Trefoil peptides are early markers of gastrointestinal maturation in the rat.

Trefoil peptides are members of a unique family of proteins found predominately throughout the gastrointestinal tract, whose proposed functions include mucus stabilization, stimulation and/or differentiation of epithelial cells during wound repair. Recent trefoil knockout studies have reported delays in epithelial cell migration or maturation pathways together with almost a complete lack of mucus. In order to fully explore the role of trefoil peptides in gastrointestinal maturation, these studies were undertaken to accurately characterize the expression of trefoil peptides in the developing rat gut. The results of RPA suggest that trefoil mRNA's are expressed as early as 15 days post coitus (dpc) in the intestine and stomach. Proteins are detected at 17 dpc by radioimmunoassay and immunohistochemical studies, which localize trefoil peptide expression to the lumenal surface of epithelial cells. At 17 dpc the gut is lined by pseudo-stratified, undifferentiated epithelial cells. Polarized, columnar cells are not detected until at least 18 dpc, with sparse mucus staining and parietal cell markers not being detected until 18 and 19 dpc respectively. This data demonstrates that trefoil peptides are early markers of epithelial cell maturation in the developing rat gut. The time course of their expression, well before the mucus cell type is specified, suggests a potential role in epithelial cell differentiation.

Surgical management of 100 consecutive esophageal strictures.

We report our experience with 100 consecutive patients with reflux-induced esophageal structure managed surgically. Preoperative dilatation, total fundoplication gastroplasty, and postoperative dilatation were used in 98 patients. Only two required resection of the esophageal structure. We have identified preoperative factors that adversely affect the results. These include scleroderma; previous operation, either esophageal or gastric, and the severity of the esophageal stricture. Results of nonresectional operations are excellent in uncomplicated cases or with the addition of only one complicating factor. The more complicating factors, the worse the results. Those patients with three preoperative complicating factors do poorly and may benefit from esophageal resection. We conclude that results obtained from this conservative nonresectional management program justify continuance of the use of total fundoplication gastroplasty with preoperative and postoperative dilatation in the management of such patients.

Myotomy for reflux-induced cricopharyngeal dysphagia. Five-year review.

This report describes 25 patients with reflux-induced cricopharyngeal dysphagia ultimately requiring surgical management. Eighteen patients underwent cricopharyngeal myotomy alone and seven patients required cricopharyngeal myotomy after an antireflux operation failed to correct this symptom. Cricopharyngeal incoordination was demonstrated at manometry in over 90% of patients. Treatment included cricopharyngeal myotomy, which was extended proximally to the pharynx and distally to the intrathoracic esophagus. Results were excellent to satisfactory in 24 of 25 patients. Pathologic examination of the cricopharyngeal muscle demonstrated a wide variety of myopathic degenerative changes. We stress that cricopharyngeal myotomy may be performed even in the presence of reflux without fear of subsequent aspiration.

The total fundoplication gastroplasty: surgical procedure and radiologic appearance.

The total fundoplication gastroplasty (TFG) consists of a combination of an esophagus-lengthening Collis gastroplasty and suturing of the gastric fundus to the esophagus and neo-esophagus to produce a stable intra-abdominal segment together with a complete Nissen fundoplication tailored in length to control reflux and avoid overcompetence. We studied 50 patients at least three months after TFG with an upper gastrointestinal examination and a tube esophagogram. Tube esophagography enhances distension of the esophagus and esophagogastric junction and eliminates the barium pool often seen in the distal esophagus in double-contrast esophagography. With this technique we were better able to understand the radiologic anatomy of the esophagogastric junction following TFG. Tube esophagography provided additional radiologic information in the five patients (10%) with preoperative peptic strictures of the esophagus. We describe the surgical and radiologic anatomy of the TFG, the technique of postoperative radiographic examination, and the postoperative problems we have encountered.

Review of the surgical management of recurrent hiatal hernia: 5-year follow-up.

Symptoms in patients with hiatal hernia often respond to treatment consisting of diet and medication. Operative procedures, designed to control gastroesophageal reflux and avoid surgically induced problems, are reserved for those with intractable symptoms. When these operative procedures fail, reoperation may be necessary. The reoperative procedure is often technically complex because of esophageal and gastric scar fixation. The authors reviewed the surgical management of recurrent hiatal hernia in 168 patients followed up to 5 years or more; 43 of them had undergone gastric surgery previously.Radiologically, 97% patients studied (142 of 146) had no evidence of anatomic recurrence or reflux post operatively. Manometric studies postoperatively in 114 patients showed that the mean tone of the high pressure zone was within the normal range and lower esophageal disordered motor activity was decreased by 34.5% from the preoperative level. Symptoms of recurrent hiatal hernia were abolished by operation in 88% of the patients; only 4.8% had serious or recurrent symptoms.

Extended esophageal myotomy and short total fundoplication hernia repair in diffuse esophageal spasm: five-year review in 34 patients.

Diffuse esophageal spasm (DES) is a rare disease, and its surgical management is controversial. There are seven major reported series totaling 148 patients and six operative variations depending on the extent of myotomy and whether or not a hernia repair should be added. There are no five-year follow-up reports. In the present study of 34 patients followed for at least five years, all had a myotomy from the apex of the chest through the high-pressure zone and all had a total fundoplication hernia repair, 16 with gastroplasty and 16 with a standard Nissen fundoplication. The length of the completion fundoplication is reduced to less than 0.5 cm to avoid problems of overcompetence. There were no operative deaths. Follow-up is 100% by clinical history, 82.4% by radiology, and 61.8% by manometry. Radiological follow-up showed no recurrence or reflux, although 1 patient had esophageal mucus retention. Thirty patients (88.2%) are eating normally without dysphagia or spontaneous pain. Two patients (5.9%) have mild dysphagia, and 1 of them also has mild spontaneous pain. One patient has major residual dysphagia, which is being treated conservatively, and 1 has required colon interposition. Good-quality results have been achieved in 94% of patients now followed 5 to 10.7 years.

Transabdominal total fundoplication gastroplasty to control reflux: a preliminary report.

Transthoracic total fundoplication gastroplasty has been reported as having a low mortality and a 1.1% recurrence rate and to produce excellent results in 93.1% of patients, moderate results in 3.7% and poor results in only 2.8% of patients. In approximately 7.0% intercostal neuritis is a serious residual problem. The transabdominal total fundoplication gastroplasty uses the identical repair technique but avoids the chest-wall pain. Previous esophageal or gastric surgery and major esophageal shortening are contraindications to an abdominal approach. The authors report their results with 50 patients who underwent transabdominal total fundoplication gastroplasty and were followed up for 6 to 20 months. There was no mortality or major morbidity. Clinical follow-up was complete, 94% of patients were assessed by roentgenography and 72% by manometry. None had anatomic recurrence, 46 (92%) were asymptomatic and 4 (8%) had minor residual gastric symptoms of fullness or occasional epigastric pain. All were much improved and none had wound pain. Long-term follow-up of transabdominal total fundoplication gastroplasty is necessary; however, since the technique of repair is identical to the thoracic approach, the results should be similar.

Total fundoplication gastroplasty (Nissen gastroplasty): five-year review.

Gastroplasty was introduced by Collis in 1961 and has undergone several modifications. The combination of total fundoplication with gastroplasty was reported in 1977 and referred to as total fundoplication gastroplasty; however, the term Nissen gastroplasty also is commonly used. This article is an extension of the original 1977 report and, to our knowledge, represents the first 5-year review of total fundoplication gastroplasty. Three hundred fifty-one consecutive patients with intractable reflux were preoperatively evaluated by history, radiographic studies, manometric studies with determination of pH, and esophagogastroduodenoscopy prior to surgical management by total fundoplication gastroplasty. There were no operative deaths. Follow-up averaged 6.5 years with an effective clinical review available for 95.4% of the patients, radiographic studies for 92.3%, and manometric studies with pH evaluation for 70.7%. Among the 335 patients with 5 or more years of follow-up, 93.1% had excellent results with normal eating and no investigative evidence of recurrence of reflux, 4.0% had mild residual symptoms, and 2.9% had persistent or recurrent symptoms. With this technique, the problems of overcompetence and dysphagia are substantially reduced because the completion fundoplication is tailored to a length of 1 cm while anatomical stability is maintained with a long intraabdominal segment.

Reflux control following gastric surgery.

Reflux is a common complication in patients who have undergone gastric surgery. These patients have bile reflux, often associated with gastric disease, and are resistant to conservative management. In this study the authors have reviewed 124 patients who were treated surgically for reflux that occurred after gastric operations. They were assessed preoperatively by history, radiologic investigation, manometry with pH and endoscopy. Seventeen patients were treated by Belsey hernia repair, 42 by partial fundoplication gastroplasty and 65 by total fundoplication gastroplasty. Thirty-seven patients required additional gastric surgery. Continued reflux was the commonest problem postoperatively; it was effectively corrected by total fundoplication gastroplasty. Of eight patients who had persistent bile gastritis, four had had bile drainage as part of their operation for reflux. From this study the authors conclude that total fundoplication gastroplasty is the most effective procedure to control reflux, but it must be carefully tailored to avoid overcompetence and dysphagia. Associated gastric problems should be treated simultaneously.

Total fundoplication gastroplasty. Long-term follow-up in 500 patients.

Total fundoplication gastroplasty was designed to combine the low anatomic recurrence rate of gastroplasty with the effectiveness of reflux control obtained by total wrap. The problems requiring evaluation are anatomic recurrence, continued reflux, dysphagia, inability to belch or vomit, and gas bloat, all of which have been described in procedures employing a total wrap. Five hundred consecutive patients were analyzed 6 to 60 months following operation. There were no deaths and a 3.6% incidence of short-term operative morbidity. Follow-up was available clinically in 98.4% (495 patients), radiologically in 89.6% (448), and manometrically in 69.5% (347). Two patients have anatomic recurrence (0.4%) and none has reflux. Excellent results occurred in 93.4% (467), improvement in 5% (25), and poor results in 1.6% (eight). Repeat operation was necessary in 0.4% (two) for recurrence and in 0.8% (four) for severe dysphagia. The other problems were minor dysphagia in 2.2% (11), gastritis in 1.2% (six), late cholelithiasis in 0.4% (two), and continued pain with poor results in 0.4% (two). The length of the gastroplasty tube and the subdiaphragmatic position of the high-pressure zone (HPZ) did not affect the result of the operation. A long tube and unwrapped supradiaphragmatic HPZ was present in 18.8% (94); none had reflux or major dysphagia. Total length of the gastroplasty wrap was 3 to 4 cm in the first 200 and the incidence of major dysphagia was 5% (10). Reducing the length of fundoplication to 1.5 to 2 cm reduced the incidence of dysphagia to 1.7% (five). Other problems of gastritis and difficulty with belching and vomiting occurred in a random fashion. This procedure is effective in reflux control, prevents anatomic recurrence and, if the completed fundoplication is maintained at 1.5 to 2 cm, yields a low incidence of significant dysphagia.

Recurrent hiatal hernia: management by thoracoabdominal total fundoplication gastroplasty.

Recurrent hiatal hernia presents a difficult diagnostic and therapeutic challenge. The authors present a series of 121 patients in whom recurrent hiatal hernia was investigated by history, radiology, endoscopy and manometry and acid perfusion testing before surgical correction by thoracoabdominal total fundoplication gastroplasty. The preoperative findings were compared with those of 238 patients who had undergone primary repair. Roentgenography was found to be less accurate in the diagnosis of anatomic recurrence than of the original hernia. Manometry and endoscopy increased the diagnostic accuracy of recurrent hernia. The thoracoabdominal approach was used to allow direct vision dissection both above and below the diaphragm. Gastroplasty minimized the risk of anatomic recurrence and allowed reflux control even in patients with an irreducible hiatal hernia. Total fundoplication, added to gastroplasty, is the most effective method of preventing reflux. There were no anatomic recurrences and no evidence of reflux in the 121 patients who had secondary repair. Two patients have required further surgery to modify the total fundoplication gastroplasty. With a 96.7% follow-up, 94.2% of the patients are considered to have excellent results.

Characteristics of esophageal pain.

Esophageal pain was investigated in 200 consecutive patients prior to surgical correction of reflux. the pain has been analyzed to determine its characteristic and its atypical features. Arm distribution of pain and exercise induced pain were the most a typical features and led to diagnostic difficulty. Although acid perfusion studies reproduced some component of the pain in 94% of patients, reproduction of arm pain was possible in only 37.2% of those with this symptom. The importance of cardiologic evaluation in patients with atypical esophageal pain is emphasized.

The gastroplasty tube and its role in reflux control: an experimental and clinical study.

The gastroplasty tube has been used in the control of reflux since it was originally described by Collis in 1961. Several variations of the procedure have been reported indicating a low frequency of anatomic recurrence but a high frequency of reflux. Two forms of gastroplasty procedure are used: partial fundoplication in which gastric fundus incompletely wraps the gastroplasty and high pressure zone, and total fundoplication in which a circumferential wrap is constructed. The authors conducted a clinical review, using the patient's history, radiology and manometry, of 135 patients with partial fundoplication gastroplasty (PFG) and 250 patients with total fundoplication gastroplasty (TFG). In both groups the anatomic recurrence rate was low; however, with PFG the frequency of reflux was 44.6% and 25.7% of patients had notable symptoms. With TFG no patient had reflux. The response of the gastroplasty tube to meal-induced gastrin release and to neurogenic stimulation was tested. Basal tube pressure was low and showed no response to gastrin release and no augmented neurogenic response. It was concluded that the gastroplasty tube did not have intrinsic properties of value in controlling reflux and that reflux control depended upon the method of fundoplication. The role of the gastroplasty tube is in preventing anatomic recurrence.

Cricopharyngeal myotomy as a method of treating cricopharyngeal dysphagia secondary to gastroesophageal reflux.

Food obstruction at the cricopharyngeal level is a common symptom of gastroesophageal reflux. In selected patients, cricopharyngeal myotomy is effective in relief of symptoms. We have used myotomy in patients whose only symptom was dysphagia, in patients too debilitated for major surgery, and in patients with persistent pharyngoesophageal dysphagia following hiatal hernia repair. All were studied by barium esophagogram, endoscopy, and manometry. Radiologic aspiration of barium was apparent in five of 19 patients. High-speed manometric tracings showed intermittent cricopharyngeal incoordination in the six consecutive patients most recently studied. This finding of incoordination has been shown to be present in 38 patients with reflux and in all with major cricopharyngeal symptoms. Myotomy was effective in relieving symptoms in patients in whom this was the only reflux symptom and in the five patients too debilitated for major surgery. Good symptomatic improvement was obtained in nine of the 12 with persistent dysphagia following hernia repair, but in three relief was partial, with persistent symptoms being secondary to distal esophageal obstruction. Investigation is necessary to exclude other causes of dysphagia. However, withcareful selection, myotomy has proved to be an effective method of treatment.

Pharyngoesophageal dysphagia and gastroesophageal reflux.

Pharyngoesophageal dysphagia occurred in 51.3 percent of 1,000 consecutive patients with gastroesophageal reflux. Aspiration, secondary to food obstruction, occurred in 30 percent of these patients, and some developed significant secondary respiratory symptoms. The site of obstruction was localized to the cricopharyngeus by timing the interval from swallow to obstruction. Cricopharyngeal incoordination was demonstrated in 20 of 52 patients studied by high speed esophageal manometry. Surgical correction of gastroesophageal reflux in patients with intractable reflux symptoms was shown to be effective in relieving pharyngoesophageal dysphagia in all but a small number of patients with very severe symptoms. In those with persistent dysphagia cricopharyngeal myotomy at a later stage was effective in giving relief.

Esophageal reconstruction: an experimental approach to the control of reflux after esophageal resection.

A study of the properties of replacement gastric tubes and colonic segments, and their use in the prevention of reflux after esophageal resection indicates that, in order to prevent reflux, these tubes must be maintained in a subdiaphragmatic position. Gastric tubes have a higher intrinsic pressure barrier than colonic tubes--a 2.5- to 6-cm segment prevents reflux and the tube maintains a pressure barrier 10 cm H2O higher than stomach presure, whereas colonic segments require 12 cm of subdiaphragmatic length to control reflux and maintain a pressure barrier only 2 cm H2O above gastric pressure. Removal of the intrinsic pressure barrier by myotomy allows free reflux in tubes that previously had prevented reflux.

Bile aspiration: an experimental study in rabbits.

It has been shown that bile injected intratracheally in rabbits produces severe pulmonary edema, atelectasis, and focal hemorrhages. The authors investigated the effect of a number of solutions, including physiological concentration of bile, hydrochloric acid pH 1.0, bile salt diluted to 1%, and bile at 100% concentrations. Whenever the bile concentration exceeded 3%, none of the test animals survived. It is not possible to apply directly the results of an experimental animal study to humans. However, the severity of the pulmonary changes produced force the conclusion that bile is a potentially dangerous aspirate in humans.