Effects of ursodeoxycholic acid in esophageal motility and the role of the mucosa. An experimental study

Esophageal motor abnormalities are frequently found in patients with gastroesophageal reflux disease. The role of bile in reflux-induced dysmotility is still elusive. Furthermore, it is questionable weather mucosal or muscular stimulation leads to motor dysfunction. The aims of this study were to analyze (i) the effect of bile in the amplitude of esophageal contractions; and (ii) the effect of mucosal versus muscular stimulation. Eighteen guinea pig esophagi were isolated, and its contractility assessed with force transducers. Three groups were studied. In group A (n= 6), the entire esophagus was incubated in 100 µmL ursodeoxycholic acid for 1 hour; in group B (n= 6) the mucosal layer was removed and the muscular layer incubated in 100 µmL ursodeoxycholic acid for 1 hour; and in group C (n= 6) (control group) the entire esophagus was incubated in saline solution. In all groups, five sequential contractions induced by 40 mm KCl spaced by 5 minutes were measured before and after incubation. Contractions amplitudes before incubation were 1.319 g, 0.306 g, and 1.795 g, for groups A, B, and C, respectively. There were no differences between groups A and C (P= 0.633), but there were differences between groups A and B (P= 0.039), and B and C (P= 0.048). After incubation amplitude of contraction were 0.709 g, 0.278 g, and 1.353 g for groups A, B, and C, respectively. Only group A showed difference when pre and post-stimulation amplitudes were compared (P= 0.030). Our results show that (i) bile exposure decreases esophageal contraction amplitude; and (ii) the esophageal mucosa seems to play an important role in esophageal motility.

Postprandial proximal gastric acid pocket and gastric pressure in patients after gastric surgery

BACKGROUND

An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been demonstrated in normal individuals (NI) and patients with gastro-esophageal reflux disease (GERD). The role of gastric anatomy and gastric motility in the physiology of the PPGAP remains elusive. This study aims to analyze the correlation of PPGAP with proximal gastric pressure after gastric surgery.

METHODS

A total of 26 individuals were studied: eight patients after open Roux-en-Y gastric bypass (RYGB) for morbid obesity, six patients after laparoscopic Nissen fundoplication for GERD, seven patients after open subtotal gastrectomy for gastric cancer and five NI. Patients underwent high resolution manometry to identify the location of the lower border of the lower esophageal sphincter (LBLES) and measure gastric pressure 1, 2, 3, 4 and 5 cm below the LBLES, immediately before swallow and after the end of the LES relaxation. A station pull-through pH monitoring was performed in all but NI, from 5 cm below the LBLES to the LBLES in increments of 1 cm in a fasting state and 10 min after a standardized fatty meal.

KEY RESULTS

Our results show that: (i) proximal gastric pressures are lower after swallow compared with before swallow in NI; (ii) patients after gastric surgery tend to have higher gastric pressure before and lower after swallow compared with NI and (iii) patients after RYGB with PPGAP have an increased gastric pressure after swallows in the segment where the PPGAP is noticed.

CONCLUSIONS & INFERENCES

Gastric motility may play a role in the genesis of PPGAP in patients after RYGB. The contribution of gastric motility for the genesis of PPGAP is still elusive in other patients.

When did the esophagus start shrinking? The history of the short esophagus

Even though the history of this condition extends for almost 100 years, the short esophagus (SE) is still one of the most controversial topics in esophageal surgery with its existence still denied by some distinguished surgeons. We reviewed the evolution behind the diagnosis and treatment of the SE and the persons who wrote its history, from the first descriptions by radiologists, endoscopists, and surgeons to modern treatment.

Gastric fundus tension before and after division of the short gastric vessels in a cadaveric model of fundoplication

Short gastric vessels (SGV) division is a controversial topic in antireflux surgery. Some surgeons do not divide the SGV routinely to perform a fundoplication; however, excessive tension of the gastric fundus (GF) forces this procedure necessary in some cases. This study aims to evaluate in a cadaveric model of Nissen fundoplication: (i) the correlation of GF tension with anatomic parameters; and (ii) the effect of SGV division on GF tension. In total, 23 fresh cadavers (18 men, mean age 62 years) were studied. The abdominal esophagus was dissected, and the GF transposed to a limit of 3 cm to the right border of the esophagus. A dynamometer was attached to the GF and the tension recorded. Cadavers were grouped according to the presence or absence of tension. SGV were divided and GF tension measured again. The presence or absence of initial GF tension was correlated to: (i) number of SGV; (ii) length of the GF; (iii) distance between His angle and the first SGV; and (iv) size of the spleen. The mean GF pressure was 0.5 N +/- 1.0 (0-2.5) before SGV division and 0.1 N +/- 0.3 (0-1.5) after SGV division (P= 0.002). Initial tension was absent in 12 (52.2%) cases. GF tension did not correlate with any of the anatomic parameters. Our results show that: (i) GF tension does not correlate with anatomic parameters; and (ii) SGV division affects GF tension significantly.

Treatment of achalasia: lessons learned with Chagas' disease

Chagas' disease (CD) is highly prevalent in South America. Brazilian surgeons and gastroenterologists gained valuable experience in the treatment of CD esophagopathy (chagasic achalasia) due to the high number of cases treated. The authors reviewed the lessons learned with the treatment of achalasia by different centers experienced in the treatment of Chagas' disease. Preoperative evaluation, endoscopic treatment (forceful dilatation and botulinum toxin injection), Heller's myotomy, esophagectomy, conservative techniques other than myotomy, and reoperations are discussed in the light of personal experiences and review of International and Brazilian literature. Aspects not frequently adopted by North American and European surgeons are emphasized. The review shows that nonadvanced achalasia is frequently treated by Heller's myotomy. Endoscopic treatment is reserved to limited cases. Treatment for end-stage achalasia is not unanimous. Esophagectomy was a popular treatment in advanced disease; however, the morbidity/mortality associated to the procedure made some authors seek different alternatives, such as Heller's myotomy and cardioplasties. Minimally invasive approach to esophageal resection may change this concept, although few centers perform the procedure routinely.

Vagal integrity in vagal-sparing esophagectomy: a cadaveric study

Esophagectomy is associated with a significant number of complications, some of them related to the concomitant vagotomy. The vagal-sparing esophagectomy is an attractive alternative to the conventional procedure; however, few clinical series have attested the integrity of the vagi nerves after esophagectomy. The surgical anatomy of the vagus in the mediastinum has received little interest as well. The anatomy of the vagus was studied in 30 fresh cadavers. Twenty cadavers were submitted to a vagal-sparing esophagectomy, and after the procedure, anatomical vagal integrity was evaluated. Concerning the anatomy of the vagus, one or more vagal trunks were present in all cases. Four patterns were identified: Type I, two distinct trunks without communicating branches, present in eight (26.7%) cases; Type II, two distinct trunks with communicating branches, present in 17 (56.7%) cases; Type III, one or more bifurcated trunks, present in four (13.3%) cases; and Type IV, crossing trunks, present in one (3.3%) case. Regarding the esophagectomy, operative accidents were not noticed; in five cases, there was incomplete removal of the muscular layer of the esophagus. In all cases vagi nerves were preserved. The vagus is preserved in a cadaveric model of the vagal sparing esophagectomy, irrespective of the anatomy of the vagus in the mediastinum.

Eponyms in esophageal surgery, part 2

Eponyms in medicine are frequently criticized because they may not represent the person who first described a syndrome or disease. Although eponyms are very commonly used, most readers are probably unaware of who it was that named the diseases and whether the original description of the disease still corresponds to the modern definition. The 10 most common eponyms in esophageal diseases were revisited. The men and the disease behind Barrett's esophagus, Boerhaave's syndrome, Mallory-Weiss syndrome, Cameron ulcer, Schatzki ring, Paterson-Kelly syndrome, Plummer-Vinson, Chagas's disease, Zenker diverticulum and Killian diverticulum are reviewed here.

Eponyms in esophageal surgery

Eponyms are frequently used in the surgery in homage to remarkable surgeons, specially creators of new surgical techniques and instruments. Sometimes, however, the right person is not revered or the name persists, but the author's technique has been changed over time and the original procedure is lost. Eponyms of the 10 most famous procedures in esophageal surgery are revisited. Names like Lortat-Jacob, Toupet, Dor, Heller, Nissen, Ivor Lewis, Collis, Merendino, Hill, and Belsey, are reviewed, analyzing the man behind the name, the original technique and its modifications.

Short esophagus: literature incidence

There are controversies regarding existence and incidence of short esophagus. The authors reviewed the literature incidence of short esophagus among operated patients due to gastroesophageal reflux disease in the last 3 years. The overall incidence of short esophagus was 1.53%. The proposed risk factors (paraesophageal hernia, Barrett's esophagus, reoperation, esophageal strictures and access route) do have a higher incidence of short esophagus, with the exception of the Barrett's esophagus. Although several biases can be associated with the review, the authors identified the short esophagus incidence in the literature.

Efficacy of mediastinal lymphadenectomy in transhiatal esophagectomy with and without diaphragm opening: a cadaveric study

Transhiatal esophagectomy (THE) is believed to induce a lower morbidity and mortality compared with transthoracic esophagectomy, but to be inefficient in performing mediastinal lymphadenectomy. Some surgeons are convinced that lymphadenectomy of the lower mediastinum in THE and transthoracic esophagectomy are equivalent. To test this, the authors performed THE in 20 cadavers (10 with and 10 without diaphragm opening). The number of lymph nodes resected with the esophagus and dissected through the hiatus was counted. After THE, the thorax was opened and the number of residual lymph nodes was evaluated. Complications were also assessed. The results show that lymphadenectomy in THE is incomplete in the lower mediastinum and not possible in the upper mediastinum; comparing THE with and without diaphragm opening, the first permits resection of a superior number of lymph nodes with the esophagus and dissection of a higher number of nodes through the hiatus. It is concluded that THE does not provide an effective mediastinal lymphadenectomy.

Human cadavers as an experimental model for esophageal surgery

The use of cadavers in experimental esophageal surgery is reviewed. Items useful to cadaveric studies such as post-mortem changes, biosafety, ethics, and legislation are discussed. Tactics used in minimally invasive procedures (thoracoscopy and laparoscopy) are shown. Cadaveric use in studies concerning esophagectomy, gastroesophageal reflux disease, esophageal atresia, Boerhaave's syndrome, and Mallory-Weiss tears are discussed. It is concluded that human bodies represent a good but underused model for esophageal surgery.

'Raccoon eyes' (periorbital haematoma) as a sign of skull base fracture

This is a study of the relationship between skull base fracture and the raccoon eyes sign in a prospective study in cadavers. Fifty cadavers were analysed with cranio encephalic trauma and skull base fracture or the raccoon eyes sign. Both conditions were present in 24 (48.0%) cases. The association was significantly higher in cases with a frontal basal fracture and epidural haematoma. The raccoon eyes sign is easily recognised and can be associated with basal fractures.

[Late results of Heller operation and fundoplication for the treatment of the megaesophagus: analysis of 83 cases]

BACKGROUND

Retrospective study of the late results of the Heller's cardiomyotomy and fundoplication for the treatment of the megaesophagus.

MATERIAL AND METHODS

Were studied 83 patients with a follow-up from one to 186 months (average 40.0 +/- 47.4 months). The fundoplications used were in three plans in 15.7% and posterior in 83.1%. The main pre-operatory complain was dysphagia followed by regurgitation and loss of weight. Chagas, Disease as the etiology was confirmed in 72.3% of the patients.

RESULTS

In the follow-up 55.4% of the patients were assymptomatic, 34.9% complained of sporadic dysphagia, 14.4% of heartburn, 8.4% of regurgitation and 2.4% did not changed the dysphagia, these being re-operated and had improvement the symptoms. Gastro-esophageal reflux was noted in 8.4% of the patients. Other late complications were par-esophageal hernia, sliping of the fundoplication, Barrett esophagus and cancer.

CONCLUSIONS

The necessity of a long-term clinical and endoscopical follow-up, even after surgery, owing to the possibility of late complications, especially cancer was emphasized. The late results are good in relation to the dysphagia. Myotomy is proposed as an alternative to patients with advanced megaesophagus with bad clinical conditions who can not be submitted to an esophagectomy.

[Obstruction of terminal ileum due to heterotopic gastric mucosa]

Heterotopic gastric mucosa situated in the small bowel distal to the Treitz suspensory ligament is very rare, except in Meckel's diverticulum and in intestinal duplications. There are two forms of this disease, congenital and acquired. The former is secondary to inflammatory bowel disease. The main difference between these forms is histological, although determining diverse physiopathological aspects. A case of a 34 year old man with heterotopic gastric mucosa in the terminal ileum manifested by intestinal obstruction is reported. He was treated surgically by enterectomy of two small bowel segments, both reconstructed by primary suture. His postoperative course was remarkable. The histopathologic study showed a typical pattern of the acquired type because of the presence of antral the antral mucosa and intense fibrosis. That is probably related to intestinal tuberculosis, but was not histologically confirmed. Individual and family recent history of pulmonary tuberculosis corroborates the suspicion. This is a unique report in the literature, among 28 other heterotopic gastric mucosa situated in the jejunum and ileum.

[Upper gastrointestinal hemorrhage caused by a fistula from a right anomalous subclavian artery to the esophagus]

Bleeding from an arterio-esophageal fistula is a rare and nearly lethal condition and surgical treatment is the only curative option. We report a case of bleeding from a fistula from an aberrant right subclavian artery to the esophagus. Diagnosis was made only at necropsy, despite of three previous laparotomies. This anatomical variation is found in 0.5% of the general population. Development of a communication between this artery and the esophagus, secondary to aneurysmatic dilatation or to prolonged nasogastric intubation, as probably occurred with this patient, is a extremely rare condition. Surgical treatment depends on the early recognition of clinical signs of the arterio-esophageal communication, before the onset of systemic complications of hypovolemic shock.

[Schwannoma of duodenum: a case report]

We report a case of malignant schwannoma of the duodenum, a neural tumor, which rarely occurs in the gastroduodenal tract. The diagnosis was done after an hemorragic episode of the upper gastrointestinal tract and the treatment done was a local resection. Two years later the patient had no symptoms, but the control endoscopy showed a recurrence of the tumor in the second portion of the duodenum and the patient was submitted to a gastroduodenopancreatectomy. The authors reported the case and make a revision on intestinal schwannomas.

[Carcinosarcoma of the esophagus: diagnostic importance of partial endoscopic polypectomy]

The clinical and pathological manifestations of a case of carcinosarcoma of the esophagus are reported. Barium swallow and endoscopy revealed a polypoid mass in mid esophagus. The tumor was large, pedunculated, covered by smooth mucosa with some erosions. Histologically the tumor was composed of a mixture of invasion keratinizing cells and intermingled bundle of spindle shaped cells resembling fibrosarcoma. The tumor was removed with surgery and did not show submucosa infiltration. It was not detected any metastasis or local recurrence during the 12 months follow-up period. The diagnosis was made by an endoscopic partial polypectomy. We conclude that partial polypectomy may be of value in preoperative diagnosis of esophageal polypoid mass.

[Alkaline reflux gastritis. Surgical treatment]

The authors present the results of 35 patients with alcaline gastritis submitted to truncal vagotomy and jejunostomy by Roux in technic. Preoperative diagnosis was founded in clinical symptoms and endoscopy with histopathology. In a follow-up of 84,8% of the patients, clinical results were excellent or good in 92,8%, showing relief of pain and vomits, gastric endoscopy almost normal and on histopathology.