Belsey and Nissen operations for gastroesophageal reflux.

From 1972 to 1985, 37 consecutive patients underwent primary Belsey repair and 40 consecutive patients underwent primary Nissen fundoplication because of reflux disease. The operative procedures were performed by a single surgeon in each group. For the purpose of comparison, both groups were divided into two subsets: (1) patients with proved reflux, and (2) patients with different indications. The first subset consisted of 30 patients in the Belsey series and 32 in the Nissen series. The remaining patients were included in the second subset. One death occurred in the Belsey series; morbidity consisted of minor pulmonary complications in the Belsey series (10.8%) and spleen injuries requiring splenectomy (5%) in the Nissen series. In patients with proved reflux good-to-excellent results were achieved in 89.3% of subjects of the Belsey series and 86.6% of patients of the Nissen group. The failures rates were 7.1% and 10%, respectively. Inability to vomit and/or belch was reported in 7.1% of patients with proved reflux of the Belsey group and 10% of patients with proved reflux of the Nissen group. In patients with different indications there were no failures after either operation. Finally 82.2% of subjects in the Belsey group and 73.3% of patients in the Nissen group declared that they were satisfied with the operative results. In conclusion the Belsey and the Nissen procedures are equally able to achieve long-term control of reflux disease in comparable groups of patients. Failures and gastrointestinal symptoms are equally frequent after either procedure and do not affect the overall patient acceptance of antireflux surgery.     

Validation of air plethysmography,photoplethysmography, and duplex ultrasonography in the evaluation of severe venous stasis

Purpose: The purpose of this study was to validate the diagnostic capabilities of the most commonly used noninvasive modalities for evaluation of chronic venous insufficiency.Methods: Twenty limbs in 20 patients were studied with air plethysmography (APG), photoplethysmography (PPG), and duplex ultrasonography. Ten limbs (group 1) were clinically without any venous disease. Group 2 consisted of 10 limbs with severe, class 3 venous stasis. Duplex ultrasonography, complemented with Doppler color-flow imaging was used to examine the superficial and deep venous systems to identify reflux.Results: Ultrasonography identified deep venous reflux in eight of 10 limbs in group 2. Severe superficial reflux was identified in the two remaining limbs. Seven limbs with deep reflux also demonstrated severe superficial reflux. Superficial venous reflux was identified in one leg in group 1. APG accurately separated normal limbs from those with reflux. Parameters that were significantly different (p < 0.05) between the two groups were the venous filling index, (group 1 = 1.37 ± 0.16 ml/sec, group 2 = 29.5 ± 6.2 ml/sec), venous volume (group 1 = 107 ± 10.1 ml, group 2 = 220 ± 22.5 ml), ejection fraction (group 1 = 52.5% ± 2.3%, group 2 = 32.5% ± 4.6%), and residual volume fraction (group 1 = 21.4 ± 2.0%, group 2 = 52.1% ± 2.5%). PPG refill times were significantly shortened in group 2 versus those of group 1 (6.4 ± 0.89 sec vs 20.2 ± 1.1 sec). The sensitivity of PPG refill times to identify reflux was 100%, but the specificity was only 60%, whereas the sensitivity and specificity for the residual volume fraction was 100%. The venous filling index was able to identify reflux and determine whether only superficial reflux was present with a sensitivity of 100% and a specificity of 90%. The κ coefficient of agreement between duplex scanning and APG was 0.83, whereas between duplex and PPG it was only 0.47.Conclusions: APG accurately identifies limbs with and without venous reflux when compared with duplex ultrasonography. APG is a better method of evaluating clinically significant venous reflux than PPG. PPG is a sensitive method of detecting reflux, but the specificity is poor, and PPG refill times cannot accurately predict the location of reflux. The combination of APG and duplex ultrasonography provides the best means of assessing venous reflux. (J VASC SURG 1994;20:721-7)     

Acid normalization and improved esophageal motility after Nissen fundoplication: equivalent outcomes in patients with normal and ineffective esophageal motility

BACKGROUND: Severe gastroesophageal reflux disease may result in acquired esophageal dysmotility. The correct surgical approach to associated gastroesophageal reflux disease and dysmotility is controversial, in particular whether the "gold-standard" total fundoplication of Nissen is appropriate compared with partial fundoplication. Our unit has performed total fundoplication for all patients, irrespective of esophageal motility, and this article describes that experience. METHODS: Ninety-eight patients undergoing antireflux surgery were divided into 2 groups. Group 1 (n=60) consisted of patients with normal esophageal motility, and group 2 (n=38) had dysmotility. All patients underwent preoperative and postoperative manometry, 24-hour pH testing, symptom scoring, and quality-of-life assessment. RESULTS: The median postoperative acid score was not significantly different between groups 1 and 2. Eighty-eight percent of patients with normal motility and 89% of patients with dysmotility had no symptoms or minor symptoms, with a significant improvement in quality of life 6 months after surgery. There was a significant increase in esophageal wave amplitude in both groups, and 20 patients (53%) in the dysmotility group reverted to normal motility after surgery. Recurrent symptoms were associated with postoperative abnormal pH profiles in 5 patients from group 1 and 3 from group 2. CONCLUSIONS: Preoperative dysmotility is not a contraindication for total fundoplication. Postoperative acid control is associated with improved esophageal clearance and symptoms.     

Follow-up of 104 children with "primary" VUR. Incidence of unstable bladder, its impact on resolution of VUR and progression of renal scar

One hundred and four children (48 boys and 56 girls, ranging in age from 3 months to 15 years, and follow-up period of more than 2 years in all) with "primary" vesicoureteral reflux (VUR) were retrospectively analyzed with particular emphasis on resolution of VUR and occurrence of renal scar. All underwent cystoscopic examinations which failed to demonstrate any organic vesicourethral obstruction, and all were neurologically normal. The patient population was divided into 2 groups based on cystometric findings. Group 1 consisted of 74 patients with unstable bladder and Group 2 consisted of 30 patients without unstable bladder. Although both groups were initially kept under antibacterials, in Group 1 frequent voiding and anticholinergics were maintained until the bladder stabilized by itself. There was no difference in the grade of reflux between the two groups. The rate of spontaneous resolution of reflux was 18% in group 1 in which more than 60% of the patients were with high grade reflux, while in Group 2 it was 17%, similarly to Group 1, but all were with low grade reflux. The presence or absence of renal scar and its subsequent evolution were determined in 73 patients in whom serial urograms were available enough to evaluate nephrographic renal outline. The incidence of renal scar at the first visit was 26% in Group 1 and 36% in Group 2. New formation of renal scar was not found in either group. The progression of preexisting renal scar was seen only in Group 1 (5/55 patients, 9%), and not in Group 2 (0/18 patients, 0%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Prospective evaluation of laparoscopic and open 360 degree fundoplication in mild and severe gastro-oesophageal reflux disease.

OBJECTIVE: To investigate the relationship between five-year control of reflux and early postoperative oesophageal function after total fundoplication done either laparoscopically or through a laparotomy in severe and mild reflux disease. DESIGN: Prospective open study. SETTING: University hospital, Sweden. PATIENTS: In the group with severe disease 9 patients had a laparotomy and 7 laparoscopy. The corresponding figures for the group with mild disease were 21 and 34 respectively. RESULTS: The increase in lower oesophageal sphincter pressure 6 months after operation in patients with recurrent disease was significantly less than that for patients with good reflux control (p < 0.01). In patients who had laparotomy, including 30% (9/30) with severe reflux disease, good long-term reflux control was found in 93% (27/29). In patients operated on laparoscopically including 17% (7/41) with severe reflux disease good long-term reflux control was found in 90% (35/39). CONCLUSION: The mechanism of recurrence differed between patients with severe disease who had a laparotomy and patients with mild disease operated on laparoscopically. Early postoperative manometry was prognostic for recurrence. Long-term reflux control seems to be similar after laparotomy and laparoscopy. Further randomised studies are needed.     

Optimal therapy for advanced chronic venous insufficiency

INTRODUCTION: While definitive therapy awaits level I evidence, controversy persists regarding the optimal operation for treatment of advanced chronic venous insufficiency (CVI). We propose a pragmatic approach to the correction or amelioration of venous hypertension resulting from hydrodynamic and hydrostatic venous reflux. We evaluated a strategy of balloon dissection, subfascial endoscopic perforating vein surgery (SEPS) with routine posterior deep compartment fasciotomy, including ligation and stripping of the superficial system, for use when reflux is documented at duplex ultrasound (US) scanning. METHODS: This is a cooperative, multicenter, retrospective review of 832 patients stratified by CEAP classification. The series consisted of 300 patients with C4 CVI, 119 patients with C5 CVI, and 413 patients with C6 CVI. A subset of 92 patients with C4 disease were prospectively randomized, and ambulatory venous pressure (AVP) was determined preoperatively and postoperatively. All patients underwent duplex US scanning to document reflux in the deep, superficial, and perforating venous systems. Efficacy, safety, and durability were evaluated over follow-up of 1 to 9 years (mean, 31/2 years). Uniformity was attempted by adoption of the senior author's protocol and technique through on-site preceptorship in each surgeon's operative theater. RESULTS: This technique interrupted 3 to 14 (mean, 7) incompetent perforating veins per patient. Of the 832 patients undergoing SEPS, 460 (55%) underwent saphenous vein ligation and stripping at the same operation. In 92% ulcers healed or were significantly improved within 4 to 14 weeks. In 64 (8%) patients, ulcers failed to heal or there was no benefit from the operation. Thirty-two patients (4%) experienced recurrent ulceration or skin deterioration at 6 months-2 years (mean, 15 mo). Repeat SEPS was successful in 25 of these 96 patients, and deep valve repair was successful in 4 patients. In the 92 randomized patients with C4 disease, 41 refused postoperative AVP, leaving 51 compliant patients. The SEPS group (n = 25) had significantly reduced AVP (P <.01) compared with the control group (n = 26). Complications in 825 patients were less than 3% and consisted mostly of transient neurologic disorders (eg, paradysthesia), but deep venous thrombosis occurred in 2 patients, with pulmonary embolus in 1. No operative deaths occurred. Follow-up for 1 to 9 years (mean, 31/2 years) demonstrated durability. CONCLUSION: The efficacy, safety, and durability of this operative protocol proved beneficial in our clinical experience with 832 patients during 9 years of follow-up. The SEPS subset of randomized patients with C4 disease experienced significant decrease in AVP, objectively supporting the effectiveness of reflux surgery in advanced CVI. Until definitive level I evidence is available, this operative technique is advocated as optimal therapy for CVI.     

Vesicoureteral reflux in the renal transplantation candidate.

The incidence and severity of urinary tract infection episodes were evaluated in two groups of renal transplantation patients. Group 1 consisted of 11 patients transplanted following successful surgical correction of a noninfected vesicoureteral reflux in native kidneys, and group 2 of 28 patients transplanted with a noninfected vesicoureteral reflux. An increased incidence of acute urinary tract infection episodes was noted in group 2 as compared to group 1 (42.8 vs. 18%), with a mean of 2.6 +/- 1.4 episodes per patient in group 2 and 0.5 +/- 0.32 in group 1. Asymptomatic bacteriuria was not statistically different in the two groups (36.4 vs. 25%). In group 2, the incidence of urinary tract infection episodes increased in patients presenting high-grade (3 and 4) reflux in native kidneys. Despite the relatively low number of patients involved, our observations indicate that high-grade vesicoureteral reflux in native kidneys must be operated before transplantation, even when there is no history of urinary tract infections and urine cultures are sterile.     

Clinical significance of ostial great saphenous vein reflux.

PURPOSE: To evaluate anatomical and haemodynamic differences in patients with great saphenous vein (GSV) insufficiency by duplex scanning and air plethysmography. MATERIAL AND METHODS: Duplex scanning and air plethysmography examination were undertaken. One hundred and twenty-one limbs in 91 patients were selected prospectively and divided into three groups: group A consisted of 27 controls; group B consisted of 25 limbs with GSV reflux and normal saphenous femoral junction (SFJ) and group C consisted of 69 limbs of patients with GSV and SFJ reflux. The presence of reflux and GSV diameter (SFJ, proximal and medial thirds of the thigh, the knee and medial and distal thirds of the calf) were assessed by duplex scanning. Air plethysmography was used to evaluate haemodynamic parameters: total venous volume (VV), venous filling index (VFI), residual volume fraction (RVF) and ejection fraction (EF). RESULTS: There was a significant difference in GSV diameter among the three groups in almost all segments evaluated (e.g. medial thigh group A = 2.4 SD 0.3 mm; B = 3.2 SD 0.7 mm; C = 5.9 SD 2.2mm p<0.001, Anova). A significant difference in VFI was found among the groups (group A = 1.2 SD 0.5; B = 2.0 SD 1.4; C = 4.0 SD 2.5 p<0.05, Anova). VV was statistical different between groups A and C (p = 0.004) and B and C(p = 0.03). EF and RVF were comparable in all groups. The VFI was normal in 68% in group B comparing with only 14.5% in group C patients, finding a reflux more than 5ml/s (determined by VFI) in 26.1% of the group C patients, comparing with only 4% of group B patients (p<0.05). CONCLUSION: We have shown that in patients with GSV reflux those with incompetence of the ostial valve of the GSV show greater venous reflux and dilatation of the saphenous trunk than those in whom the ostial valve is competent.     

Venous outflow obstruction: An underestimated contributor to chronic venous disease

OBJECTIVE: To assess the importance of iliac venous outflow obstruction in limbs with and without concomitant deep or superficial reflux, we performed a retrospective analysis of data contemporaneously entered into a set time-stamped electronic medical records program. MATERIAL AND METHOD: Four hundred forty-seven limbs underwent iliac vein stenting of chronic, nonmalignant obstruction when greater than 50% morphologic stenosis was found at transfemoral venography or intravascular ultrasonography. Group 1 (female-male ratio, 3.4:1; left limb-right limb, 2.7:1; nonthrombotic-thrombotic, 1.8:1) included 187 stented limbs in 176 patients with absence of deep and superficial reflux as identified at erect duplex Doppler scanning. Group 2 (female-male, 1.7:1; left-right, 1.9:1, nonthrombotic-thrombotic limb, 1:2.1) included 260 limbs in 253 patients with combination obstruction and reflux. Reflux was left untreated during the observation period. Clinical outcome (ulcer healing and recurrence rate, degree of pain per visual analog scale, swelling grade) and hemodynamic effects (ambulatory venous pressure, venous refilling time, venous filling index at 90 seconds) of iliac venous stenting were assessed. RESULT: Patients with reflux and obstruction had more severe disease (clinical class 4-6, 53% in group 2 vs 24% in group 1; P <.001). Similarly, rate of active ulcer was low in limbs with obstruction only (3% vs 24%, groups 1 and 2, respectively). Mean clinical follow-up was 13 +/- 12 months (SD) in 86% of limbs. Because of the presence of reflux in group 2, venous pressure was higher, venous filling time was shorter, and venous filling index at 90 seconds increased, compared with group 1. Multisegment scores were 2.6 +/- 1.6 and 0, respectively. Of greater interest, there was no deterioration in venous hemodynamics in group 2 after stenting. There was substantial clinical improvement in both groups after stenting. Approximately half of patients were completely relieved of pain after stenting, and a third were completely relieved of swelling. In addition, 55% of ulcerated limbs healed. CONCLUSION: Iliac venous outflow obstruction appears to have an important role in clinical expression of chronic venous insufficiency, particularly in producing pain, and is easily overlooked, mainly because of diagnostic difficulty. The combination of reflux and obstruction is seen more frequently with severe clinical disease than is obstruction alone. Ulcer prevalence is clearly associated with reflux, with a low incidence in patients with obstruction alone. Removal of iliac vein outflow obstruction does not result in increased axial reflux, with clinical deterioration in limbs with combined reflux and obstruction.     

Total fundoplication is superior to partial fundoplication even when esophageal peristalsis is weak

BACKGROUND: About a decade ago, partial (240 degrees) fundoplication became popular for treating gastroesophageal reflux disease in cases where the patient's primary esophageal peristalsis was weak. A total (360 degrees) fundoplication was reserved for patients with normal peristalsis (tailored approach). The theory was that partial fundoplication was an adequate antireflux measure, and by posing less resistance for the weak esophageal peristalsis to overcome, it would give rise to less dysphagia. Short-term results seemed to confirm these ideas. STUDY DESIGN: This study reports the longterm followup of patients in whom a tailored approach (type of wrap chosen to match esophageal peristalsis) was used, and the results of a nonselective approach, using a total fundoplication regardless of the amplitude of esophageal peristalsis. We analyzed clinical and laboratory findings in 357 patients who had an operation for gastroesophageal reflux disease between October 1992 and November 2002. Group 1 was composed of 235 patients in whom a tailored approach was used between October 1992 and December 1999 (141 patients, partial fundoplication and 94 patients, total fundoplication). Group 2 contained 122 patients in whom a nonselective approach was used (total fundoplication regardless of quality of peristalsis). RESULTS: In group 1, heartburn from reflux (ie, pH monitoring test was abnormal) recurred in 19% of patients after partial fundoplication and in 4% after total fundoplication. In group 2, heartburn recurred in 4% of patients after total fundoplication. The incidence of postoperative dysphagia was similar in the two groups. CONCLUSIONS: These data show that laparoscopic partial fundoplication was less effective than total fundoplication in curing gastroesophageal reflux disease, and compared with a partial (240 degrees) fundoplication, a total (360 degrees) fundoplication was not followed by more dysphagia, even when esophageal peristalsis was weak.     

Transient Lower Esophageal Sphincter Relaxation in Morbid Obesity

Background  There is strong evidence that morbid obesity is often accompanied by gastroesophageal reflux. Gastroesophageal reflux is caused predominantly by transient lower esophageal sphincter relaxations (TLESRs). Only few data are available about TLESRs in patients with stage III obesity (body mass index > 35). The aim of this study was to analyze the frequency and types of TLESRs in patients with morbid obesity in different physiological stages (postprandial: upright and recumband) compared to patients with normal weight gastroesophageal reflux disease (GERD) and diffuse esophagus spasm (DES). Methods  In order to measure TLESRs in obese patients with and without GERD, three subgroups were prospectively performed: group I consisted of seven healthy controls, group II consisted of seven obese patients, group III consisted of seven non-obese patients with GERD, and in group IV, five patients were recruited with diffuse esophageal spasm. All participants underwent both conventional water-perfused stationary esophagus manometry and a 24-h ambulatory esophagus manometry, 24-h ambulatory pH monitoring, and esophago-gastroscopy. In order to measure the lower esophageal sphincter pressure (LESP) over a prolonged time under physiological conditions, a special solid-state sleeve catheter was used. Additionally, all patients were interviewed using a standardized questionnaire. Results  Compared to normal subjects, patients with morbid obesity and patients with gastroesophageal reflux show a substantial increase of TLESRs in the postprandial phase. There was a tendency towards more TLESRs per hour in patients with DES than in healthy subjects, but the difference was not statistically significant. The types of TLESRs differed with the LESP. The majority of isolated TLESRs were complete and incomplete. Some of the isolated TLESRs were accompanied by contractions of the tubular esophagus. Conclusion  Morbid obesity is associated with gastroesophageal reflux. The frequency of TLESRs has significantly increased compared to healthy subjects and does not differ statistically from patients with GERD. Isolated TLESRs are mostly incomplete in patients with a hypotonic LES.     

Comparison of 1% and 3% polidocanol foam in ultrasound guided sclerotherapy of the great saphenous vein: a randomised, double-blind trial with 2 year-follow-up. "The 3/1 Study".

OBJECTIVES: To compare 1% and 3% POL foam in treating the great saphenous vein (GSV) by ultrasound guided sclerotherapy. DESIGN: Multicentre, prospective, randomised, double-blind trial with 2 year-follow-up. PATIENTS AND METHODS: 148 patients with GSV reflux (saphenous trunk diameter 4-8 mm) were randomised to undergo ultrasound guided foam sclerotherapy using either 1% or 3% POL foam in a single session. Foam production was standardised using a sterile disposable syringe kit including sterile air and the Turbofoam machine. Duplex ultrasonography was used to assess the outcome at 3 weeks, 6 months, 1 year, 18 months and 2 years. The main criterion of success was the disappearance of the venous reflux. The length of occlusion of the vein (only measured at 3 week-echography assessment) was a secondary criterion. Side effects were assessed. RESULTS: 74 patients were included in each group. The mean volume of foam injected was 4.4 ml for the 3% group and 4.6 ml for the 1% group. After 3 weeks, reflux was abolished in 96% (71 patients) of the 3% group and 88% (68 patients) of the 1% group (NS). The mean occlusion length of the vein was 38 cm for the 3% group and 34 for the 1% group (NS). After 2-years, reflux was absent in 69% of the 3% group and 68% of the 1% group (NS). 14 patients were lost to follow-up at 2 years. CONCLUSION: This study demonstrates equivalent efficacy for 1% POL and 3% POL foam in sclerotherapy of the GSV where the trunk is less than 8 mm in diameter. These data obtained two years of follow-up confirm our previously reported 6 month-follow-up data published in 2005.     

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.

     

What is the difference between proximal and total gastrectomy regarding postoperative bile reflux into the oesophagus?

BACKGROUND: Tumours of the oesophagogastric junction and the gastric cardia can be treated either with proximal or with total gastrectomy. Reflux of bile and other duodenal contents into the oesophagus following proximal gastrectomy has generally been considered worse than reflux after total gastrectomy. The aim of the present study was to test this assumption given that there is limited literature regarding objective evaluation of the postoperative duodeno-oesophageal reflux. PATIENTS AND METHODS: We carried out bilirubin monitoring with the ambulatory spectrophotometer Bilitec 2000 in two groups of patients and in one group of healthy volunteers matched in age and sex. The proximal gastrectomy group consisted of 8 patients who underwent proximal gastrectomy and an end-to-side oesophagogastrostomy without pyloric drainage procedure. The total gastrectomy group consisted of 11 patients who underwent total gastrectomy and Roux-en-Y reconstruction with a 50-cm-long jejunal limb. The control group consisted of 8 healthy volunteers. In all cases, an absorption value of 0.14 was used as the threshold for reflux episodes. RESULTS: The median fraction of time that bilirubin absorbance was >0.14 in the proximal versus total gastrectomy group was 47.4 and 13.4%, respectively (p = 0.02). The difference between the two groups was significant in the supine position (p = 0.03), whilst the upright position, meal and postprandial periods were not found to have significant difference. Likewise, no significant difference was found in the number of reflux episodes. The median fraction of time in the proximal gastrectomy group compared with controls was 47.4 versus 3.95% (p < 0.001), whilst in the total gastrectomy group compared with controls, it was 13.4 versus 3.95% (p > 0.05). The number of reflux episodes in the proximal gastrectomy group compared with controls was 74 versus 21 (p = 0.02), whilst in the total gastrectomy group compared with controls, it was 103 versus 21 (p > 0.05). CONCLUSIONS: Total gastrectomy with Roux-en-Y reconstruction reduces the time of oesophageal exposure to duodenal juices as compared with proximal gastrectomy. This effect seems to be more prominent in the supine position.     

Prevalence of varicose veins and venous anatomy in patients without truncal saphenous reflux.

OBJECTIVES: To determine the prevalence and distribution of primary venous reflux in the lower limbs in patients without truncal saphenous reflux. DESIGN: Prospective cohort study. PATIENTS AND METHODS: One thousand and seven hundred and twelve patients with suspected venous disease were examined by duplex ultrasonography. Seven hundred and thirty-five patients had primary varicose veins with competent saphenous trunks. Limbs with truncal saphenous reflux, deep vein reflux or obstruction, previous injection sclerotherapy or vein surgery, arterial disease and inflammation of non-venous origin were excluded from further consideration. The CEAP classification system was used for clinical staging. Systematic duplex ultrasound examination was undertaken to assess the distribution of incompetent saphenous tributaries. RESULTS: The prevalence of primary reflux with competent saphenous trunks was 43%. Reflux of GSV calf tributaries was the most common. The majority of the limbs (96%) belonged to chronic venous disease classes C1 and C2 of the CEAP classification. CONCLUSIONS: Superficial venous reflux causing varicose veins in the presence competent saphenous trunks is very prevalent in this series in contrast to other studies, presumably reflecting differing patient populations. Our data clearly show that varicose veins may occur in any vein and do not depend on truncal saphenous incompetence. Careful duplex ultrasound evaluation allows the pattern of venous reflux to be established in this group of patient ensuring appropriate management of varices.     

The prevalence of distal and proximal gastroesophageal reflux in patients awaiting lung transplantation

OBJECTIVE: To determine the prevalence and proximal extent of gastroesophageal reflux (GERD) in patients awaiting lung transplantation. BACKGROUND: GERD has been postulated to contribute to accelerated graft failure in patients who have had lung transplantations. However, the prevalence of reflux symptoms, esophageal motility abnormalities, and proximal esophageal reflux among patients with end-stage lung disease awaiting lung transplantation are unknown. METHODS: A total of 109 patients with end-stage lung disease awaiting lung transplantation underwent symptomatic assessment, esophageal manometry, and esophageal pH monitoring (using a probe with 2 sensors located 5 and 20 cm above the lower esophageal sphincter). RESULTS: Reflux symptoms were not predictive of the presence of reflux (sensitivity, 67%; specificity, 26%). Esophageal manometry showed a high prevalence of a hypotensive lower esophageal sphincter (55%) and impaired esophageal peristalsis (47%) among patients with reflux. Distal reflux was present in 68% of patients and proximal reflux was present in 37% of patients. CONCLUSIONS: These data show that in patients with end-stage lung disease: 1) symptoms were insensitive and nonspecific for diagnosing reflux; 2) esophageal motility was frequently abnormal; 3) 68% of patients had GERD; 4) in 50% of the patients with GERD, acid refluxed into the proximal esophagus. We conclude that patients with end-stage lung disease should be screened with pH monitoring for GERD.     

Use of the dysfunctional voiding symptom score to predict resolution of vesicoureteral reflux in children with voiding dysfunction

PURPOSE: Dysfunctional voiding influences the presence and persistence of vesicoureteral reflux. We used a standardized published instrument, the dysfunctional voiding symptom score, to evaluate the association of dysfunctional voiding with vesicoureteral reflux. We report its use for monitoring improvement in and resolution of vesicoureteral reflux. MATERIALS AND METHODS: In 1998, 114 patients with dysfunctional voiding were placed on behavioral modification. Of 58 patients (51%) who presented with urinary tract infection 27 (47%) had abnormal voiding cystourethrography, including 19 with reflux only. Baseline and followup dysfunctional voiding symptom score was determined in these 19 patients, who underwent prospective observational therapy and behavioral modification. We correlated the dysfunctional voiding symptom score with the evolution of vesicoureteral reflux. RESULTS: Vesicoureteral reflux was present in 19 of the 58 patients (33%) with dysfunctional voiding and urinary tract infection. All affected patients were female with a mean age of 6.7 years and a mean followup of 24 months. Reflux grade in the 24 units was I to IV in 7, 9, 7 and 1, respectively. Mean dysfunctional voiding symptom score was 13.3 in patients with normal voiding cystourethrography and 11.7 in the vesicoureteral reflux group (p = 0.6). Reflux resolved in 3, 2 and 2 cases of grades I, II and III disease, respectively, while improvement (decrease of 2 or more grades) was noted in 4. Initial dysfunctional voiding symptom score in these 11 cases decreased from a mean of 9.6 (range 4 to 18) to 3.7 (range 0 to 12, p = 0.01). The 8 patients with persistent reflux had an initial dysfunctional voiding symptom score of 14.4 (range 4 to 21), which decreased to 11.1 (range 1 to 19, p = 0.18). CONCLUSIONS: A significant decrease in the dysfunctional voiding symptom score appears to confirm compliance with behavioral modification and predicts ultimate reflux resolution. The dysfunctional voiding symptom score provides a noninvasive means of monitoring compliance with therapy during expectant treatment of patients with vesicoureteral reflux.     

Gastroesophageal reflux disease: symptoms versus pH monitoring results.

OBJECTIVES: The reason why some patients with gastroesophageal reflux disease (GERD) have symptoms of upper aerodigestive system irritation, while others mainly have gastroenterologic symptoms, is not well established. This retrospective case series study was designed to examine the existence of a correlation between symptoms and reflux characteristics, based on data obtained from esophageal pH monitoring. METHODS: The study population consisted of 139 patients; 97 patients presented with laryngopharyngeal symptoms of GERD, including unexplained hoarseness, throat clearing, chronic cough, laryngospasm, globus, throat pain, and 42 patients presented with gastroenterologic symptoms, including heartburn and regurgitation. The results of 24-hour, double-channel ambulatory esophageal pH monitoring were analyzed comparing 2 symptom groups. The incidence of abnormal acid reflux at the upper and lower esophageal segments and the effects of upright and supine positions on reflux parameters were evaluated. RESULTS: The incidence of laryngopharyngeal reflux was significantly higher in the laryngopharyngeal symptom group than in the other (52% versus 38%). The patients with laryngopharyngeal reflux from both groups showed no significant differences in terms of number of acid reflux episodes, percentage of times pH was 4, and esophageal acid clearance. Upright and supine parameters did not show significant differences between the patient groups. Upright acid reflux episodes were, however, common in both groups at the lower esophageal and laryngopharyngeal segments. CONCLUSION: Recent studies suggesting that otolaryngologic patients commonly show upright, daytime reflux with normal esophageal clearance and that typical GERD patients commonly have supine, nocturnal reflux with prolonged esophageal clearance are not supported by this study. This study indicates that acid reflux parameters and positional changes are not sufficient to explain why patients with GERD experience different symptoms. The regional symptoms of GERD may be attributed to the impairment of epithelial resistance, motor activity, and buffering systems for the esophageal antireflux barrier.     

The nonsaphenous vein of the popliteal fossa: prevalence, patterns of reflux, hemodynamic quantification, and clinical significance

BACKGROUND: A large tortuous vein coursing over the posterior aspect of the knee and the upper calf may give rise to a constellation of varicose veins unrelated to the great (GSV) or small (SSV) saphenous veins. Designated the popliteal fossa vein (PFV), it perforates the deep popliteal fascia and empties into the deep system. We examined the prevalence, anatomic reflux patterns, hemodynamic role, and clinical significance of the PFV. METHODS: We examined 543 patients (818 limbs) with venous disease, aged 14 to 94 years (median, 55 years). The study consisted of group A, comprising limbs with a PFV, and group B, formed by the remaining limbs. The history, clinical examination, and venous duplex scan findings were analyzed retrospectively. Venous clinical severity and venous segmental disease scores of group A were compared with those of an equal number of CEAP-, sex-, and age-matched control limbs. In situ venous hemodynamics of the PFV obtained with duplex scan are reported. RESULTS: A PFV was found in 24 (2.93%) of 818 limbs (95% confidence interval [CI], 1.8%-4.1%); 24 (4.4%) of 543 subjects (95% CI, 2.7%-6.2%), 12 men and 12 women aged 23 to 82 years (median, 54 years) had a PFV. CEAP clinical classes in limbs with a PFV were as follows: C2, 15 limbs; C3, 5 limbs; C4, 2 limbs; C5, 1 limb; and C6, 1 limb. Proximal and distal (92%), superficial (100%), perforator (87.5%), and complex-pattern (41.7%) reflux occurred more often in group A (P < .01). Incompetence in the GSV (75%), posterior arch, and posteromedial and saphenous tributaries was also more frequent in group A (P < .05). SSV reflux in group A (29%) matched that in group B. The PFV terminated at the deep system (96% in the popliteal vein) above the SSV (median distance, 1.5 cm; 95% CI, 0.5-2 cm). The odds ratio for a PFV in limbs with prior SSV disconnection was 5.68. Deep reflux was evenly distributed in group A (41.7%) and group B (27%). The prevalence of incompetent perforators was 283% (95% CI, 194%-373%) in group A and 96% (95% CI, 95%-98%) in group B (P < .001). PFV tributaries were distributed at the popliteal area (100%); the posterior (87.5%), medial (62.5%), and lateral (37.5%) upper calf; and the posterior distal thigh (17%), often projecting to the posterior GSV arch (50%). The (median) peak velocity of reflux in the PFV was 82.6 cm/s, the mean velocity was 17.7 cm/s, the duration was 2.4 seconds, the volume flow was 231.5 mL/min, and the expelled volume was 9.3 mL. The median diameter of the PFV at the crossing of the fascia was 0.527 cm. Venous clinical severity (range, 2-17; median, 5.5) and venous segmental disease (range, 0.5-8; median, 2.75) scores in limbs with a PFV exceeded (P 相似文献   

Sclerotherapy of sapheno-femoral reflux of blood in patients with initial stages of varicose disease of the lower extremity veins

The results of ultrasonic investigation and the following phlebosclerosing treatment of an incompetent saphenofemoral anastomosis were analyzed in two groups of patients with initial stages of varicose disease of the lower extremity veins. The first group included 48 patients treated by injection-sclerosing therapy by the technology of "empty vein". The second group consisted of 82 patients treated by catheter sclerotherapy of the sapheno-femoral anastomosis. In the first group the treatment was effective in 73.1%, in the second group - in 91.5%. The terminal hemodynamic criteria of performing the injectional and catheter sclerotherapy were determined in elimination of high sapheno-femoral reflux of blood.