The role of esophageal sphincter tonus and of gastric motility in the extent of reflux esophagitis]

Thirty-two patients with symptomatic gastroesophageal reflux disease were investigated by esophagogastroduodenoscopy, 24 h pH monitoring, esophageal manometry and measurement of gastric emptying of solids, in order to elucidate the relative importance of lower esophageal sphincter tone, amount of acid reflux and gastric emptying on the degree of esophagitis. The mechanical competency of lower esophageal sphincter was significantly deranged in patients with moderate/severe esophagitis than in patients with mild esophagitis. The gastric emptying time was significantly delayed in patients with moderate/severe esophagitis than in patients with mild esophagitis. No relationship was observed between amount of acid reflux, lower esophageal sphincter function and gastric emptying time. Our results suggest that resting pressure of lower esophageal sphincter and the gastric motor function play a major role in severity of reflux esophagitis.     

Evaluation of the nissen antireflux procedure by esophageal manometry and twenty-four hour pH monitoring

Fifteen normal volunteers without symptoms of gastroesophageal reflux and sixteen patients with symptoms of gastroesophageal reflux unresponsive to medical management and having endoscopic esophagitis had esophageal manometry and twenty-four hour pH monitoring of the distal esophagus. The symptomatic patients underwent a Nissen antireflux procedure and were restudied at four months. After surgery, patients had less reflux, a higher sphincteric pressure, and an equal amount of sphincter within the abdomen as did asymptomatic control subjects.     

Endoscopic grading of the gastroesophageal valve in patients with symptoms of gastroesophageal reflux disease (GERD)

Background: It has been suggested that endoscopic grading of the gastroesophageal flap valve is a good predictor of the reflux status. Methods: To test this hypothesis, 268 symptomatic patients underwent endoscopic grading of the gastroesophageal valve using Hill's classification, with grades I through IV. Esophageal acid exposure, lower esophageal sphincter characteristics, and the degree of esophageal mucosal injury were compared among the groups. Results: The prevalence of a mechanically defective sphincter, abnormal esophageal acid exposure, erosive esophagitis, and Barrett's esophagus increased with increasing alteration of the gastroesophageal valve. The presence of a grade IV valve indicated increased esophageal acid exposure in 75% of patients. As a predictor, this is similar to lower esophageal sphincter pressure but not as good as the presence of esophageal mucosal injury. Conclusions: Endoscopic grading of the gastroesophageal valve provides useful information about the reflux status but is less useful as an indicator of gastroesophageal reflux disease (GERD) than the presence of esophageal mucosal injury. Received: 28 April 1999/Accepted: 23 June 1999     

Spontaneous rupture and functional state of the esophagus.

Esophageal function was investigated after 1 to 8 years in five consecutive patients surviving spontaneous esophageal rupture (Boerhaave's syndrome) and treated by suturation. Only one patient was symptom free and had almost normal esophageal function as judged by manometry, 24-hour pH monitoring, endoscopy, and barium swallow. In the other four patients reflux symptoms and a severe functional disturbance of the esophagus were observed. In four patients the manometry revealed a lack of propulsive peristaltic movements and esophageal muscular incoordination (particularly in the upper part of the esophagus) closely mimicking those seen in the nonspecific esophageal motility disorder. In 24-hour intraesophageal pH monitoring a pathologic gastroesophageal reflux with long-lasting single reflux periods was observed, suggesting poor esophageal clearance. Also endoscopic and histologic signs of reflux esophagitis were seen in the same four patients. In contrast, lower esophageal sphincter pressure was normal in all five survivors. It is concluded that patients with spontaneous esophageal rupture have a severe disturbance of esophageal motility. The concomitant reflux esophagitis may be caused primarily by the esophageal motility disturbance, which may also contribute to the origin of the rupture.     

Inflammation and specialized intestinal metaplasia of cardiac mucosa is a manifestation of gastroesophageal reflux disease.

OBJECTIVE: The purpose of the study was to test the hypothesis that cardiac mucosa, carditis, and specialized intestinal metaplasia at an endoscopically normal-appearing cardia are manifestations of gastroesophageal reflux disease. SUMMARY BACKGROUND DATA: In the absence of esophageal mucosal injury, the diagnosis of gastroesophageal reflux disease currently rests on 24-hour pH monitoring. Histologic examination of the esophagus is not useful. The recent identification of specialized intestinal metaplasia at the cardia, along with the observation that it occurs in inflamed cardiac mucosa, led the authors to focus on the type and condition of the mucosa at the gastroesophageal junction and its relation to gastroesophageal reflux disease. METHODS: Three hundred thirty-four consecutive patients with symptoms of foregut disease, no evidence of columnar-lined esophagus, and no history of gastric or esophageal surgery were evaluated by 1) endoscopic biopsies above, at, and below the gastroesophageal junction; 2) esophageal motility; and 3) 24-hour esophageal pH monitoring. The patients were divided into groups depending on the histologic presence of cardiac epithelium with and without inflammation or associated intestinal metaplasia. Markers of gastroesophageal reflux disease were compared between groups (i.e., lower esophageal sphincter characteristics, esophageal acid exposure, the presence of endoscopic erosive esophagitis, and hiatal hernia). RESULTS: When cardiac epithelium was found, it was inflamed in 96% of the patients. The presence of cardiac epithelium and carditis was associated with deterioration of lower esophageal sphincter characteristics and increased esophageal acid exposure. Esophagitis occurred more commonly in patients with carditis whose sphincter, on manometry, was structurally defective. Specialized intestinal metaplasia at the cardia was only seen in inflamed cardiac mucosa, and its prevalence increased both with increasing acid exposure and with the presence of esophagitis. CONCLUSION: The findings of cardiac mucosa, carditis, and intestinal metaplasia in an endoscopically normal-appearing gastroesophageal junction are histologic indicators of gastroesophageal reflux disease. These findings may be among the earliest signs of gastroesophageal reflux and contribute to the authors understanding of the pathophysiology of the disease process.     

Duodenogastric biliary reflux assessed by scintigraphic scan in patients with reflux symptoms after sleeve gastrectomy: preliminary results

BackgroundBile reflux is a factor in the appearance of severe esophagitis and Barrett’s esophagus, which have been reported after sleeve gastrectomy (SG). Incompetent lower esophageal sphincter and increased gastroesophageal acid reflux have been demonstrated after this operation. Some reports have shown bile content in the antrum during endoscopic control, but no investigations objectively confirm the presence of duodenogastric bile reflux in these patients.ObjectivesTo evaluate the presence of duodenogastric bile reflux (DGR) after SG in patients presenting reflux symptoms.SettingUniversity hospital.MethodsProspective study of 22 patients presenting reflux symptoms who underwent SG for morbid obesity and who received endoscopic evaluation and scintigraphic study to confirm esophagitis and duodenogastric bile reflux.ResultsErosive esophagitis was observed in 11 patients and Barrett’s esophagus in 2 patients. Seven patients (31.8%) presented positive DGR. Among them, 3 had type B and C esophagitis. The other 4 patients did not present esophagitis in spite of reflux symptoms.ConclusionDGR may be present in patients with gastroesophageal reflux after SG. This line of investigation requires further studies to confirm this hypothesis.     

On the pathogenesis of gastroesophageal reflux: the concept of gastroesophageal dyssynergia

OBJECTIVES: The cause of lower esophageal sphincter incompetence in gastroesophageal reflux disease is not clearly understood. We investigated the hypothesis that the esophagogastric junction incompetence results from failure of the gastric distention to produce the lower esophageal sphincter and crural diaphragm contraction caused by a disordered reflex action. METHODS: The study was performed in 19 subjects (mean age, 42.6 +/- 7.2 years; 11 men and 8 women) who had reflux esophagitis and hiatus hernia and were scheduled for a fundoplication operation. Eight control volunteers (mean age, 41.8 +/- 6.9; 5 men and 3 women) who had huge supraumbilical ventral hernia but no reflux esophagitis or hiatus hernia were studied during operative hernia repair. The electromyographic activity and pressure response of the lower esophageal sphincter and crural diaphragm to separate esophageal and gastric distention were recorded. RESULTS: In the control subjects (volunteers) esophageal distention caused diminished electromyographic activity of the crural diaphragm and lower esophageal sphincter with decreased esophagogastric junction pressure, whereas gastric distention increased the electromyographic activity of the crural diaphragm and lower esophageal sphincter with increased esophagogastric junction pressure. In the patients the crural diaphragm and lower esophageal sphincter showed diminished resting electromyographic activity, with either no response or a paradoxical response to esophageal or gastric distention. CONCLUSION: The current study has demonstrated that the lower esophageal sphincter and crural diaphragm in patients with gastroesophageal reflux disease exhibited a diminished resting electric activity and either did not respond or reacted paradoxically to esophageal and gastric distention, constituting what we call esophagosphincteric and gastroesophageal paradox or dyssynergia. The cause of lower esophageal sphincter and crural diaphragm dysfunction is not known; a neurogenic cause was proposed. Further studies are required to investigate this point.     

Gastroesophageal reflux disease and mucosal injury with emphasis on short-segment Barrett’s esophagus and duodenogastroesophageal reflux

Gastroeosphageal reflux disease has been associated with long segments of Barrett’s esophagus (≥3 cm), but little is known about its association with shorter segments. The aim of this study was to evaluate anatomic and physiologic alterations of the cardia and esophageal exposure to gastric and duodenal juice in patients with short and long segments of Barrett’s esophagus. Furthermore, these patients were compared to each other and to patients with erosive esophagitis and those with no mucosal injury. Two hundred sixty-two consecutive patients with foregut symptoms were divided into the following four groups based on endoscopic and histologic findings: group 1, no mucosal injury; group 2, erosive esophagitis; group 3, short-segment Barrett’s esophagus; and group 4, long-segment Barrett’s esophagus. Esophageal exposure time to acid and bilirubin, lower esophageal sphincter characteristics, and endoscopie anatomy of the cardia were compared between the groups. Patients with short-segment Barrett’s esophagus had elevated esophageal acid and bilirubin exposure, decreased lower esophageal sphincter pressure and length, and a high incidence of hiatal hernia. These abnormalities were similar to those in patients with esophagitis and in general less profound than those found in patients with long-segment Barrett’s esophagus. The length of intestinal metaplasia was higher in patients with a defective lower esophageal sphincter. Short-segment Barrett’s esophagus is a complication of severe gastroesophageal reflux disease and is associated with the reflux of both gastric and duodenal juice similar to that seen in patients with long-segment Barrett’s esophagus. Presented at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14,1997.     

Techniques and outcomes of laparoscopic surgery in gastroesophageal reflux disease

BACKGROUND: The purpose of this study is to report personal experience in laparoscopic antireflux surgery and to analyze the clinical and functional outcomes of this procedure, also in relation to the different techniques used. METHODS: From 1996 to 2000, 20 patients with gastroesophageal reflux disease associated with hiatal hernia underwent laparoscopic surgery. The indication for surgery was failure of long-term medical therapy. All patients had severe acid reflux on 24 hrs-pH monitoring, endoscopic evidence of esophagitis and hiatal hernia, and defective lower esophageal sphincter. A Nissen fundoplication was performed in 13 patients with normal esophageal body motility, and a 270 degrees posterior fundoplication in seven patients with low esophageal motility. RESULTS: Mortality and conversion rate were 0. Mean operative time was 135 min and mean postoperative hospital stay 5 days. Operative morbidity was 15%. All the patients were completely cured of reflux symptoms; transient mild postoperative dysphagia occurred in two patients (10%). There was a significantly improvement of the results in postoperative esophageal manometry and 24 hrs-pH monitoring. CONCLUSIONS: This preliminary experience suggests that laparoscopic surgery represents a safe and effective procedure for the treatment of gastroesophageal reflux disease. Precise selection of patients and adequate surgical technique are essential.     

Effect of antireflux operation on Barrett's mucosa

Regression of Barrett's epithelium after antireflux operations remains a controversial topic. We evaluated the effect of antireflux procedures in patients with Barrett's esophagus on the regression of columnar epithelium and dysplasia and its potential protective effect on the subsequent development of carcinoma. Of the 241 patients with Barrett's esophagus treated at the Lahey Clinic from 1973 to 1989, 37 patients underwent an antireflux operation. Regression was defined as histological evidence of regenerating squamous mucosa that completely or partially replaced the columnar epithelium. Improvement in lower esophageal sphincter pressure to 12 mm Hg or greater occurred in 19 of 26 patients (73%) who had perioperative manometry. Symptomatic relief of esophagitis occurred in 34 of 37 patients (92%). Four patients had partial regression with regenerating squamous mucosa juxtaposed with areas of columnar epithelium. Carcinoma developed in 3 of 37 patients (8.1%). One patient had recurrence of severe symptoms of reflux esophagitis before development of carcinoma. Patients with Barrett's esophagus who have undergone a successful antireflux operation with symptomatic relief and evidence of improvement in lower esophageal sphincter pressures rarely show regression of Barrett's mucosa and may still be at risk for development of carcinoma. Therefore, the indications for antireflux operation in Barrett's esophagus should remain the same as for other patients with gastroesophageal reflux, but yearly endoscopic and histological surveillance should be continued postoperatively.     

Diagnosis of gastroesophageal reflux and Barrett esophagus

Gastroesophageal reflux is a very common disorder. Typical symptoms are heartburn, regurgitation and chest pain. Recently, it has been demonstrated that gastroesophageal reflux may generate or worse extraesophageal symptoms such as asthma, chronic bronchitis, posterior laryngitis, and chronic cough. The diagnosis of gastroesophageal reflux is suggested by typical symptoms which improve under a therapy with proton pump inhibitors. pH-monitoring over 24 hours is able to establish directly the diagnosis by measuring acid reflux into the esophagus. Manometry detects the two most common causes of gastroesophageal reflux: insufficiency of the lower esophageal sphincter or esophageal motility abnormalities. Gastroesophageal reflux can lead to reflux esophagitis, which is diagnosed endoscopically. An endoscopy should routinely be performed in case of dysphagia, anemia, or loss of weight. A long-term sequela of gastroesophageal reflux is the development of Barrett's-esophagus, a condition which has to be verified by endoscopy and biopsy. This premalignant lesion is defined by a metaplastic change from the normal squamous mucosa to a specialized intestinal epithelium characterized by goblet cells. Because dysplasia in these metaplastic areas can lead to esophageal adenocarcinoma, regular endoscopic surveillance with biopsies is recommended. Gastroesophageal reflux can significantly impair the quality of life and can cause complications that include the neoplastic progression from Barrett's esophagus to carcinoma. Therefore, appropriate diagnostic procedures and adequate therapy are required. This article summarizes the diagnostic approach to patients with gastroesophageal reflux, reflux esophagitis and Barrett's-esophagus. The impact of endoscopy, pH-monitoring, esophageal manometry, radiology and scintigraphy are reviewed.     

The extent of Barrett's esophagus depends on the status of the lower esophageal sphincter and the degree of esophageal acid exposure

OBJECTIVE: The purpose of this study was to assess whether the extent of intestinal metaplasia is related to the severity of the gastroesophageal reflux disease. METHODS: A total of 556 consecutive patients with symptoms suggestive of foregut disease had upper gastrointestinal endoscopy with extensive biopsies from the gastroesophageal junction and the esophagus. All patients had esophageal motility and 24-hour pH monitoring. In 411 patients, cardiac-type mucosa was identified; in 147 patients, the cardiac-type mucosa showed intestinal metaplasia. They were divided into 3 groups based on the extent of intestinal metaplasia commonly seen clinically: long segments (>3 cm), short segments (<3 cm), and limited to the gastroesophageal junction. The duration of symptoms, the status of the lower esophageal sphincter, the degree of esophageal acid exposure, and the time to clear a reflux episode were assessed in each group. RESULTS: The presence of intestinal metaplasia in cardiac-type mucosa was associated with the hallmarks of gastroesophageal reflux disease. The extent of intestinal metaplasia correlated strongly with the degree of esophageal acid exposure (r = 0.711; P <.001) and inversely with the lower esophageal sphincter pressure (r = 0.351; P <.001) and length (r = 0. 259; P =.002). Patients with a long segment of intestinal metaplasia (>3 cm) had longer duration of symptoms (16 years) than those patients with a segment of intestinal metaplasia less than 3 cm (10 years; P =.048) or those patients with intestinal metaplasia limited to the gastroesophageal junction (10 years; P =.01). CONCLUSION: The extent of intestinal metaplasia, that is, Barrett's esophagus, is related to the status of the lower esophageal sphincter and the degree of esophageal acid exposure.     

The treatment of gastroesophageal reflux disease with laparoscopic Nissen fundoplication: prospective evaluation of 100 patients with "typical" symptoms.

OBJECTIVE: To evaluate prospectively the outcome of laparoscopic fundoplication in a large cohort of patients with typical symptoms of gastroesophageal reflux. SUMMARY BACKGROUND DATA: The development of laparoscopic fundoplication over the past several years has resulted in renewed interest in the surgical treatment of gastroesophageal reflux disease (GERD). METHODS: One hundred patients with typical symptoms of GERD were studied. The study was limited to patients with positive 24-hour pH studies and "typical" symptoms of GERD. Laparoscopic fundoplication was performed when clinical assessment suggested adequate esophageal motility and length. Outcome measures included assessment of the relief of the primary symptom responsible for surgery; the patient's and the physician's evaluation of outcome; quality of life evaluation; repeated upper endoscopy in 30 patients with presurgical esophagitis; and postsurgical physiologic studies in 28 unselected patients, consisting of 24-hour esophageal pH and lower esophageal sphincter manometry. RESULTS: Relief of the primary symptom responsible for surgery was achieved in 96% of patients at a mean follow-up of 21 months. Seventy-one patients were asymptomatic, 24 had minor gastrointestinal symptoms not requiring medical therapy, 3 had gastrointestinal symptoms requiring medical therapy, and 2 were worsened by the procedure. Eighty-three patients considered themselves cured, 11 were improved, and 1 was worse. Occasional difficulty swallowing not present before surgery occurred in 7 patients at 3 months, and decreased to 2 patients by 12 months after surgery. There were no deaths. Clinically significant complications occurred in four patients. Median hospital stay was 3 days, decreasing from 6.3 in the first 10 patients to 2.3 in the last 10 patients. Endoscopic esophagitis healed in 28 of 30 patients who had presurgical esophagitis and returned for follow-up endoscopy. Twenty-four-hour esophageal acid exposure had returned to normal in 26 of 28 patients studied after surgery. Lower esophageal sphincter pressures had also returned to normal in all patients, increasing from a median of 5.1 mmHg to 14.9 mmHg. CONCLUSIONS: Laparoscopic Nissen fundoplication provides an excellent symptomatic and physiologic outcome in patients with proven gastroesophageal reflux and "typical" symptoms. This can be achieved with a hospital stay of 48 hours and a low incidence of postsurgical complications.     

Radiologic and Endoscopic Characteristics of Laparoscopic Antireflux Wrap: Correlation With Outcome

After antireflux surgery for gastroesophageal reflux disease, 10% to 15% of patients may have unsuccessful results as a result of abnormal restoration of the esophagogastric junction. The purpose of this study was to evaluate the postoperative endoscopic and radiologic characteristics of the antireflux barrier and their correlation with the postoperative results. After surgery, endoscopic and radiologic features of the antireflux wrap were evaluated in 120 consecutive patients. Jobe''s classification of the postoperative valve was used for the definition of a “normal” or “defective” wrap. Patients were evaluated 3 to 5 years later in order to determine the clinical and objective failed fundoplication. A “normal” antireflux wrap was associated with successful results in 81.7% of the patients. On the contrary, defective radiologic or endoscopic antireflux wrap was observed in 19% of cases. Among these patients, hypotensive lower esophageal sphincter was observed in 50% to 65% of patients, abnormal 24-hour pH monitoring in 91%, and recurrent postoperative erosive esophagitis in 50% of patients, respectively (P < 0.001). “Defective” antireflux fundoplication is associated with recurrent reflux symptoms, presence of endoscopic esophagitis, hypotensive lower esophageal sphincter, and abnormal acid reflux.     

Acute food bolus impaction without stricture in children with gastroesophageal reflux

BACKGROUND/PURPOSE: This report identifies a group of children in whom severe acute food bolus impaction (AFBI) was the leading symptom of gastroesophageal reflux (GER) in the absence of stricture. METHODS: The esophageal structure and function of 8 patients treated for AFBI requiring endoscopic removal of alimentary foreign bodies in 6 of them (up to 4 times in 1 case) were investigated by barium meal, esophagoscopy-biopsy, pH-metering, pull-through stationary manometry, and 24-hour ambulatory manometry. The results were compared with those in a group of age-matched regular refluxers (n = 14) without AFBI. RESULTS: Six boys and 2 girls aged 108 +/- 59 months had impaction. Six children had symptoms of GER like vomiting during infancy, heartburn, or respiratory tract disease. Barium swallow ruled out stenosis in all patients and showed small hiatal hernias in 3. All had endoscopic and histologic esophagitis (moderate to severe in 6), and one had Schatzki ring. All but one (who had 8.45 mm Hg) had normal lower esophageal sphincter pressure (16.2 +/- 4.7 mm Hg, mean +/- SD), and all showed normal sphincteric relaxation. Esophageal body motility was not significantly different from that in regular refluxers except in 6 children in whom energetic distal peristalsis after reflux episodes could be seen particularly during the night. Three of them had amazingly powerful distal waves during the day and even stronger, simultaneous, wide and bizarre-shaped waves during sleep. Symptoms improved in all cases after antireflux medication. Four patients were cured after antireflux surgery. CONCLUSIONS: AFBI is a dramatic but practically unheard of symptom of GER in children. It should be differentiated from dysphagia and reveals motor dysfunction, sometimes severe, of the esophageal body in the absence of sphincteric obstruction. Antireflux medication or surgery were uniformly successful in our patients.     

Gastric banding interferes with esophageal motility and gastroesophageal reflux

BACKGROUND: Gastroesophageal reflux and progressive esophageal dilatation can develop after gastric banding (GB). HYPOTHESIS: Gastric banding may interfere with esophageal motility, enhance reflux, or promote esophageal dilatation. DESIGN: Before-after trial in patients undergoing GB. SETTING: University teaching hospital. PATIENTS AND METHODS: Between January 1999 and August 2002, 43 patients undergoing laparoscopic GB for morbid obesity underwent upper gastrointestinal endoscopy, 24-hour pH monitoring, and stationary esophageal manometry before GB and between 6 and 18 months postoperatively. MAIN OUTCOME MEASURES: Reflux symptoms, endoscopic esophagitis, pressures measured at manometry, esophageal acid exposure. RESULTS: There was no difference in the prevalence of reflux symptoms or esophagitis before and after GB. The lower esophageal sphincter was unaffected by surgery, but contractions in the lower esophagus weakened after GB, in correlation with preoperative values. There was a trend toward more postoperative nonspecific motility disorders. Esophageal acid exposure tended to decrease after GB, with fewer reflux episodes. A few patients developed massive postoperative reflux. There was no clear correlation between preoperative testing and postoperative esophageal acid exposure, although patients with abnormal preoperative acid exposure tended to maintain high values after GB. CONCLUSIONS: Postoperative esophageal dysmotility and gastroesophageal reflux are not uncommon after GB. Preoperative testing should be done routinely. Low amplitude of contraction in the lower esophagus and increased esophageal acid exposure should be regarded as contraindications to GB. Patients with such findings should be offered an alternative procedure, such as Roux-en-Y gastric bypass.     

Intraoperative measurement of lower esophageal spincter pressure.

The lower esophageal sphincter pressure has been measured intraoperatively in 200 patients with gastroesophageal reflux and in three patients with achalasia. Lower esophageal sphincter pressure is measured before and during repair. Calibrating the cardia during performance of the median arcuate posterior gastropexy allows a sphincter pressure between 50 and 57 mm. Hg to be obtained at operation. The postoperative pressures have ranged between 15 and 25 mm. Hg, or approximately half of the intraoperative pressure. No patient with a spincter pressure of 15 mm. Hg or greater has reflux according to postoperative pH and pressure studies. Correction of reflux correlates well with relief of symptoms. Three patients with achalasia had intraoperative manometrics during myotomy. The lower esophageal sphincter pressure was lowered and the length of the lower esophageal sphincter was shortened. Dysphagia was corrected without producing reflux. This is the first report of measurement of lower esophageal sphincter pressure in anesthetized patients. Intraoperative measurement of sphincter pressure is a safe, simple, and reliable technique which allows the surgeon, for the first time, to determine the status of the lower esophageal sphincter during the operation. This technique should be standard for all operations on the gastroesophageal junction.     

Long-term esophageal function following repair of esophageal atresia.

Primary repair of esophageal atresia restores gastrointestinal continuity, but does not ensure normal esophageal function. To date 22 patients, six to 32 (average 15) years after repair of their esophageal atresias, have been evaluated by personal interview and esophageal manometrics and acid reflux testing. Previous barium swallow examinations had demonstrated varying degrees of anastomotic narrowing (12 patients), abnormal esophageal motor function (11 patients), gastroesophageal reflux (two patients), and hiatal hernia (one patient). Ten patients experience intermittent dysphagia for solid foods. Seven have typical symptoms of gastroesophageal reflux. Esophageal function tests including manometry and intraesophageal pH recording, have demonstrated varying abnormalities of esophageal motility in 21 patients and moderate to severe gastroesophageal reflux in 13. Two patients have required reconstruction of the esophagogastric junction for control of severe reflux esophagitis. The unexpected high incidence of gastroesophageal reflux in these patients, coupled with their abnormal esophageal motility which impairs normal acid clearing, renders them more prone to reflux esophagitis. Careful long-term evaluation for gastroesophageal reflux and its complications is indicated following primary repair of esophageal atresia. Evaluation of esophageal function with intraesophageal pressure and pH recordings is a far more sensitive indicator of esophageal physiology than the barium swallow examination.     

Nissen fundoplication for reflux esophagitis. Long-term clinical and endoscopic results in 109 of 127 consecutive patients.

OBJECTIVE: This study evaluates the clinical and endoscopic long-term results of Nissen fundoplication in reflux esophagitis. SUMMARY BACKGROUND DATA: Nissen fundoplication has been reported to give good results in the treatment of gastroesophageal reflux with success rates up to 78-97%. Most of the previous studies on long-term results of fundoplication have, however, been based on interviews with only sporadic endoscopic examinations. METHODS: Of 127 patients consecutively treated with Nissen fundoplication for reflux esophagitis, 109 were available for follow-up after a median of 77 months. Upper gastrointestinal endoscopy was done in 105 cases, and all the patients with reflux symptoms or abnormal endoscopic observations were referred to esophageal 24-hour pH monitoring and manometry. RESULTS: No symptoms of gastroesophageal reflux were reported by 73 of the 109 patients, but dysphagia was present in 47. Endoscopy showed defective fundic wrap in 24 patients. Objective evidence of reflux was found in 24 patients (endoscopic esophagitis in 18 and pathologic 24-hour pH score without esophagitis in 6). Esophagitis was found in 14 of the 24 patients with defective wrap, but in only 4 of the 81 with infact wrap. CONCLUSIONS: Nissen fundoplication alleviated symptoms of gastroesophageal reflux and cured esophagitis in great majority of cases. The main determinant of outcome was the state of the fundic wrap.     

Factors affecting esophageal motility in gastroesophageal reflux disease

BACKGROUND: There are conflicting data concerning the effect of gastroesophageal reflux disease (GERD) on esophageal motor function. HYPOTHESIS: Duration of GERD might affect severity of symptoms, grade of esophageal mucosal injury, and esophageal motor behavior. DESIGN: Retrospective study of a defined cohort. SETTINGS: Two referral centers, one of them academic, for esophageal gastrointestinal motility disorders. PATIENTS: One hundred forty-seven patients with documented GERD. MAIN OUTCOME MEASURES: Symptoms, grade of mucosal injury on esophagoscopy, esophageal manometry, ambulatory esophageal pH monitoring, and esophagogram. RESULTS: Patients with GERD had significantly decreased lower esophageal sphincter resting pressure (P =.02), lower amplitude of esophageal peristalsis at all levels of measurement (P<.001), and more delayed esophageal transit (P =.007) compared with control subjects. Patients with dysphagia, severe esophagitis, and Barrett esophagus presented with a longer history of the disease, significantly worse esophageal motor function (P<.01), and more prolonged esophageal transit than patients without the above features of the disease. Impairment of esophageal peristalsis and lower esophageal sphincter resting pressure were significantly inversely related to the duration of the disease (P<.001). Also, delay of esophageal transit was significantly related to the duration of the disease (P =.002) and inversely related to the amplitude of esophageal peristalsis (P<.001). Unlike the manometric variables, the extent of reflux, as assessed by ambulatory 24-hour esophageal pH monitoring, was not related to the duration of the disease. CONCLUSION: A long history of GERD is more commonly associated with presence of dysphagia, delayed esophageal transit, severe esophagitis, presence of Barrett esophagus, and impaired esophageal motility.