Crystalline shielding mitigates structural rearrangement and localizes memory in jammed systems under oscillatory shear.

The nature of yield in amorphous materials under stress has yet to be fully elucidated. In particular, understanding how microscopic rearrangement gives rise to macroscopic structural and rheological signatures in disordered systems is vital for the prediction and characterization of yield and the study of how memory is stored in disordered materials. Here, we investigate the evolution of local structural homogeneity on an individual particle level in amorphous jammed two-dimensional (athermal) systems under oscillatory shear and relate this evolution to rearrangement, memory, and macroscale rheological measurements. We define the structural metric crystalline shielding, and show that it is predictive of rearrangement propensity and structural volatility of individual particles under shear. We use this metric to identify localized regions of the system in which the material's memory of its preparation is preserved. Our results contribute to a growing understanding of how local structure relates to dynamic response and memory in disordered systems.

Predator-Prey Interactions Examined Using Lionfish Spine Puncture Performance.

Puncture mechanics can be studied in the context of predator-prey interactions and provide bioinspiration for puncture tools and puncture-resistant materials. Lionfish have a passive puncture system where venomous spines (dorsal, anal, and pelvic), the tool, may embed into a predator's skin, the target material, during an encounter. To examine predator-prey interactions, we quantified the puncture performance of red lionfish, Pterois volitans, spines in buccal skin from two potential predators and porcine skin, a biological model for human skin. We punctured dorsal, anal, and pelvic lionfish spines into three regions of buccal skin from the black grouper (Mycteroperca bonaci) and the blacktip shark (Carcharhinus limbatus), and we examined spine macro-damage (visible without a microscope) post puncture. Lionfish spines were more effective, based on lower forces measured and less damage incurred, at puncturing buccal skin of groupers compared to sharks. Anal and dorsal spines incurred the most macro-damage during successful fish skin puncture trials, while pelvic spines did not incur any macro-damage. Lionfish spines were not damaged during porcine skin testing. Anal spines required the highest forces, while pelvic spines required intermediate forces to puncture fish skin. Dorsal spines required the lowest forces to puncture fish skins, but often incurred macro-damage of bent tips. All spine regions required similar forces to puncture porcine skin. These data suggest that lionfish spines may be more effective at puncturing humans such as divers than potential fish predators. These results emphasize that puncture performance is ultimately determined by both the puncture tool and target material choice. Lionfish puncture performance varies among spine region, when taking into account both the puncture force and damage sustained by the spine.

Scaling of relaxation and excess entropy in plastically deformed amorphous solids.

When stressed sufficiently, solid materials yield and deform plastically via reorganization of microscopic constituents. Indeed, it is possible to alter the microstructure of materials by judicious application of stress, an empirical process utilized in practice to enhance the mechanical properties of metals. Understanding the interdependence of plastic flow and microscopic structure in these nonequilibrium states, however, remains a major challenge. Here, we experimentally investigate this relationship, between the relaxation dynamics and microscopic structure of disordered colloidal solids during plastic deformation. We apply oscillatory shear to solid colloidal monolayers and study their particle trajectories as a function of shear rate in the plastic regime. Under these circumstances, the strain rate, the relaxation rate associated with plastic flow, and the sample microscopic structure oscillate together, but with different phases. Interestingly, the experiments reveal that the relaxation rate associated with plastic flow at time t is correlated with the strain rate and sample microscopic structure measured at earlier and later times, respectively. The relaxation rate, in this nonstationary condition, exhibits power-law, shear-thinning behavior and scales exponentially with sample excess entropy. Thus, measurement of sample static structure (excess entropy) provides insight about both strain rate and constituent rearrangement dynamics in the sample at earlier times.

Quantification of plasticity via particle dynamics above and below yield in a 2D jammed suspension.

The yield transition of amorphous materials is characterized by a swift increase of energy dissipation. The connection between particle dynamics, dissipation, and overall material rheology, however, has still not been elucidated. Here, we take a new approach relating trajectories to yielding, using a custom built interfacial stress rheometer, which allows for measurement of shear moduli (G',G'') of a dense athermal suspension's microstructure while simultaneously tracking particle trajectories undergoing cyclic shear. We find an increase in total area traced by particle trajectories as the system is stressed well below to well above yield. Trajectories may be placed into three categories: reversibly elastic paths; reversibly plastic paths, associated with smooth limit cycles; and irreversibly plastic paths, in which particles do not return to their original position. We find that above yield, reversibly plastic trajectories are predominantly found near to the shearing surface, whereas reversibly elastic paths are more prominent near the stationary wall. This spatial transition between particles acting as liquids to those acting as solids is characteristic of a 'melting front', which is observed to shift closer to the wall with increasing strain. We introduce a non-dimensional measure of plastic dissipation based on particle trajectories that scales linearly with strain amplitude both above and below yield, and that is unity at the rheological yield point. Surprisingly, this relation collapses for three systems of varying degrees of disorder.

Ovarian cancer in Manitoba: trends in incidence and survival, 1992-2011.

BACKGROUND: Because the International Cancer Benchmarking Partnership, in a study of diagnosis years between 1995 and 2007, showed lower-than-expected survival for Manitoba's ovarian cancer patients, we undertook an analysis to describe the features of ovarian cancer diagnosed in Manitoba during a 20-year period. We also determined the most recent trends in survival to see if the previous results were sustained. METHODS: In this retrospective cohort study, ovarian cancer cases diagnosed during 1992-2011 were extracted from the Manitoba Cancer Registry. The incidence of ovarian cancer was calculated for the overall group and for age, morphology, residence, treatment, and stage. Trends over time, with a particular focus on changes that might correlate with poor survival, were analyzed. The 1- and 3-year relative survival rates were also calculated. RESULTS: The incidence of ovarian cancer did not vary over time (p = 0.640), even when stratified by age or morphology groups. Use of adjuvant chemotherapy decreased (p = 0.005) and use of neoadjuvant chemotherapy increased over time (p = 0.002). Diagnoses of stage iv cancers declined over time (p < 0.020). Trends in incidence did not coincide with previously observed decreases in relative survival. CONCLUSIONS: A decline in diagnoses of stage iv ovarian cancer could be responsible for a recent increase in relative survival. However, sample size might have limited power in some analyses, and the previously reported decrease in relative survival might have been due to a random fluctuation in the data. Future efforts will focus on continued monitoring of the patterns of ovarian cancer presentation and outcomes in Manitoba.

Lesbian and bisexual women's gynaecological conditions: a systematic review and exploratory meta-analysis.

BACKGROUND: Little is known about the gynaecological health of lesbian and bisexual (LB) women. OBJECTIVES: To examine differences in incidence and/or prevalence of gynaecological conditions in LB compared with heterosexual women. SEARCH STRATEGY: The systematic review protocol was prospectively registered (PROSPERO-CRD42015027091) and searches conducted in seven databases. SELECTION CRITERIA: Comparative studies published 2000-2015, reporting any benign (non-infectious) and/or malignant gynaecological conditions with no language or setting restrictions. DATA COLLECTION AND ANALYSIS: Inclusions, data extraction and quality assessment were conducted in duplicate. Meta-analyses of condition prevalence rates were conducted where ≥3 studies reported results. MAIN RESULTS: From 567 records, 47 full papers were examined and 11 studies of mixed designs included. No studies directly addressing the question were found. Two chronic pelvic pain studies reported higher rates in bisexual compared with heterosexual women (38.5 versus 28.2% and 18.6 versus 6.4%). Meta-analyses showed no statistically significant differences in polycystic ovarian syndrome, endometriosis and fibroids. There was a higher rate of cervical cancer in bisexual than heterosexual women [odds ratio (OR) = 1.94; 95% CI 1.46-2.59] but no difference overall (OR = 0.76; 95% CI 0.15-3.92). There was a lower rate of uterine cancer in lesbian than heterosexual women (OR = 0.28; 95% CI 0.11-0.73) and overall (OR = 0.36; 95% CI 0.13-0.97), but no difference in bisexual women (OR = 0.43; 95% CI 0.06-3.07). CONCLUSIONS: More bisexual women may experience chronic pelvic pain and cervical cancer than heterosexual women. There is no information on potential confounders. Better evidence is required, preferably monitoring sexual orientation in research using the existing validated measure and fully reporting results. TWEETABLE ABSTRACT: Lesbians have less uterine cancer than heterosexual women; bisexuals have more pelvic pain and cervical cancer.

Photodeoxygenation of dinaphthothiophene, benzophenanthrothiophene, and benzonaphthothiophene S-oxides.

Photoinduced deoxygenation of dibenzothiophene S-oxide (DBTO) has been suggested to release atomic oxygen [O((3)P)]. To expand the conditions and applications where O((3)P) could be used, generation of O((3)P) at longer wavelengths was desirable. The sulfoxides benzo[b]naphtho-[1,2,d]thiophene S-oxide, benzo[b]naphtho[2,1,d]thiophene S-oxide, benzo[b]phenanthro[9,10-d]thiophene S-oxide, dinaphtho[2,1-b:1',2'-d]thiophene S-oxide, and dinaphtho[1,2-b:2',1'-d]thiophene S-oxide all absorb light at longer wavelengths than DBTO. To determine if these sulfoxides could be used to generate O((3)P), quantum yield studies, product studies, and computational analysis were performed. Quantum yields for the deoxygenation were up to 3 times larger for these sulfoxides compared to DBTO. However, oxidation of the solvent by these sulfoxides resulted in different ratios of oxidized products compared to DBTO, which suggested a change in deoxygenation mechanism. Density functional calculations revealed a much larger singlet-triplet gap for the larger sulfoxides compared to DBTO. This led to the conclusion that the examined sulfoxides could undergo deoxygenation by two different mechanisms.

Tibial nerve motor conduction with recording from the first dorsal interosseous: a comparison with standard tibial studies.

PURPOSE: The lateral plantar nerve (LPN) branch of the tibial nerve provides the primary supply to the first dorsal interosseous (FDI) muscle of the foot. A consistent clear response has been observed with recording of the LPN from the FDI muscle. This clarity is not always found with the standard recording site for the LPN. As there are no published normative values for the FDI recording site, the purpose of this study is to describe these values and compare them with standard tibial values. METHODS: Fifty four healthy adult volunteers with 102 limbs were studied to determine the nerve conduction velocity, distal latency, amplitude, and waveform characteristics. RESULTS: The FDI recording demonstrated a significantly greater amplitude than did the standard recording, with the mean values being 7.7 and 3.6 mV respectively. The recording from the FDI also demonstrated much greater waveform clarity than did the standard tibial nerve recordings. CONCLUSIONS: These findings may aid interpretation of data collected from the FDI in tibial nerve testing. LPN recording from the FDI may be particularly valuable in those with global axonal loss or preferential involvement of the LPN as may occur in posterior tarsal tunnel syndrome.

KTP laser ablation of Barrett's esophagus after anti-reflux surgery results in long-term loss of intestinal metaplasia. Potassium-titanyl-phosphate.

BACKGROUND: Efforts to ablate Barrett's epithelium have met with mixed results. We report the long-term follow-up evaluation of the preliminary cohort of patients who underwent thermal ablation of Barrett's epithelium with the potassium-titanyl-phosphate (KTP) laser after anti-reflux surgery. METHODS: Nine patients with intestinal metaplasia (IM) of the esophagus underwent fundoplication (7 laparoscopic Nissen, 1 laparoscopic Toupet, 1 open Nissen) between May 1993 and October 1994. Three patients had an IM less than 3 cm long (33%). One year after the operation, all the patients were symptom free, had discontinued medications, and had a normal 24-h pH study. From June 1995 to February 1996, these patients underwent a median of two (range, 1-5) endoscopic procedures with directed mucosal ablation using the KTP laser. A comparative cohort of 21 patients (IM length, <3cm; 38%) treated during the same period with fundoplication alone served as a control. The patients were followed prospectively with annual or biennial endoscopy and biopsy. All the patients were contacted by mail, telephone, or clinic visit annually to determine symptomatic and quality-of-life outcome of antireflux surgery. RESULTS: The mean follow-up period was 6.8 years (range, 6-7.5 years). At this writing, the study patients are alive and well. Eight of the patients have experienced histologic loss of IM (89%) according to their last biopsy result. One patient has had regression of low-grade dysplasia to IM. The patients treated with fundoplication alone had a mean follow-up period of 5.6 years (range, 4.7-7.2 years). On the basis of the last biopsy result, 7 of 21 patients (33%) had no evidence of IM. CONCLUSIONS: A program of tailored antireflux surgery followed by thermal mucosal ablation causes a loss of IM in a majority of patients with Barrett's esophagus. This may represent a significant improvement in histologic outcome over that of treatment with fundoplication alone (p = 0.007 Fisher's exact test).

Long-term outcome of laparoscopic repair of paraesophageal hernia.

BACKGROUND: It has been reported that the laparoscopic repair of paraesophageal hernias is associated with higher complication and recurrence rates than the open methods of repair. METHODS: We identified 136 consecutive patients who underwent laparoscopic repair of a paraesophageal hernia between 1993 and 1999. Patient demographics and symptom scores for regurgitation, heartburn, chest pain, and dysphagia at presentation and at last follow-up were recorded (0 = none, 1 = mild, 2 = moderate, 3 = severe). The operative records were reviewed, and early and late complications were noted. Only patients with a follow-up of >1 were included in the analysis. RESULTS: The median age was 64 years, and there was a female preponderance (1.8:1). Most patients had some medical comorbidity; the American Society of Anesthesiologists (ASA) scores were <2 in eight patients and ?2 in 117 patients. Three laparoscopic operations were converted to open procedures. There were nine intraoperative complications, five early complications, and three related deaths (morbidity and mortality rates of 10.2% and 2.2%, respectively). Follow-up data were available for 83 patients (66%), and the mean follow-up time was 40 months (range, 12-82). The percentage of patients experiencing chest pain, dysphagia, heartburn, and regurgitation in the moderate to severe range dropped from a range of 34-47% to 5-7% (p <0.05). Three patients underwent repeat laparoscopic repair for symptomatic recurrence. CONCLUSION: The laparoscopic repair of paraesophageal hernias provides excellent long-term symptomatic relief in the majority of patients and has a low rate of symptomatic recurrence. The complication and death rates may be related in part to the higher incidence of comorbidities in this somewhat elderly patient population.

Outcomes of laparoscopic fundoplication for gastroesophageal reflux disease and paraesophageal hernia.

BACKGROUND: Laparoscopic fundoplication has become the standard for operative treatment of gastroesophageal reflux disease (GERD). METHODS: We reviewed our experience with 1,000 consecutive patients receiving laparoscopic fundoplication for GERD (n = 882) or paraesophageal hernia (n = 118) between October 1991 and July 1999. Patients with achalasia and failed fundoplication were excluded from analysis. All the patients were evaluated preoperatively by upper endoscopy, esophageal manometry, and barium swallow. After 1994, 24-h pH monitoring was performed selectively in patients with extraesophageal symptoms and/or those without erosive esophagitis. There were 490 men 510 women in this review. Their mean age was 49 years. Procedures performed were 360 degrees floppy fundoplication (n = 879), 360 degrees fundoplication without fundus mobilization (Rossetti) (n = 22), 270 degrees posterior fundoplication (n = 96), and anterior fundoplication (n = 2). Esophageal lengthening procedure (Collis gastroplasty) was performed in combination with fundoplication in 15 patients. In seven patients the treatment was converted to open fundoplication. OUTCOMES: The average length of hospitalization was 2.2 days, and 136 patients stayed longer than 2 days. Major complications occurred in 21 patients: esophageal perforation (n= 10), acute paraesophageal herniation (n = 4), splenic bleeding (n = 2), cardiac arrest (n = 1), pneumonia (n = 3), and testicular abscess (n = 1). Additional operations were required to manage the complications in 14 patients (70%): Four of these procedures were performed emergently, and 10 patients underwent reoperation between 6 h and 10 days. There were three deaths, all of which involved elderly patients with paraesophageal hernia. There were 35 late failures requiring reoperation for recurrence of GERD or development of new symptoms: The treatment of 32 patients was revised laparoscopically, and 4 patients required laparotomy. Beyond 1 year (median follow-up period, 27 months), 94% of the reviewed patients were satisfied with their surgical outcome.

Nissen fundoplication improves gastric motility in patients with delayed gastric emptying.

BACKGROUND: Fundoplication hastens gastric emptying in pediatric patients with gastroesophageal reflux disease (GERD). However, among adult GERD patients with impaired gastric emptying, the degree of improvement offered by fundoplication and the value of pyloroplasty are less well defined. Therefore, we compared outcomes in GERD patients with delayed gastric emptying after fundoplication alone or fundoplication with pyloroplasty. METHODS: Of 616 consecutive GERD patients who submitted to primary fundoplication (601 laparoscopic) between October 1991 and October 1997, 82 underwent preoperative solid-phase nuclear gastric emptying analysis. Of these, 25 had delayed gastric emptying (half-time >100 min). Of 12 patients with emptying half-times between 100 and 150 min, one underwent pyloroplasty at the time of Nissen fundoplication. Of 13 patients with emptying half-times >150 min, 11 had pyloroplasty at the time of Nissen fundoplication. Patients were asked to use a 0 ("none") to 4 ("incapacitating") scale to describe the severity of their symptoms of heartburn, regurgitation, dysphagia, bloating and diarrhea preoperatively and at 6 weeks and 1 year postoperatively. Eight patients consented to a postoperative analysis of gastric emptying. RESULTS: One year after fundoplication, patients with delayed gastric emptying and controls reported a similar improvement in heartburn, regurgitation, and dysphagia, with no increase in undesirable side effects such as bloating and diarrhea. Among the patients with delayed gastric emptying who consented to undergo a repeat gastric emptying study after their operation, fundoplication alone provided a 38% improvement (p < 0.05) in gastric emptying, whereas fundoplication with pyloroplasty resulted in a 70% improvement in gastric emptying (p < 0.05). CONCLUSION: Fundoplication improves gastric emptying. The addition of pyloroplasty results in even greater improvement and may have particular value for patients with severe gastric hypomotility.

Pediatric acute pain management.

The past decade has brought about an explosion of knowledge about the physiology of nociception and many new techniques for pain relief, new analgesic drugs, and new applications of old analgesic drugs. These techniques include methods of opioid administration by transdermal and transmucosal absorption and the use of neuraxial analgesia for the management of pain in children. Interest in the use of regional anesthesia in children has been rekindled, and analgesic properties and pre-emptive analgesic properties of many agents not typically considered analgesics, such as clonidine and ketamine, have been recognized. Perhaps the greatest advance has been the paradigm shift in the recognition that pain not only exists in infants and children but also is a significant cause of morbidity and even mortality. Given the unprecedented interest in pain management in adults and children, physicians can now look forward to the development of new methods of drug delivery and of receptor-specific drugs that divorce analgesia from the untoward side effects of existing analgesics. Improvement in the quality of life of hospitalized children also will occur.

Pain and symptom control in terminally ill children.

The management of pain in terminally ill pediatric patients has incalculable benefits to patients, their families, and physicians and nurses. A therapeutic management plan is dependent on a thorough understanding of the causes of pain in these patients, on pain assessment, and on the myriad drugs and drug strategies that are essential in pain treatment. Aggressive symptom control of treatment-related side effects can ensure successful implementation of such a plan.

Heartburn is more likely to recur after Toupet fundoplication than Nissen fundoplication.

Toupet (270 degrees) fundoplication is commonly recommended for patients with gastroesophageal reflux (GER) and esophageal dysmotility. However, Toupet fundoplication may be less effective at protecting against reflux than Nissen (360 degrees) fundoplication. We therefore compared the effectiveness and durability of both types of fundoplication as a function of preoperative esophageal motility. From January 1992 through January 1998, 669 patients with GER underwent laparoscopic fundoplication (78 Toupet, 591 Nissen). Patients scored heartburn, regurgitation, and dysphagia preoperatively, and at 6 weeks and 1 year postoperatively, using a 0 ("none") to 3 ("severe") scale. We compared symptom scores (Wilcoxon rank sum test) and redo fundoplication rates (Fisher exact test) in Toupet and Nissen patients. We also performed subgroup analyses on 81 patients with impaired esophageal motility (mean peristaltic amplitude, <30 mm Hg or peristalsis <70% of wet swallows) and 588 patients with normal esophageal motility. Toupet and Nissen patients reported similar preoperative heartburn, regurgitation, and dysphagia. At 6 weeks after operation, heartburn and regurgitation were similarly improved in both groups, but dysphagia was more prevalent among Nissen patients. After 1 year, heartburn and regurgitation were re-emerging in Toupet patients, and dysphagia was again similar between groups. Patients with impaired motility who have Nissen fundoplication are no more likely to suffer persistent dysphagia than their counterparts who have Toupet fundoplication. In addition, patients with normal motility are more likely to develop symptom recurrence after Toupet fundoplication than Nissen fundoplication, with no distinction in dysphagia rates. We conclude that since Toupet patients suffer more heartburn recurrence than Nissen patients, with similar dysphagia, selective use of Toupet fundoplication requires further study.

Laparoscopic fundoplication failures: patterns of failure and response to fundoplication revision.

OBJECTIVE: To determine rates and mechanisms of failure in 857 consecutive patients undergoing laparoscopic fundoplication for gastroesophageal reflux disease or paraesophageal hernia (1991-1998), and compare this population with 100 consecutive patients undergoing fundoplication revision (laparoscopic and open) at the authors' institution during the same period. SUMMARY BACKGROUND DATA: Gastroesophageal fundoplication performed through a laparotomy or thoracotomy has a failure rate of 9% to 30% and requires revision in most of the patients who have recurrent or new foregut symptoms. The frequency and patterns of failure of laparoscopic fundoplication have not been well studied. METHODS: All patients undergoing fundoplication revision were included in this study. Symptom severity was scored before and after surgery by patients on a 4-point scale. Evaluation of patients included esophagogastroscopy, barium swallow, esophageal motility, 24-hour ambulatory pH, and gastric emptying studies. Statistical analysis was performed with multiple chi-square analyses, Fisher exact test, and analysis of variance. RESULTS: Laparoscopic fundoplication was performed in 758 patients for gastroesophageal reflux disease and in 99 for paraesophageal hernia. Median follow-up was 2.5 years. Thirty-one patients (3.5%) have undergone revision for fundoplication failure. The mechanism of failure was transdiaphragmatic herniation of the fundoplication in 26 patients (84%). In 40 patients referred from other institutions, after laparoscopic fundoplication, only 10 (25%) had transdiaphragmatic migration (p < 0.01); a slipped or misplaced fundoplication occurred in 13 patients (32%), and a twisted fundoplication in 12 patients (30%). The failure mechanisms of open fundoplication (29 patients) followed patterns previously described. Fundoplication revision procedures were initiated laparoscopically in 65 patients, with six conversions (8%). The morbidity rate was 4% in laparoscopic procedures and 9% in open ones. There was one death, from aspiration and adult respiratory distress syndrome after open fundoplication. A year or more after revision operation, heartburn, chest pain, and dysphagia were rare or absent in 88%, 78%, and 91%, respectively, after laparoscopic revision, and were rare or absent in 91%, 83%, and 70%, respectively, after open revision, but 11 patients ultimately required additional operations for continued or recurrent symptoms, 3 after open revision (17%), and 8 after laparoscopic fundoplication (11%). CONCLUSIONS: Laparoscopic fundoplication failure is infrequent in experienced hands; the rate may be further reduced by extensive esophageal mobilization, secure diaphragmatic closure, esophageal lengthening (applied selectively), and avoidance of events leading to increased intraabdominal pressure. When revision is required, laparoscopic access may be used successfully by the laparoscopically experienced esophageal surgeon.

Asthma and gastroesophageal reflux: fundoplication decreases need for systemic corticosteroids.

An association between gastroesophageal reflux (GER) and asthma has been suggested for many decades. Although antireflux therapy (medical and surgical) has been shown to be beneficial in patients with asthma, response to therapy has not been well quantified. The aim of this study was to evaluate long-term outcome in patients with asthma and associated GER undergoing fundoplication. From a database of more than 600 patients with GER treated surgically between 1991 and 1996, 39 patients with asthma as their primary indication for surgery were identified. Asthma symptom scores were determined using the National Asthma Education Program classification, and medication frequency scores were determined preoperatively and at latest follow-up (median follow-up 2.7 years). Comparisons were made using the Wilcoxon rank-sum test. Asthma symptom scores decreased significantly after antireflux surgery. More important, the medication scores for use of systemic corticosteroids decreased significantly postoperatively (2.2 preoperatively vs. 0.7 postoperatively; P = 0.0001). Of the nine patients who required daily oral corticosteroids, seven have discontinued treatment entirely (78%). In patients with asthma associated with GER, symptoms of asthma are improved following fundoplication. Especially important has been the ability to wean patients from systemic corticosteroids postoperatively. Fundoplication should be offered to those patients with GER-associated asthma, especially those who are steroid dependent.

Fundoplication provides effective and durable symptom relief in patients with Barrett's esophagus.

BACKGROUND: Columnar-lined esophagus with intestinal metaplasia (IM), also called Barrett's esophagus, is a manifestation of severe gastroesophageal reflux (GER) and may predict poor symptom relief and high failure rate after fundoplication. We compared symptom scores and reoperation rates in GER patients with and without Barrett's esophagus. METHODS: Between July 1992 and July 1997, 646 patients underwent fundoplication (626 laparoscopic). Of 150 endoscopic biopsies of suspected columnar-lined esophagus, 80 confirmed IM, 50 identified cardiac or fundic epithelium, and 20 revealed only esophagitis. Typical GER symptoms were scored by patients preoperatively and postoperatively (0 to 4 scale). We compared symptom response (Wilcoxon rank sum test) and failure rates (t test) in patients with IM and GER controls without IM. Preoperative data were available for 74 IM patients and 496 controls. One-year follow-up was available in 45 IM patients and 301 controls. Intermediate follow-up (2 to 5 years) was available in 20 IM patients and 99 controls. RESULTS: Preoperatively and postoperatively, patients with IM reported heartburn, regurgitation, and dysphagia scores similar to controls. Procedure failure, requiring redo fundoplication, appeared more likely in IM patients than controls (6.3% versus 2.5%), but this difference did not reach statistical significance (P = 0.061). CONCLUSION: Fundoplication provides equivalent symptom relief for patients with and without IM.