Can intraoperative manometry during laparoscopic fundoplication predict postoperative dysphagia?

BACKGROUND: Many trials have used intraesophageal manometry (IEM) to measure the adequacy of fundoplication. This pilot study aimed to assess the value of IEM in predicting postoperative dysphagia. METHODS: A series of 40 patients underwent IEM studies before operative correction of gastroesophageal reflux disease and repeat studies 3 months after the procedure. During the operation, IEM studies were undertaken before pneumoperitoneum was established, after pneumoperitoneum, after pneumoperitoneum with fundoplication, and after fundoplication without pneumoperitoneum. All the patients were followed up 1, 6, and 12 months after the procedure for assessment to detect persistent reflux and postfundoplication dysphagia. RESULTS: Three patients demonstrated persistent dysphagia at the 12-month follow-up point. No statistically significant differences in preoperative manometry findings were observed in the dysphagic and nondysphagic groups, with the dysphagic group showing higher pressures. However, at the operation, statistically significant differences in the lower esophageal sphincter pressures were observed after anesthesia and no pneumoperitoneum (30.3 vs. 13.4 cm H(2)O; p =0.002), after anesthesia with pneumoperitoneum (40.3 vs. 18.3 cm H(2)O; p < 0.001), and after fundoplication with pneumoperitoneum (47.3 vs. 23.4 cm H(2)O; p = 0.001). No statistically significant differences were demonstrated in postoperative manometry at the 3-month follow-up point. CONCLUSION: Intraoperative manometry may be a useful tool compared with postoperative manometry in identifying patients who may experience postfundoplication dysphagia.

The effect of argon plasma coagulation ablation on esophageal motility and chemoreceptor sensitivity in Barrett's esophagus patients.

Patients with Barrett's esophagus usually demonstrate impaired esophageal motility, which affects acid clearance, together with reduced chemo-receptor sensitivity and symptom severity. Ablative endoscopic techniques are now used to eliminate Barrett's cells. The hypothesis for this study was that ablation with argon plasma coagulation (APC) may affect esophageal sensitivity and motility in patients with Barrett's esophagus, and the aim of this study was to assess differences in these parameters before and after APC treatment. Twenty patients with Barrett's esophagus were investigated before and after APC therapy. After standard pull through manometry, water bolus aliquots were given to assess primary peristalsis and rapid water and air bolus injections to assess secondary peristalsis. Sensitivity studies were carried out using weak solutions of either hydrochloric acid or sodium hydroxide, together with saline washouts. Onset time for typical symptoms (t), sensory intensity rating (I), and a sensory score (SS) = (t) x (I)/100 was observed. There were no significant differences in the lower esophageal sphincter pressures (13.6 mm Hg versus 12.6 mm Hg, P= 0.8) and successful test swallows (3 mm Hg versus 5 mm Hg, P= 0.5) before and after treatment, but there was a trend for secondary peristalsis to improve (air bolus 0 versus 2, P= 0.05, water bolus 0 versus 1, P= 0.07). Sensitivity studies showed a smaller sensitivity intensity rating to both acid (61 versus 31, P= 0.02) and alkaline (91 versus 64, P= 0.03) after treatment. In conclusion, we have shown no substantive changes in esophageal motility after ablation of Barrett's esophagus cells, but have demonstrated reduced sensitivity to reflux type solutions.

Preoperative shuttle walking testing and outcome after oesophagogastrectomy.

BACKGROUND: Objective assessment of cardiorespiratory reserve has been recommended before major surgery to identify patients with impaired oxygen delivery who may be at increased operative risk. Access to formal cardiopulmonary exercise (CPX) testing is limited outside larger centres. Following a previous audit of morbidity and mortality after oesophagectomy, we decided to add a simpler form of exercise test to our preoperative screen and review the outcomes. METHODS: Fifty-one patients who had surgical resection of an oesophageal cancer in our unit between April 2002 and April 2005 carried out an incremental shuttle walk exercise test before operation. Thirty-day outcome data were collected for each patient. RESULTS: Overall mortality in the group was 10%. No patient who walked 350 m or more died within 30 days. Five of the eight patients who could not achieve this distance died and two others remained in the critical care unit at 30 days. CONCLUSION: Preoperative shuttle walk testing using a standard protocol appears to be a sensitive indicator of operative risk in this group of patients. The apparent threshold value of 350 m is consistent with previously reported measures of functional capacity obtained using formal CPX testing.

Laparoscopic gastric bypass in a patient with malrotation of the intestine.

The increased prevalence of morbid obesity is associated with an increased prevalence of obesity co-morbidities. Bariatric surgery is generally the only effective treatment. Gastric bypasses are the most common bariatric operation in many countries, and more than half are performed laparoscopically. We discuss the challenges encountered in performing laparoscopic gastric bypass and cholecystectomy in a morbidly obese patient who was found to have malrotated small and large bowel when the procedure started. In the absence of past gastrointestinal symptoms and investigations, there is no way of diagnosing this anomaly preoperatively. However, when such a problem is posed at the time of surgery, it is safe to perform the planned operation if the surgeon has experience and skills in advanced laparoscopic techniques.

Loss of human leucocyte antigen class I and gain of class II expression are early events in carcinogenesis: clues from a study of Barrett's oesophagus.

BACKGROUND: Human leucocyte antigen (HLA) expression is altered in oesophageal carcinomas compared with normal tissue. It is unclear, however, whether this phenotype precedes malignant transformation or results as a consequence of it. AIM: To investigate HLA class I and II expression in Barrett's oesophagus and normal squamous oesophageal tissue. METHODS: Asian patients with Barrett's oesophagus (n = 64) and a control group (n = 60) with a normal oesophagus but without reflux symptoms were recruited using endoscopic and histopathological criteria. Tissue samples were stained with monoclonal antibodies specific for HLA-ABC, HLA-DR alpha chain or HLA-DP/DQ/DR, and scored semiquantitatively. The results of immunohistochemical staining were correlated with clinical and histopathological characteristics of patients. RESULTS: Marked expression of HLA-ABC was observed in 50% of Barrett's oesophagus sections as compared with 68.3% of controls (p = 0.038). HLA-DR staining was seen in 51.6% of Barrett's oesophagus samples versus 11.7% of controls (p<0.001). Expression of HLA-DP/DQ/DR was evident in 73.4% of oesophageal intestinal metaplasia tissue as opposed to 18.3% of controls (p<0.001). Importantly, a total loss of HLA-ABC and a concomitant gain of HLA-DP/DQ/DR expression were seen in 37.5% of patients with Barrett's oesophagus but in none of the controls (p<0.001). Interestingly, this phenotype was associated positively with dysplasia (adjusted p, p* = 0.031) but negatively with non-steroidal anti-inflammatory drug use (p* = 0.004). CONCLUSIONS: HLA class I expression is down regulated and class II expression is up regulated in Barrett's oesophagus. As these changes predate malignant transformation, altered major histocompatibility complex expression may be a key event in disease progression, possibly in facilitating evasion from immune surveillance.

Photodynamic therapy for Barrett's oesophagus and oesophageal carcinoma-How I do it.

We have considerable experience in the use of both ALA and Photofrin-induced photodynamic therapy in the treatment of Barrett's oesophagus (with and without dysplasia) and both early and advanced oesophageal carcinoma. The drugs used and the techniques vary depending on the condition being treated. The techniques and doses used for the various conditions are outlined here.

Light dosimetry measurements during ALA-PDT of Barrett's oesophagus.

A fibre optic probe and compact light detection system has been used to monitor the fluence-rate at the tissue surface during 5-aminolaevulinic acid based photodynamic therapy (PDT) of Barrett's oesophagous. The contributions from three specific wavelengths were recorded, corresponding to the combination of therapeutic laser light and fluorescence emission from protoporphyrin IX (635nm), the fluorescence from an oxidation product of the photosensitiser (670nm), and the protoporphyrin IX fluorescence alone (705nm). We have found that light scattering results in an enhancement of the therapeutic fluence-rate, and hence light dose, by approximately 70%. At the onset of therapy the fluorescence provides a 10% contribution to the overall fluence-rate at 635nm. The dynamics of photosensitiser bleaching could be extracted from the depletion in light signals. By defining a bleaching dose as the 635nm light fluence delivered over the period during which the photosensitiser fluorescence decays to 1/e(3) of its initial value, we find that the average ratio of bleaching to total dose is 33%. Further, the fluorescence contributes approximately 5% of the bleaching light dose. These results suggest that the prescribed period of therapeutic light exposure may be reduced with no loss in clinical efficacy, but with a consequent improvement in patient tolerance to this therapy.

The effect of photodynamic therapy (PDT) on oesophageal motility and acid clearance in patients with Barrett's oesophagus.

BACKGROUND: Barrett's oesophagus is the major risk factor for oesophageal adenocarcinoma. It is proposed that long-term re-epithelialisation, which has been achieved following ablation using 5-aminolaevulinic acid (5-ALA) photodynamic therapy (PDT) may reduce the risk of malignant change. However, it is not known whether PDT modifies oesophageal motility. AIM: To assess oesophageal pH and motility before and after PDT ablation in treated and untreated areas of the oesophagus. METHODS: Twelve patients (10 male) with Barrett's oesophagus, median segment length 4 cm, were treated with PDT ablation. Twenty-four hours pH assessment and oesophageal manometry were performed before and 4-6 weeks after ablation. PDT was carried out using 635 nm red light, 4-6h after administration of 30 mg/kg 5-ALA. Proximal (untreated) and distal (treated) oesophageal resting pressure, wave amplitude, percentage peristalsis and percentage study time oesophageal pH<4, were assessed. Proton pump inhibitors (PPI) were administered throughout the study. RESULTS: There were no significant differences in oesophageal motility in treated or untreated areas of the oesophagus after PDT compared to pre-treatment values. Patients who continued to experience oesophageal acid exposure required more treatments to achieve complete Barrett's ablation. CONCLUSIONS: Oesophageal motility following ALA-PDT suggests a trend toward enhanced wave propagation however continued oesophageal acid exposure may affect PDT efficacy.

Human leucocyte antigen determinants of susceptibility to Barrett's oesophagus in Asians--a preliminary study.

BACKGROUND: Characteristic immune profiles have been demonstrated in gastro-oesophageal reflux disease. However, the genetic basis of gastro-oesophageal reflux disease remains unclear. AIM: To investigate whether certain human leucocyte antigen genes are associated with Barrett's oesophagus. METHODS: Asian patients of Malay, Chinese and Indian descent with Barrett's oesophagus (n = 59) and those without reflux symptoms and a normal oesophagus (n =60) were recruited prospectively using endoscopic and histopathological criteria. Human leucocyte antigen class I and II typing was performed using a polymerase chain reaction sequence-specific primers method. RESULTS: The HLA-B7 allele was present in 17% (10 of 59) of patients with Barrett's oesophagus when compared with 0% (zero of 60) of controls [P = 0.0006, corrected P = 0.0171, OR = 25.67]. Subgroup analysis revealed that the HLA-B7 allele was confined almost exclusively to Indians with Barrett's oesophagus, 43% (nine of 21) vs. 0% (zero of 19) Indian controls (P = 0.0014, corrected P = 0.0406, OR = 29.64). No class II associations, protective human leucocyte antigens or extended haplotypes for disease susceptibility were identified. CONCLUSIONS: Barrett's oesophagus in Asians, particularly Indians, is strongly positively associated with HLA-B7; reinforcing a genetic component to gastro-oesophageal reflux disease. A larger sample size and different ethnic populations should be genotyped to further confirm this association and identify possible additional risk factors in the human leucocyte antigen locus.

History of photodynamic therapy in Great Britain.

Although the concept photodynamic therapy has been recognised for over a century, it is only over the last 25 years that it has been used in Great Britain. The first applications in the UK were in 1981 by John Carruth, who treated patients with advanced ENT and skin cancers. The following year, he and Stephen Bown set up the British Medical Laser Association (BMLA). Since that time, the use of PDT in the UK has slowly expanded in all fields of medicine and surgery. In 1986, Bown set up the National Medical Laser Centre (NMLC) and later collaborated with Liverpool gastroenterologist, Neville Krasner, in animal studies on rat colon. In 1997, Keyvan Moghissi founded the Yorkshire Laser Centre (YLC) and began treating patients with advanced inoperable bronchial and oesophageal cancers. Stan Brown in Leeds set up the Centre for Photobiology and Photodynamic Therapy at the University of Leeds, working in close collaboration with the Yorkshire Cancer Research Centre. Other pioneers include Hugh Barr in Gloucester, Colin Hopper in London, Grant Fullarton in Glasgow and Roger Ackroyd, Malcolm Reed and Nicky Brown in Sheffield. PDT has now been used in the UK in the treatment of skin, oral, ENT, oesophageal, lung, bladder and gynaecological malignancies.

Mentoring for new consultants.

There is increasing evidence of the benefits of having a mentor during the early years as a consultant. Mentoring encourages and provides support to an individual in their professional development. Although there are different forms of mentoring there is recognition that developing a formal mentoring scheme can provide a consistent approach and support within a framework. The Royal College of Physicians of Edinburgh has introduced a mentoring scheme for new consultants that provides a forum for supporting them in their ongoing professional wellbeing. There is potential that the process of mentoring can improve an individual's development, and motivate and encourage them to develop the skills needed to achieve their goals, thus having an impact on ultimately improving their ability to deliver an effective patient-centred service.

Endoscopic ablation of Barrett's oesophagus: a randomized-controlled trial of photodynamic therapy vs. argon plasma coagulation.

BACKGROUND: Barrett's oesophagus is the major risk factor for oesophageal adenocarcinoma. 5-Aminlevulinic acid-induced photodynamic therapy and argon plasma coagulation have been shown to be effective for ablating Barrett's oesophagus, but a comparative trial of these two modalities has not been reported. AIMS: To compare photodynamic therapy and argon plasma coagulation for the ablation of Barrett's oesophagus. METHODS: A total of 68 patients (54 male, 14 female; median age 61) with Barrett's oesophagus were randomized to photodynamic therapy (n = 34) or argon plasma coagulation (n = 34). Photodynamic therapy was performed using 5-aminlevulinic acid (30 mg/kg) and red light. Argon plasma coagulation was administered at a power setting of 65 W. Multiple treatment sessions were performed, with follow-up to 24 months. RESULTS: All patients showed a macroscopic reduction in the area of Barrett's oesophagus. This was greatest in the argon plasma coagulation group with 33 of 34 (97%) ablated, compared with 17 of 34 (50%) in the photodynamic therapy group; in the remainder, there was a reduction in the length of Barrett's oesophagus (median 50%, range: 5-90). Buried glands were found in 24% of photodynamic therapy patients, and in 21% of argon plasma coagulation patients. The median follow-up is 12 months (range: 6-24). CONCLUSIONS: Photodynamic therapy and argon plasma coagulation are both effective for ablating Barrett's oesophagus. Argon plasma coagulation appears more effective than photodynamic therapy, but the impact of both on carcinoma development requires larger studies with long-term follow-up.

Ablation treatment for Barrett oesophagus: what depth of tissue destruction is needed?

AIM: To establish the depth of Barrett's columnar epithelium and normal squamous oesophageal epithelium, in order to determine the depth of destruction required in ablation treatment for Barrett oesophagus. METHODS: Histological specimens from 100 cases of Barrett oesophagus and 100 samples of normal squamous oesophageal epithelium were studied. Using a system of multiple measurements until the change in cumulative mean values varied by less than 5%, the overall mean and normal range of depth was calculated for each type of epithelium. RESULTS: Barrett columnar epithelium is minimally thicker (mean (SEM) 0.50 (0.004) mm; range 0.39 to 0.59 mm) than normal squamous epithelium (0.49 (0.003) mm; 0.42 to 0.58 mm), although this difference is probably too small to be of clinical relevance. CONCLUSIONS: Although there are numerous clinical reports of various methods of ablation treatment for Barrett oesophagus, little attention has been paid to the depth of tissue destruction required. This is the first study to look specifically at this issue, and it provides information on the necessary depth of epithelial ablation.

A prospective randomized trial of laparoscopic Nissen fundoplication with anterior vs posterior hiatal repair.

HYPOTHESIS: The technique used for repair of the esophageal hiatus during laparoscopic Nissen fundoplication can influence the likelihood of postoperative dysphagia. DESIGN: A prospective double-blind randomized control trial. SETTING: A university teaching hospital. PARTICIPANTS: A total of 102 patients with proven gastroesophageal reflux disease, undergoing a laparoscopic Nissen fundoplication were randomized to undergo fundoplication with either anterior (47 patients) or posterior (55 patients) repair of the diaphragmatic hiatus. Patients were excluded for the following reasons: they had esophageal motility disorders, required a concurrent abdominal procedure, had undergone previous antireflux surgery, or had very large hiatus hernias. INTERVENTIONS: Laparoscopic Nissen fundoplication with anterior vs posterior hiatal repair. MAIN OUTCOME MEASURES: Independent assessment of dysphagia, heartburn, patient satisfaction, and other symptoms 1, 3, and 6 months following surgery, using multiple standardized clinical grading systems. Objective measurement of lower esophageal sphincter pressure, esophageal emptying time, distal esophageal acid exposure, and endoscopic assessment of postoperative anatomy and esophageal mucosa. RESULTS: Symptoms of postoperative dysphagia, relief of heartburn, and overall satisfaction 6 months after surgery were not influenced by the hiatal repair technique. However, to achieve a similar incidence of dysphagia, more patients who initially underwent posterior hiatal repair required a second surgical procedure (6 vs 0 patients). The hiatal repair technique did not affect the likelihood of early postoperative paraesophageal herniation. CONCLUSION: Anterior suturing of the hiatus appears to be at least as good in the short-term as posterior suturing as a method of narrowing the hiatus during laparoscopic Nissen fundoplication.

The history of photodetection and photodynamic therapy.

Light has been employed in the treatment of disease since antiquity. Many ancient civilizations utilized phototherapy, but it was not until early last century that this form of therapy reappeared. Following the scientific discoveries by early pioneers such as Finsen, Raab and Von Tappeiner, the combination of light and drug administration led to the emergence of photochemotherapy as a therapeutic tool. The isolation of porphyrins and the subsequent discovery of their tumor-localizing properties and phototoxic effects on tumor tissue led to the development of modern photodetection (PD) and photodynamic therapy (PDT). This review traces the origins and development of PD and PDT from antiquity to the present day.

5-Aminolevulinic acid photosensitization of dysplastic Barrett's esophagus: a pharmacokinetic study.

Photodynamic therapy (PDT) using 5-aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) may have a role in the treatment of dysplastic Barrett's esophagus. Before ALA-induced PDT can be used clinically, optimum treatment parameters must be established. In this study of 35 patients, the issues of drug dosage, time interval between drug and light delivery and side effects of oral ALA administration are addressed. Spectrofluorometric analysis of tissue samples demonstrates that oral ALA administration induces porphyrin accumulation in esophageal tissues, with maximum levels at 4-6 h. High-performance liquid chromatography confirms the identity of this porphyrin as PpIX, and fluorescence microscopy analysis demonstrates that it preferentially accumulates in the esophageal mucosa, rather than in the underlying stroma. Side effects of ALA administration included malaise, headache, photosensitivity, alopecia, transient derangement of liver function, nausea and vomiting. Fewer side effects and less hepatic toxicity was seen with 30 mg/kg than 50 mg/kg ALA. In conclusion, oral ALA administration induces preferential PpIX accumulation in the esophageal mucosa, with peak PpIX fluorescence noted at 4 h and minimal systemic toxicity at a dose of 30 mg/kg.

Gastric carcinoma in siblings with Friedreich's ataxia.

Friedreich's ataxia is a hereditary neurological condition characterized by severe ataxia. We report the cases of two siblings with this condition, both of whom developed signet ring cell adenocarcinoma of the stomach at a young age. This association has not been previously described and it suggests the presence of an unidentified aberrant gene.

Laparoscopic cardiomyotomy and anterior partial fundoplication for achalasia.

BACKGROUND: Although surgical myotomy is considered the gold standard, many different treatments have been advocated for achalasia. There are now a number of reports of cardiomyotomy being performed laparoscopically. METHODS: This is a prospective study of 82 patients (47 male and 35 female; median age, 47 years) who underwent laparoscopic cardiomyotomy and anterior partial fundoplication for achalasia. RESULTS: Four of the 82 procedures required conversion to open surgery, all during the early stages of the series, and two required early reoperation for a postoperative problem. The median operating time was 80 min (range, 32-210). the median hospital stay was 3 days (range, 2-18), and normal physical activity was resumed after a median of 2 weeks (range, 3 days to 12 weeks). Follow-up ranged up to 8 years (median, 2). Postoperatively, symptoms of dysphagia (to both solids and liquids), heartburn, odynophagia, chest pain, regurgitation, and cough were significantly reduced in all patients. The median overall satisfaction score (graded from 0 to 10, with 10 representing total satisfaction) was 9 (range, 0-10), and 90% of patients were highly satisfied with the surgical outcome. CONCLUSION: Laparoscopic cardiomyotomy with anterior partial fundoplication achieves excellent symptomatic relief for patients with achalasia, and it can be performed with minimal morbidity.