Gastroesophageal reflux

Endoscopic diagnosis and treatment of mucosal lesions of the esophagus

The rapid evolution of fiberoptic endoscopes over the past three decades has greatly enhanced our understanding of esophageal diseases and has stimulated significant improvements in their management. With the early endoscopic diagnosis of infectious and inflammatory lesions, specific medical or surgical treatment can be initiated promptly and the results monitored easily. Although the diagnosis of malignant lesions is still commonly delayed because of the absence of early symptoms, surveillance of Barrett's esophagus offers the hope of more definitive management in these patients. Endoscopy has assumed an increasingly important therapeutic role in patients with inoperable cancer because it provides access for new ablative techniques or the placement of palliative prosthetic devices. Continuing advances in the use of endoscopic ultrasound, the delivery of photodynamic therapy, and the adjunctive application of intraluminal irradiation promise to further broaden the scope of fiberoptic intervention.

Is an antireflux procedure necessary in conjunction with parietal cell vagotomy in the absence of preoperative reflux?

During a 4 year period, we found no objective evidence that parietal cell vagotomy contributes to the production of gastroesophageal reflux. The fact that patients without reflux preoperatively achieved the same satisfactory clinical results whether parietal cell vagotomy was or was not accompanied by an antireflux procedure supports this view. Therefore, in the absence of reflux, we cannot recommend the prophylactic use of an antireflux procedure in combination with parietal cell vagotomy in the treatment of patients with duodenal ulcer. On the other hand, patients with duodenal ulcer should be evaluated for gastroesophageal reflux before operation because it is desirable to combine parietal cell vagotomy with an antireflux procedure if both conditions exist. Patients who have mild reflux preoperatively but no symptoms of reflux after parietal cell vagotomy alone, as in three of the four patients in Group IV, may have such symptoms subsequently. Therefore, we think that the combined procedure does not increase the morbidity over that of parietal cell vagotomy alone and recommend the combination of parietal cell vagotomy and an antireflux procedure for any patient undergoing operation for duodenal ulcer who also demonstrates an abnormal degree of gastroesophageal reflux.

Gastric tube esophagoplasty

After a short review of the historical development of replacement of the esophagus, the possibilities, techniques, and results of gastric-tube esophagoplasty are discussed. Ten of 14 patients were followed up for 14 years, two were lost to follow-up and two died. Fistulas, anastomotic strictures, and also reflux could be treated successfully. A single perforation by endoscopy was surgically corrected. A peptic ulcer in the gastric tube was healed with antacid therapy. The gastric tube can be assumed to be a sufficient esophageal substitute. Long-term follow-up is still necessary.

Esophageal emptying and acid neutralization in patients with symptoms of esophageal reflux

Clearance of refluxed acid from the distal esophagus is due to bolus emptying and salivary neutralization of acid. We compared results of 24-hour pH monitoring with acid clearance tests (ACT) and radioisotope swallows (RIS) in 26 symptomatic patients to determine which of the components of acid clearance is better correlated with gastroesophageal acid reflux (GER). Seven of eight patients with GER had delayed esophageal emptying on RIS. Abnormal salivary clearance of acid was present in nine of 18 patients without GER, accounting for a high false-positive rate of ACT. Delayed esophageal bolus emptying, not deficient acid neutralization by saliva, is the predominant component of abnormal acid clearance in patients with GER. RIS is superior to ACT as part of the evaluation of reflux symptoms, and may prove to be a valuable screening test for this condition.

Twenty-four hour exophageal pH monitoring in gastroesophageal reflux

Twenty-four hour pH esophageal monitoring has been studied in 123 children with gastroesophageal reflux (GER) with ages ranging between 6 mo to 6 yr. The technique is described and the scoring system modified to evaluate gastroesophageal reflux in these patients. For the first time the normal patterns are presented in pediatrics (n = 20). The results obtained in 103 patients are presented, divided into pre- and post-nonoperative and surgically treated groups. The test is more objective, has greater precision, sensitivity, and reliability than contrast studies, endoscopy, acid perfusion or acid reflux tests. The study seems to indicate that esophagitis depends more on the duration of the reflux than on the number, for which the concept of esophageal acid clearance is of paramount importance. The prone position generally lessens the number of refluxes but in this position the esophageal acid clearance is altered. With a greater knowledge and more experience in this technique, we would be able to identify children at risk to develop severe complications, control them and aid in the selection of those patients requiring surgical intervention.

Surgery in children with gastroesophageal reflux and respiratory symptoms

We reviewed our seven-year experience in 63 children with an operation to control gastroesophageal reflux and respiratory symptoms. The age at operation, sex, major associated disorders, and control of vomiting in this group of children were compared with another group of 72 children without respiratory symptoms who also had an antireflux operation during the same period. Associated central nervous system, pharyngeal, or esophageal disorders were common in both groups. Vomiting was controlled in 96% of patients. Fifty-six of 61 (92%) children had at least partial relief of respiratory symptoms postoperatively. The complete relief of these symptoms was more likely in patients without major associated disorders (97% vs 59% P = 0.0009). Central nervous system disorders were present in most children with incomplete resolution of respiratory symptoms. It appears that a significant number of affected infants and children may have respiratory difficulties unrelated to the presence of GER.

Antral patch esophagoplasty. A new procedure for acid-peptic esophageal stricture

Antral patch esophagoplasty is a new procedure for intractable fibrous stricture of the esophagus secondary to acid-peptic reflux. A full-thickness patch of gastric antrum, supplied by a pedicle based on the left gastroepiploic vessels, is inserted, mucosal surface to lumen, into the opened stricture. A fundoplication is done below the esophagoplasty to prevent reflux. The functional results were excellent in five of six patients. The procedure may have application also in other types of benign esophageal stricture.

[Significance of diagnostic procedures in reflux esophagitis (author's transl)]

The diagnosis of reflux esophagitis can be confirmed by a variety of diagnostic procedures. Beside the morphologic findings of the reflux demonstrated by X-ray, endoscopy, and histology, the degree of disturbed cardial function can be determined by manometry, pH determination, and scintiscan. Each method entails a number of errors. Therefore a distinction must be made between absolutely necessary and valuable methods for clarifying the degree of the symptoms of esophageal reflux.