A safe and noninvasive test for vagal integrity revisited.

HYPOTHESIS: Measurement of pancreatic polypeptide (PP) response to sham feeding and pharmacological stimulation is a safe, noninvasive, and sensitive test for vagal integrity. DESIGN: Interventional study with control arms. SETTING: Tertiary center for esophageal surgery. PATIENTS: Thirty healthy volunteers and 25 patients who underwent total esophagectomy formed the control group with intact vagi and known vagotomy, respectively. INTERVENTION: Blood samples were obtained 15 minutes before and immediately before sham feeding to determine basal PP levels. Samples were also obtained 15, 30, 45, and 60 minutes after the sham feeding and 10 and 20 minutes after administration of 5 mg of intravenous edrophonium hydrochloride. MAIN OUTCOME MEASURE: Pancreatic polypeptide response to sham feeding and edrophonium administration were compared in both groups and the optimal percentage of rise from basal levels with maximal sensitivity and specificity was determined. RESULTS: Basal levels were similar in both groups (50 vs 45 ng/L). The maximum percentage of rise within 30 minutes after sham feeding was significantly higher in healthy subjects than in patients who underwent vagotomy (P<.001). A rise of 50% was seen in 24 (83%) of the 29 healthy subjects vs 2 (8%) of the 25 patients who underwent vagotomy (P<.001). This rise in PP level had a sensitivity of 83%, specificity of 92%, and a positive predictive value of 92% for identifying an intact vagus. The administration of endrophonium did not improve these results. CONCLUSIONS: A rise of more than 50% in the PP level within 30 minutes of sham feeding is a strong indicator of vagal integrity. This test has the potential to investigate vagal injury after gastroesophageal surgery.

Minimally invasive surgery for esophageal motility disorders.

Laparoscopic Heller myotomy has emerged as an excellent primary treatment for patients with dysphagia secondary to achalasia. A laparoscopic rather than thoracoscopic approach has stood the test of time. An antireflux procedure combined with the myotomy is crucial to the maintenance of the antireflux barrier. Thoracoscopic long myotomy offers effective relief for spastic disorders of the esophagus. Endoscopic stapled diverticulotomy is a safe and effective procedure for Zenker's diverticulum and has potential advantages over the open approach.

Esophageal function testing with combined multichannel intraluminal impedance and manometry: multicenter study in healthy volunteers.

BACKGROUND & AIMS: Combined multichannel intraluminal impedance and manometry (MII-EM) assesses esophageal function by simultaneous measurement of both pressure and bolus transit. Normative data for this method have not been published. The aim of this study was to establish normative data for combined MII-EM and to correlate liquid and viscous bolus transit by impedance with esophageal contractions by manometry. METHODS: Forty-three normal volunteers recruited from 4 centers (15 women, 28 men; age range, 21-72 years) underwent combined MII-EM with a catheter containing 4 impedance-measuring segments and 4 solid-state pressure transducers. Each center recruited and analyzed subjects independently, according to pre-established criteria. Each subject received 20 x 5 mL swallows, 10 liquid and 10 viscous material. Tracings were analyzed manually for bolus presence time, bolus head advance time, segmental transit times, total bolus transit time, contraction amplitude, duration, and onset velocity. RESULTS: Ninety-seven and four-tenths percent of manometrically normal liquid and 96.1% of manometrically normal viscous swallows had complete bolus transit by impedance. Almost half (47.2%) of manometrically ineffective liquid and 34.7% of ineffective viscous swallows had complete bolus transit, whereas 91.7% of manometric simultaneous liquid swallows and 54.5% of simultaneous viscous swallows had complete bolus transit. More than 93% of normal individuals had at least 80% complete liquid or at least 70% complete viscous bolus transit. CONCLUSIONS: This study establishes normative data for combined MII-EM. Combined MII-EM may be a more sensitive tool in assessing esophageal function compared to standard manometry because impedance can distinguish different bolus transit patterns. Studies in patients with manometrically defined esophageal motility abnormalities should help clarify the functional importance of manometric ineffective and simultaneous swallows.

Cytokeratin and DAS-1 immunostaining reveal similarities among cardiac mucosa, CIM, and Barrett's esophagus.

OBJECTIVE: The normal histology at the gastroesophageal junction, and in particular the nature of cardiac mucosa, remains in dispute. Likewise, the relationship of intestinal metaplasia at the gastroesophageal junction (CIM) to Barrett's and intestinal metaplasia of the stomach (GIM) is unclear. The aim of this study was to assess the immunostaining characteristics of cardiac mucosa and CIM and compare their staining pattern with that of other foregut mucosal types. We hypothesized that the immunostaining patterns of these foregut tissues would provide insight into the nature and etiology of cardiac mucosa and CIM. METHODS: Paraffin-embedded biopsy specimens from 50 patients with normal antral or fundic mucosa, cardiac mucosa, squamous mucosa, CIM, GIM, or Barrett's were obtained and immunostained with a panel of monoclonal antibodies including those for cytokeratins 7 and 20 (CK7/CK20) and DAS-1. RESULTS: Biopsies from normal gastric antral and fundic mucosa and squamous esophageal mucosa all showed a non-Barrett's type CK7/CK20 immunostaining pattern, whereas in 85% of patients, cardiac mucosa had a Barrett's type CK7/CK20 pattern (p < 0.001). A Barrett's type CK7/ CK20 staining pattern was seen in 100% of Barrett's, 78% of CIM, and 0% of GIM patients. Likewise, DAS-1 staining was similar in patients with CIM and Barrett's and significantly different in patients with GIM. CONCLUSIONS: Cytokeratin immunostaining of cardiac mucosa demonstrates significant differences from recognized normal gastric and esophageal mucosa but a similarity to Barrett's. This suggests that cardiac mucosa, like Barrett's, may be acquired. Likewise, immunostaining similarities between CIM and Barrett's biopsies point to the possibility of a reflux etiology for CIM in some patients.

Vagal-sparing esophagectomy: a more physiologic alternative.

OBJECTIVE: To evaluate the function of the vagal nerves and the gastric reservoir after vagal-sparing esophagectomy. SUMMARY BACKGROUND DATA: Esophagectomy as currently performed includes division of the vagal nerves and surgical alteration of the stomach, with attendant postoperative dumping, diarrhea, reduced meal capacity, and weight loss. Vagal-sparing esophagectomy has been introduced as a technique for removal of the esophagus while preserving the vagal nerves and gastric reservoir. The procedure is touted as having a low morbidity and is applicable to patients with end-stage benign or early malignant disease. METHODS: A random sample of 15 patients at a median of 20 months after a vagal-sparing esophagectomy was compared to 23 asymptomatic normal subjects; 10 randomly selected patients, 29 months after esophagogastrectomy with colon interposition; and 10 randomly selected patients, 47 months after standard esophagectomy with gastric pull-up. Gastric mucosal acidification was tested with Congo red staining. Vagal secretory function was measured by gastric acid output and pancreatic polypeptide response to sham feeding. Vagal motor function was assessed by a technetium gastric emptying scan and a questionnaire to evaluate dumping and diarrhea. Gastric reservoir function was evaluated by measuring meal capacity and postoperative changes in body mass index. RESULTS: Vagal-sparing esophagectomy preserved the function of the vagi, as evident by an increase in gastric acid output, a rise in serum pancreatic polypeptide following sham feeding, and preservation of normal postoperative gastric emptying in 70% of the patients. After vagal-sparing esophagectomy, patients were free of dumping and diarrhea and were analogous to normal subjects in meal capacity but had a slight reduction in the speed of eating. CONCLUSIONS: Vagal-sparing esophagectomy preserves gastric secretory, motor, and reservoir function. Postoperatively, patients have normal alimentation, bowel regulation, and no weight loss. It is an ideal procedure for patients with end-stage benign disease, Barrett's esophagus with high-grade dysplasia, or esophageal carcinoma limited to the lamina propria.