after the operation. Columnar-lined esophagus was detected in 8 patients a mean of 143.1 months (range, 85 to 230 months) after the operation. Mild to moderate dysplasia was found in 5 of 8 patients with columnar-lined esophagus a mean of 191.6 months after the operation (range, 152 to 287 months), and intramucosal adenocarcinoma was found in 1 patient with columnar-lined esophagus after 8 years. CONCLUSIONS: Dysphagia secondary to insufficient myotomy and periesophageal scarring recurs early, not later than 3 years. Conversely, abnormal gastroesophageal reflux with related complications can appear more than 10 years postoperatively. Five years after the operation the follow-up should be primarily endoscopic and histologic. Results should withstand a follow-up of at least 10 years.

Actuarial Analysis↗

PubMed1993

Intraoperative study on the relationship between the lower esophageal sphincter pressure and the muscular components of the gastro-esophageal junction in achalasic patients.

OBJECTIVE: The lower esophageal sphincter (LES) resting tone originates from the tension of the muscular fibers of the gastro-esophageal (GE) junction. This study determined which of the muscular structures' of the GE junction are actually responsible and to what degree for the LES resting tone in achalasic patients. SUMMARY BACKGROUND DATA: Controversy still exists as to the length of myotomy on the esophageal and gastric sides of the GE junction. Experimental and clinical studies have supposed that the anatomical complex formed by the U and the sling fibers of the lesser curvature of the stomach can be part of the LES. METHODS: The variations induced on the LES resting tone by the separate division of the esophageal and gastric muscular fibers of the GE junction were studied by means of intraoperative manometry in 32 patients who underwent myotomy for achalasia. RESULTS: After surgical preparation of the GE junction, the mean pressure was 29.3 +/- 13 mmHg. After esophageal side myotomy, the mean LES pressure decreased to 13.6 +/- 7.9 mmHg (paired t test, p < 0.0005). The residual pressure was further reduced after gastric side myotomy (3.4 +/- 1.9 mmHg; paired t test, p < 0.0005). CONCLUSIONS: In achalasic patients, 45% of the LES resting tone is maintained by the gastric side anatomical component of the GE junction. The range of variability of the gastric component of the LES is wide. This information should be taken into account when performing extramucosal myotomy as therapy for esophageal achalasia.

Esophageal Achalasia↗

PubMed1992

Indications for 24-hour gastric pH monitoring with single and multiple probes in clinical research and practice.

The methodology of prolonged gastric pH monitoring has not yet been standardized with regard to the number and position of pH probes. Twenty-seven healthy volunteers and 11 patients affected by nonulcer dyspepsia have been submitted to 24-hr ambulatory simultaneous pH monitoring of the distal esophagus, fundus, and antrum. Fundic and antral pH profiles have been compared and causes of pH variations (pH > 4) identified. Both in healthy volunteers and dyspeptic patients, percentile curves of fundic and antral pH were statistically different in more than one of the daily periods considered (24-hr, postprandial, interdigestive, nocturnal). Percent time of duodenogastric reflux is significantly higher in the antrum than in the fundus in both groups. Modalities of gastric alkalinization secondary to food or duodenogastric reflux were different for the fundus and for the antrum both in healthy and dyspeptic subjects and between the two groups. These differences suggest that single and multiple pH monitoring of the stomach have different indications, and the position of the probes should vary according to the purpose of the test.

Adult↗

PubMed1991

[Monitoring esophageal pressure: comparison of various methods and a unique solution].

Ambulatory monitoring of intraesophageal pressure requires probes and techniques which are different from those used in the laboratory approach. In particular the perfusion system for the measurement of the pressure is not suitable and the development of alternative solutions is mandatory. In this perspective an accurate analysis of the theoretical basis of different methods is necessary in order to avoid incorrect results and difficulties in the subsequent phase of analysis. A prototype probe, which is based on inextensible thin plastic balloons filled with oil or saline, was tested in comparison with traditional (perfused) and microtransducer systems to outline the positive and negative aspects of the solution. The results were satisfactory as regards linear output and frequency response up to 5 Hz for the prototype probe and even superior, for instance, to the response of the perfused system to applied pressure, whose curves of the four open tips resulted different, and to the response of Millar transducer. The new prototype probe seems to be adequate to the clinical and research needs.

Equipment Design↗

PubMed1991

[Intraoperative esophageal manometry].

Intraoperative manometry has been proposed as a supportive procedure during the execution of anti-reflux operations and in the surgical treatment of achalasia. This procedure is not necessary in preparing anti-reflux plasty such as Belsey or Nissen, the outcome of which depends mostly on the correct execution of the surgical technique. Utilization of intra-operative manometry provides considerable benefits during the surgical treatment of achalasia, both when executing the extra-mucous myotomy and for the correct preparation of the anti-reflux plasty according to Dor, which is associated to it. Manometric control has made it possible to define the various anatomical components that, at both the esophageal and gastric levels, constitute the area which functionally corresponds to the lower esophageal sphincter and therefore a correct execution of the myotomy. As demonstrated by the follow-up study of our surgical patients, the intraoperative manometric measurement of the strain and of the length of the anti-reflux plasty is the determining factor affecting outcome over time. The pressure is apt to decrease even 5 year after surgery; maintaining given length and strain standards when executing the plasty can prevent delayed complications, such as esophagitis from gastro-esophageal reflux.

Esophageal Achalasia↗

PubMed1991

[Definition of a normal tracing in pH monitoring].

The adoption of specific criteria for the reading of tracings, together with a comparison of the results obtained during the course of patient tests with the thresholds of normality calculated in groups of healthy volunteers, are required to determine the normality or abnormality of pH monitoring. From such comparisons performed among groups of healthy volunteers, selected especially on the basis of age or nationality, it was found that age bears no significant influence in calculating the parameters pertinent to pH monitoring. On the other hand, different dietary and life habits could be responsible for a few, albeit limited, discrepancies, such as, for instance, the number of recorded occurrences of gastro-esophageal acid reflux. Use of esophago-gastric pH monitoring, which makes it possible to identify both acid and non-acid gastro-esophageal reflux (mixed and alkaline), authorizes the diagnosis of that limited number of patients in whom this latter component of reflux only exceeds normal limits (3.3%) and an improved definition of the clinical picture in a larger share of patients (20%). Use of different statistical methods to calculate the thresholds of normalcy does not substantially improve the sensitivity of the examination, changing the thresholds by a few tenths of a unit and the fact that the examination is slightly over, or slightly under, the threshold being of ineffectual clinical significance. The study of the correlation between symptoms and pH monitoring events seems a valid interpretative criterion of these tests and capable of improving the diagnostic efficiency of the examination (0.88) when combined with mathematical evaluation.

Adult↗

PubMed1991

Fluoroscopically guided percutaneous gastrostomy: is gastric fixation necessary?

In this animal study the authors evaluated the safety of inserting gastrostomy catheters percutaneously without the aid of gastric fixation. In a laboratory model (excised dog stomachs) there was not leakage around gastrostomy tubes of different sizes (nos. 8 to 18 French), despite maximum gastric distension and intragastric pressures of up to 100 mm Hg. When the tubes were removed, the risk of leakage from the gastrostomy increased in proportion to the size of the gastric defect. Percutaneous gastrostomy catheters (no. 14 French) were then placed in five live dogs without gastric fixation and were immediately withdrawn. All animals remained well. Autopsies performed 7 days later showed no evidence of leakage. The authors conclude that there is no leakage around correctly placed gastrostomy tubes. Although gastric defects larger than no. 10 French leak easily in vitro, a defect of no. 14 French is well tolerated in vivo. The authors suggest that percutaneous gastrostomy may be performed safely without gastric fixation devices in patients as long as the size of the initial cathether used is no. 14 French or smaller.

Animals↗

PubMed1990

Ambulatory 24-hr pH monitoring of esophagus, fundus, and antrum. A new technique for simultaneous study of gastroesophageal and duodenogastric reflux.

A method for outpatient 24-hr simultaneous recording of pH in the distal esophagus, fundus, and antrum was developed in order to detect acid, alkaline, alkalacid gastroesophageal reflux, and duodenogastric reflux and to study these phenomena in patients complaining of gastroesophageal reflux and dyspepsia related symptoms. Two hundred ninety-four studies were performed in 42 healthy volunteers and 237 patients. Three-probe ambulatory 24-hr esophagogastric pH monitoring applicability, tolerability, and capability to determine a relationship between symptoms which occurred during the tests, gastroesophageal reflux, and duodenogastric reflux episodes were assessed. Eighty-nine percent of the three-probe esophagogastric pH studies were easily performed. The examination was tolerated well by 86.1% of the patients and poorly by 13.9%. A temporal correlation between symptoms and pH activities was recognized in 61.3% when the esophageal tracing was considered (acid gastroesophageal reflux recording) and in 95.6% when the three pH traces were simultaneously interpreted. Alkalacid gastroesophageal reflux and duodenogastric reflux total percentage times were significantly higher in patients complaining of dyspeptic symptoms than in patients only affected by typical gastroesophageal symptoms. Three-probe 24-hr ambulatory esophagogastric pH monitoring is a simple, well-tolerated test that should be routinely adopted for the study of patients complaining of unclear upper gastrointestinal tract symptomatology.

Adolescent↗

PubMed1989

Reliability of 24-hour home esophageal pH monitoring in diagnosis of gastroesophageal reflux.

Twenty-four-hour home esophageal pH monitoring is proposed in order to study gastroesophageal reflux (GER) so that prolonged use of costly hospital equipment and staff can be curtailed and the diagnostic accuracy of the examination improved. Eighty-six patients affected by GER symptoms and 20 healthy volunteers underwent 24-hr home esophageal pH monitoring, x-rays, and endoscopy of the upper gastrointestinal tract to investigate reliability of outpatient recording. Fifteen more patients consecutively underwent out- and inpatient recording to detect possible differences between these methods in the two daily periods. Outpatient monitoring was well tolerated in 94.7% of the patients; 14.3% of them markedly reduced their routine activities. The range of normality of outpatient recording does not differ from that of inpatients. In the 15 patients who consecutively underwent out- and inpatient monitoring, no significant differences were reported. The sensitivity of 24-hr home esophageal pH recording is 0.85, the specificity 1, the accuracy for negative prediction 0.68, and the accuracy for positive prediction 1. The reliability of 24-hr home esophageal pH monitoring is comparable to inpatient recording. It allows hospital cost reduction and is also better tolerated by patients but has not greatly improved the diagnostic accuracy of the gastroesophageal reflux pH monitoring.

Adult↗

PubMed1987

Pathophysiology and natural history of acquired short esophagus.

The choice of therapy--whether medical or surgical--for patients with gastroesophageal reflux (GER) is often a subject of debate. After a period in which surgery was almost the exclusive mode of treatment in patients with severe complications resulting from GER or in patients who did not respond to medical therapy, long-term follow-up showed that in 20 cases of GER in which only medical treatment was given, a progressive shortening of the esophagus--frequently in the absence of esophagitis--had developed. To investigate the pathophysiology of acquired short esophagus, we studied 34 patients--20 from the initial group and 14 who already had this condition. Clinical assessment consisted of interview, radiologic examination of the upper digestive tract, endoscopic and histologic examinations, and 24-hour home esophagogastric pH monitoring. We noted that acid GER causes shortening in the presence of severe mucosal lesions, while "nonacid" GER--a combination of gastric, pancreatic, and hepatic secretions--causes shortening of the esophagus even without evident mucosal lesions. Symptom evaluation, acid GER pH recording, and endoscopy are not sufficient for determination of the current choice of therapy. It is also important to quantify GER that results from the mixing of gastric and biliopancreatic secretions with use of the esophagogastric pH recording. This should reduce the possibility of silent shortening of the esophagus.

Adult↗

PubMedDate not supplied

Duodenogastric and non acid gastro-oesophageal reflux in patients with reflux oesophagitis.

BACKGROUND/AIM: The role and the identification criteria of non acid gastro-oesophageal reflux (GOR) are still debated. Moreover, the relationship between nonacid GOR and gastric alkalinizations, particularly if secondary to duodeno-gastric reflux is yet to be defined. MATERIALS AND METHODS: One hundred and forty one patients affected by GORD symptoms and oesophagitis entered the study. Oesophagitis was divided into four categories, according to a modified Savary and Miller classification. Acid (pH<4), alkalacid (4 7), alkaline (pH>7) GOR and duodenogastric reflux were measured by means of ambulatory three channel esophago-gastric pH monitoring with a combined analysis of the pH traces recorded in the oesophagus fundus and antrum. RESULTS: Total time percentage (T%) of acid GOR was significantly greater in patients than in healthy volunteers (HV) and between groups of patients in direct relation with the severity of the oesophagitis. Alkaline GOR was hardly detectable in every class of esophagitis. Alkalacid GOR increased with the grade of severeness of oesophagitis. Alkalacid GOR occurred prevalently in the postprandial period; it was only 8% of the time in patients with mild reflux oesophagitis and even less in patients with moderate or severe oesophagitis. The 24 hr total time percentage of duodenogastric reflux was similar in the patients and healthy volunteer groups. The frequency distribution in 0.1 intervals of fundic and antral pH samples showed a greater number of them in the acid range (0.8-1.2) in the patients than in healthy volunteer group (0.0006 7) samples was similar in patients and in healthy volunteers. CONCLUSIONS: Our findings demonstrate that alkaline GOR is rare in GORD patients and that non acid GOR has a minor role in the pathophysiology of reflux esophagitis.

Adolescent↗

PubMedDate not supplied

Surgery for esophageal achalasia. long-term results with three different techniques.

BACKGROUND/AIMS: In surgery for achalasia, the length of the myotomy and the opportunity of associating an antireflux procedure are still debated. Prospective and comparative studies on different techniques are few. The aims of this work is to compare the long term results of three different techniques successively adopted by the same surgical group. MATERIALS AND METHODS: Between January 1955 and December 1991, 185 achalasic patients were submitted to myotomy by using in temporal sequence three different techniques. The first technique utilized (1955-1972) was a long esophagogastric abdominal myotomy (83 patients), secondly (1973-1978) a limited transthoracic myotomy (30 patients) and at last (1979-1991) a long esophagogastric abdominal myotomy associated to the Dor gastroplasty (72 patients). Since 1972, patients were prospectively followed up according to a protocol which included a clinical interview, x-rays, manometry and endoscopy at given dates. Post-operative esophagogastric transit and gastro-esophageal reflux were assessed to verify the therapeutical outcome. Results obtained with the three different techniques were analyzed and compared by using the actuarial Kaplan-Meier curves. RESULTS: The mean follow up was 193.3 months for the patient group that underwent abdominal myotomy (62/83 patients), 137.3 months for the thoracic myotomy group (30/30 patients) and 86.9 months for the abdominal myotomy plus Dor gastroplasty group (69/72 patients). Long-term results in the abdominal myotomy and in the thoracic myotomy groups were respectively poor in 51.6% and in 46.6% of patients. Major causes of failure were insufficient myotomy (6.5%), periesophageal scarring (9.6%) and reflux esophagitis (22.6%) for the abdominal myotomy group; insufficient myotomy (20%) and reflux esophagitis (23%) for the thoracic myotomy group. In the abdominal myotomy plus Dor gastroplasty group long-term results were excellent or good in 87% of patients and poor in 13%. Reflux esophagitis (10% of cases) was the principal cause of failure. CONCLUSIONS: The comparison of the actuarial curves shows a significantly better long term outcome for the abdominal myotomy plus Dor antireflux procedure than for the abdominal myotomy (p = 0.01) and for the thoracic myotomy (p = 0.002) techniques.

Actuarial Analysis↗