Columnar epithelium morphology after esophagectomy: clinical insight into the development of Barrett's esophagus.

BACKGROUND: The presence of Barrett's mucosa in the esophageal remnant is a result of post-esophagectomy anastomotic site exposure to gastric acid and is regarded as a human model of Barrett's esophagus onset. Here, we attempted to clarify the relationship between duodenogastric reflux and formation of columnar epithelium by following the changes over time after esophagectomy. METHODS: A total of 96 patients underwent esophagectomy due to superficial cancer from April 2000 to March 2018 were included in this study. Cases were divided into two groups according to the reconstruction technique after esophagectomy as either the gastric pull-up (Ga) group and ileocolonic interposition (Ic) group. Previously obtained endoscopic pictures of the cases were reviewed retrospectively and chronologically. RESULTS: There were 24 cases of columnar epithelium in the Ga group (42%) and 1 in the Ic group (2.6%) (P < 0.01) with 32 reflux cases (56%) in the Ga group and 1 (2.6%) in the Ic group (P < 0.01). Reflux precedes the development of columnar epithelium in both the Ga- and Ic groups. Multivariate analysis revealed surgical technique (odds ratio 10.6, 95% CI 1.2-97.5, P = 0.037) and reflux (odds ratio 4.5, 95% CI 1.3-15.6, P = 0.0017) as risk factors. CONCLUSIONS: The development of columnar epithelium was preceded by reflux comprising principally gastric acid and was strongly associated with a strong inflammatory state.

Durable Flap-Valve Mitigation of Duodenogastric Reflux, Remnant Gastritis and Dumping Syndrome Following Billroth I Reconstruction.

BACKGROUND: We have reported the short-term results of pylorus reconstruction gastrectomy (PRG) that prevents duodenogastric reflux (DGR) and remnant gastritis after distal gastrectomy. We herein report the long-term results of the PRG. PATIENTS AND METHODS: PRG was performed in 37 patients (age 31 to 86 [mean 67.8 ± 12.3] years, male:female = 22:15) with gastric cancer from June 2006 through December 2013. We examined the long-term outcome in 28 patients (age 41 to 86 [mean 67.0 ± 10.7] years, male:female = 18:10) that passed over 3 years after surgery (LTR 44.1 ± 11.7 months), and compared with their short-term result after the operation (STR 13.1 ± 6.9 months). The adverse events of gastric surgery evaluated in this study consisted of the degree of remnant gastritis, the presence of dumping syndrome, and degree of weight loss (%). RESULTS: There was no difference in the degree of DGR and remnant gastritis by gastroscopic finding between LTR and STR after PRG (P = 0.21). Statistically, there was no difference in the bile acid concentration of remnant gastric juice between LTR and STR (108.4 ± 254.1 vs. 94.0 ± 208.6 µmol/L, P = 0.33), and weight loss of LTR was the same as that of STR (5.67 ± 7.08 vs. 4.59 ± 5.63%, P = 0.34). There were few morphological changes in the reconstructed pylorus by the long-term course, but 2 patients showed mild atrophy. CONCLUSION: The form of reconstructed pylorus and the effect that reduces side effects of Billroth I seem to last for a long time.

Elevated serum dopamine increases while coffee consumption decreases the occurrence of reddish streaks in the intact stomach.

BACKGROUND AND AIM: Reddish streaks in an intact stomach are an endoscopic feature of duodenogastric reflux. This study aimed to identify which factors are associated with gastric reddish streaks and thus help prevent mucosal damage from duodenogastric reflux. METHODS: Demographic data, personal habits, stressful life events, and psychological distress were compared between subjects with only gastric reddish streaks and those with normal mucosa who underwent upper gastrointestinal endoscopy as part of a self-paid physical checkup. Stress hormones dopamine and cortisol were also checked by high-performance liquid chromatography and radioimmunoassay methods respectively. RESULTS: There were 95 subjects with gastric reddish streaks and 52 subjects with normal mucosa. No significant differences in age, gender, blood groups, education levels, marital status, religion, aspirin or nonsteroidal anti-inflammatory drug (NSAID) use, smoking habit, alcohol consumption, and intake of tea was found between the two groups, but intake of coffee was borderline more common in subjects with normal mucosa (38.5% vs 22.1%, P = 0.055). Subjects with gastric reddish streaks had lower Helicobacter pylori infection rate (37.8% vs 19.3%, P < 0.05). There were no significant differences in psychological distress and stressful life events between the two groups. Multivariate analysis shows that serum dopamine concentrations (odds ratio = 11.31, 95% confidence interval = 2.11-60.48, P = 0.005) and being without the consumption of coffee (odds ratio = 2.97, 95% confidence interval = 1.27-6.94, P = 0.012) were associated with gastric reddish streaks. CONCLUSIONS: Elevated serum dopamine and less coffee consumption are associated with gastric reddish streaks. These findings implicate that increased dopamine level plays a role for abnormal duodenogastric reflux.

Prevention of gastroduodenal content reflux and delayed gastric emptying after esophagectomy: gastric tube reconstruction with duodenal diversion plus Roux-en-Y anastomosis.

Reflux of gastroduodenal contents and delayed gastric emptying are the most common and serious problems after esophagectomy with gastric reconstruction. However, attempts to reduce the above symptoms, surgically as well as non-surgically, had no or limited effect. To address this issue, we performed retrosternal gastric reconstruction with duodenal diversion plus Roux-en-Y anastomosis (RY) in eight patients with thoracic esophageal cancer and compared the outcomes with control patients who underwent standard reconstruction. The procedure is simple, safe, and not associated with any postoperative complications. The pancreatic amylase concentrations in the gastric juice samples on postoperative day 2 were slightly lower in the non-RY group than in the RY group (1884 ± 2152 vs. 25,790 ± 23,542IU/mL, respectively, P= 0.07). Postoperative endoscopic examination showed neither reflux esophagitis nor residual gastric content in the RY group. Quality of life assessed by the Dysfunction After Upper Gastrointestinal Surgery-32 questionnaire postoperatively was significantly better in the RY group than in the non-RY group for 'decreased physical activity,''symptoms of reflux,''nausea and vomiting,' and 'pain.' The results of this pilot study suggest that gastric reconstruction with duodenal diversion plus RY seems effective in improving both the reflux and delayed gastric emptying. The benefits of this procedure need to be further assessed in a large-scale, randomized controlled trial.

Laparotomy attenuates lipopolysaccharide-induced gastric bleeding in the rat.

Lipopolysaccharide (LPS) increases systemic inflammation and causes duodenogastric reflux of bile and gastric bleeding. Laparotomy prevents gastric injury from the luminal irritant bile, but its effects on LPS-induced gastric injury are unknown. We hypothesized that laparotomy would diminish inflammation and attenuate gastric bleeding caused by LPS. In the rat, laparotomy, done either before or after administration of LPS, attenuated LPS-induced bile reflux, gastric bleeding, and cyclooxygenase-2, but not inducible nitric oxide synthase, expression when compared to controls given LPS. Laparotomy also blunted LPS-induced changes in serum cytokine production. These data suggest that laparotomy has gastroprotective effects by preventing LPS-induced bile reflux and gastric bleeding and by a mechanism mediated, at least in part by cyclooxygenase-2.

The advantages and disadvantages of a Roux-en-Y reconstruction after a distal gastrectomy for gastric cancer.

In Japan, the Billroth I and Billroth II operations have been used for reconstruction after a distal gastrectomy for gastric cancer. However, a Roux-en-Y reconstruction is increasingly performed to prevent duodenogastric reflux. We herein discuss the indications for Roux-en-Y in gastric surgery and review the literature to determine its advantages and disadvantages. Indications for Roux-en-Y reconstruction after a distal gastrectomy are: (a) When the primary lesion has directly invaded the duodenum or head of the pancreas, the Billroth I operation is likely to result in local recurrence near the anastomosis; (b) in addition, the Billroth I operation is not indicated after a subtotal gastrectomy due to an unacceptable anastomotic tension; reconstruction using a nonphysiological route is therefore preferred. The advantages of Roux-en-Y reconstruction after a distal gastrectomy include a reduction of reflux gastritis and esophagitis, a decreased probability of gastric cancer recurrence, and a reduction in the incidence of surgical complications such as ruptured suture lines. The disadvantages of Roux-en-Y reconstruction include the possible development of stomal ulcer, an increased probability of cholelithiasis, increased difficulty with an endoscopic approach to the ampulla of Vater, and the possibility of Roux stasis syndrome. The principal advantage of a Roux-en-Y reconstruction is that it is less likely than the Billroth I operation to result in duodenogastric reflux. Roux-en-Y reconstruction or Billroth I operation can only be selected after considering their respective advantages and disadvantages.

Proton pump inhibitor influence on reflux in Barrett's oesophagus.

OBJECTIVES: It is important to identify factors responsible for the development of Barrett's oesophagus (BO). The effect of proton pump inhibitors (PPIs) on oesophageal clearance of both acid and alkaline reflux in these patients is uncertain and studies comparing BO patients and healthy controls (HCs) have not been performed earlier. METHODS: Two groups of patients were studied: 18 HCs and 12 BO patients. Oesophageal motility, acid reflux and duodenogastro-oesophageal reflux (DGOR) were measured using a three-pressure transducer catheter with an antimony pH tip, connected to a sodium ion selective electrode. All patients were studied both on and off PPIs. RESULTS: Without PPI therapy, BO patients had significantly more upright and supine acid reflux and upright DGOR compared with HCs. During acid reflux, HC demonstrated more peristalsis than BO [HC, % peristalsis=64 (9), BO=53 (8), P<0.01], but this was not seen during DGOR. [HC, % peristalsis=68 (14), BO=56 (11)]. In Barrett's patients, DGOR was significantly reduced with PPIs [off PPI, % upright DGOR=61 (17), on PPIs=19 (15), P<0.01], and no oesophageal motility differences were seen compared with results without PPIs. CONCLUSION: HCs demonstrate better oesophageal motility compared with BO patients to prevent acid and alkaline reflux. When acid reflux occurred, HCs had better coordinated motility to remove it. This increased coordination did not occur during DGOR, suggesting different stimulation mechanisms. PPI reduced DGOR in BO patients, without any change in oesophageal motility.

Effect of Roux-en-Y gastric bypass in obese patients with Barrett's esophagus: attempts to eliminate duodenogastric reflux.

BACKGROUND: To assess the effect of Roux-en-Y gastric bypass (RYGB) at a tertiary referral Center of Excellence for bariatric surgery on the length and presence of dysplasia in morbidly obese patients with Barrett's esophagus (BE). Esophageal reflux of gastroduodenal contents (acid, bile) contributes to the development of BE and progression in the dysplasia-carcinoma sequence. Obese patients have a high prevalence of gastroesophageal reflux and might be at an increased risk of developing BE and esophageal adenocarcinoma. The effect of eliminating duodenogastroesophageal reflux on BE is not known. METHODS: We performed a retrospective review of all patients with pre-existing, biopsy-proven, long-segment (>3 cm) BE undergoing RYGB at our institution. Only patients with >1 year of endoscopic, biopsy-controlled follow-up (mean 34 mo) were included. RESULTS: Five patients (3 men and 2 women) were identified. The mean +/- standard error of the mean preoperative length of BE was 6 +/- 2 cm; 2 patients had low-grade dysplasia and 1 indeterminate dysplasia. At the postoperative follow-up (>1 yr) examinations, the length of BE had decreased in 4 patients; the overall length was 2 +/- 1 cm; and only 1 patient had dysplasia. All patients experienced a decrease in the length of BE (n = 4), complete disappearance of BE (n = 2), or improvement in the degree of dysplasia (n = 3). The body mass index had decreased from 43 +/- 4 kg/m(2) to 33 +/- 3 kg/m(2), and all experienced subjective improvement in reflux symptoms postoperatively. RYGB resulted in complete or partial regression of BE in 4 of 5 patients and improvement in reflux symptoms in all. CONCLUSION: Our results suggest that RYGB might be the procedure of choice in morbidly obese patients with BE requiring surgical treatment for gastroesophageal reflux disease.

[Functional and technical bases of valve anastomosis].

The present work studies stomach resection by Vitebski modification and suggests theoretically and tactically valid improvement of the anastomosis functions. The authors suggest that during the application of end-to-side anastomosis with transverse section of small intestine, the anatomic parameters of small intestine should be taken into consideration as well as the diameter of the anastomosis. To prove the above two groups of patients were examined in the remote period after operation: the first group of 25 patients were operated without strict consideration of anastomosis and small intestine diameter, while the second group of 40 patients were operated in accordance with the above approach. The clinical roentgenological research has shown that in spite of smaller number of patients, in the first group the number of functional disorders was significantly larger both in quantity and in degree than in the second group.

Systematic review: the application of molecular pathogenesis to prevention and treatment of oesophageal adenocarcinoma.

BACKGROUND: Oesophageal adenocarcinoma is an increasingly common cancer with a poor prognosis. It develops in a stepwise progression from Barrett's metaplasia to dysplasia, and then adenocarcinoma followed by metastasis. AIM: To outline the key molecular changes in oesophageal adenocarcinoma and to summarize the chemopreventative and therapeutic strategies proposed. METHODS: A literature search was performed to identify appropriate research papers in the field. Search terms included: Barrett's (o)esophagus, intestinal metaplasia, (o)esophageal adenocarcinoma, molecular changes, genetic changes, pathogenesis, chemoprevention, therapeutic strategies and treatment. The search was restricted to English language articles. RESULTS: A large number of molecular changes have been identified in the progression from Barrett's oesophagus to oesophageal adenocarcinoma although there does not appear to be an obligate order of events. Potential chemoprevention strategies include acid suppression, anti-inflammatory agents and antioxidants. In established adenocarcinoma, targeted treatments under evaluation include receptor tyrosine kinase inhibitors of EGFR and cyclin-dependent kinase inhibitors, which may benefit a subgroup of patients. CONCLUSIONS: Advances in molecular methodology have led to a greater understanding of the oesophageal adenocarcinoma pathways, which provides opportunities for chemoprevention and therapeutic strategies with a mechanistic basis. More work is required to assess both the safety and efficacy of these new treatments.

Duodenogastric reflux after esophagectomy and gastric pull-up: the effect of the route of reconstruction.

Duodenogastric reflux (DGR) is a common sequel of subtotal esophagectomy and gastric pull-up, and it may contribute to mucosal changes of both the gastric conduit and the esophageal remnant. This study investigated the effect of the route of reconstruction on the DGR. 24-hour ambulatory bilirubin monitoring was performed on patients who underwent transhiatal subtotal esophagectomy and a gastric tube interposition either in the posterior mediastinum (PM group, n = 11), or in the retrosternal space (RS group, n = 8): A Control group of 8 healthy volunteers was also studied. The median percentage of reflux time, the median number of reflux episodes, and the median number of reflux episodes longer than 5 minutes, in PM versus RS groups, were 29.1% versus 0.15% (p < 0.001), 185 versus 8 (p = 0.002) and 10 versus 0 (p = 0.001), respectively. The values of the above variables in PM versus control groups were 29.1% versus 3.95% (p = 0.007), 185 versus 21 (p = 0.02), and 10 versus 2 (p = 0.009), respectively, whereas in RS versus control groups they were 0.15% versus 3.95% (p = 0.01), 8 versus 21 (p = 0.04), and 0 versus 2 (p = 0.05), respectively. Posterior mediastinal gastric interposition is associated with high reflux of duodenal contents, whereas retrosternal interposition minimizes the reflux at levels even lower than those of the healthy individuals. The latter type of reconstruction may be a good alternative from that perspective, especially in patients with long life expectancy.

Reconstructive procedure after distal gastrectomy to prevent remnant gastritis.

BACKGROUND/AIMS: Gastroduodenostomy (Billroth I) or gastrojejunostomy (Billroth II) after distal gastrectomy is associated with duodenogastric reflux and remnant gastritis. This study sought to determine which reconstructive procedure is least likely to cause remnant gastritis and to determine the correlation between duodenogastric reflux and remnant gastritis. METHODOLOGY: Sixty patients who underwent curative distal gastrectomy for gastric cancer were classified into three groups by reconstructive procedure: group A, Roux-Y (n=18); group B, Billroth I (n=25); group C, Billroth II (n=17). Intragastric bile reflux was monitored using the Bilitec 2000 14 days after surgery, and endoscopy was performed and a patient questionnaire was completed 12 weeks after surgery. RESULTS: Bile reflux occurred in 23.9%, 40.4%, and 73.4% of the time (p<0.001), and remnant gastritis developed in 33%, 76%, and 100% of patients (p<0.001), in groups A, B, and C, respectively. Helicobacter pylori infection did not correlate with remnant gastritis (p=0.57). Symptoms following Roux-Y reconstruction were comparable to those following Billroth I and II reconstructions. CONCLUSIONS: Roux-Y reconstruction following distal gastrectomy is superior to Billroth I and II reconstruction in preventing remnant gastritis because it reduces duodenogastric reflux.

Effectiveness of Roux-en-Y reconstruction after distal gastrectomy based on an assessment of biliary kinetics.

PURPOSE: To evaluate the efficiency of Roux-en-Y reconstruction (RY) after distal gastrectomy we compared postoperative physiological functions and disorders among patients who underwent RY, conventional Billroth I reconstruction (BI), or Billroth II reconstruction (BII). METHODS: The subjects were 91 patients who had undergone distal gastrectomy for gastric cancer more than 1 month earlier. To examine the severity of gastroesophageal reflux, acid reflux and alkali reflux were assessed, and to examine the severity of duodenal reflux into the remnant stomach, biliary scintigraphy was performed. The degree of inflammation in the esophagus and remnant stomach was examined by endoscopy. Questionnaires on postoperative complaints were sent out to the patients to determine how serious their reflux symptoms were. RESULTS: Both acid and alkali reflux were mild in the RY group. Biliary reflux into the remnant stomach, as assessed by biliary scintigraphy, was significantly less severe in the RY group than in the BI and BII groups. Endoscopy showed that inflammation of the lower esophagus and remnant stomach was much less severe in the RY group than in the BI and BII groups. According to the questionnaire survey, none of the patients in the RY group reported any reflux symptoms. CONCLUSIONS: In this series, RY was found to be a superior reconstruction method after distal gastrectomy since it was rarely accompanied by the reflux of duodenal juice into the remnant stomach or gastric reflux into the lower esophagus.

Reconstructive procedure after distal gastrectomy for gastric cancer that best prevents duodenogastroesophageal reflux.

Billroth I and II reconstructions are commonly performed after distal gastrectomy. Both may cause duodenogastric and duodenogastroesophageal reflux, conditions reported to have carcinogenetic potential. The aim of this study was to investigate which reconstructive procedure would most effectively prevent bile reflux into the gastric remnant and esophagus after distal gastrectomy. A group of 92 patients who underwent curative distal gastrectomy for gastric cancer were subjected and classified into three groups retrospectively by the reconstructive procedure undertaken: group A, Roux-en-Y (Roux-Y) reconstruction (n = 29); group B, Billroth I reconstruction (n = 41); group C, Billroth II reconstruction (n = 22). The bile reflux periods (percent time) for the gastric remnant and esophagus were measured with the Bilitec 2000 under standardized conditions. The percent time for the gastric remnant was significantly less in group A than in group B or C. In 61% of all patients, bile reflux into the esophagus was found to be more than 5.0% of the time; it was less in group A than in group B or C (p = 0.057). A questionnaire revealed a good correlation between the incidence of reflux symptoms and the percent time for the gastric remnant and esophagus. Roux-Y reconstruction is superior to either Billroth I or II reconstruction for preventing bile reflux into the gastric remnant and esophagus after distal gastrectomy.

[Barrett's esophagus]. / Endobrachy-oesophage.

Barrett's oesophagus is a complication of oesophagogastric reflux. Diagnosis is made on the basis of endoscopy and histology showing glandular and intestinal metaplasia above the oeso-gastric junction. The most severe complication is adenocarcinoma. Endoscopic follow up is effective in individual patients. Other solutions would be either to protect the Barrett oesophagus from carcinogenic and cocarcinogenic agents contained in particular in the duodenal reflux fluid, or to ablate Barrett's mucosa by thermal or physicochemical processes, allowing subsequent regrowth of normal malpighian mucosa by suppression of the oesophagogastric reflux.

[The pathogenesis of achlorhydria of the operated stomach and the functionally optimal volumes for distal resection in areflux gastrointestinal anastomosis]. / Patogenez akhlorgidrii operirovannogo zheludka i funktsional'no optimal'nye ob''emy distal'noi rezektsii pri arefliuksnom zheludochno-kishechnom anastomoze.

Examinations of 68 patients after operations of selective proximal vagotomy and 59 patients after the Billroth-II and Roux resections were performed within the periods of about 16 years. It was found that reflux was of main significance in the genesis of achlorhydria of the operated stomach. Gastric changes caused by Helicobacter pylori did not result in so rapid suppression of functional activity of the operated stomach. Hemiresection is thought to be optimal for the areflux Roux gastrojejunal anastomosis with hypersecretion. In patients with normal secretion a resection of 2/3 of the stomach is expedient. In cases with hypersecretion and unknown boundaries of the antrum a resection of 50-60% of the stomach must be supplemented with vagotomy.