Preferred location for the development of esophageal adenocarcinoma within a segment of intestinal metaplasia.

BACKGROUND: Barrett's metaplasia is the predominant precursor for the development of esophageal adenocarcinoma. This precancerous lesion has become the focus of various surveillance programs aimed at detecting earlier and therefore potentially curable lesions. However, sampling error by missing invasive cancer lesions is a common problem. This study aimed to identify preferred locations within a segment of Barrett's mucosa for the development of esophageal adenocarcinoma. METHODS: The study group consisted of 213 patients with histologically proven esophageal adenocarcinoma. Of those, there were 134 cases of early cancer and 79 cases of locally advanced lesions. These patients received neoadjuvant chemotherapy. The frequency of intestinal metaplasia and the location of the tumor occurrence within the segment of intestinal metaplasia were assessed. RESULTS: Intestinal metaplasia was found in 83% of the early lesions and in 98% of the advanced tumors after neoadjuvant chemotherapy. In 82.2% of the cases, the tumor was located at the distal margin of the intestinal metaplasia in patients with early tumor manifestations. The remaining tumor mass after neoadjuvant therapy also was located predominantly at the distal margin of the segment of intestinal metaplasia (85% of the cases). CONCLUSIONS: The results demonstrate that almost all adenocarcinomas of the esophagus are based on the development of a segment of intestinal metaplasia. The distal margin of Barrett's mucosa seems to be the most vulnerable location for the development of invasive cancer.

[Barrett's esophagus]. / Barrett-Osophagus Verhältnis zwischen Ausmass der intestinalen Metaplasie, Funktion des unteren Osophagussphinkters und Säure- bzw. Gallereflux.

INTRODUCTION: It is widely accepted that long segments of Barrett's esophagus are caused by end-stage gastroesophageal reflux disease (GERD), but little is known about the correlation of severity of GERD and extent of metaplasia. METHODS: Twenty normal volunteers and 142 patients with different extent of intestinal metaplasia (39 with intestinal metaplasia limited to the esophagogastric junction, 48 with short segments of Barrett's esophagus, and 55 with long segments) underwent manometry and combined pH-bilirubin monitoring. RESULTS: The extent of intestinal metaplasia correlated to the exposition of gastric and duodenal juice in the esophagus and inversely with a competent lower esophageal sphincter. CONCLUSIONS: The extent of intestinal metaplasia is related to the severity of GERD.

Assessment of respiratory symptoms with dual pH monitoring in patients with gastro-oesophageal reflux disease.

BACKGROUND: Gastro-oesophageal reflux disease (GORD) is a commonly underestimated aetiological factor in patients with respiratory symptoms. In this study, acid reflux in healthy volunteers and patients with GORD with and without respiratory symptoms was investigated by dual pH monitoring. METHODS: Thirty healthy volunteers and 43 patients with GORD underwent oesophageal manometry and dual pH monitoring with one probe in the proximal and one in the distal oesophagus. Nineteen of the 43 patients complained of respiratory symptoms. RESULTS: There were no differences in proximal probe measurements between volunteers and patients without respiratory symptoms. Patients with GORD and respiratory symptoms had a higher prevalence of abnormally high exposure to gastric juice and more reflux episodes in the proximal oesophagus compared with patients with GORD and no respiratory symptoms. Some 17 of 19 patients with GORD and respiratory symptoms showed deteriorated oesophageal body motility. CONCLUSION: Dual pH monitoring is feasible and well tolerated, and provides an objective means of evaluating patients with GORD and respiratory symptoms. Prolonged exposure of the proximal oesophagus to gastric juice and disorders of oesophageal body motility seem to be responsible for the development of respiratory symptoms.

The value of endosonographic rectal carcinoma staging in routine diagnostics: a 10-year analysis.

BACKGROUND: Endosonography is currently the gold standard for the local staging of rectal carcinoma, but its accuracy varies from 62% to 91%. This study aimed to determine the accuracy of endosonography, to evaluate the interobserver variability, and to compare the performance of the 7.5-MHz and the 10-MHz ultrasound scanners. METHODS: Between 1990 and 2000, 458 patients with rectal cancer were included in the study. All the patients had undergone rectal endosonography with a 7.5-MHz scan (period 1: 1990-1996) or a 10-MHz scan (period 2: 1997-2000). Endosonographic staging was compared with pathologic staging. RESULTS: The overall rate for correctly classified patients was 69% with respect to the T category and 68% with respect to the N category. There was no difference between the two scanners. In terms of accuracy, the T3 category tumors were the most (86%) and the T4 tumors the least (36%) accurately classified. Overstaging of tumors (19%) was much more frequent than understaging (12%). A high interobserver variability of 61% to 77% was noted. For pT1 tumors, the 10-MHz scan was almost two times more accurate than the 7.5-MHz scan (71% vs 36%). CONCLUSIONS: The accuracy of endosonographic staging of rectal carcinoma very much depends on the T category. A high-resolution scanner and an experienced examiner can help to ensure that endosonography remains an important tool in the staging process of patients with rectal carcinoma, especially early carcinoma.

Preoperative chemotherapy unmasks underlying Barrett's mucosa in patients with adenocarcinoma of the distal esophagus.

BACKGROUND: Intestinal metaplasia of the distal esophagus frequently cannot be detected in patients with esophageal adenocarcinoma. It has therefore been questioned whether Barrett's esophagus is the primary precursor lesion of such lesions. We hypothesized that the underlying Barrett's mucosa may be masked by tumor overgrowth in the majority of these patients. METHODS: The pretherapeutic endoscopy and biopsy records of 79 patients with locally advanced esophageal adenocarcinoma who had undergone preoperative chemotherapy were reviewed and compared to findings on restaging endoscopy/biopsy and subsequent resection and histopathologic analysis of the resected specimen. RESULTS: Pretherapeutic endoscopy and biopsy showed associated Barrett's esophagus in 59/79 patients, whereas there was no evidence of associated intestinal metaplasia in 20/79 patients on extensive biopsies. Following neoadjuvant chemotherapy, Barrett's mucosa was unmasked and later documented by biopsy or histopathologic assessment of the resected specimen in 18 of the latter 20 patients. This resulted in an overall association of Barrett's mucosa with adenocarcinoma in the distal esophagus of 97.4% CONCLUSION: Underlying Barrett's mucosa is frequently masked by tumor overgrowth in patients with locally advanced adenocarcinoma of the distal esophagus.

Transcutaneous electrogastrography: a non-invasive method to evaluate post-operative gastric disorders?

BACKGROUND/AIMS: With the development of high-performance computer programs, transcutaneous electrogastrography has experienced a renaissance in the last few years and is widely recommended as a non-invasive diagnostic tool to evaluate functional gastric disorders. We assessed the clinical value of electrogastrography in symptomatic and asymptomatic patients after a variety of procedures of the upper gastrointestinal (GI) tract. METHODOLOGY: Electrogastrography tracings were recorded with a commercially available data logger using a recording frequency of 4 Hz. A standard meal was given between a 60 min preprandial and a 60 min postprandial period. The following parameters were analyzed pre- and postprandially utilizing Fourier and spectral analysis: Regular gastric activity (2-4 cycles/minute), bradygastria (0.5-2 cycles/minute), tachygastria (4-9 cycles/minute), dominant frequency and power of the dominant frequency. Nineteen asymptomatic healthy volunteers served as a control group. Forty-nine patients, who had undergone upper intestinal surgery, were included in the study (cholecystectomy n = 10, Nissen fundoplication n = 10, subtotal gastrectomy n = 8, truncal vagotomy, and gastric pull-up as esophageal replacement n = 6). Twenty of these patients complained of epigastric symptoms post-operatively, while 12 of these 20 patients also had a scintigraphic gastric emptying study with Tc99m labeled semisolid meal. RESULTS: Preprandial gastric electric activity was between 2 and 4 cycles/minute in 60-90% of the study time in healthy volunteers. In all study groups the prevalence and power of normal electric activity increased significantly after the test meal (p < 0.001). After cholecystectomy, Nissen fundoplication, subtotal gastrectomy or vagotomy and gastric pull-up pre- and postprandial gastric electric activity showed a greater variability compared to normal volunteers (p < 0.05), but no typical electrogastrography pattern could be identified for the different surgical procedures. There was no significant difference in the electrogastrography pattern between asymptomatic and symptomatic patients and patients with normal or abnormal scintigraphic gastric emptying curves. CONCLUSIONS: There is no specific electrogastrography pattern to differentiate between typical surgical procedures or epigastric symptoms. To date, electrogastrography does not contribute to the diagnosis and analysis of gastric motility disorders after upper intestinal surgery.

Bile acids as components of the duodenogastric refluxate: detection, relationship to bilirubin, mechanism of injury, and clinical relevance.

Excessive reflux of bile into the stomach or esophagus has been associated with a variety of benign and malignant foregut disorders. The interaction of gastric acid with bile acids and the development of mucosal damage has been studied extensively in in vitro and in vivo animal models. These studies show that soluble bile acids can enter mucosal cells when in their non-ionized lipophilic form, accumulate there up to eight times the luminal concentration, and thus cause injuries to cell membranes and tight junctions. Entrance of mucosal cells and accumulation are pH-dependent and more pronounced at acidic pH ranges. The noxious effect of bile on intestinal mucosa is thus related not only to the concentration of luminal bile acids but also to the pH and the mucosal exposure time. Due to the lack of objective and accurate tests to quantitate reflux of bile acids in vivo over prolonged periods of time, the concept of bile reflux as a pathogenic factor in the clinical situation has been controversial. Recent studies indicate that intraluminal bilirubin can be used as a reliable marker of bile reflux into the stomach or esophagus. Combined 24-hour monitoring of intraluminal pH and bilirubin with the newly-developed Bilitec system, despite some system-inherent shortcomings, therefore has the potential to clarify the interactions between bile reflux, mucosal injury and gastroesophageal carcinogenesis.

Bile reflux in benign and malignant Barrett's esophagus: effect of medical acid suppression and nissen fundoplication.

Bile reflux has been implicated in the pathogenesis and malignant degeneration of Barrett's esophagus, but clinical studies in patients with adenocarcinoma arising in Barrett's esophagus are lacking. Ambulatory esophageal measurement of acid and bile reflux was performed with the previously validated fiberoptic bilirubin monitoring system (Bilitec) combined with a pH probe in 20 asymptomatic volunteers, 19 patients with gastroesophageal reflux disease (GERD) but no mucosal injury, 45 patients with GERD and erosive esophagitis, 33 patients with GERD and Barrett's esophagus, and 14 patients with early adenocarcinoma arising in Barrett's esophagus. Repeat studies were done in 15 patients under medical acid suppression and 16 patients after laparoscopic Nissen fundoplication. The mean esophageal bile exposure time showed an exponential increase from GERD patients without esophagitis to those with erosive esophagitis and benign Barrett's esophagus and was highest in patients with early carcinoma in Barrett's esophagus (P <0.01). Pathologic esophageal bile exposure was documented in 18 (54.5%) of 33 patients with benign Barrett's esophagus and 11 (78.6%) of 14 patients with early adenocarcinoma in Barrett's esophagus. Nissen fundoplication but not medical acid suppression resulted in complete suppression of bile reflux. Bile reflux into the esophagus is particularly prevalent in patients with Barrett's esophagus and early cancer. Bile reflux into the esophagus can be completely suppressed by Nissen fundoplication but not medical acid suppression alone.

Esophageal replacement for end-stage benign esophageal disease.

BACKGROUND: Benign esophageal diseases constitute a common group of disorders that are generally managed with medical therapy or surgery designed to improve foregut function. A small subset of patients, however, has advanced disease that requires esophageal replacement to achieve symptomatic relief. PATIENTS AND METHODS: One hundred four patients with benign esophageal disease who underwent esophageal reconstruction over a 21-year period (1975 to 1996) were reviewed retrospectively. Dysphagia was the major symptom driving surgery in 80% of the patients. Colon was used to reconstruct the esophagus in 85 patients; stomach, in 10 patients; and jejunum, in 9 patients. Forty-two patients who had lived with their reconstruction for 1 year or more answered a postoperative questionnaire concerning their long-term functional outcome. RESULTS: In the 104 patients, the primary underlying abnormality leading to esophageal replacement was end-stage gastroesophageal reflux (37 patients), an advanced motility disorder (37 patients), traumatic, iatrogenic or spontaneous perforation (15 patients), corrosive injury (8 patients), congenital abnormality (6 patients), or extensive leiomyoma (1 patient). Ninety-eight percent of patients reported that the operation had cured or improved the symptom driving surgery. Ninety-three percent were satisfied with the outcome of the operation. The overall hospital mortality rate was 2%, and the median hospital stay was 17 days. Graft necrosis occurred in 3% of patients, and anastomotic leak occurred in 6% of patients (or 2% of the total number of anastomoses). CONCLUSIONS: Esophageal replacement for benign disease can be accomplished with a low mortality rate and a marked improvement in alimentation. Reconstruction restores the pleasure of eating and is viewed by the patient to be highly successful.

Referral patterns and motivation for anti-reflux surgery of patients suffering from gastroesophageal reflux disease.

Due to a better understanding of the pathophysiology of gastroesophageal reflux disease (GERD), as well as the improvements in surgical technique, the number of anti-reflux procedures has increased world-wide during the last decade. This trend has been facilitated by the advent of minimally invasive surgery. Although a great number of publications deal with the indications or selection of patients for surgery, only a few discuss the motivation of patients for choosing surgery rather than long-term medical treatment. In order to evaluate the different elements of motivation of patients suffering from primary gastroesophageal reflux disease, the data of 115 patients who had undergone anti-reflux surgery between January 1990 and June 1997 at the Department of Surgery, Technical University, Munich, were evaluated. As laparoscopic anti-reflux surgery has only been regularly performed since 1994 in our Department, the study period was divided and the two periods (1990-1993 and 1994-1997) were analyzed separately. The data were evaluated according to the referral pattern and the motivation of patients with GERD who chose surgery. In the period from 1990 to 1993, 38.5% of the patients were referred to surgery by general practitioners, 38.5% by internists, 10% by practicing surgeons and 8% by gastroenterologists. In 5% of the cases the patients themselves initiated surgery. The corresponding results for the period from 1994 to 1997 were 29%, 38%, 12%, 8% and 13%, respectively. The most common reason for a patient to choose surgery was moderate or only short-term response to appropriate conservative treatment, which accounted for 98% and 92% of the patients, respectively, during the study periods. This was followed by avoidance of life-long medical therapy and its potential risks in 77% and 85% of the patients. Fear of cancer was reported in 10% and 25%, respectively. In the second period, the option of a minimally invasive procedure was reported as an important factor in 45% of the patients. Although the number of anti-reflux procedures performed per year is increasing and there is also an increasing tendency regarding the application of minimally invasive procedures, the factors leading to referral failed to show significant differences in the two periods. The motivation of patients, however, clearly changed in favour of surgical therapy, mainly because of the availability of a minimally invasive approach.

Composition and concentration of bile acid reflux into the esophagus of patients with gastroesophageal reflux disease.

BACKGROUND: Reflux of duodenal contents into the esophagus of patients with gastroesophageal reflux disease has been suggested by pH and bilirubin monitoring but is rarely directly measured. A portable device has been developed and was used to collect and quantitate material refluxed into the esophagus under ambulatory conditions during a prolonged time period. The objective of this study was to use this device to quantitate the composition and concentration of bile acids refluxed into the esophagus of patients with gastroesophageal reflux disease. METHODS: Esophageal aspiration was performed on 43 normal subjects and 37 patients with reflux disease during a 17-hour period. Aspiration was performed through a modified 16F Salem sump tube, positioned 5 cm above the lower esophageal sphincter and connected to a portable, battery powered pump that aspirated continuously at 100 mm Hg pressure. Validation studies showed that minimal amounts of saliva and swallowed liquids were aspirated and that gastric pressure was not altered. Postprandial, upright, and supine collections were performed. Total bile acids were assayed by a standard enzymatic assay; specific conjugated bile acids were analyzed by high-performance liquid chromatography. RESULTS: There was no difference in the total aspiration volume between normal volunteers and patients with gastroesophageal reflux disease, although patients tended to have a higher volume in the supine and postprandial periods. Bile acids could be detected in 58% of normal subjects and 86% of patients (p < 0.003). The mean concentration of bile salt exposure (micromole per liter) was higher in patients during the postprandial and supine periods. The mean bile acid reflux rate (micromole per hour) during all three aspiration periods was significantly higher in patients. On a molar basis the composition of the bile acids was 60% glycocholic acid, 16% glycodeoxycholic acid, and 15% glycochenodeoxycholic acid. Taurocholic, taurodeoxycholic, taurochenodeoxycholic, and glycolithocholic acid constituted the remaining 10%. CONCLUSIONS: Patients with reflux disease have an increased concentration of bile acids in their esophageal aspirates. Most of the exposure occurs during the postprandial and supine periods. A variety of bile acids were detected, most of which were in their glycine conjugated form.

Outcome of respiratory symptoms after antireflux surgery on patients with gastroesophageal reflux disease.

OBJECTIVE: To investigate factors predictive of relief of respiratory symptoms associated with gastroesophageal reflux disease (GERD). DESIGN: A case series of patients with GERD and respiratory symptoms undergoing fundoplication from 1987 to 1994 at a tertiary care university hospital. PATIENTS: Of 118 patients undergoing fundoplication for cardinal symptoms of GERD, 63 had respiratory symptoms. Postoperative follow-up information was available in 50 patients at a median of 3 years. INTERVENTIONS: The presence of GERD was documented on the basis of barium swallow, esophagoscopy, esophageal manometry, and 24-hour pH studies. A standardized questionnaire was used to score symptoms. A Nissen fundoplication was performed in 39 patients, a Collis-Belsey fundoplication in 3 patients. MAIN OUTCOME MEASURES: A repeat standardized questionnaire was used to evaluate the response to surgery for each symptom experienced. Univariate analysis was performed to evaluate factors influencing outcome. RESULTS: Respiratory symptoms were present in 53% (63/118) of patients with GERD. Fundoplication relieved the respiratory symptoms in 76% (38/50) of the patients. Reflux symptoms were relieved in 86% (43/50) of the patients. Abnormalities of esophageal motility were present in 34% (17/50) of the patients, and these were significantly more common in patients who did not experience relief of their respiratory symptoms (9/12 vs 8/38, chi 2 = 9.54, P = .002). CONCLUSIONS: Respiratory symptoms are common in patients with GERD. Unlike classic reflux symptoms, the beneficial effects of antireflux surgery on respiratory symptoms are less predictable. The probability of relief of these respiratory symptoms with antireflux surgery is directly dependent on esophageal motor function.

Mixed reflux of gastric and duodenal juices is more harmful to the esophagus than gastric juice alone. The need for surgical therapy re-emphasized.

OBJECTIVE: The author's goal was to determine the role of duodenal components in the development of complications of gastroesophageal reflux disease. SUMMARY AND BACKGROUND DATA: There is a disturbing increase in the prevalence of complications, specifically the development of Barrett's esophagus among patients with gastroesophageal reflux disease. Earlier studies using pH monitoring and aspiration techniques have shown that increased esophageal exposure to fluid with a pH above 7, that is, of potential duodenal origin, may be an important factor in this phenomenon. METHODS: The presence of duodenal content in the esophagus was studied in 53 patients with gastroesophageal reflux disease confirmed by 24-hour pH monitoring. A portable spectrophotometer (Bilitec 2000, Synectics, Inc.) with a fiberoptic probe was used to measure intraluminal bilirubin as a marker for duodenal juice in the esophagus. Normal values for bilirubin monitoring were established for 25 healthy subjects. In a subgroup of 22 patients, a custom-made program was used to correlate simultaneous pH and bilirubin absorbance readings. RESULTS: Fifty-eight percent of patients were found to have increased esophageal exposure to gastric and duodenal juices. The degree of mucosal damage increased when duodenal juice was refluxed into the esophagus, in that patients with Barrett's metaplasia (n = 27) had a significantly higher prevalence of abnormal esophageal bilirubin exposure than did those with erosive esophagitis (n = 10) or with no injury (n = 16). They also had a greater esophageal bilirubin exposure compared with patients without Barrett's changes, with or without esophagitis. The correlation of pH and bilirubin monitoring showed that the majority (87%) of esophageal bilirubin exposure occurred when the pH of the esophagus was between 4 and 7. CONCLUSIONS: Reflux of duodenal juice in gastroesophageal reflux disease is more common than pH studies alone would suggest. The combined reflux of gastric and duodenal juices causes severe esophageal mucosal damage. The vast majority of duodenal reflux occurs at a pH range of 4 to 7, at which bile acids, the major component of duodenal juice, are capable of damaging the esophageal mucosa.

A tailored approach to antireflux surgery.

Tailored surgical antireflux procedures were done in 104 patients during a 7-year period. Presenting symptoms included heartburn in 95 patients (91%), regurgitation in 83 patients (80%), and dysphagia in 61 patients (60%). Evaluation before operation included video barium esophagography, endoscopy, 24-hour esophageal pH monitoring, and esophageal motility studies. On the basis of anatomic and functional findings, the following procedures were performed: 15 laparoscopic and 49 open transabdominal Nissen fundoplications, 23 transthoracic Nissen fundoplications, seven Belsey partial fundoplications, and 10 Collis gastroplasty and Belsey partial fundoplications. The severity of symptoms was assessed before and after operation according to a previously published grading score. Eighty-five of the 104 patients (82%) were able to be contacted for a follow-up evaluation by means of a standardized questionnaire. Median length of follow-up was 4 years, with 40 patients having follow-up beyond 5 years. The tailored operation cured the symptoms of heartburn in 97%, regurgitation in 91%, and dysphagia in 92%. Ninety-eight percent of the patients reported that operation had cured their preoperative symptoms and 93% were satisfied with the outcome of the operation. To obtain optimal results, surgical treatment of gastroesophageal reflux disease should be tailored to the patient's anatomic and functional assessments. For early, uncomplicated disease a transabdominal Nissen fundoplication is done, laparoscopically when expertise exists. Patients with complicated disease should undergo an open antireflux procedure tailored to specific anatomic or functional abnormalities.

Esophageal resection with colon interposition for end-stage achalasia.

OBJECTIVE: To review the potential benefits of esophageal resection with colon interposition in patients with achalasia. DESIGN: Retrospective review. SETTING: University-based tertiary care center. PATIENTS: Nineteen patients (13 men, six women; median age, 44 years; age range, 26 to 77 years) with achalasia and recurrent or persistent dysphagia despite a variety of previous treatments. INTERVENTIONS: Esophageal resection and replacement with colon interposition. MAIN OUTCOME MEASURES: Mortality and morbidity of the procedure, symptomatic outcome, nutritional impact, ability to ingest a meal, and overall patient satisfaction. RESULTS: Follow-up results were available in 15 patients. The procedure accounted for no deaths and complications in four patients. Outcome assessment was done at a median of 6 years (range, 1 to 14 years) after resection. Overall, the symptomatic outcome was excellent to good in 12 patients. Eleven of the 15 patients gained weight (median weight loss, 6.3 kg) after the procedure. Thirteen patients were able to eat three meals daily; seven had the capacity to eat a steak dinner; five, an airline meal; and three, a snack. Nine of the 15 patients enjoyed an unrestricted diet. The speed of ingesting a meal was reduced in that most (11 of 15) were the last to finish when eating in a group. Fourteen of the 15 believed that the operation had cured or improved their preoperative symptoms, and a similar percentage were satisfied with the overall outcome of surgery. Most patients (12 of 15) would have the operation again. CONCLUSIONS: Esophageal replacement for end-stage achalasia can be accomplished with safety and marked improvement of preoperative symptoms. Despite multiple previous therapeutic failures, normal alimentation was restored in the majority of patients, with 93% judging the operation to be highly beneficial, improving their quality of life. Based on this success, guidelines for resection in end-stage achalasia are established.

Clinical and physiologic comparison of laparoscopic and open Nissen fundoplication.

BACKGROUND: Although recent reports have documented the safety and efficacy of laparoscopic fundoplication, none have compared outcomes to that of open Nissen fundoplication. STUDY DESIGN: Eighty-one patients had either open (n = 47) or laparoscopic (n = 34) Nissen fundoplication. Relief of symptoms was measured by a standardized questionnaire and scored by a modified Visick-Index. Physiologic outcome was assessed by postoperative pH monitoring and manometry in a subset of both groups. RESULTS: Primary symptoms were heartburn in 55 percent of the patients, regurgitation in 9 percent, dysphagia in 11 percent, and atypical in 25 percent of patients. Twenty-seven (84 percent) of 32 patients in the laparoscopic group and 31 (84 percent) of 37 patients in the open group were cured or improved. Operative time was significantly longer in the laparoscopic group (218 compared to 168 minutes). The period of hospitalization was shorter for the laparoscopic group (4.7 compared to 9.2 days, p < 0.0001). Postoperative pressures in the lower esophageal sphincter (LES) were significantly higher in the laparoscopic group (20.9 compared to 12.1, p = 0.006). Augmentation of sphincter length was similar for both groups. More patients in the laparoscopic group failed to relax their LES completely after fundoplication (32 compared to 71 percent, p = 0.1). CONCLUSIONS: Symptomatic outcome after laparoscopic fundoplication is similar to that of open surgery. Physiologic studies reveal a greater augmentation of LES pressure and a low prevalence of sphincter relaxation after laparoscopic fundoplication.

Does duodenal juice reflux into the esophagus of patients with complicated GERD? Evaluation of a fiberoptic sensor for bilirubin.

BACKGROUND: It is controversial whether duodenal juice can damage esophageal mucosa in patients with gastroesophageal reflux disease (GERD). The issue remains unresolved partly because of difficulties in detecting the presence of duodenal juice in the lower esophagus. OBJECTIVES AND METHODS: This study utilized an in vitro portable spectrophotometer with a fiberoptic probe capable of detecting bile as a marker of duodenal juice. Absorbance/concentration curves were established with known bilirubin concentrations at pH 1.4 and pH 7.7. Esophageal pH and bilirubin absorbance were monitored in vivo over a 24-hour period in 20 healthy volunteers to determine the absorbance threshold for clinical use. The study population consisted of 21 patients with GERD. Four had no mucosal injury, 5 erosive esophagitis, and 12 Barrett's esophagus. RESULTS: The correlation between absorbance and bilirubin concentration was 0.98 and 0.99 for acid and alkaline environments, but bilirubin absorbance was 35% less in an acid environment. Using an absorbance threshold of 0.14, patients with GERD taken in toto had elevated esophageal exposure to bilirubin. No difference was observed in bilirubin exposure between reflux patients without mucosal injury and controls. Highest exposure occurred in patients with Barrett's esophagus. An important observation was that esophageal bilirubin exposure frequently occurred during periods when the esophageal pH was in the normal range. CONCLUSIONS: The fiberoptic probe accurately detects esophageal bilirubin as a marker of duodenal juice. Esophageal exposure to bilirubin is uncommon in normal subjects. Patients with erosive esophagitis and Barrett's metaplasia have increased esophageal exposure to duodenal juice compared to normal subjects. Reflux of duodenal juice into the esophagus can occur when the esophageal pH is within its normal range and is undetectable by pH monitoring alone.