Predictive factors of Barrett esophagus: multivariate analysis of 502 patients with gastroesophageal reflux disease.

HYPOTHESIS: Risk factors for the presence and extent of Barrett esophagus (BE) can be identified in patients with gastroesophageal reflux disease (GERD). DESIGN: Case-comparison study. SETTING: University tertiary referral center. PATIENTS: Five hundred two consecutive patients with GERD documented by 24-hour esophageal pH monitoring and with complete demographic, endoscopic, and physiological evaluation, divided in groups according to the presence and extent of BE (328 patients without BE and 174 with BE [67 short-segment BE and 107 long-segment BE]). MAIN OUTCOME MEASURES: Clinical, endoscopic, and physiological data, studied by multivariate analysis, to identify the independent predictors of the presence and extent of BE. RESULTS: Seven factors were identified as predictors of BE. They were abnormal bile reflux (odds ratio [OR], 4.2; 95% confidence interval [CI], 1.9-9.7), hiatal hernia larger than 4 cm (OR, 4.1; 95% CI, 2.1-8.0), a defective lower esophageal sphincter (OR, 2.7; 95% CI, 1.4-5.4), male sex (OR, 2.6; 95% CI, 1.6-4.3), defective distal esophageal contraction (OR, 2.2; 95% CI, 1.4-3.5), abnormal number of reflux episodes lasting longer than 5 minutes (OR, 2.2; 95% CI, 1.1-4.6), and GERD symptoms lasting for more than 5 years (OR, 2.1; 95% CI, 1.4-3.2). Only abnormal bile reflux (OR, 4.8; 95% CI, 1.7-13.2) was identified as a predictor of short-segment BE (baseline, no BE). Three factors were identified as predictors of long-segment BE (baseline short-segment BE). They were hiatal hernia larger than 4 cm (OR, 17.8; 95% CI, 4.1-76.6), a defective lower esophageal sphincter (OR, 16.9; 95% CI, 1.6-181.4), and an abnormal longest reflux episode (OR, 8.1; 95% CI, 2.8-24.0). CONCLUSIONS: Among patients with GERD, specific factors are associated with the presence and extent of BE. Elimination of reflux with an antireflux operation in patients with 1 or more of these factors may prevent the future development of BE.

Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate.

BACKGROUND: Recent studies based on symptomatic outcomes analyses have shown that laparoscopic repair of large type III hiatal hernias is safe, successful, and equivalent to open repair. These outcomes analyses were based on a relatively short followup period and lack objective confirmation that the hernia has not recurred. The aim of this study was to compare the outcomes of laparoscopic and open repair of large type III hiatal hernia using both symptomatic evaluation and barium study to assess the integrity of the repair. STUDY DESIGN: Fifty-four patients underwent repair of a large type III hiatal hernia between 1985 and 1998. The surgical approach was laparotomy in 13, thoracotomy in 14, and laparoscopy in 27. An antireflux procedure was included in all patients. Symptomatic outcomes were assessed using a structured questionnaire at a median of 24 months and was complete in 51 of 54 patients (94%). A single radiologist, without knowledge of the operative procedure, assessed the integrity of the repair using video esophagram. Videos were performed at a median of 27 months (35 months open and 17 laparoscopic) and were completed in 41 of 54 patients (75%). RESULTS: Symptomatic outcomes were similar in both groups with excellent or good outcomes in 76% of the patients after laparoscopic repair and 88% after an open repair. Reherniation was present in 12 patients and was asymptomatic in 7. A recurrent hernia was present in 12 of the 41 patients (29%) who returned for a followup video esophagram. Forty-two percent (9 of 21) of the laparoscopic group had a recurrent hernia compared with 15% (3 of 20) of the open group (p < 0.001 log-rank value on recurrence-free followup). CONCLUSIONS: Laparoscopic repair of type III hiatal hernias is associated with a disturbingly high (42%) prevalence of recurrent hernia. More than half such recurrences have few, if any, symptoms.

Current concepts in the management of paraesophageal hiatal hernia.

Herniation of a portion of the stomach through the esophageal hiatus into the posterior mediastinum is a common affliction of humans. The incidence of hiatal hernia is difficult to determine because of the absence of symptoms in a large number of patients. Upper gastrointestinal barium examinations in symptomatic patients identify some type of hiatal hernia in as many as 15% of patients.

Effect of transjugular intrahepatic portosystemic shunt on secondary hypersplenism.

BACKGROUND: Portal hypertension is frequently associated with secondary hypersplenism, two common clinical manifestations of which are leukopenia and thrombocytopenia. Surgical portosystemic shunts alleviate portal hypertension but their effect on hypersplenism remains unpredictable. Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive procedure for portal decompression. From current reports it is not clear if TIPS improves hypersplenism in patients with portal hypertension. We present a retrospective review of our experience with TIPS to determine the effect on hypersplenism. PATIENTS AND METHODS: Sixty-five patients who had a TIPS procedure between December 1991 and June 1994 were evaluated retrospectively. The records were specifically reviewed for platelet and white blood cell counts performed before the procedure, within a week after the procedure, and then again within the subsequent 3 weeks. Hypersplenism was defined as thrombocytopenia (platelet count of <100,000/mm3), leukopenia (white blood cell count of <5,000/mm3), or both. RESULTS: Thrombocytopenia alone was present in 33 patients and leukopenia alone in 4 patients before TIPS was performed. Both leukopenia and thrombocytopenia were present in 12 individuals. At least one of these indices of hypersplenism was present in 49 patients. Leukocyte count improved in 11 of 16 patients (69%) whereas platelet count improved in 34 of 45 patients (75%) within a week of the procedure. In the subsequent 3 weeks, leukopenia was relieved in 5 of 10 patients (50%) and thrombocytopenia in 21 of 28 patients (75%), respectively. Of the 12 patients who had both leukopenia and thrombocytopenia before TIPS, the indices improved in 4 patients (33%) within a week of the procedure. Thrombocytopenia was more consistently corrected as opposed to leukopenia, albeit in the short term. CONCLUSION: The TIPS procedure is a promising, minimally invasive method of portal decompression that is effective in the treatment of complications of portal hypertension including secondary hypersplenism.

Reduction in tissue blood flow in J-shaped pelvic ileal reservoirs.

PURPOSE: This study sought to evaluate tissue blood flow during J-shaped ileal reservoir construction. METHODS: Using laser Doppler flowmetry, tissue blood flow was measured at various locations in J-shaped ileal reservoirs constructed in 10 dogs before pouch-anal anastomosis. For 12 weeks postoperatively, animals were assessed for clinical complications. In another five dogs, tissue blood flow was measured at various stages of J-pouch construction. RESULTS: Tissue blood flow in the reservoir was reduced and was lowest at the "apex" of the "J", the site of clinical stricture in one animal. During reservoir construction, longitudinal enterotomy was associated with the greatest reduction in tissue blood flow. Lowest blood flow in the reservoir was at the site of the intended pouch-anal anastomosis (11.5 +/- 1.6 ml/100 g/min vs. 43.4 +/- 3.4 ml/100 g/min (controls); P < 0.05). CONCLUSIONS: Operative maneuvers of J-shaped ileal reservoir construction, particularly longitudinal enterotomy, significantly reduce tissue perfusion in the involved bowel segment. Tissue blood flow in the pouch is lowest at the site of intended pouch-anal anastomosis, and this may contribute to development of complications seen clinically.

Gastric stasis of solids after Roux gastrectomy: is the jejunal transection important?

To investigate the effect of jejunal transection on the rate of gastric emptying after Roux gastrectomy, a two-part study was conducted. First, we investigated the relationship between Roux limb slow wave frequency and gastric emptying of solids. Six dogs underwent Roux-en-Y gastrectomy with vagal preservation and placement of intestinal electrodes. Gastric emptying studies were performed on each animal with simultaneous pacing of the Roux limb, either at the slowest rate (Pmin) or the fastest rate (Pmax) at which entrainment could be achieved. Gastric emptying studies were also performed in the unpaced (control) condition. Gastric half-emptying times (X +/- SEM minutes) and slow wave frequencies (X +/- SEM cycles per minute), respectively, were Pmin 117 +/- 26 min, 15.7 +/- 0.1 cpm; Pmax 97 +/- 18 min, 19.0 +/- 0.3 cpm; and unpaced 127 +/- 16 min, 15.1 +/- 0.3 cpm. The gastric half-emptying time during Pmax was significantly lower than unpaced controls (P = 0.01). The second part of the study sought to determine if transecting the intestine at 10 cm distal to the pylorus rather than at 20 cm distal to the ligament of Treitz would improve gastric emptying in animals with a truncal vagotomy and Roux-en-Y gastrectomy. Gastric half-emptying times were 149 +/- 21 and 164 +/- 24 min (ns), respectively. Slow wave frequencies were 17.01 +/- 0.06 and 15.7 +/- 0.17 cpm (P < 0.05), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Migrating myoelectric complex and jejunal slow-wave propagation after Roux gastrectomy in dogs.

Roux-en-Y gastrectomy is associated with a high incidence of symptoms of gastric stasis. Retrograde propagation of jejunal electrical slow waves and spike bursts has been implicated in the Roux Y stasis syndrome. Since the fasted state may persist after feeding, this study examined the extent of retrograde slow-wave propagation in the fasted state, particularly during aboral migration of phase III. Six dogs underwent Roux gastrectomy and placement of bipolar electrodes along the Roux limb. Four normal dogs with electrodes acted as controls. Thirty-five migrating myoelectric complexes were recorded in Roux dogs and 13 in controls. In Roux dogs, the incidences of retrograde propagation of slow waves during the migrating myoelectric complex were phase I 56 +/- 13%, phase II 60 +/- 12% and phase III 58 +/- 14% (not significant). For controls, the incidences were 0%, 0%, and 1%, respectively (P < 0.006 versus Roux dogs). In the Roux limb, retrograde propagation of slow waves, and hence spike bursts, occurs even during aboral migration of phase III. This abnormality may contribute to the Roux Y stasis syndrome.

Pancreatic complications following cardiopulmonary bypass. Factors influencing mortality.

Pancreatic complications following cardiopulmonary bypass are infrequent but are associated with high mortality. All cases of pancreatic complications following cardiopulmonary bypass from 1972 to 1987 at a single institution were retrospectively reviewed. Of 5621 patients who underwent cardiopulmonary bypass, 25 (0.44%) sustained pancreatic complications. There were 15 cases of acute pancreatitis and 10 cases of pancreatic necrosis, with 11 deaths in the group reviewed, a mortality rate of 44%. Factors that were correlated with mortality associated with pancreatic complications in this study include preoperative hypotension, preoperative use of inotropic agents, and renal failure (preoperative and postoperative). Factors that have been previously associated with mortality from pancreatic complications in other studies, such as fluid sequestration, respiratory failure, sepsis, tachycardia, hypocalcemia, age greater than 55 years, and abnormal laboratory findings, were not found to be significantly associated with mortality in this study. Of the five patients for whom complete data were available, not one patient received greater than 800 mg of calcium per square meter of body surface area in the perioperative period. While the exact mechanism of pancreatic injury remains unclear, based on experimental studies and clinical correlation, it is likely that pancreatic ischemia remains a significant contributing factor. We conclude that no factor specifically associated with cardiopulmonary bypass was correlated significantly with mortality.

Gastric emptying of solids after Roux-en-Y gastrectomy: is extragastric vagal innervation important?

Truncal vagotomy, antrectomy with Roux-en-Y gastrojejunostomy is frequently complicated by poor gastric emptying. The aim of this study was to determine whether the vagal denervation beyond the stomach (extragastric vagal denervation) contributes to this delay in gastric emptying. Three groups of six female mongrel dogs underwent antrectomy, Roux-en-Y gastrojejunostomy, and either truncal vagotomy, gastric vagotomy, or no vagotomy. After operation each dog underwent two separate radioisotope gastric-emptying studies with a small volume solid meal. The dogs were scanned by a gamma-camera continuously for 4 hours, and images of the gastric remnant were summed by computer every 6 minutes. Radioactivity in the gastric remnant region of interest was compared to overall activity and plotted as a function of time. The half-emptying times (X +/- SEM) for each group were truncal vagotomy 164 +/- 24 minutes, gastric vagotomy 79 +/- 23 minutes, and no vagotomy 117 +/- 10 minutes. Animals with a gastric vagotomy had a significantly faster rate of gastric emptying than did those with truncal vagotomy (p = 0.02, Scheffe's test). Therefore the extragastric vagal innervation appears to play a role in determining the rate of emptying of solids after antrectomy and Roux-en-Y gastrojejunostomy.

Postprandial changes in intestinal slow-wave propagation reflect a decrease in cell coupling.

The purpose of these studies was to determine the effects of feeding on jejunal slow-wave propagation velocity (SWPV). Nine cats were instrumented with six pairs of electrodes implanted 4 cm apart on the jejunum. Electrical activity was recorded at the end of an 18-h fast after which each animal was fed 60 g of canned cat food. Recordings were continued during feeding and for several hours thereafter. This procedure was repeated at least twice for each cat. Average SWPV (cm/s) decreased from a fasting level of 2.28 +/- 0.20 (mean of means +/- SE) to 1.93 +/- 0.16 at 10-20 min, 1.51 +/- 0.11 at 1 h, and 1.37 +/- 0.10 at 3 h postprandially. Corresponding SW frequencies (SWFs) were 19.6 +/- 0.3, 18.7 +/- 0.2, 19.2 +/- 0.2, and 19.0 +/- 0.2 cycles/min, respectively. The differences between the fasting SWPV and that at 1 and 3 h were significant (P less than 0.05). When SWPV was plotted as a function of SWF, the slopes of the corresponding curves were also found to decrease postprandially (P less than 0.05, fasting vs. 1 and 3 h). There was no apparent change in SW amplitude, maximum rate of SW depolarization, or threshold. In the absence of changes in these parameters, the divergence of the slopes at lower SWFs indicates that the decrease in SWPV is because of increased internal resistance, probably the result of uncoupling of intestinal muscle cells. The change is rapid in onset and long in duration, suggesting that an uncoupling factor is released during ingestion of a meal, and that its effect persists for several hours.

Changes in intercellular electrical coupling of smooth muscle accompanying atrophy and hypertrophy.

Longitudinal tissue impedance was determined for cat circular intestinal muscle that was either hypertrophied due to volume overloading or atrophied due to defunctionalization. These conditions were produced by bypassing 50 cm of jejuno-ileum in six cats and, 2-6 mo later, removing segments from the proximal jejunum of the hypertrophied functional gut and from the atrophied proximal end of the bypassed loop. Impedances were compared with those of jejunal circular muscle from 15 normal cats. Specific tissue impedance was determined by a modification of the method of Tomita (J. Physiol. Lond. 201: 145-159, 1969), which employs Krebs and Krebs-sucrose solutions; a tissue shrinkage of 5%, empirically found to occur in Krebs-sucrose solution, was corrected for. Impedance values were determined at 20 frequencies between 30 Hz and 30 kHz. The value at 30 kHz was taken to represent the specific myoplasmic resistance (Rmyo) of each tissue, while the difference between the value of 30 Hz and 30 kHz was taken to represent the specific junctional resistance (Rj). Values (in omega X cm) for Rmyo were control 134 +/- 2, functional 128 +/- 5, bypassed 151 +/- 6 (mean of means +/- SE). Corresponding values for Rj were control 173 +/- 15, functional 96 +/- 27, bypassed 340 +/- 75. Calculated values (in microF/cm) for junctional capacitance were control 2.66, functional 6.10, bypassed 1.97. Acid uncoupling by saturating the bathing solutions with 100% CO2 revealed a pH-sensitive resistive component of Rj, assumed to be attributable to gap junctions.(ABSTRACT TRUNCATED AT 250 WORDS)

Side-to-side and end-to-side anastomosis in partial gastrectomy and hemicolectomy using the EEA stapler.

We have described a new technique for side-to-side gastrojejunostomy as performed in Billroth II gastrectomy and for end-to-side ileocolostomy after right hemicolectomy utilizing the EEA stapler. By introducing the stapler through the area to be resected, we eliminated the need to close insertion enterostomies. This stapling technique also reduces the hazards and complications associated with multiple pursestring sutures normally required for end-to-end anastomosis with the EEA stapler, since, at most, one such suture is used. With minor modifications, the surgical technique can be applied to other operations in the alimentary tract, thus enhancing the utility of the EEA surgical stapler.

Consequences of intraperitoneal bile: bile ascites versus bile peritonitis.

Recent experience with patients with bile ascites and bile peritonitis prompted a review of other case histories in the medical literature of these conditions. The clinical courses of 24 patients with bile ascites and 34 with bile peritonitis were reviewed. Bile ascites occurred most often as a postoperative complication of biliary tract operations and also occasionally after trauma. Clinical signs were minimal except for abdominal distention, and operations were delayed for an average of 30 days. Peritoneal fluid was sterile in the 11 patients studied. In contrast, bile peritonitis occurred most commonly after spontaneous perforation of the gallbladder or hepatic ducts but also after trauma. All patients had severe signs of peritoneal irritation, and operation was performed earlier, at a mean of 4 days after onset of symptoms. Of 11 patients with specimens of their peritoneal fluid cultured, 6 had sterile fluid and 5 had bacteria. Although both bile salt concentration and bacteria have been implicated in the development of bile peritonitis rather than bile ascites, our understanding of the mechanisms involved is still incomplete.

Ninety-five percent duodenectomy. An experimental study.

Subtotal excision of the duodenum with preservation of the pancreas and bile and pancreatic ducts was achieved in five dogs without complications. Reconstruction was performed by direct anastomosis of the jejunum to the duodenal strip remaining attached to the head of the pancreas. Radiologic, metabolic, and histologic parameters 4 months postoperatively documented the success of this procedure. We suggest that this technique may be used to further investigate the role of the duodenum in digestive physiologic functions and may have clinical applications for benign diseases of the duodenum.

Chronic electrical activity of cat intestine.

Spontaneous electrical activity was recorded with bipolar electrodes from the gastrointestinal tracts of unanesthetized fasted cats (upper and lower cut-off frequencies: 35 and 3 Hz). In addition to slow waves (SWs) and spike potentials (SPs), the following three patterns of activity were recorded that are not observed in vitro. 1) Intense bursts of SPs (migrating spike complexes, MSCs) migrate caudally at a velocity of approximately 1 mm/s. MSCs resemble migrating myoelectric complexes (MMCs) in their velocity and by their traversal of intestinal anastomoses. SWs are usually suppressed during and immediately after the MSC, and, on their return, propagate at a higher velocity than they do prior to the MSC. Unlike its effect on MMCs, motilin does not appear to elicit MSCs, a finding consistent with the fact that MSCs occur infrequently in the duodenum and not at all in the antrum. 2) Bursts of SPs are found in the absence of recorded SWs. The SP bursts are of variable duration and occur virtually simultaneously at several recording sites, or propagate at 1-2 cm/s in either direction along the jejunum. The more usual caudally propagating SPs occur when SWs reappear. 3) "Minute rhythms," periods of spiking SWs, occur simultaneously over long lengths of upper bowel, sometimes including antrum, at intervals of about 1-2 min. It is proposed that, despite their differences, the cat MSC may be the functional counterpart of the MMC, that cat SWs are not omnipresent, and that the minute rhythms described here are of central origin.

Effective surgical therapy of esophagitis. Experience with Belsey, Hill, and Nissen operations.

During the years 1971 to 1978, 252 patients needed surgical treatment of primary or secondary esophagitis. Major operations performed were 73 Belsey Mark IV repairs, 55 Hill repairs, and 129 Nissen repairs. In the group with primary reflux, barium swallow tests and endoscopy were useful in confirming the diagnosis in patients with typical symptoms; routine biopsy, lower esophageal sphincter, manometry or an acid infusion test did not add to diagnostic certitude. If symptoms were atypical, a biopsy was helpful but manometry and acid infusion were not. Mean symptom scores in this group of patients were improved by each of the "valve-building" operations. Intraoperative dilation after mobilization of the esophagus coupled with a valve-building operation was successful in managing 26 of 29 strictures. Reoperation after an operation failed carried appreciable morbidity and mortality but resulted in good control of symptoms. Addition of a Belsey or Nissen procedure to myotomy for management of primary esophageal motility disorders diminished symptoms and did not cause disabling obstruction.