Effectiveness of a written clinical pathway for enhanced recovery after transthoracic (Ivor Lewis) oesophagectomy.

BACKGROUND: This study assessed the feasibility of a protocol-driven written clinical pathway for multidisciplinary postoperative management after oesophagectomy for oesophageal neoplasia, and examined whether the application of such a protocol could shorten hospital stay and reduce postoperative morbidity and mortality. METHODS: Consecutive patients undergoing transthoracic oesophagectomy for oesophageal neoplasia were divided into those treated between 2003 and 2008 to whom a clinical pathway was applied for postoperative management (group 1), and a control group treated between 1998 and 2002 when no clinical pathway was applied (group 2). RESULTS: There were 74 patients in each group. Morbidity rates were similar in the two groups: 31 per cent in group 1 and 38 per cent in group 2. There were more pulmonary complications in group 2 (23 versus 14 per cent; P = 0.025). One patient (1 per cent) in group 1 and four (5 per cent) in group 2 died after surgery (P = 0.010). The median (range) length of hospital stay was 9 (5-98) days for group 1 and 13 (8-106) days in group 2 (P = 0.012). CONCLUSION: Use of a written clinical pathway in patients undergoing oesophageal resection significantly reduced pulmonary complications, postoperative mortality and hospital stay.

Zenker's and epiphrenic diverticula in a patient with cutis laxa: should the surgical technique be modified?

Currently, most of esophageal diverticula arise as the result of a pulsion effect. Some esophageal motor disorders increase the intraluminal pressure and after some time, the diverticula grow through a weak point of esophageal wall. In these cases, the surgical treatment of choice is the myotomy associated with diverticulopexy or diverticulectomy. Adding a fundoplication is accepted to avoid the consequences of gastroesophageal reflux after myotomy in the epiphrenic diverticula surgery. There are other causes of esophageal diverticula that change the resistance of esophageal wall. Cutis laxa, a congenital or acquired connective disease, is a strange one. In our patient, a good result was reached modifying the standard technique accord to its ethiopathogenic mechanism.

[Quantification of gastro-esophageal reflux in Barrett's esophagus]. / Cuantificación del reflujo gastro-esofágico en el esófago de Barrett.

In the present paper we analyze the importance of gastro-oesophageal reflux in 20 patients with Barrett's oesophagus and in 20 patients with esophagitis without Barrett's mucosa; ten of this last group had mild esophagitis and ten severe inflammatory changes. In all the cases the oesophageal pH was measured during 24 hours; the results showed that although the reflux was more important in the group of patients with Barrett's esophagus than in the whole group of patients with esophagitis without Barrett's esophagus, figures were similar in the group with severe oesophagitis and the group with Barrett's oesophagus. We conclude that the pathogenesis of Barrett's esophagus includes factors other than gastroesophageal reflux.

[Early cancer of the stomach. Review of 29 cases]. / Cáncer gástrico precoz. Revisión de 29 casos.

A series of 29 patients with early gastric cancer operated on in our department over a period of 10 years is presented; this figure represents 9.10% of total number of gastric cancers. The most common symptom was epigastric pain, present in 51.72% of cases. Diagnosis was established by endoscopy and biopsy in 96.5% patients. Treatment was subtotal gastrectomy in 28 cases; most lesions (24) were located in the distal third of the stomach. Lesion was intramucosal in 44.8% of cases; in 55.17% there was infiltration of the submucosal layer and only 13.8% of tumors presented lymph node metastases. Macroscopically the most common pattern of the lesions was the ulcerated type. All patients have been followed up at least 4 years; of them died: one of carcinoma of the bladder and three of chronic respiratory failure. There were no recurrences of the gastric lesion and the 5 years actuarial survival was 84.32%.

[Esophageal perforations. Presentation of 23 cases]. / Perforaciones esofágicas. Presentación de 23 casos.

AIM: Esophageal perforations are the most serious perforations of the digestive tract and their treatment remains controversial. The aim of this study was to analyse the outcome of patients with esophageal perforations given surgical and conservative treatment. PATIENTS AND METHODS: Retrospective study of 23 patients with esophageal perforations, 8 cervical (35%) and 15 thoracic (65%). Medical treatment was indicated in patients who fulfilled Cameron's criteria (minimal signs of clinical sepsis; disruption contained in the mediastinum; drainage of the cavity back into the esophagus; minimal symptoms). The remaining patients underwent surgery. RESULTS: Two patients with cervical perforations (25%) met Cameron's criteria. Evolution after conservative treatment was favourable. The remaining patients (75%) were surgically treated: simple closure of the perforation was performed in four and drainage of the cervical abscess in two. Two of the patients who underwent surgery presented pleural hemorrhage, one of which was associated with pneumonia. Four patients with thoracic perforation (27%) met the criteria for conservative treatment. One presented respiratory distress syndrome during treatment and required intensive care. Evolution was favorable in all. The remaining 11 patients (73%) received surgical treatment: in five (46%) simple closure of the perforation was performed, in three (27%) bipolar exclusion was performed and in the remaining patients, other techniques were used. Morbidity was 82% (nine patients) mainly due to pneumonia and mortality was 46% (five patients). CONCLUSIONS: Treatment of esophageal perforation should be individualized. Conservative treatment should be considered in patients meeting Cameron's criteria as their evolution is favorable, with low morbidity and mortality and surgery is not necessary.

Evaluation of the magnitude of gastro-oesophageal reflux in Barrett's oesophagus.

A manometric study to determine the role of gastro-oesophageal reflux in Barrett's oesophagus was performed on 20 patients with Barrett's oesophagus and 53 patients with reflux oesophagitis without Barrett's oesophagus (25 with mild oesophagitis and 28 with severe oesophagitis). For the same reason, the 20 patients with Barrett's oesophagus also underwent 24 hour continuous oesophageal pH monitoring, and the results obtained were compared with those of 20 oesophagitis patients without Barrett's oesophagus (10 with mild oesophagitis and 10 with severe oesophagitis). The manometric results show that the motor changes found in the Barrett's group are specific but similar to the motor dysfunction associated with reflux oesophagitis. Motor anomalies are probably related more to the inflammatory process in the oesophageal wall than to the metaplastic changes themselves. The pH monitoring results show that while reflux in the Barrett's oesophagus patients was greater overall than in the oesophagitis group without Barrett's oesophagus, the changes are similar when the results are compared with the severe oesophagitis group. In conclusion there are other factors besides gastro-oesophageal reflux involved in the pathogenesis of Barrett's oesophagus.

Ineffective oesophageal motility does not affect the clinical outcome of open Nissen fundoplication.

BACKGROUND: Nissen fundoplication is considered the 'gold standard' in antireflux surgery but some surgeons employ a different surgical strategy when gastro-oesophageal reflux disease (GORD) is associated with motor disorders of the oesophageal body. METHODS: Ninety-three patients undergoing surgery for GORD were divided into two groups: 52 patients (group 1) had normal oesophageal body motility and 41 (group 2) had ineffective oesophageal motility (IOM). All patients had a short Nissen fundoplication via a laparotomy. The median follow-up was 5 years in group 1 and 6.5 years in group 2. RESULTS: The clinical outcome was satisfactory in more than 90 per cent of the patients in both groups. Only one of ten patients with IOM and dysphagia before operation still had dysphagia after surgery. One patient in each group developed postoperative dysphagia. Six of 52 patients with normal motility and eight of 41 with IOM had persistent pathological acid reflux after surgery. Significant increases in contractile wave pressure and a decrease in the percentage of non-propagated waves were found in group 2 after fundoplication. CONCLUSION: Patients with IOM did not have an increased rate of dysphagia after total fundoplication compared with those with normal motility, but they did have a higher rate of recurrence of endoscopic and pH-proven reflux.

Gastric surgery does not increase the risk of developing Barrett's esophagus.

OBJECTIVE: Barrett's esophagus is currently believed to be related to severe and prolonged pathological acid gastroesophageal reflux. However, other factors have been discussed, especially pancreatic biliary reflux. To determine the importance of pancreatic-biliary reflux in the genesis of Barrett's esophagus, we assessed the prevalence of Barrett's esophagus in patients with an intact stomach and in those with previous gastric surgery. METHODS: This is a retrospective study in which 22,236 upper digestive endoscopy reports were reviewed and classified into two groups: intact stomach (n = 21,023) and operated stomach (n = 1,213). In turn, these two groups were divided into five subgroups according to surgical techniques. In each of the groups and subgroups, we calculated the percentage of patients with esophagitis, the percentage of esophagitis patients with Barrett's esophagus, and the percentage of Barrett's esophagus patients with complications. Results were compared by chi2 test. RESULTS: With regard to the prevalence of Barrett's esophagus, we found no significant differences between the study groups. CONCLUSIONS: We conclude that previous gastric surgery does not increase the risk that esophagitis patients will develop Barrett's esophagus.

Long-term results of Nissen fundoplication in reflux esophagitis without strictures. Clinical, endoscopic, and pH-metric evaluation.

The present paper evaluates the efficiency of Nissen fundoplication as an antireflux technique in a series of 51 patients with different grades of esophagitis. Follow-up time averaged 6.6 years. The evaluation includes a clinical assessment, endoscopic study, and 24-hr pH monitoring. The results reveal an acceptable rate of recurrences, with clinical (9.8%) being less frequent than endoscopic (13.7%) or pH-metric (19.6%) recurrences. Side effects appeared in 37.3% of the patients (mainly inability to belch or vomit, and postprandial fullness), which were mild and transitory in most cases. Nissen fundoplication proved effective in controlling long-term gastroesophageal reflux, as over 80% of the patients presented an excellent-to-good clinical situation, without or with minimal digestive consequences.

Can pH recordings suggest defective esophageal peristalsis in patients with gastroesophageal reflux?

The data provided by 24-h pH monitoring in 40 patients with gastroesophageal reflux, divided in three groups in accordance with esophageal motor pattern, were compared. Patients with hypomotility had significantly greater reflux rates than those with normal motility or hypermotility, if we consider both total time with pH < 4 and time with pH < 4 corresponding to episodes of > 5 min duration. We conclude that when 24-h pH monitoring shows very high reflux rates, basically corresponding to episodes lasting > 5 min, we should suspect the presence of defective esophageal peristalsis, which must be confirmed with a manometric study.

Short myotomy for vigorous achalasia.

Vigorous achalasia has been considered an indication for surgery, in which a thoracic approach is recommended for extending the myotomy along the whole of the oesophageal body to the point where manometry shows high-amplitude waves. Clinical results and postoperative manometric findings in 16 patients with vigorous achalasia undergoing abdominal surgery with myotomy limited to the lower oesophageal sphincter (LOS) were analysed to assess whether extended myotomy is necessary in surgery for this form of achalasia. The clinical results were excellent or good in all cases. Surgery induced a significant decrease (P < 0.01) in the diameter of the oesophagus as determined radiologically. The most significant postoperative manometric changes were a decrease in the resting pressure of the LOS and oesophageal body, a lowering of wave amplitude at all levels of the oesophagus, and a reduction in the proportion of repetitive waves. The results suggest that vigorous achalasia can be treated surgically in the same way as classical achalasia and question, at least from a therapeutic viewpoint, the use of the term vigorous achalasia.

Factors involved in the return of peristalsis in patients with achalasia of the cardia after Heller's myotomy.

OBJECTIVE: To assess the reappearance of peristalsis in a group of 45 patients with achalasia of the cardia undergoing surgery and to analyze the factors involved in this phenomenon. METHODS: According to the postoperative manometric data, the 45 patients were divided into two groups, depending on whether or not they presented a return of peristalsis. A statistical comparison of age, sex, duration of the disease, pre- and postoperative radiological diameter of the esophagus, classic or vigorous nature of the achalasia, and manometric data of the lower esophageal sphincter and esophageal body was made. RESULTS: In 46.6% of the patients, peristalsis returned to the upper esophagus, and 100% of the waves were progressive; in 24.4%, peristalsis returned to the middle third also, but only 50% of the waves were progressive; and in 8.8% (four patients), peristalic activity returned to the whole esophagus, but only 40% of the waves were progressive. The group of patients with a return of peristalsis had a shorter duration of dysphagia, less preoperative dilation of the esophagus, and a greater contractile activity of the esophageal body. CONCLUSIONS: Return of peristalsis is a frequent phenomenon after myotomy in patients with achalasia of the cardia, especially in cases of short clinical evolution, little esophageal dilation, and a conserved contractile capacity, although its accurate production mechanism is unknown.

Diagnosis and treatment of oculopharyngeal dystrophy: a report of three cases from the same family.

Oculopharyngeal muscular dystrophy is a hereditary pathology transmitted in an autosomal dominant manner. The clinical symptoms are palpebral ptosis, oropharyngeal dysphagia and proximal limb weakness. Upper gastro-esophageal endoscopy is recommended to study the dysphagia, a video-radiology study with barium and an esophageal manometry to study the pharyngeo-esophageal motor disorder. Muscle biopsy reveals the presence of atrophic fibers substituted by an increase in fat and connective tissue. In 1998 Brais described the genetic alteration responsible for this pathology, a limited expansion of the triplet of GCG nucleotides in PABP2 gene on chromosome 14q11. Normal individuals have the homozygotic form (GCG)6 of this triplet, whereas patients with the described syndrome have the heterozygotic form (GCG)6-(GCG)9 or (GCG)6-(GCG)10. We present three siblings from the same family with diagnoses and genetic confirmations of oculopharyngeal dystrophy. Two of the patients underwent cricopharyngeal myotomy to relieve the dysphagia.

24-h pH monitoring is necessary to assess acid reflux suppression in patients with Barrett's oesophagus undergoing treatment with proton pump inhibitors.

BACKGROUND: Control of acid reflux is the main objective of treatment for Barrett's oesophagus. However, as these patients have a reduced sensitivity to acid reflux, disappearance of symptoms may not correlate with efficient control of acid reflux. The aim of this study was to determine in a group of patients with Barrett's oesophagus whether treatment with proton pump inhibitors suppressed pathological acid reflux once the symptoms of reflux had been controlled and the associated inflammatory lesions cured. METHODS: Eighteen consecutive patients with Barrett's oesophagus were studied, all of whom presented with heartburn. Twenty-four-hour oesophageal pH monitoring before treatment showed pathological acid reflux in all cases: median percentage of total time with pH less than 4, 22 (range 8-52) per cent. All patients received proton pump inhibitors (dose 20-60 mg/day) until symptoms were controlled. RESULTS: While on therapy, pH was reduced (median percentage of total time with pH less than 4, 3 versus 22 per cent; P < 0.001). However, three patients had persistent pathological rates of acid reflux. CONCLUSION: Disappearance of symptoms is not a good indicator of control of pathological acid reflux in patients with Barrett's oesophagus. Twenty-four-hour pH monitoring should be performed for proper adjustment of the dose of medication.

Surgery improves defective oesophageal peristalsis in patients with gastro-oesophageal reflux.

Postoperative manometry was carried out in 12 patients with gastro-oesophageal reflux associated with hypomotility of the oesophageal body. A Nissen fundoplication was carried out in all patients. After a median follow-up of 3.5 years, patients underwent clinical, endoscopic, radiological, manometric and pH-metric evaluation. Manometric results revealed an overall improvement in oesophageal motor function with an increase in the amplitude of deglutition waves and a decrease in the percentage of deglutitions without response. Six of the patients (one with complete motor failure) recovered normal peristaltic function. Non-specific oesophageal motor disorders may be secondary to gastro-oesophageal reflux and are reversible in nature.

Quantification of duodenogastric reflux in Barrett's esophagus.

OBJECTIVES: Our objective was to assess the role of reflux of duodenal contents in the genesis of Barrett's esophagus. Therefore, we performed a study to quantify duodenogastric reflux, using 99mTc-HIDA quantification in gastric juice after continuous intravenous infusion of the same. METHODS: The study contained 20 patients with Barrett's esophagus (10 uncomplicated and 10 complicated by ulcers and/or stenosis), 10 patients with peptic esophagitis without Barrett's esophagus (two grade I, four grade II, and four grade III, according to Savary-Miller), and 10 healthy volunteers who made up the control group. Comparisons were made between the groups. RESULTS: When we considered the groups overall, we observed that the 20 patients with Barrett's esophagus had higher reflux rates (p < 0.01) than either the 10 patients with peptic esophagitis without Barrett's esophagus, or the 10 controls. Complicated Barrett's esophagus presented higher reflux rates than uncomplicated Barrett's esophagus, although the differences were not statistically significant. However, on analyzing the results after considering the groups case by case, we see that the mean reflux rate in the Barrett's esophagus groups is due to five patients presenting much higher rates than the rest. CONCLUSIONS: Our results suggest that duodenogastric reflux might be involved in the appearance of Barrett's esophagus and its related complications, although only in certain cases. The pathogenesis of Barrett's esophagus is probably multifactorial, and other factors must be involved.

[Does the ingestion of caustics produce irreversible motor changes in the esophagus? Manometric study of 17 cases]. / Produce la ingesta de cáusticos alteraciones motoras esofágicas irreversibles? Estudio manométrico de 17 casos.

During the acute period of caustic esophagitis, important alterations in esophageal motor function appear. However, it is not known if these alterations persist later. To determine whether motor disorders persist (after the aggression) in the esophagus that has suffered caustic aggression, a manometric study was made in two groups of patients classified as mild (9 cases) or severe esophagitis (8 cases), and results were compared with those of a control group. Patients who had developed stenosis or suffered the caustic aggression less than a year earlier were excluded. The probable existence of motor anomalies could determine the appearance of dysphagia or reduce the effectiveness of motor clearance of the esophageal body, thus conditioning a situation of esophageal defenselessness against physiological or eventual abnormal episodes of gastroesophageal reflux (RGE). Our results indicate that in a variable percentage of cases some peristaltic dysfunctions can persist in the esophageal body in relation to the severity of the initial lesion.

Conservative treatment versus antireflux surgery in Barrett's oesophagus: long-term results of a prospective study.

The results obtained for the treatment of 59 patients diagnosed with Barrett's oesophagus, randomized to receive medical treatment (n = 27) or antireflux surgery (n = 32) were assessed prospectively. Median follow-up for the patients undergoing medical treatment was 4 (range 1-11) years and for patients undergoing surgical treatment 5 (range 1-11) years. Satisfactory symptomatic control (excellent to good results) was achieved in 24 patients after medical therapy and in 29 after antireflux surgery. The proportion of patients with persistent inflammatory lesions (54 per cent) and persistent or recurrent stenosis (47 per cent) was significantly higher after conservative treatment than after surgery (5 and 15 per cent, respectively). A decrease in the length of the segment of columnar mucosa was observed in eight of the patients who underwent antireflux surgery, and in only two of those given medical therapy. Conversely, an upward progression of the columnar lining was more frequent in the latter group (11 versus three). Mild dysplasia was observed in five patients, all from the group undergoing medical treatment. Severe dysplasia was detected in two patients, one undergoing medical treatment and the other following surgical therapy, in whom an antireflux procedure had failed previously. Both patients underwent oesophageal resection, with confirmation of a carcinoma in situ. The patients in whom antireflux surgery proved effective showed no dysplastic change or progression to adenocarcinoma. These results, despite the small number of patients and methodological limitations, question the systematic conservative approach in the initial management of patients with Barrett's oesophagus.

Primary eosinophilic esophagitis.

Eosinophilic esophagitis is an uncommon pathology that generally affects children with a history of allergies and intrinsic asthma. We present a clinical case of eosinophilic esophagitis in a 16-year-old boy with upper dysphagia for solids since childhood. The analytical study showed only a repeat serum eosinophilia. Barium transit disclosed a reduction in caliber of the whole esophagus. Functional esophageal tests with pH monitoring and manometry were normal. Endoscopy showed a small-diameter esophagus and fibrosis with a very friable mucosa. The histological study of the esophageal biopsies revealed a full thickness major eosinophil infiltration of the esophagus. These findings suggest a differential diagnosis with a great variety of pathologies that can cause similar lesions in the esophagus, especially between primary eosinophilic esophagitis and eosinophilic esophagitis secondary to gastro-esophageal reflux disease (GERD). We implemented medical treatment with oral corticoids and total suppression of allergens from the diet, and the patient was asymptomatic.

Quantification of duodenogastric reflux in gastroduodenal peptic ulcer and in gastric operation patients, using a 24-h gastric pH measurement as a quantification technique.

Twenty-four-hour gastric pH measurement was used to study duodenogastric reflux. To differentiate between gastric hyposecretion and duodenogastric reflux, we also measured bile acid concentrations in the gastric juice, and regarded pH increases to above 4 as possible episodes of reflux. The procedure was used in 60 patients, divided into the following groups: (1) control group (ten patients); (2) duodenal ulcer (ten patients); (3) type 1 gastric ulcer (five patients); (4) type 3 gastric ulcer (five patients); (5) bilateral truncal vagotomy plus pyloroplasty (ten patients); (6) truncal vagotomy plus Billroth I partial gastrectomy (ten patients); and (7) truncal vagotomy plus Billroth II partial gastrectomy (ten patients). The amount of reflux (areas of pH greater than 4) in the type 1 gastric ulcer and Billroth I and Billroth II groups was significantly greater than that found in the control, duodenal ulcer, type 3 gastric ulcer and truncal vagotomy plus pyloroplasty groups. The mean concentration of total bile acids was also greater in the gastrectomized patients than in the rest of the groups studied. In the type 1 gastric ulcer group the mean bile acid concentration was similar to that of the control group.