Elastic fiber depletion in the supporting ligaments of the gastroesophageal junction: a structural basis for the development of hiatal hernia.

BACKGROUND: The position of the gastroesophageal junction is maintained by a complex of fibroelastic ligaments. The purpose of this study was to characterize and compare the histology of these ligaments in patients with gastroesophageal reflux disease (GERD) and hiatal hernia (HH) versus GERD alone, with emphasis on the elastin morphology. STUDY DESIGN: Thirteen patients were examined at the time of laparoscopic fundoplication for symptomatic GERD; nine had no significant HH and four had large diaphragmatic hernias (GERD/HH). Tissue biopsies were obtained from the gastrohepatic ligament (GHL, n=5 and n=3, GERD and GERD/HH, respectively), the phrenoesophageal ligament (n=7 and n=4, respectively), and the gastrophrenic ligament (n=6 and n=4, respectively). Sections of fixed tissue were stained with hematoxylin and eosin, Masson's trichrome, and resorcin-fuchsin for analysis of elastic fibers by light microscopy, and elastin area was quantified and expressed as a percentage of the imaged tissue. RESULTS: Elastin and collagen fibers were prominent in all ligaments in patients with GERD alone. In patients with GERD/HH, there was fragmentation and distortion of elastin in the phrenoesophageal ligament and gastrohepatic ligament, and to a lesser degree, in the gastrophrenic ligament. Compared with patients with GERD alone, the presence of hiatal hernia was associated with a reduction in elastin area by more than 50% in the phrenoesophageal ligament ([mean +/- SEM] 31.0%+/-3.3% versus 15.1%+/-1.3%, p < 0.01) and gastrohepatic ligament (26.9% +/- 0.5% versus 12.5%+/-0.1%, p < 0.008). There was no decrease with respect to elastin in the gastrophrenic ligament. CONCLUSIONS: The periesophageal ligaments in patients with GERD are characterized by prominent elastic fibers. In contrast, GERD/HH is associated with depletion of elastic fibers in two of three ligaments supporting the gastroesophageal junction. Elastic fiber depletion in the periesophageal ligaments thereby provides a structural basis for the development of HH. It remains unclear if this represents a primary (etiologic) alteration or if it is a secondary phenomenon.

Incidence of residual choledocholithiasis detected by intraoperative cholangiography at the time of laparoscopic cholecystectomy in patients having undergone preoperative ERCP.

INTRODUCTION: The purpose of this study is to determine the incidence of residual common bile duct (CBD) stones after preoperative ERCP for choledocholithiasis and to evaluate the utility of routine intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) in this patient population. METHODS: All patients who underwent preoperative ERCP and interval LC with IOC from 5/96 to 12/05 were reviewed under an Institutional Review Board (IRB)-approved protocol. Data collected included all radiologic imaging, laboratory values, clinical and pathologic diagnoses, and results of preoperative ERCP and LC with IOC. Standard statistical analyses were used with significance set at p < 0.05. RESULTS: A total of 227 patients (male:female 72:155, mean age 51.9 years) underwent preoperative ERCP for suspicion of choledocholithiasis. One hundred and eighteen patients were found to have CBD stones on preoperative ERCP, and of these, 22 had choledocholithiasis diagnosed on IOC during LC. However, two patients had residual stones on completion cholangiogram after ERCP and were considered to have retained stones. Therefore, 20 patients overall were diagnosed with either interval passage of stones into the CBD or a false-negative preoperative ERCP. In the 109 patients without CBD stones on preoperative ERCP, nine patients had CBD stones on IOC during LC, an 8.3% incidence of interval passage of stones or false-negative preoperative ERCP. In both groups, there was no correlation (p > 0.05) between an increased incidence of CBD stones on IOC and a longer time interval between ERCP and LC, performance of sphincterotomy, incidence of cystic duct stones, or pathologic diagnosis of cholelithiasis. CONCLUSIONS: The overall incidence of retained or newly passed CBD stones on IOC during LC after a preoperative ERCP is 12.9%. Although the natural history of residual CBD stones after preoperative ERCP is not known, the routine use of IOC should be considered in patients with CBD stones on preoperative ERCP undergoing an interval LC.