Risk of gestational hypertension in pregnancies complicated with ovarian hyperstimulation syndrome

OBJECTIVE

Ovarian hyperstimulation syndrome (OHSS) is the most common iatrogenic complication due to ovulation stimulation during assisted reproductive technology. Pathophysiology of this syndrome is not completely clarified, and there is no some specific treatment. Human chorionic gonadotropin is considered as the most significant factor in etiopathogenesis of OHSS. The results of some clinical studies related to influence of OHSS on pregnancy are variable. The aim of this study was to investigate hypertensive disease of pregnancies in patients admitted to hospital due to severe forms of OHSS with reference to maternal characteristics.

Methodology

A case control study was conducted at the Obstetrics and Gynaecology Clinic "Narodni Front" and involved 50 patients admitted to hospital due to severe form of OHSS during a period from January 2008 to March 2015. A control group was created based on age and it involved 59 patients with pregnancy achieved with IVF/ICSI during the same period, but in which OHSS did not occur. For comparing mean values of continuous variables, Independent samples t test was applied.

RESULTS

Patients with pregnancy complicated by OHSS, had considerably higher rate of hypertension (14% vs. 3.2 %, p=0.046).

CONCLUSIONS

Pregnancies achieved by IVF/ICSI, being complicated with severe OHSS could be related to gestational hypertension.

Women’s health in Serbia - past, present, and future

Cardiovascular and reproductive health of women have been going hand in hand since the dawn of time, yet links have been poorly studied. Still, once basis of their connections started to be established, it depended on local regional abilities and level of progressive thinking to afford women comprehensive care beyond the ?bikini medicine?. Further research identified different associations rendering more conditions sex-specific and launching therefore a slow, yet initial turn around in clinical trials? concept as the majority of global cardiovascular guidelines rely on the results of research conducted on a very modest percentage of women and even less on the women of color. Currently, the concept of women?s heart centers varies depending on the local demographics? guided needs, available logistics driven by budgeting and societal support of a broad-minded thinking environment, free of bias for everyone: from young adults questioning their gender identity, via women of reproductive age both struggling to conceive or keep working part time when healthy and line of work permits it during pregnancy, up to aging and the elderly. Using ?Investigate-Educate-Advocate-Legislate? as the four pillars of advancing cardiovascular care of women, we aimed to summarize standing of women?s health in Serbia, present ongoing projects and propose actionable solutions for the future.

Risk of spontaneous preterm labor in pregnancies achieved by in vitro fertilization and complicated with severe form of ovarian hyperstimulation syndrome: A case control study

Objectives:

The purpose of this study was to examine the potential impact of severe Ovarian hyper stimulation syndrome (OHSS) on the risk of preterm birth. Severe ovarian hyperstimulation syndrome is a serious complication in the methods of in vitro fertilization. The pathophysiology of this process is not clear enough and the treatment is symptomatic. Human chorionic gonadotropin (h-CG) is the most important known cause of this condition. Findings of other authors often do not match when it comes to complications that may occur in pregnancy.

Methods:

In the Gynecology and Obstetrics Clinic “Narodni Front” a case control study was conducted on 50 female patients with severe forms of OHSS in the period from January 2008 to March 2015. A control group was created based on age and it involved 59 patients with pregnancy achieved with IVF/ICSI during the same period, but in which OHSS did not occur.

Results:

Patients with the pregnancy complicated by OHSS, had a considerably higher rate of preterm labor, whether this was labor before gestation week 37 (56.0% vs. 30.5%) or before gestation week 34 (34.0% vs. 6.8%); significantly lower weight of newborns, as in the newborns with low body weight <2500g (45.6% vs. 25.0%) and specially in the newborn with very low body weight <1500 grams (19.1% vs. 3.8%), as well as preterm premature rupture of membranes (PPROM), (11.76% vs. 1.59%).

Conclusions:

Pregnancy achieved by the IVF/ICSI method in which severe form of OHSS has been developed could have an increased risk of preterm birth.

Psychological effects of concurrent cytology and colposcopy testing in women referred to cancer counseling outpatient clinic in Belgrade

PURPOSE

To investigate the psychological effects of PAP smear and colposcopy performed simultaneously and receipt of abnormal tests' results on women's well-being and quality of life (QoL) using different relative questionnaires.

METHODS

A prospective cohort study included 324 women with abnormal PAP smear result obtained at the primary care centers, requiring repeat smear test and colposcopy in our hospital. Questionnaires regarding the patient demographic characteristics, 7-point Likert scales which indicate concern about the smear and colposcopy results and risk of developing cervical cancer, Bek Anxiety Inventory (BAI), European QoL questionnaire - Euro QoL (EQ-5D) and visual analogue scale (EQ VAS) were used. Women filled in the questionnaires at the pre-procedural assessment, and again, 7-10 days after testing, just after the reception of results.

RESULTS

According to BAI scale, almost one-quarter of women (23.5%) showed mild to severe anxiety; higher level of anxiety had women with abnormal test results (p=0.008). After adjustment for age, the difference reached statistical significance in the follow up period, too (p<0.05). At the pre-procedural assessment, there was no significant difference in the concern about test results (4.09 vs 4.22) and the perceived risk of developing cervical cancer (3.99 vs 4.14) using self-assessment by the Likart scales. However, women with abnormal test results had lower quality of life compared to women with normal PAP smear and colposcopy (mean EQ-VAS score 77.35 ± 15.63 vs 81.14 ± 16.07; p=0.020).

CONCLUSIONS

We conclude that referral for evaluation after a first abnormal PAP test leads to anxiety. Close and clear communication about test meaning and its consequences is needed in the organized screening test.

Obstetric and neonatal outcomes in women aged 40 years or older after in vitro fertilization

PURPOSE OF INVESTIGATION

The aim of this study was to determine the rate of complications in pregnancy and during delivery, as well as neonatal outcomes, in women who underwent in vitro fertilization (IVF) and who are 40 years of age or older.

MATERIALS AND METHODS

This was a prospective study. The study group consisted of 29 women who underwent IVF. The control group consisted of women who had a spontaneous pregnancy.

RESULTS

Pregnancy complications occurred in 86.21% of women in the study group, an 46.87% of women in the control group. The proportion of cesarean sections (CS) was 84.62% in the study group, and 21.87% in control group. Birth weight < 1,500 grams and < 2,500 grams was present in 17.16% and 22.86% of newborns in the study group, spectively. In the control group, birth weight < 1,500 grams and < 2,500 grams was present in 5.55% and 8.33% of newborns, respectively. Neonatal intensive care unit admissions included 22.86% newborns from the study group and 8.33% from the control group.

CONCLUSION

Pregnancy, delivery, and neonatal complications were more frequent in the study (IVF) group.

Interobserver variability and positive predictive value for ultrasonographic BI-RADS categories requiring pathohistological evaluation

OBJECTIVE

The objective of this study was an analysis of interobserver variability and positive predictive value (PPV) for BI-RADS categories requiring pathohistological evaluation: 4A, 4B, 4C, and 5.

MATERIAL AND METHODS

Interobserver variability for each of descriptors as well as PPV for final BI-RADS categories requiring pathohistological evaluation was measured in a retrospective study which included 30 ultrasonographic reports, with pathohistological verification, randomly selected from ultrasonographic reports from Institute for Oncology and Radiology of Serbia where about 1,100 breast cancers are verified every year. Ten observers, seven gynecologists, and three radiologists, independently rated each ultrasonographic report according to the fourth edition of BI-RADS atlas. Interobserver variability was measured with k coefficient.

RESULTS

There was most conformity for a category of orientation (k = 0.79). Substantial degree of conformity was also present for both boundary (k = 0.71) and shape (k = 0.65) categories. Moderate degree of conformity was achieved for posterior features (k = 0.54) and margins (k = 0.41) descriptors, while there was poor conformity in echogenicity (k = 0.38). In case of a final score, common conformity for all BI-RADS 4A, 4B, 4C, and 5 categories was (k = 0.51); it was the greatest for category 5 (k = 0.50), and it was less for categories 4C (k = 0.37), 4B (k = 0.32), and 4A (k = 0.29).

CONCLUSIONS

Interobserver conformity for ultrasonographic descriptors and final evaluation of BI-RADS 4A, 4B, 4C, and 5 categories is good. PPV implies that not only division into categories 4 and 5, but also classification into categories 4 and subcategories 4A, 4B, and 4C are justified and clinically applicable.

Delayed presentation of diaphragmatic rupture after blast injury

A diaphragmatic injury is usually associated with injury to thoracic or abdominal organs due to blunt or penetrating trauma, and is uncommon after blast injury. We describe a patient with respiratory distress due to herniation of the stomach into the chest through a diaphragmatic injury, sustained 1 year previously when he suffered a blast injury while on deployed military operations, but without obvious visceral injury at that time. At emergency laparotomy there was a gastric perforation which was exteriorised as a gastrostomy and the diaphragmatic rupture closed. Postoperative pneumonia and pelvic abscess were both treated successfully and he left the hospital in good condition. Delayed treatment of traumatic diaphragmatic injury leads to an increased risk for herniation and/or strangulation of abdominal organs, which can be life-threatening. Recognising the symptoms indicating diaphragmatic injury is especially important in cases in which the relationship to previous trauma is less clear.

Comparison of electrolytic status (Na+, K+, Ca2+, Mg2+) in preterm and term deliveries

PURPOSE OF INVESTIGATION

The objective of this study was to evaluate the electrolytic status of Na+, K+, Ca+, and Mg2+ in serum and red blood cells in idiopathic preterm and term deliveries.

METHODS

The study included 105 pregnant women diagnosed with idiopathic premature delivery (study group) and 36 pregnant women with physiologically term delivery (controls). Samples of mother's blood were collected and analyzed for the level of electrolytes in the serum/plasma and red blood cells.

RESULTS

Measured values of magnesium in red blood cells in the study group were far lower than physiological values, intracellular calcium levels were higher in the study group compared to levels measured in the controls. Sodium concentrations in cells were significantly lower in subjects with premature delivery.

CONCLUSION

The magnesium intracellular level is the best representative value of magnesium in the body.

Evaluation of utero-ovarian hemodynamics in relation to fertility and stage of endometriosis

The aim of this study was to compare hemodynamic changes in the uterine and ovarian arteries between infertile women with moderate and/or severe endometriosis and healthy women. In this prospective study, 99 women in their generative age were subjected to color Doppler ultrasonography to measure hemodynamic parameters from July 2010 to January 2011. The examination was performed during the proliferative or ovulatory phase of the natural menstrual cycle in a random sample of 54 women treated for endometriosis-induced infertility and 45 healthy women were included in control examination procedure. Irrespective of considered stage, endometriosis was most often found in the ovaries, in the sacro-uterine ligaments, peritoneum, and rectovaginally. Resistance to blood flow expressed as the resistance index (RI) in the measured arteries, was significantly higher in severe endometriosis compared to moderate form. Average values of pulsation index (PI) and RI are significantly higher, in both endometriosis stages, compared to measured values in healthy women.

Subsequent abdominal surgery after laparoscopic ventral and incisional hernia repair with an expanded polytetrafluoroethylene mesh: a single institution experience with 72 reoperations

PURPOSE

Laparoscopic ventral and incisional hernia repair (LVIHR) carries a risk of adhesion formation and can influence subsequent abdominal operations (SAOs). We performed a retrospective study of findings during reoperations of patients who had previously had an LVIHR by using an expanded polytetrafluoroethylene mesh (DualMesh; WL Gore, Flagstaff, AZ, USA).

METHODS

The medical records of all 695 patients who had LVIHR at our hospital were reviewed. Patients who underwent SAO for various indications were identified (n = 72) and analyzed.

RESULTS

Seven LVIHR patients (1%) had early SAO (within a few days). In six patients (86%), removal of the mesh was required. Intra-operatively, in all six of these patients with peritonitis, there were no adhesions against the implant identified. Late SAOs (after more than 1 month) were performed in 65 patients (9.4%). Only one patient required acute surgical intervention due to an LVIHR-related adhesion (0.15%). Laparoscopy was performed in 83% and laparotomy in 17% of patients. Adhesions against the implant were present in 83% of patients; in 65%, the adhesions involved omentum only, and in 18%, they involved the bowel. Adhesiolysis was always easy and caused no inadvertent enterotomies. SAOs were devoid of postoperative complications.

CONCLUSIONS

In this largest series of reoperations after LVIHR, the majority of patients had mild or moderate adhesions against the implant. The specific observations that: (1) no relaparoscopies had to be converted, (2) no inadvertent enterotomies were made during adhesiolysis, and (3) SAOs have practically been devoid of peri- and postoperative complications indicate that SAOs can be safely performed after previous LVIHR with DualMesh.

Impact of the mesh fixation technique on operation time in laparoscopic repair of ventral hernias

Background

Fixation of the prosthesis is one of the critical components of laparoscopic repair of ventral and incisional hernia (LRVIH). The impact of the fixation technique used on operative time has never been analyzed. We compared the duration of the operation according to the fixation technique used in a series of 138 patients with primary umbilical hernia.

Methods

All patients underwent a straightforward repair by using completely standardized techniques. One hundred and seven patients had mesh fixation with a single crown of tackers (ProTack^®, TycoUSS, Norwalk, CT) and eight transabdominal sutures (TAS). Thirty-one patients had mesh fixation with a double crown of tackers (DC) without TAS.

Results

There were no significant differences in age, sex, hospital stay, and morbidity between the two groups. Mean operating time for the technique with TAS was 50.6 min compared to 41.4 min for the DC technique. The mean difference in operating time was 9.2 min. This difference was significant (P = 0.002). During a mean follow-up of 26.4 months, there were no recurrences in the entire series.

Conclusions

The difference in operative times between the two operative techniques can be entirely accounted to the difference in the time needed for insertion of eight TAS as compared to the time needed for application of an inner crown of tackers. This strongly indicates that insertion of every single TAS prolongs LRVIH for approximately 1 min. As long as no significant differences between the two fixation techniques are demonstrated on issues of recurrence, complications, and postoperative pain, the time difference we have measured might be an argument in favor of the DC technique, especially when mesh fixation would require a large number of TAS.

Possible use of terrestrial mosses in detection of atmospheric deposition of 7Be over large areas

The activities of naturally occurring radionuclides (7)Be, (214)Bi and (210)Pb were measured in samples of terrestrial mosses collected in Serbia (42 degrees 26'19''N-45 degrees 23'12''N). The objective of this work was to establish if detectable amounts of (7)Be and (210)Pb can be found in mosses and investigate their possible variabilities over some area. These are the first steps in introducing mosses as a medium in possible monitoring of spatial distribution of (7)Be atmospheric deposition. The mean value of 360 Bq/kg of (7)Be activity was found in collected moss samples and some nonuniformity in spatial distribution (a 2.8-fold range in measured values) was observed.

[Abdominal pain following placement of an endoprosthesis in the biliary duct]

A 76-year-old man presented with diffuse progressive abdominal pain. He had undergone endoscopic retrograde pancreaticocholangiography (ERCP) 5 weeks earlier for jaundice and increased levels of liver enzymes. A dilated biliary duct with multiple concrements had been seen, and a plastic endoprosthesis was placed. During a follow-up ERCP the stent was not found, and the obstruction was still present. Another stent was placed. Abdominal x-ray revealed migration of the first endoprosthesis to the distal jejunum and signs of ileus and free gas. CT showed that the stent was stuck in a perforated diverticulum of the sigmoid, surrounded by an abscess mass. The stent was removed by laparotomy, the perforation was closed, and a double-loop stoma was made. Two weeks after initial recovery, abdominal pain recurred. CT revealed a second dislocated stent with a perforation of the jejunum. Laparotomy was performed again with removal of the stent and repair of the perforation. Migration is a known complication of biliary endoprosthesis placement, and should be considered in cases of abdominal pain after ERCP. Perforations rarely occur and mostly affect areas of the bowel that are fixed or that present obstacles to normal elimination. Two perforations within a short period of time is an extremely rare complication of migration.

Ovarian neoplasms and pregnancy

The aim of our study was to investigate the incidence of ovarian malignant neoplasms in pregnancy. In the prospective study, during a 2-year period of time, we had the ethical dilemma concerning the conciliar treatment vs the patient's wish to deliver and save the reproductive capabilities. We examined 37 pregnant women; the incidence of ovarian cancer was 13.5% vs 6.5% in other works. Diagnoses were made by ultrasound criteria and physical examinations. Statistically significant results were obtained by Student t test. Mean gestational age was 20.1 weeks and mean age 31.1 years. Treatment depends on the neoplasms type, grade, and presence of the metastatic pathways. In benign neoplasms, we used laparoscopic treatment with minor invasion. Distribution of benign neoplasms was in the same range as that in other works.

Laparoscopic Appendicostomy With Cecoplication for Antegrade Colonic Enema Procedure

Successful application of antegrade colonic enema procedure in selected patients with intractable constipation requires creation of an easy catheterizable but continent stoma. We describe a new laparoscopic technique for antegrade colonic enema procedure by using the in situ appendix that is combined with a Nissen-like cecoplication around the appendix to create a one-way valve.

Expression of Golli proteins in adult human brain and multiple sclerosis lesions

It has been suggested that Golli proteins, structurally related to myelin basic proteins (MBPs), have a role in autoimmune processes. We studied the expression of these proteins in multiple sclerosis (MS) and determined that the number of Golli-immunoreactive (ir) cells was significantly higher around lesions of chronic MS than in control white matter. Golli proteins were expressed in the adult oligodendrocyte precursor cells (OPCs), activated microglia/macrophages, and some demyelinated axons around MS lesions. Their expression in adult OPCs indicates remyelination attempts, whereas the expression in the subpopulation of microglia/macrophages suggests roles in the immune processes of MS. In addition, Golli proteins may be markers of axonal transection, which is characteristic for MS.

Identification of Golli and myelin basic proteins in human brain during early development

The myelin basic protein gene (Mbp) encodes for the major myelin structural proteins and it is included in the Golli-Mbp gene complex. Previously, we observed MBP-like proteins in the human central nervous system (CNS) at developmental stages preceding myelination. In an effort to distinguish between Golli (HOG5 and HOG7) and MBP mRNAs and to determine their spatiotemporal distribution, we performed in situ hybridization using two human Golli specific probes: one corresponding to exon 5a absent from all MBP transcripts, and the other corresponding to exon 5c specific for HOG5. HOG7 transcript was observed first, in 5 gestational week-old embryos, whereas both Golli transcripts were detected at 6-7 weeks gestation in the proliferative zones of the entire CNS. Golli proteins immunoreactivity was observed in microglia and early neurons of the developing telencephalon. During midgestation (17-22 weeks gestation), at the onset of myelination, MBP and Golli mRNAs were observed in the telencephalic subventricular zone and occasionally in the future cerebral cortex. Developmental expression of the human Golli-Mbp indicates that the two Golli proteins have different onset of expression, distribution and possibly function. These results support the hypothesis that at least one of them, HOG7, may be involved in the regulation of early neurogenesis, while both may have additional, still undefined function at the onset of myelination.

Protein S and pregnancy: Report of a case

Protein S is a cofactor of protein S which lowers the activat- ed factors VIII and V. Pregnancy reduces the level of protein S to 40-50% of normal levels but it is not clear whether the lowered protein S levels increase the risk of developing thrombo-embolism during pregnancy. This is a report of a 39-year old woman, multipart whose pregnancy terminated as IUGR and who had previously two stillbirths. After the third pregnancy loss of functional protein S level was 20%. Two months after delivery protein S activity was 60%. As it was suspected that low protein S level was a risk factor of complications in pregnancy anticoagulant therapy was used. Thereafter pregnancy and delivery at 38.5 weeks of gestation were successful and the baby weighted 3400 gr at birth. The aim of this report is to emphasize the important role of follow-up of the level of protein S in pregnancy in order to avoid the risk of thrombo-embolism in pregnancy. Anticoagulant therapy is very successful in such a pregnancy and may ensure safe birth.

Stapled laparoscopic gastropexy for paraesophageal hernia

A minimally invasive correction of symptomatic paraesophageal hernia in high-risk elderly patients is described with an emphasis on a new method of laparoscopic gastropexy that is simple, reliable, and can be performed rapidly.

Programmed cell death in the developing human telencephalon

Programmed cell death (PCD) in the form of apoptosis is recognized as one of the central events in the development of the central nervous system. To study the time of onset, extent and distribution of PCD in the human telencephalon, embryos and fetuses from 4.5 to 27 gestational weeks (g.w.) were examined using the TUNEL (TdT-mediated dUTP-biotin nick-end labelling) in situ method. At 4.5 g.w. sparse TUNEL(+) nuclei were observed in the ventricular zone of the neural tube. With the formation of the cortical plate at 7-8 g.w. , TUNEL(+) nuclei were seen in all developmental layers of the cortical anlage, as well as in the subcortical regions such as the ganglionic eminence and the internal capsule. The proliferative zones (the ventricular zone, the subventricular zone and the ganglionic eminence) contained the majority of all apoptotic nuclei observed in each specimen. However, the apoptotic index was highest in the subplate zone and in layer I. Double-labelling experiments suggested that neuronal precursors were the main population of cells undergoing PCD in the first trimester of gestation, whereas glial cells probably start dying around midgestation. The onset of labelling of microglial cells and apoptotic nuclei were synchronous, indicating the involvement of microglia in PCD. In conclusion, two distinct types of PCD were observed during human telencephalic development: embryonic apoptosis, which was synchronous with proliferation and migration of neuronal cells and probably not related to establishment of neuronal circuitry, and fetal apoptosis, which coincided with differentiation and synaptogenesis, and therefore may be related to the development of axonal-target connectivity.

Perforation of gastric ulcer associated with paraesophageal hernia causing diffuse peritonitis

BACKGROUND/AIMS

Free peritoneal perforation of a gastric ulcer associated with paraesophageal hernia causing diffuse peritonitis is an extremely rare event.

METHODS

Two new cases of this rare condition and the specificities of management are described.

RESULTS

One patient recovered well after surgery, while the other died with signs of persisting sepsis and multiple system organ failure.

CONCLUSION

In the wide spectrum of complications related to paraesophageal hernia, free peritoneal perforation of an associated ulcer seems to be one of the gravest. Early elective repair of the paraesophageal hernia is justified.

Incidence and onset of critical illness polyneuropathy in patients with septic shock

BACKGROUND

To estimate the incidence and onset of critical illness polyneuropathy (CIP) in patients in septic shock.

METHODS

Prospective, observational study, no interventions, in a general 9-bed ICU of a large teaching hospital. Twenty-five patients consecutively admitted to the ICU for treatment of septic shock were studied. Within 72 h of admission to the ICU a complete neurological examination and electromyografic studies were done. Studies were repeated weekly until discharge of ICU or death or CIP confirmed.

RESULTS

Nineteen patients developed CIP (76%), with a majority (80%) within 72 h after onset of septic shock. All twenty-two patients with multi organ dysfunction syndrome (MODS) had CIP. The three patients without MODS did not have CIP (P<0.01).

CONCLUSIONS

In a group of patients suffering from septic shock the incidence of CIP is high (76%). The onset is early, within 72 h after onset of septic shock. CIP is an early feature of MODS, developing after septic shock.

Early development and composition of the human primordial plexiform layer: An immunohistochemical study

The early expression of reelin, calcium-binding proteins (calretinin, calbindin, and parvalbumin), and neurofilament proteins have been explored in the developing central nervous system of human embryos and fetuses during the first trimester of gestation. Our objective has been to determine further the nature, developmental roles, and contributions of the early neurons and fibers of the original subpial neuropil, i.e., the primordial plexiform layer (PPL). In young embryos (4-5 weeks old), neurofilament protein-labeled fibers run through the subpial neuropil of the caudal portion of the neural tube, reaching the mesencephalon rostrally. At this age, calretinin-immunoreactive and calbindin-immunoreactive neurons are also found among cells already detached from the ventricular zone. The expression of neurofilament protein, calretinin, and calbindin follows an ascending caudorostral gradient, reaching the cerebral vesicles by the 6th-7th week of gestation. In the cerebral cortex, this timing coincides with the initial expression of reelin in the PPL. The reelin immunoreactivity throughout the most superficial cellular population of the cortical PPL supports the early genesis of Cajal-Retzius cells, around the 6th week of gestation. After the splitting of the PPL by the formation of the cortical plate (7-8 weeks of gestation), reelin-immunoreactive cells remain only in the newly established layer I. This study proposes that an initial PPL may be a universal feature of the developing central nervous system.

Role of esophageal body function in gastroesophageal reflux disease: implications for surgical management

BACKGROUND

Effective esophageal peristalsis is a major determinant of esophageal clearance function. The relation of esophageal body function with a mechanically defective lower esophageal sphincter and the development of esophageal mucosal injury in patients with gastroesophageal reflux disease is unclear.

STUDY DESIGN

We analyzed the relations among the manometrically determined esophageal clearance function, lower esophageal sphincter dysfunction, esophageal acid exposure, and the presence and severity of esophageal mucosal injury in patients with gastroesophageal reflux disease. Normal values for the manometric assessment of esophageal clearance function were established in 50 normal volunteers and subsequently applied to 160 symptomatic patients with increased esophageal exposure to gastric juice and various grades of esophageal mucosal injury (no minimal surgery, esophagitis, stricture, and Barrett's esophagus).

RESULTS

Defective clearance function was present in 47.5% of the patients; a defective lower esophageal sphincter was documented in 63.1%. Compromised esophageal clearance function was significantly more common in patients with a defective lower esophageal sphincter than in those with normal sphincter function (55% versus 33.8%). Esophageal acid exposure time and the prevalence and severity of esophageal mucosal injury were highest in patients with a defective sphincter and compromised clearance function.

CONCLUSIONS

These data show that esophageal motor function deteriorates with increasing severity of mucosal injury. This appears to be due to persistent reflux of gastric juice across a mechanically defective lower esophageal sphincter. This may influence the choice and outcome of antireflux surgery. Surgical correction of a mechanically defective sphincter before the loss of esophageal body function is advocated.

Role of esophageal body function in gastroesophageal reflux disease: implications for surgical management

BACKGROUND

Effective esophageal peristalsis is a major determinant of esophageal clearance function. The relation of esophageal body function with a mechanically defective lower esophageal sphincter and the development of esophageal mucosal injury in patients with gastroesophageal reflux disease is unclear.

STUDY DESIGN

We analyzed the relations among the manometrically determined esophageal clearance function, lower esophageal sphincter dysfunction, esophageal acid exposure, and the presence and severity of esophageal mucosal injury in patients with gastroesophageal reflux disease. Normal values for the manometric assessment of esophageal clearance function were established in 50 normal volunteers and subsequently applied to 160 symptomatic patients with increased esophageal exposure to gastric juice and various grades of esophageal mucosal injury (no minimal surgery, esophagitis, stricture, and Barrett's esophagus).

RESULTS

Defective clearance function was present in 47.5% of the patients; a defective lower esophageal sphincter was documented in 63.1%. Compromised esophageal clearance function was significantly more common in patients with a defective lower esophageal sphincter than in those with normal sphincter function (55% versus 33.8%). Esophageal acid exposure time and the prevalence and severity of esophageal mucosal injury were highest in patients with a defective sphincter and compromised clearance function.

CONCLUSIONS

These data show that esophageal motor function deteriorates with increasing severity of mucosal injury. This appears to be due to persistent reflux of gastric juice across a mechanically defective lower esophageal sphincter. This may influence the choice and outcome of antireflux surgery. Surgical correction of a mechanically defective sphincter before the loss of esophageal body function is advocated.

Resection of the paraesophageal hernia sac

A simple technique for resection and closure of the paraesophageal hernia sac is described.

Gastric foveolar hyperplasia in patients with cancer of the intact stomach

The incidence of gastric foveolar hyperplasia, a reliable histological marker of bile reflux into the stomach, was evaluated in patients with cancer of the intact stomach. Lesions classified as foveolar hyperplasia were found in 17 of 32 gastric cancer patients and in seven of 30 controls. This difference was statistically significant (p < 0.02). Differences in the incidence of foveolar hyperplasia according to sex, tumor site, attendant chronic atrophic gastritis, and alcohol consumption were not significant, which lends support to the association of gastric cancer with duodenogastric reflux.

Prevalence and clinicopathologic features of multiple squamous cell carcinoma of the esophagus

BACKGROUND

The occurrence of independent synchronous esophageal carcinoma in patients with grossly invasive esophageal cancer (GEC) is well known. Although multiple primary carcinoma of the esophagus is not uncommon, the exact prevalence is controversial, and its clinicopathologic features remain relatively unknown.

METHODS

Fifty-four patients with squamous cell GEC who underwent transthoracic esophagectomy with systematic lymphadenectomy between 1987 and 1991 at the Institute for Digestive Diseases, Belgrade University Clinical Center, were included in the study.

RESULTS

Detailed histopathologic examination of the esophagus resected for squamous cell carcinoma was performed in 54 patients and revealed 17 patients (31%) with associated cancer independent of the main tumor. The second lesion was significantly less invasive than the main tumor. There was no significant difference (P = 0.06) in sex, age, main tumor site, tumor differentiation, tumor diameter, lymph node involvement, or tumor stage between patients with multiple cancer and patients with solitary cancer, but there was a significant difference in the depth of invasion (P < 0.01). The tumor stage in patients with multiple cancer was determined by the main tumor stage and was not influenced by the associated lesion. The prevalence of multiple primary cancer of the esophagus is lower in other reports than in this series.

CONCLUSIONS

The patients in this study had significantly more invasive main tumors. It seems likely that a higher prevalence of multiple cancer may be expected in patients with advanced main tumor penetration. These results support the concept that the entire esophagus may be considered as one entity of field cancerogenesis.

Atrophic chronic gastritis and esophagogastric anastomotic leak after resection and reconstruction for esophageal carcinoma

The incidence of anastomotic leakage after esophagectomy for cancer and reconstruction with the stomach was analyzed with respect to the presence of coexistent atrophic chronic gastritis (ACG). Of a total of 28 operated esophageal cancer patients with ACG, 6 patients developed an anastomotic leak at the cervical esophagogastrostomy (21%). Of a total of 8 operated esophageal cancer patients none of the patients developed an anastomotic leak. The ACG positive and the ACG negative patients were found to be well matched for age, sex, type of operation, transplant route, level of the anastomoses, and suture technique, and all were operated on by the same surgeons. The difference in leakage rate did not reach statistical significance.