A Buccal Mucosal Harvesting Technique for Urethral Reconstruction

Purpose

A step-by-step harvesting technique for buccal mucosa is described that maximizes graft yield while minimizing potential donor site morbidity in urethral reconstruction.

Materials and Methods

A specialized oral retractor was used to expose and retract the buccal mucosal lining of the oral cavity for graft harvesting in 12 patients.

Results

Adequate buccal mucosal graft size was obtained for each reconstruction. There were no oral donor site or urethral recipient site complications.

Conclusions

This harvesting technique offers a simple and effective method for optimizing buccal mucosal graft harvests.     

Initial Experience with New Intraluminal Devices for GERD Barrett’s Esophagus and Obesity

Background

Transoral intraluminal surgery is less painful. However, endoscopic antireflux procedures have been unsuccessful, endoscopic foregut mucosal excision procedures are often difficult to perform, and endoscopic intra-luminal suturing is both imprecise and too shallow. We have endeavored to correct these deficiencies and report here new devices for GERD, obesity, and Barrett’s mucosal excision.

Method

A retrospective review of ex vivo and in vivo animal experiments using sharp blade mucosal excision for esophageal and gastric mucosa and a suturing device with transverse needles designed to full thickness penetrate the gastric wall were completed. A total of 338 excisions were performed in 134 ex vivo tissue experiments and in 119 in vivo attempts. Suture needle testing was performed in ex vivo human stomachs and porcine stomachs and in in vivo canine and baboon stomachs.

Results

One excision perforation (0.9%) occurred in a live animal. Satisfactory mucosal excision depth for the Barrett’s device was reproducible. Progressive suture actuation reliability improved from 83% during ex vivo testing to 96.7% in in vivo experiments.

Conclusion

The results demonstrate feasibility, reliability, and safety for gastric and esophageal mucosal excision. Suturing reliability improved and further studies will be performed to finalize the instrument designs, the operative techniques, and the other device applications.

     

Influence of lower third molar position on the incidence of preoperative complications.

OBJECTIVE: The present study sought to relate the clinical outcome of mandibular third molar impaction surgery to the orthopanoramic radiographically determined position of the affected teeth based on the classifications of Pell and Gregory, and Winter. STUDY DESIGN: A retrospective study was made of 165 patients undergoing the surgical extraction of lower third molars at School of Dentistry of the University of Barcelona, Barcelona, Spain. The positions of the 259 extracted third molars were documented according to the classifications of Pell and Gregory, and Winter, together with the type of mucosal and bony coverage involved. These tooth position parameters were radiologically assessed using Radio Memory software and were retrospectively correlated to the observed infectious, noninfectious, and neurological postsurgical outcomes. RESULTS: A statistically significant relationship (P < .05) was recorded between the appearance of infectious complications and the position parameters "Pell and Gregory classification," "mucosal coverage," and "bony coverage." A statistically significant relationship (P < .05) was observed between the appearance of noninfectious problems and the parameter "Winter classification." Finally, a significant association (P < .05) was recorded between the position variables and the existence of unwanted neurological changes. CONCLUSIONS: The mandibular position of the impacted third molar may be able to be correlated to the development of complications resulting from impaction removal. Vertical third molars in positions IIA and IIB of the Pell and Gregory classification, with partial mucosal and bony coverage, are the most susceptible to undesired outcomes.     

Omeprazole is More Effective than Famotidine for Preventing Acute Gastritis in Rats

Purpose Acute gastric mucosal lesions, which can develop within a few hours after polytrauma, shock, major operations, central nervous system lesions, or severe infection, cause about 33% of cases of gastrointestinal bleeding. We analyzed and compared the effectiveness of famotidine and omeprazole on acute gastric mucosal lesions.Methods Thirty male albino Wistar rats were given ketalar anesthesia after 12h fasting, then immobilized and exposed to stress according to Brodies protocol, without restricting their respiration. We divided the rats into three groups of ten according to whether they were given famotidine, omeprazole, or normal saline (control group). All rats were ulcer-indexed according to the diameter of their ulcers. The stomach contents were aspirated for acid output and pH analysis, and sent to the laboratory. The total number of mast cells was also counted.Results Omeprazole was more effective than famotidine in keeping gastric pH high and lowering the total gastric acid output. Lower ulcer indexes in acute gastric mucosal erosions and better protected mucosal integrity were found in the omeprazole-treated rats.Conclusion Omeprazole prevents acute gastric mucosal erosions in rats more effectively than famotidine.     

Mucosal Perforation During Laparoscopic Heller Myotomy Has No Influence on Final Treatment Outcome

Background

The aims of the study were (a) to examine the final outcome in patients experiencing accidental mucosal perforation during laparoscopic Heller myotomy with Dor fundoplication (LHD) and (b) to evaluate whether perforation episodes might influence the way in which surgeons subsequently approached the LHD procedure.

Methods

We studied all consecutive patients that underwent LHD between 1992 and 2015. Patients were divided into two main groups: those who experienced an intraoperative mucosal perforation (group P) and those whose LHD was uneventful (group NP). Two additional groups were compared: group A, which consisted of patients operated by a given surgeon immediately before a perforation episode occurred, and group B, which included those operated immediately afterwards.

Results

Eight hundred seventy-five patients underwent LHD; a mucosal perforation was detected in 25 patients (2.9 %), which was found unrelated to patients’ symptom’s score and age, radiological stage, manometric pattern, or the surgeon’s experience. The median postoperative symptom score was similar for the two groups as the failure rate: 92 failures in group NP (10.8 %) and 4 in group P (16 %) (p?=?0.34); moreover, symptoms recurred in 2 patients of group A (10 %) and 3 patients of group B (15 %) (p?=?0.9).

Conclusions

Accidental perforation during LHD is infrequent and impossible to predict on the grounds of preoperative therapy or the surgeon’s personal experience. Despite a longer surgical procedure and hospital stay, the outcome of LHD is much the same as for patients undergoing uneventful myotomy. A recent mucosal perforation does not influence the surgeon’s subsequent performance.

     

Initial Assessment of Mucosal Capture and Leak Pressure After Gastrointestinal Stapling in a Porcine Model

Background

Anastomotic leak is a leading cause of morbidity and mortality in gastrointestinal surgery. The serosal aspect of staple lines is commonly observed for integrity, but the mucosal surface and state of mucosa after firing is less often inspected. We sought to assess the degree of mucosal capture when using stapling devices and determine whether incomplete capture influences staple line integrity.

Methods

Porcine ileum was transected in vivo and staple lines were collected and rated for degree of mucosal capture on a 5-point scale from 1 (mucosa mainly captured on both sides) to 5 (majority of mucosa not captured). Mucosal capture was also assessed in ex vivo staple lines, and fluid leakage pressure and location of first leak was assessed. Stapling devices studied were Echelon Flex GST with 60-mm blue (GST60B) and green (GST60G) cartridges, and Medtronic EndoGIA Universal with Tri-Staple Technology? with 60 mm medium (EGIA60AMT) reloads (purple).

Results

GST60B and GST60G staple lines produced significantly better mucosal capture scores than the EGIA60AMT staple lines (p?<?0.001, in all tests). Compared to EGIA60AMT, leak pressures were 39% higher for GST60B (p?<?0.001) and 23% higher for GST60G (p?=?0.022). Initial staple line leak site was associated with incomplete mucosal capture 78% of the time.

Conclusions

There are differences in degree of mucosal capture between commercial staplers, and the devices that produce better mucosal capture had significantly higher leak pressures. Further research is needed to determine the significance of these findings on staple line healing throughout the postoperative period.

     

Influence of cold on stress ulceration and on gastric mucosal blood flow and energy metabolism.

"Ice-cold" gastric lavage is an important part of the treatment of bleeding from stress ulceration. The purpose of this study was to find out if cooling modifies ischemic injury of the gastric mucosa. Four series of experiments were performed in rabbits. In the first, we studied the influence of cooling on the rate of breakdown of gastric mucosal high energy phosphates during complete, ex vivo ischemia achieved by rapid excision of the stomach. We then studied the influence of cold versus warm gastric lavage on the severity of gastric mucosal injury and on the rate of breakdown of gastric mucosal adenosine phosphates during hemorrhagic shock. In a fourth series of experiments, we examined the influence of cold versus warm gastric lavage on gastric mucosal blood flow measured by injection of radioactive microspheres. Although the rate of breakdown of mucosal high energy phosphates was less rapid during a short period of complete, ex vivo ischemia when the stomach was cooled, this rate was more rapid during hemorrhagic shock under in vivo conditions when the stomach was lavaged with cold solution. The latter also increased the severity of shock-induced gastric mucosal injury. Cold gastric lavage reduced gastric mucosal blood flow before, during and after hemorrhagic shock.     

Occult mucosal injuries with radiofrequency ablation of the palate.

OBJECTIVE: To determine the true incidence of mucosal injury after radiofrequency ablation of the palate (RFAP) for snoring and mild obstructive sleep apnea, and to evaluate the consequences of this injury. STUDY DESIGN AND SETTING: A prospective, nonrandomized analysis of RFAP was undertaken at Stanford University Hospital. Endoscopic examinations of the nasal surface of the palate and of the posterior pharyngeal wall were performed to supplement the routine oral cavity examinations in the postoperative period. Visual analog scales of pain were completed by the patients. Twenty-three patients underwent a total of 54 RFAP procedures using the Somnus system at the recommended level of energy (600 J in the midline palate, and 300 J to each lateral palate). RESULTS: Fourteen of the 23 first stage procedures were associated with a total of 16 mucosal injuries representing an incidence of 60.9%. Mucosal injury at the 1st stage prompted a reduction in energy at the 2nd stage to 500 J in the midline and 250 J laterally; there were 4 injuries among 19 2nd stage procedures (21.1%). The overall incidence of mucosal injury, including stage 3 and 4 procedures, was therefore 42.6%; 37% of these were "occult" (only visualized endoscopically). CONCLUSIONS AND SIGNIFICANCE: RFAP, although intended to be mucosa-sparing, is nevertheless associated with a high incidence of mucosal injuries, many of which are occult. The occurrence of these mucosal ulcers is usually associated with only a trivial degree of increased pain postoperatively.     

Total orthotopic small bowel allotransplantation in the dog. Features of atypical rejection and graft-versus-host reaction

The critical histologic review of our experience with small bowel allotransplantation in the dog is presented. While "classical" rejection with dense small cell infiltration and mucosal destruction does occur, more common is the "atypical" rejection reaction in which cellular infiltration is sparse. This "atypical" rejection was characterized by a significant decrease of mucosal epithelial structures with increased mitotic figures in crypt cells and frequent vascular changes, including segmental fibrinoid necrosis and thrombosis with or without overlying mucosal destruction. Substantial regenerating capacity of bowel mucosa tends to compensate for the destruction, complicating the histology. The host lymph nodes and spleen present a histologic picture highly suggestive of GVH reaction. The reduction in host lymphocytes in these organs from karyorrhexis with replacement by histiocytes and subsequently by plasma cells is described. It is emphasized that rejection and GVH are not mutually exclusive and occur simultaneously. The decrease of functional mucosal mass could well account for the nutritional malsequelae. Also, the weakening of immune structures on the host and the graft side may predispose to catastrophic enterogenous infections, perhaps explaining the large number of animals that die without overt signs of rejection following small bowel transplantation.     

Robotic intragastric surgery: A new surgical approach for the gastric lesion

Background

Intragastric surgery is accepted as a minimally invasive procedure for mucosal or submucosal lesions. Robotic surgery promises to extend the capabilities of the minimally invasive surgeon and many surgical specialties are applying this new technology. However, there is no report of robotic intragastric surgery. We describe the use of the da Vinci^® Surgical System for intraluminal mucosal resection of the stomach.

Methods

We developed our porcine intragastric surgery model using the Tuebingen MIS Trainer. We set a tentative lesion on the posterior wall near the esophagocardiac junction (ECJ) of the stomach and performed mucosal resection of the lesion using the da Vinci Surgical System. We also performed closure of the defect after mucosal resection and subsequent closure of the intentional gastric perforation.

Results

Using our porcine intragastric surgery model, we successfully performed mucosal resection of the tentative lesion. We also smoothly completed closure of the defect and closure of the perforation without any complications. The mean size of the mucosa was 6 cm and the mean duration of the procedure was only 12 min.

Conclusions

The safety and efficacy of robotic intragastric surgery was preliminarily established in this study. However, further studies are needed to prove its practical feasibility in humans using the da Vinci Surgical System to make it an effective operation.

     

Mucosal nerve deficiency in chronic childhood constipation: a postmigration defect?

Purpose

Idiopathic chronic childhood constipation (ICCC) includes children who are severely constipated and who are resistant to behavioral or medical treatments. These children are distinguished from those with Hirschsprung's disease (HSCR) by the presence of enteric ganglia in rectal biopsy specimens. We investigated potential autonomic dysfunction by examining nerves in rectal mucosa.

Methods

Immunostaining, confocal microscopy, and nerve analysis were performed on formalin-fixed and on Zamboni-fixed rectal biopsy specimens from children who were severely constipated. A computer-assisted neuron tracing technique was used to determine mucosal nerve density in Zamboni-fixed biopsy sections.

Results

Nerves in Zamboni-fixed biopsy specimens were better stained than in formalin-fixed biopsy specimens. Regardless of fixation method, a deficiency of mucosal nerves was observed in ICCC when compared to children who are not constipated. Analysis of autotraced mucosal nerves confirmed the deficiency in ICCC biopsy specimens. Mucosal nerves were also severely deficient in patients with HSCR, even in transitional segments that contained ganglia.

Conclusions

Most patients with ICCC had decreased innervation of the rectal mucosa. Because mucosal nerves are critical for the peristaltic reflex, water secretion, and absorption, their deficiency can be related to patient constipation. Mucosal nerve density provides a pathologic basis for diagnosis of dysfunction in children who do not have HSCR but are chronically constipated. The study validates the neuron tracing method for objective evaluation of mucosal innervation.     

加速康复外科模式对腹腔镜下胰十二指肠切除术后患者肠道黏膜屏障影响的研究

目的研究加速康复外科(ERAS)模式对腹腔镜下胰十二指肠切除术(LPD)术后患者的肠黏膜屏障功能的影响。方法回顾性分析2015年1月至2018年12月接受LPD术的患者145例,根据干预方案不同分为ERAS组78例及传统组67例。数据采用SPSS 24.0进行统计学分析,术后并发症发生率等计数资料采用χ^2检验;围术期各项指标、肠黏膜屏障功能指标以(±s)表示,独立t检验;P<0.05为差异有统计学意义。结果ERAS组术后恢复情况均优于传统组,其中首次排气时间、首次进食时间、引流管拔管时间及术后住院时间差异均有统计学意义(P<0.05);两组术后死亡率差异无统计学意义(P>0.05);ERAS组患者胃排空延迟的发生例数(3例,3.8%)明显少于传统组(5例,7.5%)(P<0.05),其余并发症比较差异无统计学意义(P>0.05);两组患者术后肠黏膜屏障功能指标ERAS组患者优于传统组,但差异无统计学意义(P>0.05)。结论加速康复外科能使LPD术获得更好的临床效果,并可促进LPD患者术后肠黏膜屏障功能的恢复。     

Laparoscopic transgastric esophageal mucosal resection: 4-year minimum follow-up

Background

The management of high-grade esophageal dysplasia has included surveillance, endoscopic ablative techniques, and esophagectomy. Herein we describe an alternative treatment, laparoscopic transgastric esophageal mucosal resection.

Methods

Laparoscopic transgastric esophageal mucosal resection was accomplished through an anterior gastrotomy. The mucosa was stripped from the Z-line to the proximal extent of the abnormal epithelium. The gastrotomy then was closed with a linear stapler, and a Nissen fundoplication was performed.

Results

Six patients with high-grade dysplasia of the distal esophagus underwent mucosal resection. After 4 to 7 years of endoscopic surveillance, all patients have regenerated squamous epithelium. One patient developed nondysplastic Barrett's esophagus after 2 years and was treated medically. Two strictures were treated successfully with dilatation.

Conclusions

Laparoscopic transgastric esophageal mucosal resection was a reasonable treatment for high-grade dysplasia in this small sample of patients. This technique is a potential alternative treatment for high-grade dysplasia of the esophagus.     

Limited resuscitation with hypertonic saline, hypertonic sodium acetate, and lactated Ringer's solutions in a model of uncontrolled hemorrhage from a vascular injury

BACKGROUND: Hypertonic sodium acetate-dextran solution (HAD) causes vasodilatation and buffers metabolic acidosis. In controlled hemorrhage models, HAD in small volumes increases cardiac output without increasing blood pressure, thus creating a "high flow-low pressure" state. The objective of this study was to determine whether limited resuscitation of uncontrolled hemorrhage with HAD solution improves gut perfusion as measured by intestinal mucosal tonometry. METHODS: Three groups of 10 swine were bled 25 mL/kg by means of a femoral artery catheter to produce a mean blood pressure of 30 mm Hg. A 4-mm abdominal aortic laceration was then produced by pulling out a preimplanted wire loop. Groups were then randomly assigned to be resuscitated with either lactated Ringer's solution, a hypertonic saline-dextran solution or HAD solution sufficient to maintain a mean blood pressure of 45 mm Hg for 5 hours or until death. Outcomes were measured by survival, intraperitoneal blood loss, hemodynamic monitoring, and ileal mucosal tonometry. RESULTS: HAD infusions caused transient worsening of hypotension and were associated with increased mortality (p = 0.038). Blood loss and volumes required for resuscitation were significantly increased in the lactated Ringer's solution group. HAD showed significant buffering effect against metabolic acidosis in arterial blood only, but intestinal ileal mucosal tonometry was not different among the groups. CONCLUSION: HAD did not improve gut perfusion despite buffering the systemic acidosis of shock and caused increased mortality. Limited resuscitation with any of these solutions is associated with significant mucosal acidosis.     

Gastric siderosis: patterns and significance

Recently, we encountered 2 cases of diffuse iron deposition in gastric antral and fundic glandular epithelium, which in 1 patient eventually led to the diagnosis of hemochromatosis. Gastric mucosal siderosis (GS) has previously been described in hemochromatosis patients, alcoholics, and in association with iron medications. However, the prevalence of various patterns of iron deposition in the gastric mucosa and their clinical significance have not been studied in detail. The 2 index cases mentioned above and 500 additional consecutive gastric biopsies examined over a period of 8 months at our institution were stained for iron by the Prussian blue method. In addition, all patients with genetic hemochromatosis diagnosed by liver biopsy in our department between 1998 and 2003 who also had gastric biopsies were identified from the surgical pathology files and included in the study (n = 3). The location of iron deposition [stromal cells (endothelium, fibroblasts, macrophages), glandular epithelium, or extracellular] was recorded and subjectively graded as 1+ to 3+ according to the severity of deposition within the mucosa. Relevant histologic changes (inflammation, presence of H. pylori, ulceration) and clinical features were reviewed. Three patterns of GS were identified: A) "nonspecific GS" with predominant iron deposition in the stromal cells including macrophages, and focally in epithelium; B) "iron-pill gastritis" with often mild gastritis and reactive gastropathy type changes, and mostly extracellular deposition with focal stromal cells and epithelial deposition; and C) predominant deposition in antral and fundic glandular epithelium. Of the 500 cases studied, a total of 18 (3.6%) cases were found to have GS. Of these 18 cases, 11 (2.2%) showed pattern A, 4 (0.8%) showed pattern B, and 3 (0.6%) showed pattern C. The GS in patterns A and B was always focal or patchy (1+ to 2+), whereas in pattern C it was generally diffuse and strong (2+ to 3+). A history of oral iron medication was present in 2 (n = 11, 0.4%) patients with pattern A, in all patients with pattern B (n = 4, 100%), and in none of patients with pattern C (n=3, 0%). Varying degrees of mucosal inflammation were noted in patients with pattern A cases, and 2 had evidence of active Helicobacter pylori infection. Of the 3 cases with known hemochromatosis, only one gastric biopsy showed pattern C GS (1+). In conclusion, gastric mucosal siderosis is relatively uncommon (3%) but is important to look for as it may lead to a diagnosis of hemochromatosis in some cases. Three patterns are recognized: A) a "nonspecific" stromal cell predominant pattern, which may be associated with gastric inflammation, possibly prior mucosal hemorrhages or iron medications; B) extracellular coarse clumps of crystalline iron deposition associated with oral iron medications, mild gastritis, and reactive gastropathy type changes ("Iron-pill gastritis"); and C) gastric glandular siderosis, which may be associated with systemic iron overload/hemochromatosis.     

High prevalence of pelvic floor muscle dysfunction in hospitalized elderly women with urinary incontinence

Introduction and hypothesis

The purpose of this study was to determine pelvic floor muscle (PFM) function in hospitalized elderly women with urinary incontinence (UI).

Methods

A cross-sectional study was performed using data of 704 patients, routinely collected by means of a clinical UI assessment.

Results

Only 25.5% of the patients were able to perform normal PFM contractions (Oxford grading scale score ≥3); 74.5% were unable to contract their PFM or showed weak PFM activity without circular contraction or elevation of the vagina. Vulvovaginal mucosal dystrophy was noted in 84% of the patients. A significant positive correlation of PFM function was found to cognitive status (MMSE score), mobility (Tinetti performance score), and history of previous PFM training; a negative correlation of PFM function was found to patients’ age and vulvovaginal mucosal dystrophy, and no significant correlation to body mass index, parity, or history of hysterectomy.

Conclusions

Targeted clinical UI assessment including digital vaginal palpation should be performed in all incontinent elderly women in order to detect PFM dysfunction and to optimize therapeutic measures.     

Focal gastric mucosal blood flow in aspirin-induced ulceration.

Focal gastric mucosal blood flow was studied during aspirin injury by hydrogen gas clearance in a chambered segment model of canine gastric corpus. Measurements were made simultaneously every 15 minutes at ulcerated and nonulcerated areas 1.5 hours before, during (20 mM of aspirin in 150 mM of HCl for 1 hour), and 2 hours after exposure of the mucosa to topical aspirin. There was a highly significant decrease (p less than 0.001) in flow at the ulcerated areas 30 minutes after exposure to aspirin, coinciding with the appearance of focal mucosal pallor followed by subsequent hemorrhagic foci and ulceration. This was not followed by recovery to basal flow values. Blood flow to the non-ulcerated areas was significantly but less severely reduced than in the ulcerated areas (p less than 0.05) 90 minutes after exposure to aspirin. This was followed by recovery to basal levels. It is proposed that aspirin induces reduction of focal mucosal blood flow of varying degrees and that mucosal areas with flow reduced to below a "critical value" develop gross damage.     

Multifactorial Analysis of Prognostic Factors and Survival Rates Among 706 Mucosal Melanoma Patients

Background

The hypothesis that mucosal melanomas from different anatomic sites would have different prognostic features and survival outcome was tested in a multifactorial analysis.

Methods

Complete clinical and pathological information from 706 mucosal melanoma patients from different anatomical sites was compared for overall survival (OS) and prognostic factors.

Results

Mucosal melanomas arising from different anatomical sites did not have any significant differences in OS in a multivariate analysis (p?=?0.721). Among all 706 stage I–IV mucosal melanoma patients, depth of tumor invasion (p?<?0.001), number of lymph node metastases (p?<?0.001), and sites of distant metastases (p?<?0.001) were independent prognostic factors for OS; among 543 stage I–III patients, depth of tumor invasion (p?<?0.001) and number of lymph node metastases (p?<?0.001) were independent prognostic factors for OS; and among 547 stage IV patients, depth of tumor invasion (p?=?0.009), number of lymph node metastases (p?<?0.001), and combined distant metastases and elevation of serum lactate dehydrogenase (LDH; p?<?0.001) were independent prognostic factors for OS. The presence of c-KIT or BRAF mutations was not predictive of survival.

Conclusions

This is the first large-scale study comparing outcomes of mucosal melanomas from different anatomic sites in a multifactorial analysis. There were no significant survival differences among mucosal melanomas arising at different sites when matched for staging and prognostic and molecular factors, thus rejecting our hypothesis. We concluded that prognostic characteristics of mucosal melanomas can be staged as a single histological group, regardless of the anatomic site of the primary tumor.

     

Endoscopic mucosal resection as a staging technique to determine the depth of invasion of esophageal adenocarcinoma

Background

Endoscopic ablation and vagal-sparing esophagectomy offer the potential for reduced morbidity in patients with high-grade dysplasia or early esophageal adenocarcinoma, but neither includes a lymphadenectomy. Although adequate for intramucosal tumors, both are potentially inadequate for patients with submucosal tumor invasion given the high prevalence of nodal metastases with these lesions. Currently there is no test including endoscopic ultrasound that can accurately determine whether a small tumor is confined to the mucosa or has penetrated into the submucosa. The aim of this study was to compare the pathologic depth of invasion by endoscopic mucosal resection with findings and outcome after surgical resection to assess the accuracy and reliability of endoscopic mucosal resection for staging early esophageal adenocarcinoma.

Methods

From 2001 to 2003, 7 patients presented with small, endoscopically visible adenocarcinomas. All underwent endoscopic mucosal resection followed by surgical resection.

Results

Analysis of the resected specimens confirmed that the endoscopic mucosal resection had accurately determined the depth of tumor invasion in all patients, and had completely excised the lesion in all but 1 patient (86%). Lymph node dissection was included as part of the resection in 2 patients with submucosal invasion by endoscopic mucosal resection, and a vagal-sparing esophagectomy was used in the 5 patients with only intramucosal tumors. All patients are alive and disease-free at a median follow-up of 7 months.

Conclusions

Endoscopic mucosal resection accurately determines the depth of tumor invasion, and should be used as a staging procedure in patients with early esophageal cancer when therapies that do not include a lymphadenectomy are considered.     

Acute gastric mucosal ulcerogenesis is dependent on the concentration of bile salt.

Studies on animals implicating reflux of bile salts in formation of "stress ulcer" often are suspect because of the inordinately high intragastric concentrations of bile salts used to induce experimental acute gastric mucosal damage. We studied reflux of bile salt in 11 patients after operation. Nine refluxed bile salts in a mean intragastric concentration of 1.87 +/- 0.24 mM. (range, 0.34 to 4.88 mM.). In the present study, therefore, the ulcerogenic potential of physiologic concentrations of bile salts was evaluated. With use of vascularized, chambered canine gastric mucosa, groups of animals were studied during three consecutive periods. Group A = topical acid test alone (ATS) during periods 1, 2, and 3; Group B = (1) ATS, (2) ATS, (3) ATS + vasopressin (VP = 0.1 U per Kg.-min. via the splenic artery); Group C = (1) ATS, (2) ATS + topical 1 mM. sodium taurocholate (TC), (3) ATS + 1 TC + VP; Group D = (1) ATS, (2) ATS + 2 TC, (3) ATS + 2 TC + VP; Group E = (1) ATS (2) ATS + 5 TC, (3) ATS + 5 TC + VP. Parameters evaluated were (1) net fluxes H+, Na+; (2) electrical potential difference (PD); (3) clearance of aminopyrine, a measure of mucosal blood flow (MBF); and (4) formation of lesions, graded zero to six by an independent observer who used photographs. In nonischemic mucosa, bile salts produced no ulcers, a significant concentration-dependent increase in H+ "back diffusion" and fall in PD, and a noncentration-dependent increase in MBF. In ischemic mucosa, the combination of topical acid, topical bile salts, and mucosal ischemia was acutely ulcerogenic. The severity of mucosal injury was dependent on the concentration of bile salt (y = 0.108 + 1.53x, r = 0.90, p less than 0.01). These data indicate that acute mucosal damage occurs in the presence of physiologic concentrations of bile salt, i.e., those routinely found in the gastric contents of postoperative patients.