The Role of the Transdiaphragmatic Pressure Gradient (TGP) in the Pathophysiology of Proximal Reflux.

INTRODUCTION: An increased transdiaphragmatic pressure gradient (TGP) is a main element for distal gastroesophageal reflux disease (GERD). The role of TGP for proximal reflux is still unclear. This study aims to evaluate the presence, severity, and importance of proximal reflux in relationship to the TGP, comparing healthy volunteers, obese individuals, and patients with chronic obstructive pulmonary disease (COPD). METHODS: We studied 114 individuals comprising 19 healthy lean volunteers, 47 obese individuals (mean body mass index 45 ± 7 kg/m2), and 48 patients with COPD. All patients underwent high-resolution manometry and dual-channel esophageal pH monitoring. Esophageal motility, thoracic pressure (TP), abdominal pressure (AP), TGP, DeMeester score, and % of proximal acid exposure time (pAET) were recorded. RESULTS: Pathologic distal GERD was found in 0, 44, and 57% of the volunteers, obese, and COPD groups, respectively. pAET was similar among groups, only higher for obese individuals GERD + as compared to obese individuals GERD - and COPD GERD -. pAET did not correlate with any parameter in healthy individuals, but it correlated with AP in the obese, TP in the COPD individuals, and TGP and DeMeester score in both groups. When all individuals were analyzed as a total, pAET correlated with AP, TGP, and DeMeester score. DeMeester score was the only independent variable that correlated with pAET. CONCLUSIONS: Our results show that (a) TGP is an important mechanism associated with distal esophageal acid exposure and this fact is linked with proximal acid exposure and (b) obesity and COPD both seem to be primary causes for GERD but not directly for proximal reflux.

Does DeMeester score still define GERD?

Gastroesophageal reflux disease (GERD) clinical presentation may encompass a myriad of symptoms that may mimic other esophageal and extra-esophageal diseases. Thus, GERD diagnosis by symptoms only may be inaccurate. Upper digestive endoscopy and barium esophagram may also be misleading. pH monitoring must be added often for a definitive diagnosis. The DeMeester score (DMS) is a composite score of the acid exposure during a prolonged ambulatory pH monitoring that has been used since 1970s to categorize patients as GERD+ or GERD-. We showed in this review that DMS has some limitations and strengths. Although there is not a single instrument to precisely diagnose GERD in all of its variances, pH monitoring analyzed at the light of DMS is still a reliable method for scientific purposes as well as for clinical decision making. There are no data that show that acid exposure time is superior-or for that matter inferior-as compared to DMS.

High-resolution manometry findings in patients with achalasia and massive dilated megaesophagus.

Achalasia may present in a non-advanced or an advanced (end stage) stage based on the degree of esophageal dilatation. Manometric parameters and esophageal caliber may be prognostic for the outcome of treatment. The correlation between manometry and disease stage has not been yet fully studied. This study aims to describe high-resolution manometry findings in patients with achalasia and massive dilated megaesophagus. Eighteen patients (mean age 61 years, 55% females) with achalasia and massive dilated megaesophagus, as defined by a maximum esophageal dilatation >10 cm at the barium esophagram, were studied. Achalasia was considered secondary to Chagas' disease in 14 (78%) of the patients and idiopathic in the remaining. All patients underwent high-resolution manometry. Upper esophageal sphincter was hypotonic and had impaired relaxation in the majority of patients. Aperistalsis was seen in all patients with an equal distribution of Chicago type I and type II. No type III was noticed. Lower esophageal sphincter did not have a characteristic manometric pattern. In 50% of the cases, the manometry catheter was not able to reach the stomach. Our results did not show a manometric pattern in patients with achalasia and massive dilated esophagus.

Upper esophageal sphincter motility in gastroesophageal reflux disease in the light of the high-resolution manometry.

This study aims to evaluate the upper esophageal sphincter (UES) motility in patients with gastroesophageal reflux disease (GERD) as compared to healthy volunteers. We retrospectively studied the HRM tests of 44 patients (median age: 61 years, 54% females) under evaluation for GERD. The manometric UES parameters of these patients were compared to 40 healthy volunteers (median age: 27 years, 50% females). Almost half of the patients had a short and hypotonic UES. Patients with extraesophageal symptoms had a higher proportion of hypotonic UES as compared to patients with esophageal symptoms. Reflux pattern did not influence manometric parameters. Proximal reflux (any number of episodes) was present in 37(84%) patients (median number of proximal episodes = 6). Manometric parameters are similar in the presence or absence of proximal reflux. There is not a correlation between the UES length and UES basal pressure. In conclusion, our results show that: (1) the manometric profile of the UES in patients with GERD is characterized by a short and hypotonic UES in half of the patients; (2) this profile is more pronounced in patients with extraesophageal symptoms; and (3) neither the presence of proximal reflux nor reflux pattern bring a different manometric profile.

Comparison of idiopathic achalasia and Chagas' disease esophagopathy at the light of high-resolution manometry.

The comparison between idiopathic achalasia (IA) and Chagas' disease esophagopathy (CDE) may evaluate if treatment options and their outcomes can be accepted universally. This study aims to compare IA and CDE at the light of high-resolution manometry. We studied 86 patients with achalasia: 45 patients with CDE (54% females, mean age 55 years) and 41 patients with IA (58% females, mean age 49 years). All patients underwent high-resolution manometry. Upper esophageal sphincter parameters were similar (basal pressure CDE = 72 ± 45 mmHg, IA = 82 ± 57 mmHg; residual pressure CDE = 9.9 ± 9.9 mmHg, IA = 9.8 ± 7.5 mmHg). In the body of the esophagus, the amplitude was higher in the IA group than the CDE group at 3 cm (CDE = 15 ± 14 mm Hg, IA = 42 ± 52 mmHg, P = 0.003) and 7 cm (CDE = 16 ± 15 mmHg, IA = 36 ± 57 mmHg, P = 0.04) above the lower esophageal sphincter (LES). The LES basal pressure (CDE = 17 ± 16 mmHg, IA = 40 ± 22 mmHg, P < 0.001) and residual pressure (CDE = 12 ± 11 mmHg, IA = 27 ± 13 mmHg, P < 0.001) were also higher in the IA group. Our results show that: (i) there is no difference in regards to the upper esophageal sphincter; (ii) higher pressures of the esophageal body are noticed in patients with IA; and (iii) basal and residual pressures of the LES are lower in patients with CDE. Our results did not show expressive manometric differences between IA and CDE. Some differences may be attributed to a more pronounced esophageal dilatation in patients with CDE.

Progression of diffuse esophageal spasm to achalasia: incidence and predictive factors.

The progression of certain primary esophageal motor disorders to achalasia has been documented; however, the true incidence of this decay is still elusive. This study aims to evaluate: (i) the incidence of the progression of diffuse esophageal spasm to achalasia, and (ii) predictive factors to this progression. Thirty-five patients (mean age 53 years, 80% females) with a manometric picture of diffuse esophageal spasm were followed for at least 1 year. Patients with gastroesophageal reflux disease confirmed by pH monitoring or systemic diseases that may affect esophageal motility were excluded. Esophageal manometry was repeated in all patients. Five (14%) of the patients progressed to achalasia at a mean follow-up of 2.1 (range 1-4) years. Demographic characteristics were not predictive of transition to achalasia, while dysphagia (P= 0.005) as the main symptom and the wave amplitude of simultaneous waves less than 50 mmHg (P= 0.003) were statistically significant. In conclusion, the transition of diffuse esophageal spasm to achalasia is not frequent at a 2-year follow-up. Dysphagia and simultaneous waves with low amplitude are predictive factors for this degeneration.

Esophageal diverticula and cancer.

Esophageal diverticula are rare. The association of cancer and diverticula has been described. Some authors adopt a conservative non-surgical approach in selected patients with diverticula whereas others treat the symptoms by diverticulopexy or myotomy only, leaving the diverticulum in situ. However, the risk of malignant degeneration should be may be taken in account if the diverticulum is not resected. The correct evaluation of the possible risk factors for malignancy may help in the decision making process. We performed a literature review of esophageal diverticula and cancer. The incidence of cancer in a diverticulum is 0.3-7, 1.8, and 0.6% for pharyngoesophageal, midesophageal, and epiphrenic diverticula, respectively. Symptoms may mimic those of the diverticulum or underlying motor disorder. Progressive dysphagia, unintentional weight loss, the presence of blood in the regurgitated material, regurgitation of peaces of the tumor, odynophagia, melena, hemathemesis, and hemoptysis are key symptoms. Risk factors for malignancy are old age, male gender, long-standing history, and larger diverticula. A carcinoma may develop in treated diverticula, even after resection. Outcomes are usually quoted as dismal because of a delayed diagnosis but several cases of superficial carcinoma have been described. The treatment follows the same principals as the therapy for esophageal cancer; however, diverticulectomy is enough in cases of superficial carcinomas. Patients must be carefully evaluated before therapy and a long-term follow-up is advisable.

Postprandial proximal gastric acid pocket and gastroesophageal reflux disease.

An unbuffered layer of acidity that escapes neutralization by food has been demonstrated in volunteers and gastroesophageal reflux disease patients. This postprandial proximal gastric acid pocket (PPGAP) is manometrically defined by the presence of acid reading (pH<4) in a segment of the proximal stomach between nonacid segments distally (food) and proximally (lower esophageal sphincter or distal esophagus). The PPGAP may have important clinical implications; however, it is still poorly understood. Gastric anatomy and physiology seem to be important elements for PPGAP genesis. Gastric operations and acid suppression medications may decrease distal - proximal intragastric acid reflux and help control gastroesophageal reflux.

Postprandial proximal gastric acid pocket in patients after distal gastrectomy.

BACKGROUND: An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been noticed in the majority of normal individuals and patients with gastroesophageal reflux disease. The role of gastric anatomy, specifically the antrum, in the physiology of the PPGAP is not yet fully elucidated. This study aims to analyze the presence of PPGAP in patients submitted to distal gastrectomy. METHODS: A total of 15 patients who had a distal gastrectomy plus DII lymphadenectomy and Roux-en-Y reconstruction for gastric adenocarcinoma (mean age 64.3±8.4 years, 12 females) were studied. All patients were free of foregut symptoms after the operation. Patients underwent a high-resolution manometry. A station pull-through pH monitoring was performed from 5cm below the lower border of the lower esophageal sphincter (LBLES) to the LBLES in increments of 1cm in a fasting state and 10min after a standardized fatty meal. Postprandial proximal gastric acid pocket was defined by the presence of acid reading (pH<4) in a segment of the proximal stomach between non-acid segments distally (food) and proximally (LBLES). The PPGAP extent was recorded. The protocol was approved by local ethics committee. Key Results Acidity was not detected in the stomach of nine patients before meal. After meal, PPGAP was not found in three patients. In three patients (20%), a PPGAP was noted with an extension of 1, 1 and 3cm. CONCLUSIONS & INFERENCES: In conclusion, PPGAP is present in a minority of patients after distal gastrectomy; this finding may suggest that the gastric antrum may play a role in the genesis of the PPGAP.

Postprandial proximal gastric acid pocket and gastric pressure in patients after gastric surgery.

BACKGROUND: An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been demonstrated in normal individuals (NI) and patients with gastro-esophageal reflux disease (GERD). The role of gastric anatomy and gastric motility in the physiology of the PPGAP remains elusive. This study aims to analyze the correlation of PPGAP with proximal gastric pressure after gastric surgery. METHODS: A total of 26 individuals were studied: eight patients after open Roux-en-Y gastric bypass (RYGB) for morbid obesity, six patients after laparoscopic Nissen fundoplication for GERD, seven patients after open subtotal gastrectomy for gastric cancer and five NI. Patients underwent high resolution manometry to identify the location of the lower border of the lower esophageal sphincter (LBLES) and measure gastric pressure 1, 2, 3, 4 and 5 cm below the LBLES, immediately before swallow and after the end of the LES relaxation. A station pull-through pH monitoring was performed in all but NI, from 5 cm below the LBLES to the LBLES in increments of 1 cm in a fasting state and 10 min after a standardized fatty meal. KEY RESULTS: Our results show that: (i) proximal gastric pressures are lower after swallow compared with before swallow in NI; (ii) patients after gastric surgery tend to have higher gastric pressure before and lower after swallow compared with NI and (iii) patients after RYGB with PPGAP have an increased gastric pressure after swallows in the segment where the PPGAP is noticed. CONCLUSIONS & INFERENCES: Gastric motility may play a role in the genesis of PPGAP in patients after RYGB. The contribution of gastric motility for the genesis of PPGAP is still elusive in other patients.

When did the esophagus start shrinking? The history of the short esophagus.

Even though the history of this condition extends for almost 100 years, the short esophagus (SE) is still one of the most controversial topics in esophageal surgery with its existence still denied by some distinguished surgeons. We reviewed the evolution behind the diagnosis and treatment of the SE and the persons who wrote its history, from the first descriptions by radiologists, endoscopists, and surgeons to modern treatment.

Gastric fundus tension before and after division of the short gastric vessels in a cadaveric model of fundoplication.

Short gastric vessels (SGV) division is a controversial topic in antireflux surgery. Some surgeons do not divide the SGV routinely to perform a fundoplication; however, excessive tension of the gastric fundus (GF) forces this procedure necessary in some cases. This study aims to evaluate in a cadaveric model of Nissen fundoplication: (i) the correlation of GF tension with anatomic parameters; and (ii) the effect of SGV division on GF tension. In total, 23 fresh cadavers (18 men, mean age 62 years) were studied. The abdominal esophagus was dissected, and the GF transposed to a limit of 3 cm to the right border of the esophagus. A dynamometer was attached to the GF and the tension recorded. Cadavers were grouped according to the presence or absence of tension. SGV were divided and GF tension measured again. The presence or absence of initial GF tension was correlated to: (i) number of SGV; (ii) length of the GF; (iii) distance between His angle and the first SGV; and (iv) size of the spleen. The mean GF pressure was 0.5 N +/- 1.0 (0-2.5) before SGV division and 0.1 N +/- 0.3 (0-1.5) after SGV division (P= 0.002). Initial tension was absent in 12 (52.2%) cases. GF tension did not correlate with any of the anatomic parameters. Our results show that: (i) GF tension does not correlate with anatomic parameters; and (ii) SGV division affects GF tension significantly.

Treatment of achalasia: lessons learned with Chagas' disease.

Chagas' disease (CD) is highly prevalent in South America. Brazilian surgeons and gastroenterologists gained valuable experience in the treatment of CD esophagopathy (chagasic achalasia) due to the high number of cases treated. The authors reviewed the lessons learned with the treatment of achalasia by different centers experienced in the treatment of Chagas' disease. Preoperative evaluation, endoscopic treatment (forceful dilatation and botulinum toxin injection), Heller's myotomy, esophagectomy, conservative techniques other than myotomy, and reoperations are discussed in the light of personal experiences and review of International and Brazilian literature. Aspects not frequently adopted by North American and European surgeons are emphasized. The review shows that nonadvanced achalasia is frequently treated by Heller's myotomy. Endoscopic treatment is reserved to limited cases. Treatment for end-stage achalasia is not unanimous. Esophagectomy was a popular treatment in advanced disease; however, the morbidity/mortality associated to the procedure made some authors seek different alternatives, such as Heller's myotomy and cardioplasties. Minimally invasive approach to esophageal resection may change this concept, although few centers perform the procedure routinely.

Eponyms in esophageal surgery, part 2.

Eponyms in medicine are frequently criticized because they may not represent the person who first described a syndrome or disease. Although eponyms are very commonly used, most readers are probably unaware of who it was that named the diseases and whether the original description of the disease still corresponds to the modern definition. The 10 most common eponyms in esophageal diseases were revisited. The men and the disease behind Barrett's esophagus, Boerhaave's syndrome, Mallory-Weiss syndrome, Cameron ulcer, Schatzki ring, Paterson-Kelly syndrome, Plummer-Vinson, Chagas's disease, Zenker diverticulum and Killian diverticulum are reviewed here.

Eponyms in esophageal surgery.

Eponyms are frequently used in the surgery in homage to remarkable surgeons, specially creators of new surgical techniques and instruments. Sometimes, however, the right person is not revered or the name persists, but the author's technique has been changed over time and the original procedure is lost. Eponyms of the 10 most famous procedures in esophageal surgery are revisited. Names like Lortat-Jacob, Toupet, Dor, Heller, Nissen, Ivor Lewis, Collis, Merendino, Hill, and Belsey, are reviewed, analyzing the man behind the name, the original technique and its modifications.

Short esophagus: literature incidence.

There are controversies regarding existence and incidence of short esophagus. The authors reviewed the literature incidence of short esophagus among operated patients due to gastroesophageal reflux disease in the last 3 years. The overall incidence of short esophagus was 1.53%. The proposed risk factors (paraesophageal hernia, Barrett's esophagus, reoperation, esophageal strictures and access route) do have a higher incidence of short esophagus, with the exception of the Barrett's esophagus. Although several biases can be associated with the review, the authors identified the short esophagus incidence in the literature.

Efficacy of mediastinal lymphadenectomy in transhiatal esophagectomy with and without diaphragm opening: a cadaveric study.

Transhiatal esophagectomy (THE) is believed to induce a lower morbidity and mortality compared with transthoracic esophagectomy, but to be inefficient in performing mediastinal lymphadenectomy. Some surgeons are convinced that lymphadenectomy of the lower mediastinum in THE and transthoracic esophagectomy are equivalent. To test this, the authors performed THE in 20 cadavers (10 with and 10 without diaphragm opening). The number of lymph nodes resected with the esophagus and dissected through the hiatus was counted. After THE, the thorax was opened and the number of residual lymph nodes was evaluated. Complications were also assessed. The results show that lymphadenectomy in THE is incomplete in the lower mediastinum and not possible in the upper mediastinum; comparing THE with and without diaphragm opening, the first permits resection of a superior number of lymph nodes with the esophagus and dissection of a higher number of nodes through the hiatus. It is concluded that THE does not provide an effective mediastinal lymphadenectomy.

Resultados tardios da operaçäo de Heller associada à fundoplicatura no tratamento do megaesôfago: análise de 83 casos / Late results of Heller operation and fundoaplication for the treatment of the megaesophagus: analysis of 83 cases

Objetivo. Estudo retrospectivo dos resultados tardios dos pacientes submetidos a miotomia e fundoplicatura para o tratamento do megaesôfago. Casuística e Métodos. Foram estudados 83 pacientes com seguimento de um a 186 meses (média de 40,0 + 47,4 meses). A fundoplicatura em três planos, proposta por Pinotti, foi realizada em 15,7 por cento dos doentes e a fundoplicatura parcial posterior em 83,1 por cento. A queixa pré-operatória principal foi disfagia, seguida de regurgitação e perda ponderal. A etiologia chagásica pode ser comprovada em 72,3 por cento dos doentes, através de teste sorológico. Resultados. No seguimento, 55,4 por cento dos doentes estavam assintomáticos, 34,9 por cento queixavam-se de disfagia esporádica, 14,4 por cento de pirose, 8,4 por cento de regurgitação e 2,4 por cento de disfagia igual pré-operatória, sendo esses últimos pré-operados, com melhora da sintomatologia. Refluxo gastro-esofágico foi constatado em 8,4 por cento dos doentes. Outras complicações tardias foram: hérnia paraesofágica, deslizamento da fundoplicatura, esôfago de Barrett e neoplasia do esôfago. Conlcusões. Os autores salientaram a necessidade de acompanhamento clínico e endoscópico perene dos doentes, mesmo operados, devido à possibilidade de complicações tardias, em especial o câncer. Concluem por bons resultados tardios em relação à disfagia. Propõem, como alternativa à esofagectomia, a operação de Heller em pacientes portadores de megaesôfago para grau IV com más condições clínicas, que não suportariam uma cirurgia de maior porte.

Tumoral DNA analysis by flow cytometry in patients submitted to esophagectomy for squamous cell carcinoma of the esophagus

Squamous cell carcinoma of the esophagus has a poor prognosis. There are several factors influencing the prognosis. The study of DNA ploidy by flow cytometry used in many malignant tumors is very valuable in determining, as a tumor marker, this prognosis. In this study 13 cases of resected squamous cell carcinoma of the esophagus were analyzed. Despite the small sample, the authors observed that the worst prognosis was in advanced stage cases (III and IV), an aneuploid DNA pattern. The only case with a 5-year survival had a diploid DNA pattern.