Heller's esophagomyotomy with or without a 360 degrees floppy Nissen fundoplication for achalasia. Long-term results from a prospective randomized study.

Heller's esophagomyotomy relieves dysphagia but does not restore esophageal peristalsis. The myotomy may induce reflux and the addition of a 360 degrees fundoplication may be hazardous with regard to the remaining aperistaltic esophagus. The aim of this prospectively randomized clinical trial was to compare the outcome for patients with uncomplicated achalasia who underwent an anterior Heller's esophagomyotomy (H group) with or without an additional floppy Nissen fundoplication (H + N group). Between 1984 and 1995, 20 patients were prospectively randomized to one or other of the performed operations, 10 patients per group. Esophagitis including Barrett's esophagus (n = 2) was seen under medical treatment, in 6 of 9 in the H group but none in the H + N group. No patient in the H + N group required postoperative continuous acid-reducing drugs. Twenty-four-hour esophageal pH-studies in median 3.4 years after surgery showed pathological reflux expressed as a percentage of time below pH 4 of 13.1% in the H group compared to 0.15% (P < 0.001) in H + N group. One patient with recurrent dysphagia in the H + N group later had an esophagectomy. The remaining patients reported significant improvement of dysphagia without symptoms of reflux at 8.0 years follow-up. Heller's esophagomyotomy eliminates dysphagia, but can induce advanced reflux that requires medical treatment. The addition of a 360 degrees fundoplication eliminates reflux without adding dysphagia in the majority of patients and can be recommended for most patients with uncomplicated achalasia.

Endoscopic surveillance of columnar-lined esophagus: frequency of intestinal metaplasia detection and impact of antireflux surgery.

OBJECTIVE: To quantify the occurrence of intestinal metaplasia in columnar-lined esophagus (CLE) during endoscopic surveillance and to evaluate the impact of antireflux surgery on the development of intestinal metaplasia. SUMMARY BACKGROUND DATA: The malignant potential in segments of CLE is mainly restricted to those containing intestinal metaplasia. Patients with segments of CLE in which no intestinal metaplasia can be detected are rarely enrolled in a surveillance program but may still be at increased risk of developing esophageal adenocarcinoma because intestinal metaplasia may be missed or may develop with time. METHODS: The occurrence of intestinal metaplasia on biopsy samples was determined on repeated endoscopies in 177 patients enrolled in a surveillance program for CLE. The incidence of intestinal metaplasia in patients with no evidence of intestinal metaplasia on the two first endoscopies was evaluated on the subsequent endoscopies and compared in patients with medically and surgically treated gastroesophageal reflux disease. RESULTS: Intestinal metaplasia was found in 53% of the patients (94/177) on their first surveillance endoscopy and was more prevalent in long segments of CLE. The prevalence of intestinal metaplasia increased markedly with increasing number of surveillance endoscopies. Intestinal metaplasia tended to be detected early in patients with long segments of CLE; in patients with shorter segments, intestinal metaplasia was also detected late in the course of endoscopic surveillance. Patients with surgically treated reflux disease were 10.3 times less likely to develop intestinal metaplasia compared with a group receiving standard medical therapy. CONCLUSION: Biopsy samples from a single endoscopy, despite an adequate biopsy protocol, are insufficient to rule out the presence of intestinal metaplasia. Patients in whom biopsy specimens from a segment of CLE show no intestinal metaplasia have a significant risk of having undetected intestinal metaplasia or of developing intestinal metaplasia with time. Sampling error is probably the reason for the absence of intestinal metaplasia in segments of CLE longer than 4 cm, whereas development of intestinal metaplasia is common in patients with shorter segments of CLE. Antireflux surgery protects against the development of intestinal metaplasia, possibly by better control of reflux of gastric contents.

Long-term prognosis after partial gastrectomy for gastroduodenal ulcer.

The decline in duodenal ulcer disease and the established relation of peptic ulcer to Helicobacter pylori have virtually abolished the need for elective ulcer surgery. However, a substantial proportion of the population around retirement age has previously been subjected to partial gastric resection due to peptic ulcer, and the long-term outcome of these patients is of continuing relevance. Patients subjected to elective surgery could represent a selected group of healthy subjects with a lower overall morbidity, but reports indicate that patients operated on for peptic ulcer have more advanced disease associated with excess smoking and a different pattern of social behavior. The surgical procedure induces enterogastric reflux, leading to profound changes in the remnant mucosa and the formation of carcinogens in the gastric juice. In addition, metabolic abnormalities are common, especially fat malabsorption. Evaluation of the impact of these factors on morbidity and mortality is difficult. Increased mortality in gastrointestinal tumors (especially gastric stump carcinoma), respiratory diseases and other smoking-related malignancies, and suicide are found in the long-term follow-up after partial gastric resection due to peptic ulcer. However, these hazards to life are offset by a decreased mortality in cardiovascular disease. Preventive measures against suicide and especially tobacco smoking are recommended to improve th outcome for this cohort.

Anastomotic diameters and strictures following esophagectomy and total gastrectomy in 256 patients.

The prevalence of anastomotic strictures in esophageal anastomoses provides us with limited information about the anastomotic healing process. This prospective study evaluates the exact esophageal anastomotic diameters in 256 patients who underwent esophagectomy and esophagogastrostomy without pyloroplasty (n = 107) or total gastrectomy and Roux reconstruction (n = 149). No perioperative chemoradiotherapy was given. Anastomotic strictures and diameters were assessed during endoscopy by a separately inserted (inflated to the anastomotic width) balloon catheter. The anastomotic diameters increased significantly during the first postoperative year in the esophagectomy (p = 0.001) and gastrectomy (p < 0.001) groups. The anastomoses in the gastrectomy group were significantly wider than those in the esophagectomy group 3 (25.7 versus 19.9 mm), 6 (28.5 versus 22.0 mm), and 12 (30.5 versus 23.3 mm) months after surgery (p < 0.001). Neither the anastomotic site (neck or chest) in the esophagectomy group (p = 0.176) nor that in the gastrectomy group (abdomen or chest) (p = 0.577) influenced the anastomotic diameter. Benign anastomotic strictures were most frequently found after 3 months and after esophagectomy. Esophagojejunostomies performed with 2 linear stapling devices or cartridge size 28 mm showed the widest anastomoses with only 1 stricture. Esophagogastric anastomoses following esophagectomy are narrower and develop more strictures than esophagojejunal anastomoses after total gastrectomy, but both dilate during the first year.

Active or passive chest drainage after oesophagectomy in 101 patients: a prospective randomized study.

BACKGROUND: This study evaluates the efficiency and safety of two methods of chest drainage after uncomplicated oesophagectomy. METHODS: A prospective randomized study between active suction drainage and passive chest drainage was carried out in 101 patients who underwent gastric pull-up oesophagectomy. RESULTS: No difference in the prevalence of pneumothorax during treatment was noted between the active (nine of 55) and the passive (four of 46) drainage groups (P=0.20). Nor was there any difference in the size (P=0.46) and duration (P=0.53) of the pneumothorax. There was no significant difference in right (P=0.84) and left (P=0.61) basal atelectases and the amounts of right (P=0.10) and left (P=0.24) pleural effusions. There were significantly more basal atelectases (P < 0.001) and pleural effusions (P<0.001) in the non-operated left side compared with the operated right side. Postoperative hospital stay was the same in both groups (median 13 days; P=0.86). The hospital mortality rate was two of 101, and was not affected by the type of drainage. CONCLUSION: Passive drainage did not reduce hospital stay, but was as safe and effective as the active system in draining the pleural cavity after uncomplicated oesophagectomy.

Detection of adenocarcinoma in Barrett's oesophagus by means of laser induced fluorescence.

PATIENTS: Seven patients with Barrett's metaplastic epithelium and oesophageal adenocarcinoma were investigated by means of laser induced fluorescence after low dose intravenous injection (0.35 mg/kg bw) of Photofrin (QLT, Vancouver, Canada). Laser induced fluorescence measurements were performed immediately after resection of the oesophagus. METHODS: Laser induced fluorescence spectra were recorded from 15-30 locations in each surgical specimen from normal mucosa, Barrett's epithelium, and tumour tissue. Histological examination was performed on each location to correlate the fluorescence spectral characteristics with histological status of the epithelium (normal, metaplastic or malignant). Measurements were also performed during endoscopy in five patients to test the applicability of the method in a clinical setting. Fluorescence spectra were recorded and evaluated at characteristic wavelengths, and biopsy specimens were collected. Fluorescence ratios were calculated as the quotient of Photofrin fluorescence divided by autofluorescence. RESULTS: The mean (SD) fluorescence ratio values were 0.10 (0.058) for normal oesophageal mucosa, 0.16 (0.073) for normal gastric mucosa, 0.205 (0.17) for Barrett's epithelium with moderate dysplasia, 0.79 (0.54) for severe dysplasia, and 0.78 (0.56) for adenocarcinoma. The highest fluorescence ratios were obtained for adenocarcinoma tissue, which could generally be distinguished from all nonmalignant tissue. Metaplastic Barrett's epithelium also yielded higher fluorescence ratios than did normal mucosa. CONCLUSIONS: The results suggest that the technique can be used during endoscopy for real time tissue characterisation in the oesophagus, as an aid in detecting malignant transformation not macroscopically apparent at endoscopy.

Anastomotic diameter of circular stapled oesophagojejunal anastomoses and its implication for weight development. A clinical and experimental study.

OBJECTIVE: To investigate the increase in diameter of the oesophagojejunal anastomosis after total gastrectomy with a circular stapler, and to assess experimentally the influence of oesophageal diameter on weight. DESIGN: Open prospective clinical and experimental studies. SETTING: University department of surgery, Sweden. SUBJECTS AND MATERIAL: 36 Consecutive patients who underwent total gastrectomy, and 13 domestic pigs. INTERVENTIONS: Clinical study: the end to side oesophagojejunal anastomoses were made with EEA staplers size 25 or 28, and the increase in diameter over a 12 month period was studied by by fibreoptic endoscopy. Experimental study: Each pig had 0.5 cm of the distal oesophagus resected; in 7 the oesophagus was anastomosed with one layer of continuous 3/0 polyglycolic acid, and in 6 an ILS21 stapler was used. Animals were weighed and killed at 4 1/2 months, and the width of the oesophagus at and below the anastomosis was measured. MAIN OUTCOME MEASURES: Clinical study: width of the oesophagus at 12 months. Experimental study: correlation between weight and oesophageal width at time of death. RESULTS: Clinical study: The median increase in size after 12 months with the size 25 cartridge was 8.45 mm (range 6.5-22), and for the size 28 cartridge 12 mm (2.3-30.2). The larger cartridge gave a significantly larger anastomosis (p = 0.007), but the comparative increases were similar. Experimental study: There was a significant correlation between increase in weight and anastomotic width in the 10 pigs that completed the study (r = 0.86, p < 0.001). CONCLUSION: A stapled oesophagojejunal anastomosis has the ability to dilate as necessary, and this ability is not prejudiced by the presence of the staples.

On the natural history of peptic ulcer.

BACKGROUND: Three out of 1000 individuals have peptic ulcer every year, and 20% of the ulcer episodes are associated with bleeding. Whether major innovations such as endoscopy and strong acid-suppressing drugs have had any impact on the natural course of peptic ulcer disease is largely unknown. METHODS: Three hundred and fifty-one patients (median age, 63 years) with endoscopically proven peptic ulcer during 1979-1984 were included in the study and retrospectively followed up via medical records. The total population is based on two different groups of patients, the first comprising 229 consecutively diagnosed ulcer patients during 1979-81 and, to increase the number of bleeders, a second group including 122 bleeding ulcer patients consecutively diagnosed during 1981-84. At the end of the follow-up period all non-ulcer-operated patients were asked to answer a questionnaire on symptoms, investigations, and medication. RESULTS: The male to female ratio was 2.4:1 in duodenal ulcer patients, but a 1:1 ratio was shown both in gastric and prepyloric/pyloric ulcer patients (p < 0.001). Patients with bleeding ulcers were significantly older than non-bleeders (68 years versus 58 years; p < 0001), as were patients with gastric ulcers compared with prepyloric/pyloric or duodenal ulcer patients (68 years versus 63 and 61 years, respectively; p < 0.01). The 10-year cumulative mortality in the unselected group (median age, 62 years) was 43%, and the annual risk of dying of peptic ulcer disease was 0.6%. No difference in 10-year recurrence rate was seen between patients with bleeding ulcer at inclusion and non-bleeders (46.2% versus 44.3%; p = NS), but the annual risk of bleeding was 5.3% and 0.8%, respectively (p < 0.0001). In the group of patients answering the questionnaire 51% reported upper abdominal pain during the last year of follow-up. CONCLUSIONS: In spite of today's treatment regimens almost half of the patients with peptic ulcer disease experienced recurrence during a 10-year period, and more than half had ulcer symptoms after 10 years. Most probably, maintenance treatment with H2-receptor antagonists should have been offered more liberally during the 1980s.

Self-expanding stent in the treatment of benign esophageal strictures: experimental study in pigs and presentation of clinical cases.

The reaction of the normal esophageal wall to inserted self-expanding nitinol stents was studied in pigs. An inflammatory reaction with increasing fibrotic activity and degeneration of the muscular layers in the esophageal wall was demonstrated. Five patients with severe dysphagia secondary to benign esophageal strictures also underwent insertion of self-expanding nitinol stents. All of the stents expanded completely, with subsequent regression of dysphagia. One treated esophagus was resected and showed deep implantation of the stent meshwork in the esophageal wall. Significant stenoses secondary to tissue hyperplasia, located at the edges of the stent, occurred in two patients. These results show that self-expanding nitinol stents may be used for palliation of dysphagia in patients with benign esophageal strictures. Because of the observed reactions in the esophageal wall, such treatment should be restricted to selected patients until more experience has been gained.

Malignant esophageal strictures: treatment with a self-expanding nitinol stent.

A self-expanding esophageal nitinol stent was implanted under fluoroscopic guidance in 40 patients with malignant esophageal strictures and clinically significant dysphagia. The strictures were caused by squamous cell carcinoma (n = 14), adenocarcinoma (n = 12), recurrent anastomotic carcinoma (n = 8), and mediastinal tumors (n = 6). Eight stents were balloon dilated to maximum diameter immediately after insertion. Sixteen stents self-expanded to maximum diameter within 24 hours, and the other stents expanded to maximum diameter during further observation. There were no serious stent-related complications, and the dysphagia was reduced considerably in all patients immediately after stent insertion. Persistent tumor bleeding occurred in two patients, and ingrowth of tumor into the stent was seen in eight patients. Two stents occluded due to tumor ingrowth but were successfully recanalized with endoscopic laser coagulation. At the end of the study, 28 patients were dead with a mean survival of 2.9 months (range, 0.1-7.0 months), and 12 patients were alive with a mean follow-up of 8.8 months (range, 4.0-15.0 months).