Evaluation of esophageal motility and reflux in children treated for esophageal atresia with the use of combined multichannel intraluminal impedance and pH monitoring

Background

Gastroesophageal reflux (GER) and dysmotility are frequent in patients treated for esophageal atresia (EA). This aim of this study is to evaluate GER and dysmotility in young EA patients using pH-multichannel intraluminal impedance (pH-MII).

Methods

Fifteen patients with a mean age of 7.5 years (group 1) have been studied and compared with 15 children without congenital malformation, submitted to pH-MII for suspected GER (group 2). These latter patients serve as a control group of healthy subjects. The following impedance reflux and motility parameters have been studied on 10 standardized swallows: number of reflux episodes, mean acid clearing time, median bolus clearing time, bolus presence time, total bolus transit time, segmental transit time, and total propagation velocity.

Results

In the group of EA patients, mean acid clearing time and median bolus clearing time were pathological. In the control group, all reflux parameters were normal. Patients with EA had significantly longer median bolus presence time at each measuring site, median total bolus transit time, and median segmental transit time and slower total propagation velocity (P < .001).

Conclusions

pH-multichannel intraluminal impedance evaluates both GER and motility patterns. Our report studies impedance parameters of esophageal motility in healthy children and in EA patients using only pH-MII.     

Lack of distal esophageal contractions is a key determinant of gastroesophageal reflux disease after repair of esophageal atresia

Background/Purpose

The objective of this study is to investigate the characteristics of esophageal motor activity responsible for the development of gastroesophageal reflux (GER) in patients with esophageal atresia (EA).

Methods

The subjects consisted of 29 patients with EA (1 month to 19 years). Computerized esophageal manometry was conducted to investigate esophageal contractions at swallow. A topographic esophageal manometric analysis was conducted in each subject, providing 3-dimensional displays to reveal the pressure continuum representing esophageal contractions.

Results

Significant contractions in the middle esophagus just below the anastomosis were absent in all subjects. Contractions in the distal esophagus were conspicuously absent in 17 subjects. Of these 17, 6 had already undergone fundoplication, and 9 had symptomatic GER requiring fundoplication subsequent to this study. The remaining 12 patients had contractions in the distal esophagus and did not require medical/surgical intervention. A lack of distal esophageal contractions was significantly correlated with the development of GER (P < .001). There was a significant difference in esophageal acid exposure between the 2 groups (median, 38% vs 4%, P < .001).

Conclusion

Lack of distal esophageal contractions indicating an impaired clearing capacity is considered a potential key determinant of GER in patients with EA.     

The management of long gap esophageal atresia

Background

Present management of esophageal atresia has enabled the survival rate to approach 95%. Controversy remains concerning the many options for the surgical management of long gap esophageal atresia without tracheoesophageal fistula and represents the difficulty of this pathology. In the last couple of years, we have had a nonexplained outbreak of cases of long gap esophageal atresia without tracheoesophageal fistula. This article reports our experience in the management of these children.

Material and Methods

It is a retrospective study of all cases of long gap esophageal atresia without tracheoesophageal fistula managed in our institution since 1992, focusing on the antenatal period, delivery with weight and term, the associated malformations, the initial management, and the definitive surgery. Mann-Whitney U test was used for statistical analysis.

Results

Ten cases (8.7%) of long gap esophageal atresia according to Ladd's classification, 6 during the past 2 years, were taken in charge at Robert Debré Hospital between 1992 and 2002. There were 4 girls and 6 boys. Ten had a prenatal diagnosis of esophageal atresia. The average birth weight was 2496 g (range, 1400-3400 g) with an average term of 36.6-week gestation (range, 31.5-39.6). Delayed reconstruction was done in all children between 41 and 147 days of life (average of 102 days). Six had a direct anastomosis and 4 had a colonic esophagoplasty (3 with an esogastric disconnection during the same procedure). The average follow-up was 60 months (range, 27-133). There was 1 death owing to adenovirus infection at 5 years of age. Four children required a Nissen fundoplication for severe gastroesophageal reflux. At least, 2 children presented an anastomotic stricture which required pneumatic dilatations.

Conclusion

Treatment options for long gap esophageal atresia generally require several stages over several months. We propose, for their management, a direct anastomosis at 4 months of age whenever it is possible. If not, we use a colonic esophagoplasty with an esogastric disconnection to control the gastroesophageal reflux which is responsible for strictures and respiratory impairment and does not obstruct the aperistaltic tube.     

Eosinophilic infiltration of the esophagus: gastroesophageal reflux versus eosinophilic esophagitis in children--discussion on daily practice

Background/purpose

Children presenting with persistent symptoms attributed to gastroesophaeal reflux disease (GERD) that are unresponsive to both medical and surgical therapies are commonly submitted to esophageal biopsies, the results of which show an abnormal presence of eosinophils. In this setting, eosinophilic esophagitis may be the correct diagnosis. The purpose of this report is to clarify the importance of esophageal eosinophilic infiltration, regardless of whether associated with acid reflux, ie, as an independent symptomatic entity, when treating a patient with refractory GERD.

Methods

Two boys, aged 8 and 7 years, had the classic symptoms of GERD. They were treated with antacid without improvement of the esophagic lesions. Subsequent esophageal biopsy results showed marked eosinophilic infiltration. From this moment on, eosinophilic esophagitis started to be considered the main diagnosis.

Results

Although eosinophilic infiltration caused by GERD is very frequently found in esophageal biopsy, in case of refractory drug treatment and microscopic findings of a great number of eosinophils and mast cells, eosinophilic esophagitis must be considered. This disease is better treated with corticoids instead of antacid drugs. It explains the reason some patients do not respond to antacid and surgical treatment and remain symptomatic with esophagic lesions.

Conclusions

In refractory cases of GERD, eosinophilic esophagitis must be considered before any surgical measure.     

Esophagitis and Barrett esophagus after correction of esophageal atresia

Background

Gastroesophageal reflux is a frequent problem after esophageal atresia (EA) repair. Our aim was to determine the prevalence of esophagitis and Barrett esophagus more than 10 years after repair of EA.

Methods

Ninety-two patients treated between 1973 and 1985 were included in this prospective study. A questionnaire was completed by 86 patients; esophagogastroscopy was performed in 49 patients.

Results

Only 36 patients had no complaints at all. Thirty-one patients complained of difficulties swallowing solid food; 23 complained of heartburn. Esophagogastroscopy revealed grade 3 esophagitis in 2 patients and a macroscopic image of Barrett esophagus in 2. Histology showed esophagitis in 30 patients, gastric metaplasia in 3, and no intestinal metaplasia (Barrett esophagus).

Conclusions

For epidemiologic reasons, that is, the short interval of follow-up (10 years) and the low compliance of the study group, larger numbers are needed to decide if routine long-term endoscopic screening after repair of EA is necessary. For now, it cannot yet be recommended. The prevalence of symptoms of gastroesophageal reflux disease in this study group is higher than that in the general population, but we found no severe complications of gastroesophageal reflux in the pediatric age group.     

Multistaged esophageal elongation technique for long gap esophageal atresia: experience with 7 cases at a single institution

Background/Purpose

Esophageal reconstruction for long gap esophageal atresia (LGEA) is still controversial. We successfully managed 7 cases of patients with LGEA by doing staged elongation of the native esophagus and subsequent end-to-end anastomosis. The technique and efficacy of this procedure are evaluated.

Methods

During the last 10 years, 7 patients with LGEA (Gross type A, 5; B, 1; C, 1) underwent multiple extrathoracic esophageal elongations (ETEEs) of the upper esophagus and subsequent esophagoesophagostomy. Medical records were reviewed in regard to the number of ETEE before definitive esophageal reconstruction, interval between each ETEE, operation time, time before initiation of sham feeding, duration of hospital stay, and complications.

Results

The definitive esophageal reconstruction was successfully achieved without major complications in all patients after 2 to 4 stages of ETEE. The interval between each ETEE was 72 days on average. The average operation time was 98 minutes. The elongation was 1 to 3.5 cm during each session. Oral sham feeding was recommenced 4.1 days after each ETEE, and the hospital stay was 9.6 days on average. Gastroesophageal reflux occurred in all patients, requiring antireflux surgery.

Conclusions

We conclude from our experience (a) that effective esophageal lengthening with preservation of the native esophagus was achieved with multiple ETEE in LGEA and (b) that this procedure allows oral sham feeding at home until esophageal reconstruction.     

Use of radiofrequency ablation of the lower esophageal sphincter to treat recurrent gastroesophageal reflux disease

Purpose

Recurrent gastroesophageal reflux disease (GERD) after gastroesophageal surgery is a troublesome problem. Reoperative surgery often is complicated by adhesions and recurrence. Radiofrequency ablation or energy delivery (RF or the Stretta procedure) is a new method for treating GERD. This study is the first report describing the use of the Stretta procedure in pediatric patients.

Methods

Six patients who underwent previous gastroesophageal surgery presented with recurrent GERD. Medical records were reviewed and the severity of reflux graded using a modified scoring system. All underwent RF and were graded for GERD at 6 months postprocedure.

Results

Mean operating time was 80 ± 12 minutes. Mean age at initial operation was 12 ± 4 years and for the RF, 18.0 ± 3.4 years. All patients were discharged as outpatients. Early complications occurred in one child with self-resolving acute gastric distension. Five of 6 patients were completely asymptomatic at 3 months after the procedure, and 3 stopped anti secretory agents. One patient was improved but still symptomatic and needed a redo fundoplication. Another required a repeat application of RF 10 months after the initial one. Mean GERD score pre-Stretta was 5.2 ± 1.0, which improved to 1.6 ± 1.9 at 6 months postprocedure (P < .05; paired t test).

Conclusions

Use of RF treatment of the lower esophageal sphincter is a potentially successful modality to treat recurrent GERD in children. Long-term follow-up is required.     

INFLUENCE OF EXERCISE TESTING IN GASTROESOPHAGEAL REFLUX IN PATIENTS WITH GASTROESOPHAGEAL REFLUX DISEASE

Background

Gastroesophageal reflux disease is a worldwide prevalent condition that exhibits a large variety of signs and symptoms of esophageal or extra-esophageal nature and can be related to the esophagic adenocarcinoma. In the last few years, greater importance has been given to the influence of physical exercises on it. Some recent investigations, though showing conflicting results, point to an exacerbation of gastroesophageal reflux during physical exercises.

Aim

To evaluate the influence of physical activities in patients presenting with erosive and non erosive disease by ergometric stress testing and influence of the lower esophageal sphincter tonus and body mass index during this situation.

Methods

Twenty-nine patients with erosive disease (group I) and 10 patients with non-erosive disease (group II) were prospectively evaluated. All the patients were submitted to clinical evaluation, followed by upper digestive endoscopy, manometry and 24 h esophageal pH monitoring. An ergometric testing was performed 1 h before removing the esophageal pH probe. During the ergometric stress testing, the following variables were analyzed: test efficacy, maximum oxygen uptake, acid reflux duration, gastroesophageal reflux symptoms, influence of the lower esophageal sphincter tonus and influence of body mass index in the occurrence of gastroesophageal reflux during these physical stress.

Results

Maximum oxigen consumption or VO 2 max, showed significant correlation when it was 70% or higher only in the erosive disease group, evaluating the patients with or without acid reflux during the ergometric testing (p=0,032). The other considered variables didn''t show significant correlations between gastroesophageal reflux and physical activity (p>0,05).

Conclusions

1) Highly intensive physical activity can predispose the occurrence of gastroesophageal reflux episodes in gastroesophageal reflux disease patients with erosive disease; 2) light or short sessions of physical activity have no influence on reflux, regardless of body mass index; 3) the lower esophageal sphincter tonus does not influence the occurrence of reflux disease episodes during exercise testing.     

Can esophageal pH monitoring predict delayed gastric emptying?

Background/Purpose

Delayed gastric emptying (DGE) is frequent in patients with gastroesophageal reflux disease (GERD) and may require additional investigation. The current study assesses whether relative esophageal exposure, postprandial (PP) versus fasting, diagnosed by pH monitoring could predict DGE.

Methods

Thirty patients with GERD underwent extended esophageal pH monitoring and were assigned as DGE or non-DGE according to scintigraphy. The PP to fasting ratio for reflux index, relative frequency of long episodes in PP, and distribution of the longest episode were used to assess the relative esophageal exposure. The effectiveness of these parameters to predict DGE was estimated; the cutoffs for continuous variables were chosen with receiver operating characteristics (ROC) curves and the probabilities were calculated using a logistic regression model.

Results

The area under the ROC curve of PP to fasting ratio for reflux index was greater than that of relative frequency of long episodes in PP. There was a good equilibrium between sensitivity and specificity at a PP to fasting ratio of 1. A PP to fasting ratio greater than 1, ie, a reflux index in PP greater than in fasting, presented a sensitivity of 93% and a negative predictive value of 91%. The occurrence of the longest episode in PP had a specificity of 94% and a positive predictive value of 89%. A reflux index greater in PP plus a longest episode in PP presented a 94% probability of DGE; a reflux index greater in fasting plus a longest episode in fasting had a 95% probability of non-DGE. These combinations represented 60% of the series.

Conclusions

PP to fasting ratio for reflux index and distribution of the longest episode seem accurate to identify DGE; thus, additional investigation to assess gastric emptying may be avoided in the majority of patients.     

Esophageal smooth muscle reactivity is impaired in chronic reflux esophagitis by both receptor- and nonreceptor-mediated mechanisms

Aim

Esophagitis is associated with an impaired esophageal peristalsis. A few studies have been aimed at understanding the pathophysiology of abnormal peristaltic activity. The mechanism of impaired esophageal smooth muscle reactivity in the chronic gastroesophageal reflux (GER) model is investigated in vitro for the first time.

Materials and Methods

The chronic GER rat model was created by partial gastric outlet obstruction. The histopathological findings related to esophagitis were evaluated. Smooth muscle strips of the tunica muscularis mucosa of esophagus were studied in standard organ chambers. Carbachol- and KCl-induced contractile responses and serotonin- and papaverine- induced relaxant responses in both reflux and sham-operated control groups were determined.

Results

Histopathologically, chronic reflux esophagitis was observed in all specimens of the reflux group. Contractile (carbachol- and KCl-induced) smooth muscle responses were significantly decreased in the reflux group. When compared to control group, relaxant response of smooth muscle to serotonin was also significantly decreased in the reflux group. However, there was no difference in papaverine-induced relaxant responses between 2 groups.

Conclusions

Our study describes the effects of chronic GER on rat esophageal smooth muscle contractility in vitro. We found that both receptor- (carbachol, serotonin) and nonreceptor-mediated (KCl) esophageal smooth muscle reactivity were impaired in chronic reflux esophagitis. These changes may correspond to the functional motor abnormalities of the esophagus seen in patients with chronic reflux esophagitis.     

Is routine dilatation after repair of esophageal atresia with distal fistula better than dilatation when symptoms arise? Comparison of results of two European pediatric surgical centers

Background/Purpose

The aim of this study was to determine whether routine dilatation of the anastomosis after repair of an esophageal atresia with distal fistula (EADF) is superior to a wait-and-see policy with dilatation only when symptoms arise.

Methods

The records of 100 consecutive patients operated on for EADF in 2 European pediatric surgical centers (A [n = 63], B [n = 37]) were reviewed. In center A, dilatation of the anastomosis was carried out in symptomatic cases only, whereas in center B dilatation was begun 3 weeks postoperatively and repeated every 1-3 weeks until a stable diameter of 10 mm was reached. Particular attention was paid to the number of dilatations per patient, dilatation-related complications, and differences in results after 2 years.

Results

The patient materials of both centers did not differ with respect to the incidence of prematurity, tracheomalacia, gastroesophageal reflux (GER), and major postoperative complications. The incidence of associated anomalies was higher in center B (P < .05). In center A, 26 of 63 patients underwent dilatation; in center B, all 37 patients were dilated (P < .05). Median number of dilatations per patient was 4 in center A and 7 in center B (P < .05). In center A, 23 of 26 and in center B, 20 of 37 of the patients received medical treatment for GER at the time of the dilatations. Dilatation-related complications developed in 7 of 26 patients of center A and in 3 of 37 patients in the center B (P value, not significant). The median primary hospital stay was 24 days in center A and 33 days in center B (P < .05), median secondary hospital stay for dilatation was 6 days in center A and 13 days in center B (P < .05). After 2 years of follow-up, the incidence of dysphagia, respiratory problems, or bolus obstruction did not differ significantly between the 2 centers.

Conclusions

A wait-and-see policy and dilatations based on clinical indications for patients with repaired EADF is superior to routine dilatations. It appears that more than half of the patients do not require dilatations at all.     

Abnormal intrinsic esophageal innervation in congenital diaphragmatic hernia: a likely cause of motor dysfunction

Purpose

Patients with congenital diaphragmatic hernia (CDH) often have dilated esophagus and gastroesophageal reflux. Sparse intrinsic esophageal innervation has been described in rats with CDH, but this issue has not been investigated in patients with CDH. The present study tests the hypothesis that innervatory anomalies could account for motor dysfunction in human CDH.

Methods

The esophagi of CDH (n = 6) and control babies dead of other causes (n = 6) were included in paraffin, transversally sectioned, and immunostained with antineurofilament and anti-S-100 antibodies. The proportion of the section surface occupied by neural structures, the ganglionar surface, and the number of neurons per ganglion were measured in 2 to 5 low-power fields from the proximal and distal esophagus with the assistance of image analysis software. Mann-Whitney tests were used for comparing the results using a threshold of significance of P < .05.

Results

The percentage of neural/muscle surface was similar in the upper esophagus in both groups, but it was significantly decreased in the lower esophagus of patients with CDH in comparison with controls. There was a relative scarcity of neural tissue in the intermuscular plexus of the lower esophagus. On the other hand, the ganglionar surface and the number of neurons per ganglion were identical in both groups. These results were similar with both immunostainings.

Conclusion

Intrinsic innervation of the lower esophagus in CDH is abnormal in terms of decreased density of neural structures in the intermuscular plexus. These neural crest-derived anomalies could explain in part the esophageal dysfunction in survivors of CDH.     

Formula fortified with live probiotic culture reduces pulmonary and gastrointestinal bacterial colonization and translocation in a newborn animal model

Background/Purpose

Acidified diets are protective against intestinal bacterial colonization and translocation. Probiotic diets are designed to modulate the intestinal flora to enhance mucosal immunity. This study was designed to determine if formula acidified with live probiotic decreases bacterial gut colonization and translocation, and is equally tolerated as other acidified diets.

Methods

One hundred twenty-eight rabbit pups delivered via cesarean section [cesarean delivery, cesarean birth, abdominal delivery] were randomly assigned to 4 feeding groups: NAN Nestle (control, pH 7.0), NAN acidified with citric acid (pH 4.55), biologically acidified Pelargon (pH 4.55), and NAN with live Lactococcus lactis culture (pH 4.2). Pups were gavage fed every 12 hours with Enterobacter cloacae challenges of 10 colony-forming units/mL per feed and killed on day of life 3. Lungs, liver, spleen, mesenteric lymph nodes (MLNs), stomach, and cecum were cultured and quantitatively analyzed for target organism growth. Results were analyzed using χ² tests.

Results

NAN with live probiotic culture, when compared with Pelargon, acidified NAN, and NAN, significantly reduced the incidence of Enterobacter pulmonary colonization (P < .01), bacterial translocation (liver, P < .025; spleen and MLN, P < .05), and gastric and intestinal colonization (P < .001 for both).

Conclusion

Probiotic-fortified formula provides superior protection against pulmonary and gastrointestinal bacterial colonization and translocation compared with neutral and acidified formulas, and is equally tolerated.     

Gastroesophageal reflux and behavior in neurologically impaired children

Objective

This study aimed to evaluate a possible link between gastroesophageal reflux (GER) and behavior pattern indicating pain experience in a group of children with severe neurologic deficits.

Patients and methods

We prospectively evaluated 19 patients with severe neurologic impairment (10 males and 9 females; mean age, 12.7 years) suspected for GER before and after initial treatment. Repeated 24-hour pH monitorings were performed in 19 children, whereas additional repeated endoscopic investigations were carried out in 18. In these children a histologic examination of mucosal biopsies was performed. Behavior pattern was described by parents or caregivers. The level of activity was classified as no/occasional agitation, daily agitation, and autoaggressive behavior.

Results

The behavioral pattern of the children was most frequently (n = 24) described as “agitated” followed by “autoaggressive” behavior (n = 10). Neither autoaggression nor agitation was less frequent (n = 4). Children with autoaggressive behavior had a significantly higher reflux index compared with the neurologically impaired patients with agitation only (P < .01). The reflux index was significantly higher in children with behavioral abnormalities than in children without abnormalities (P < .0004). In children without agitation or autoaggression, the pH measurements were all normal. Biopsies of esophageal mucosa revealed inflammation in 27 cases (first degree in 9; second degree in 12, and third degree in 6). Patients with autoaggressive behavior and those with agitation only had a significantly higher degree of inflammation compared with children without behavioral abnormalities (1.77 and 1.35 vs 0.25, respectively; P < .05). The degree of inflammation did not differ significantly among children with behavioral abnormalities.

Discussion

The present study suggests that in children with severe neurologic impairment, autoaggressive behavior or considerable agitation may be a marker for reoccurring or first-time-diagnosed pathologic GER. The severity of reflux correlates significantly to the behavior pattern resulting from experiencing pain. Pathologic GER should be excluded in all neurologically impaired children with behavioral abnormalities to prevent reflux-related complications and improve health-related quality of life.     

Long gap esophageal atresia: lengthening technique and primary anastomosis

Objective

The treatment of long gap esophageal atresia remains a major surgical challenge. The authors describe a modification of a lengthening technique based on tissue expansion to avoid sutures cutting through the esophagus.

Methods

Between January 2004 and August 2006, 4 patients did not respond to stretching, and underwent this modified esophageal lengthening technique using silastic tubes.

Results and Follow-up

All infants recovered and have an intact esophagus. All infants developed gastroesophageal reflux. Thal antireflux procedure was performed in the first infant. The other 3 patients were managed conservatively. Follow-up ranged between 6 and 34 months.

Conclusions

The tissue expansion principle can be successfully applied in the esophagus through external traction. Silastic tube fixation at esophageal ends may help to apply even traction and avoid sutures cutting through the esophageal tissue.     

Non-acid Gastroesophageal Reflux Measured Using Multichannel Intraluminal Impedance in Older Patients

Background

Diagnosing gastroesophageal reflux disease is challenging in the older population, as comorbid conditions can obscure the disease.

Methods

This prospective study included 97 participants: 25 healthy controls (group 1), 46 reflux patients aged 26–64 (group 2), and 26 patients over 65 (group 3). Esophageal motility was assessed using conventional esophageal manometry, and 24-h pH-metry and non-acid reflux episodes were assessed using multichannel intraluminal impedance.

Results

Among the older patients (group 3), 34% had reflux disease. The rate of lower esophageal sphincter insufficiency in group 3 was comparable with that in group 2 and significantly different from group 1. Gastric 24-h pH-metry showed no significant differences between the groups. Esophageal pH-metry results for groups 1 and 3 differed significantly from those in group 2. Impedance assessment showed that older patients have non-acid reflux episodes in the recumbent position significantly more often in comparison with controls and reflux patients. Reflux patients and older patients had proximal reflux episodes significantly more often than healthy volunteers.

Conclusions

Patients aged over 65 have non-acid reflux, particularly in the recumbent position, significantly more often than normal individuals and patients with reflux disease. Non-acid reflux may mimic a negative DeMeester score in older patients with severe reflux disease.

     

Omentopexy improves vascularization and decreases stricture formation of esophageal anastomoses in a dog model

Background

Anastomotic strictures are common after primary esophageal anastomosis in pediatric patients. Recent studies provided evidence that omentopexy may improve vascularization of gastroesophageal anastomoses and decrease the rate of stricture-related complications. The effect of omentopexy on primary esophago-esophageal anastomosis, however, is unknown. The aim of the current study was to examine the role of omentopexy on the healing process of primary midesopageal anastomoses.

Methods

Six dogs were operated on. A 5-cm portion of the midesophagus was resected, and continuity was restored by end-to-end anastomosis. In 3 dogs, an omental pedicle was placed around the anastomotic region. Eating patterns were recorded and functional swallowing was evaluated by fluoroscopic studies. Eight weeks after the operations, the experimental animals were killed and anastomotic lumen diameters and vascularization of the anastomotic sites were evaluated by radiographic studies and histologic examination, respectively.

Results

Two dogs in the omentopexy group were able to resume regular feeding, whereas none of the dogs in the control group were able to tolerate solid food intake. Fluoroscopic studies found preserved motility patterns of the esophagus in the omentoesophagopexy group, while prestenotic dilatation and delayed food clearance through the anastomosis were observed in the control group. Histologically, neovascularization was observed at the anastomotic site in the omentoesophagopexy group in contrast to the marked degree of fibrosis displayed in the control group.

Conclusions

Omentopexy may improve vascularization and decrease stricture formation after primary esophagoesophageal anastomosis.     

Influence of Mannose-Binding Lectin Gene Polymorphisms on The Invasiveness of Cytomegalovirus Disease After Solid Organ Transplantation

Background

Mannose-binding lectin (MBL) is a component of the innate immune system that binds the surface of pathogens, activating the complement pathway and acting as opsonin. Certain single-nucleotide polymorphisms of MBL2 are associated with a decrease in the circulating levels of MBL. Our aim was to evaluate the influence of MBL2 polymorphisms in the invasiveness of Cytomegalovirus (CMV) disease after solid organ transplantation.

Methods

We include those solid organ transplant recipients who developed CMV disease posttransplant from 2000 to 2006. MBL2 genotyping was performed by sequencing of exon 1 (wild-type allele A and variants B, C, and D) and promoter regions (alleles H and L, X and Y, and P and Q). In the case of liver transplantation, donor MBL2 genotypes were analyzed. Associations were calculated by the chi-square test and binary logistic regression.

Results

We included 45 transplant recipients with CMV disease (22 renal, 7 simultaneous kidney-pancreas, 11 liver, and 5 heart), of whom 10 (22%) had invasive CMV disease. No differences were found regarding HH (versus HL or LL), YY and YX (versus XX) and QQ (versus QP and PP) haplotypes with invasive CMV disease (P = 1.000 for all 3 comparisons). Patients with an exon 1 wild-type (AA) haplotype had 36% invasive CMV disease in comparison with 9% of patients with A/O or O/O haplotypes (P = .035). Binary logistic regression analysis showed that patients with exon 1 AA haplotype had an independent risk of developing invasive CMV disease (odds ratio, 6.0; 95% confidence interval, 1.1-32.5).

Conclusions

Our results suggest that exon 1 wild-type genotypes are associated with a higher risk of invasive CMV disease after solid organ transplantation.     

Long gap esophageal atresia and esophageal replacement: moving toward a separation?

Background/Purpose

Treatment of long gap esophageal atresia (EA) is still a major challenge. Gastric transposition and colon interposition are the 2 most popular choices for esophageal replacement, but there is general agreement that the child’s own esophagus is the best. The aim of the study was to critically evaluate the feasibility and outcome of primary repair of long gap EA with or without tracheoesophageal fistula (TEF) by direct esophago-esophageal anastomosis as the only technique.

Methods

Seventy-one neonates with EA+/−TEF were considered. Nineteen cases were classified as long gap (≥3 cm). All infants underwent either primary or shortly delayed repair. In the latter group, a gastrostomy was performed along with an x-ray evaluation of the gap a few days before surgery (mean age, 46.4 days). To avoid disruptive anastomotic force, all infants were kept paralyzed and mechanically ventilated for an additional 6 days after esophageal anastomosis. Before starting feeding, postoperative esophagogram was done on day 7. Endoscopy was done routinely, starting 1 month after surgery; pH monitoring was conventionally performed at 1 year of age or even earlier, should gastroesophageal reflux disease (GERD) be suspected. Follow-up ranged from 11 months to 7 years.

Results

In all 19 long gap EA infants an esophago-esophageal anastomosis was performed. Six of them (31%) required an anterior esophageal flap to bridge residual gap. Complications included minor anastomotic leak in 2 cases and anastomotic stricture (<5mm) in 12 (80%) cases, which were treated with an average of 5 dilatations (1 of which with resection of the stricture). GERD occurred in 8 cases (53.3%), of which, 3 required fundoplication. None of the patients had esophageal swallowing difficulties or persistent dysphagia. Two children experienced food aversion. Mean hospital stay was 66.2 (22 to 230) days. There were 4 deaths (very low birth weight, 1; associated anomalies, 1; and late sepsis, 2).

Conclusions

Considering heat gap determination remains imprecise, it seems possible to conclude that in a well-established tertiary care level referral center: (1) long gap EA could be treated successfully with primary repair and anastomosis; (2) strictures and GER represent the most frequent postoperative problem, but additional procedures required seem “acceptable” to maintain the patient’s own esophagus and avoid replacement; (3) esophageal substitution in long gap EA should be reserved for cases in which a previous attempt of esophageal reconstruction failed.     

Laparoscopic mesh-augmented hiatoplasty as a method to treat gastroesophageal reflux without fundoplication: single-center experience with 306 consecutive patients

Background

Laparoscopic fundoplication represents the surgical standard treatment of gastroesophageal reflux disease. However, because of persisting side effects the method is not without controversy. Laparoscopic mesh-augmented hiatoplasty might be an alternative.

Methods

In 306 consecutive patients the perioperative course and symptomatic outcome was analyzed after a mean follow-up period of 52 months.

Results

The mean DeMeester symptom score decreased from 5.3 to 2.0 (P < .001). Acid-suppressive therapy on a regular basis was discontinued in 79% of patients. The gas bloating value decreased from .7 to .5 (P = .031), and the dysphagia value increased from .5 to .9 (P < .001). Belching and vomiting were possible in 93% and 88% of patients, respectively. Mesh-related complications with the need for reoperation occurred in 1% of patients.

Conclusions

Laparoscopic mesh-augmented hiatoplasty is safe and does have an antireflux effect even without fundoplication. Side effects seem to be reasonable.