Results of the operative treatment of gastroesophageal reflux in childhood with particular focus on patients with esophageal atresia.

AIM: Although the literature on fundoplications in childhood is relatively extensive, only few reports exist which correlate the rate of complications with the primary disease. Other important questions such as the incidence of postoperative dumping syndrome or Barrett's esophagus in childhood are barely treated. Nor have operative techniques such as single or double-row cuff sutures or the benefit of performing pylorotomy or pyloroplasty in addition to fundoplication been investigated with respect to their recurrence rates. In particular studies on laparoscopic fundoplications tend to be generally confined to a discussion of the feasibility of the endoscopic procedure, the duration of the intervention, the length of the hospital stay and the costs. The study presented here aims to analyze such still unanswered questions listed above for open fundoplication procedures, including an analysis of the authors' own patient population, and to discuss the questions together with the most important reports in the literature. The aim is to create a basis for later studies which will compare conventional and laparoscopic fundoplications. METHODS: In the period between 1993 and 2005, 160 children underwent a fundoplication procedure. From 2003 onwards, fundoplications were carried out laparoscopically. The data of 148 patients were analyzed, some of them on the basis of clinical follow-up and some on the basis of an extensive questionnaire and among others with the help of the parents' support group KEKS. RESULTS: The underlying disease in 87 patients was reflux disease stemming from esophageal atresia, previous diaphragmatic operation in 8 children and mental retardation with swallowing difficulties in 30 patients. Only 23 patients suffered from isolated gastroesophageal reflux disease without an underlying primary disease. Intraoperative complications occurred in 4.6 % of patients with esophageal atresia (EA), while the rate for the remaining collective of patients was 1.6 %. Postoperative complications were observed in 10.3 % of the children with esophageal atresia and in 8.2 % of the other cases. The recurrence rate was 16.1 % in the children with EA and 6.5 % in the other cases. Dysphagia and/or stenosis occurred in 17.2 % and 6.5 % of children, respectively, and dumping syndrome was observed in 18.3 % of the EA group and only in 1.6 % of the comparison group. An evaluation of 79 esophageal biopsies showed no difference between patients with EA and the comparison group concerning the degree of histological changes. When evaluating the suturing technique, it was found that a double-row fundus suture was more effective in preventing reflux recurrence than a single-row suture but also resulted in an increased rate of dysphagia. When considering the not infrequent occurrence of dumping syndrome, it was found that drainage operations such as pyloroplasty or pyloromyotomy are only indicated for reduced gastric motility. The data of the children without EA, who initially served as a comparison group, was analyzed further. Four summaries of the current literature in table form complete this discussion. CONCLUSION: Particularly in children with EA, Nissen fundoplication cannot be considered a procedure with few complications. The problems resulting from disturbed gastric and esophageal motility should not be underestimated nor should the postoperative occurrence of dumping syndrome. Postoperative long-term follow-up until the patients reach adulthood is absolutely necessary to ensure that development of a Barrett's esophagus is not overlooked.

Analysis of IgG subclass and IgE response in allergic disease caused by Aspergillus fumigatus by immunoblotting techniques.

Analysis of sera from patients suffering from allergic asthma, extrinsic allergic alveolitis (EAA) due to Aspergillus fumigatus or allergic bronchopulmonary aspergillosis (ABPA) by means of IEF immunoprint and Western blot showed characteristic IgG subclasses and IgE responses. Asthmatic patients revealed specific IgE antibodies. IgG subclass reactivities in asthmatics and healthy blood donors were weak and uncharacteristic. Major allergens recognized by asthmatic patients have isoelectric points (pI) of pI 4.4 and 4.8 and molecular weights of 20, 29, 34, 38 and 45 kD. Patients suffering from EAA typically demonstrated strong IgG subclass reactivities with an emphasis to IgG1 and IgG2, while no specific IgE was found. Various major antigens could be identified. Reaction to a pI 6.0 antigen seemed to be characteristic for EAA. ABPA patients showed strong reactivities of all IgG subclasses and of IgE. An intense IgG4 reaction appeared as a typical marker for ABPA. Several major antigens and allergens could be determined. Especially the IgG4 reactivities to proteins with pI 4.6, 5.0, 5.2, 5.4 and 6.5 and molecular weights of 14, 20, 29, 34, 38 and 45 kD seemed to be a characteristic pattern in ABPA. Furthermore, IgE antibodies to culture filtrate components of 34 and 38 kD appeared to be typical in ABPA.

[Extrinsic allergic alveolitis: IgG subclass reactivities and monoclonal antibodies against Micropolyspora faeni and Aspergillus fumigatus]. / Exogen-allergische Alveolitis: IgG-Subklassenreaktivitäten und monoklonale Antikörper gegen Micropolyspora faeni und Aspergillus fumigatus.

IgG-subclass reactivities to Micropolyspora faeni of farmer's lung patients and exposed persons were investigated. Additionally, specific IgG and IgE antibodies of patients suffering from IgE-mediated allergy and extrinsic allergic alveolitis to Aspergillus fumigatus and allergic bronchopulmonary aspergillosis (ABPA) were examined. Antibody reactivities of patients were compared with reactivities of monoclonal antibodies raised against M. faeni and A. fumigatus, respectively. The results indicate a special importance of specific IgG2 reactivity for serologic diagnosis. Monoclonal antibodies raised against M. faeni and A. fumigatus recognize components which induce antibody production in patients as well. Reactivities of monoclonal antibodies with different batches of A. fumigatus extract show the variability of these antigen preparations and illustrate the need for standardization.

[Aspergillus fumigatus: evaluations of the standardization of diagnostic extracts]. / Aspergillus fumigatus: Ansätze zur Standardisierung von Extrakten für die Diagnostik.

Extracts of Aspergillus fumigatus used for serodiagnosis of allergic diseases are of unknown and nonstandardized composition. Applying immunoprint technique subsequent to isoelectric focusing commercial and self-prepared extracts are compared. By use of an ABPA-pool serum and monoclonal antibodies recognizing antigens of this fungus, different immunological reactivities of the extracts can be demonstrated. It is suggested to use monoclonal antibodies as secondary standards as well as to improve standardization.