Collis-Belsey reconstruction of the esophagogastric junction. Indications, physiology, and technical considerations.

Twenty-four patients underwent combined Collis-Belsey reconstruction of the esophagogastric junction. The primary indication for operation in 19 patients was gastroesophageal reflux. Three patients had achalasia, one diffuse spasm, and one an incarcerated combined sliding and paraesophageal hernia. Postoperatively, symptoms were relieved in all 19 patiients undergoing repair for gastroesophgeal reflux with or without peptic strictures of the esophagus, and barium swallows showed no gastroesophageal reflux. Preoperative average mean and peak pressures in the distal esophageal high pressure zone (HPZ) were 1.38 and 2.72 mm. Hg, respectively; two thirds had no measurable HPZ. Postoperative mean and peak pressures were 6 and 12.36 mm. Hg, respectively; average HPZ length was 2.81 cm. Of 19 patients with massive reflux preoperatively, postoperative acid reflux testing demonstrated no reflux in 14 and minimal to moderate reflux in five. Collis-Belsey reconstruction ot the esophagogastric junction effectively relieves symptoms and controls the complications of gastroesophageal reflux.     

Gastroesophageal Reflux Following Gastric Operation

The combination of previous gastric operation and gastroesophageal reflux produces major difficulties in obtaining effective symptomatic relief. Seventy patients were studied by history, radiology, endoscopy, and esophageal manometry before surgical reflux control. Twenty-eight had had vagotomy and pyloroplasty; 4, vagotomy and gastroenterostomy; 11, Billroth I gastrectomy; and 27, Billroth II gastrectomy.In all patients reflux control was accomplished by hernia repair, and in 14 patients bile diversion was added for control of bile gastritis. A variety of reflux control operations were used. However, the most effective results were achieved with total fundoplication gastroplasty, and in this group of 22 patients there has been no anatomical recurrence and no reflux. The partial fundoplication gastroplasty (Belsey type) was ineffective in reflux control and should not be used in patients who have had a previous gastric procedure.Reflux control and, when necessary, bile diversion give effective relief to patients with bile gastritis and esophageal reflux following gastric operation.     

Reflux and laryngitis: a systematic review.

OBJECTIVES: To investigate and compare the prevalence of pharyngeal reflux (PR) events in normal controls and patients with clinically diagnosed reflux laryngitis. METHOD: A systematic review of the literature was performed to identify all prospective studies on the results of 24-hour double-probe (pharyngeal and esophageal) pH monitoring in normal controls and in patients with symptoms and/or signs of reflux laryngitis. RESULTS: Eleven relevant studies on 192 normal controls and 13 studies on 512 patients with reflux laryngitis were identified. One or more PR events were detected in 51 normal controls (22.9%; 95% CI, 13.9% to 33.3%) and in 154 of 422 patients (38.3%; 95% CI, 25.4% to 52.1%). There is no significant difference in the prevalence of PR events between normal controls and patients with reflux laryngitis (P = 0.079). In addition, the prevalence of PR events in patients with reflux laryngitis is much lower than reported in previous reviews on this subject. CONCLUSION: This systematic review calculated that (1) only a minority of patients with clinically diagnosed reflux laryngitis will show PR events, and (2) there is no significant difference between the prevalence of PR events in patients with reflux laryngitis and healthy controls. At the moment, there is no reliable means to confirm reflux of gastric juice in patients with suspected reflux laryngitis. This diagnostic vacuum is fundamental and may pose important questions at the current concept of reflux of gastric juice as a common cause of laryngopharyngeal inflammation.     

幽门成形联合十二指肠韧带松解对预防贲门癌术后胃食管返流的影响

目的 评价幽门成形联合十二指肠韧带松解在预防贲门癌术后返流中的临床效果.方法 将22例贲门癌近端胃切除患者术中行幽门成形联合十二指肠韧带松解作为 A组,另选未行幽门成形联合十二指肠韧带松解的18例贲门癌手术患者作为 B组对照,通过术后进行食管24 h pH监测,电子胃镜检查评价抗返流效果.结果 通过比较40例贲门癌近端胃切除手术患者不同术式两组间 24 h pH监测参数显示:24 h酸返流的总的返流次数、长于 5 min的返流次数两组间差异无统计学意义(P＞0.05);而A组的pH＜4.00 的总时间以及最长返流的时间明显低于B组,两组间差异有统计学意义(P＜0.05).A组返流性食管炎评分明显低于B组(P＜0.05).结论 综合抗返流术式方法简便,临床抗返流效果好.     

Reflux patterns in patients with achalasia without operation

Five patients with achalasia who had not had an operation underwent esophageal manometry and 24-hour, ambulatory pH monitoring to determine the pattern and extent of esophageal reflux. One patient had reflux within normal limits. In 2 patients, reflux occurred 0.5% of the total time and no episodes of supine reflux were recorded. In the 2 remaining patients, reflux was measured 16.8% and 55.3% of the total time; however, in both patients, these results were influenced by lengthy bouts of supine reflux. These indices of reflux were not influenced by differences in resting lower esophageal sphincter tone, position, or length. Twenty-four-hour esophageal pH monitoring can be useful in the preoperative assessment of patients with achalasia, and the information obtained might influence the choice of operative procedure.     

Patients with upright reflux have less favorable postoperative outcomes after laparoscopic antireflux surgery than those with supine reflux

The aim of this study was to compare symptomatic outcomes after laparoscopic antireflux surgery in patients with upright vs. supine reflux. A prospective database was used to assess postoperative clinical outcomes in relation to positional patterns of reflux in 117 patients. Supine reflux was present in 31%, upright in 24%, and the remaining 44% had bipositional reflux. Preoperatively there were no differences in the frequency of typical or atypical symptoms between groups. At a mean follow-up of 18_11 months postoperatively, there were marked differences in symptoms between groups. Patients with upright reflux noted significantly more heartburn, chest pain, odynophagia, and bloating postoperatively when compared to patients with supine and bipositional reflux (P<0.05). According to visual analog scales, patients with upright reflux expressed less satisfaction with operative results, ascribing more symptoms to the esophagus and stomach, when compared to those with supine reflux (P<0.05). Although all patients reported improvement, the extent of the relief from preoperative symptoms was less in patients with upright reflux (P<0.05). When asked if, in retrospect, they favored operative therapy, the patients with upright reflux were less enthusiastic (P<0.05). Although antireflux surgery eliminates reflux in nearly all patients, postoperative symptomatic outcome is related to the preoperative pattern of reflux. Although all patients showed symptomatic improvement, the extent of that improvement was significantly less in patients with upright reflux. These patients should be carefully counseled preoperatively regarding expected symptomatic outcomes. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation). Supported by the Washington University Institute of Minimally Invasive Surgery.     

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目的探讨下肢浅静脉剥脱术后病人深静脉反流程度的变化。方法 2007年1月至2009年1月承德医学院附属医院血管外科收治下肢静脉曲张合并有节段性深静脉反流的病人46例,对其共48条下肢采用传统手术治疗,超声观察下肢深静脉反流程度,应用临床表现严重程度评分(VCSS)评估临床症状的改善情况。结果 42例病人随访2年,术后2年VCSS为1.95±1.78,低于术前(6.33±1.78),差异具有统计学意义(P<0.01)。2年后超声检查深静脉反流程度无改变肢体22条,改善14条,加重6条,手术前后深静脉反流程度差异无统计学意义。不同CEAP分级的反流程度的改善差异无统计学意义(P=0.359)。结论浅静脉剥脱术后能改善伴有深静脉反流病人的临床症状,对部分病人可改善深静脉反流程度,改善程度与CEAP分级不相关。     

Persistent acid and bile reflux in asymptomatic patients with Barrett esophagus receiving proton pump inhibitor therapy

HYPOTHESIS: Symptom control does not reflect elimination of abnormal acid reflux or abnormal bile reflux in patients with long-segment Barrett esophagus receiving proton pump inhibitors (PPIs). DESIGN: Prospective survey. SETTING: University hospital. PATIENTS: Thirty-two patients with long-segment Barrett esophagus who were asymptomatic with PPIs. MAIN OUTCOME MEASURES: Twenty-four-hour ambulatory pH and bile reflux monitoring while continuing PPIs. RESULTS: Abnormal acid reflux (pH <4 for 11.9% [interquartile range, 6.8%-19.6%) of 24 hours] persisted in 15 patients (47%) who could not be distinguished from those with normal acid reflux (pH <4 for <4.5% of 24 hours) by any endoscopic, manometric, or therapeutic characteristic. Abnormal bile reflux (absorbance >0.14 for 8.7% [interquartile range, 3.9%-8.7%] of 24 hours) was detected in 11 (48%) of 23 patients, such that both normal bile reflux (absorbance >0.14 for <1.8% of 24 hours) and normal acid reflux were observed in only 8 patients (35%). There was no association between abnormal acid reflux and abnormal bile reflux. CONCLUSIONS: Despite symptom control with PPIs, both acid reflux and bile reflux were controlled in only one third of patients. Posttherapeutic monitoring of acid and bile reflux is recommended in future clinical trials of PPI treatment vs laparoscopic antireflux surgery.     

High-resolution impedance manometry and 24-hour multichannel intraluminal impedance with pH testing before and after sleeve gastrectomy: de novo reflux in a prospective series

BackgroundLaparoscopic sleeve gastrectomy (SG) is increasingly popular but concern regarding its effect on gastroesophageal reflux disease remain. The current literature is conflicting, and there have been little objective data.ObjectivesTo objectively and more accurately assess the impact of SG on esophago-gastric physiology.SettingCentre of Excellence in Metabolic and Bariatric Surgery, Private Hospital, Australia.MethodsProspective cohort study of 31 patients undergoing SG with high-resolution impedance manometry (HRM), 24-hour multichannel intraluminal impedance combined with pH testing (MII-pH), and Gastroesophageal Reflux Disease Symptom Assessment Scale (GSAS) questionnaire 1 month before and 6 months after SG.ResultsThere were 31 patients that underwent SG, 20 with synchronous hiatal repair and fixation, and 6 that were excluded. HRM demonstrated significantly increased intragastric pressures (15.5–29.6 mm Hg) and failed swallows (3.1–7.5%) but no other change in esophageal motility. MII-pH did not demonstrate significant changes in acid exposure time (8.5%–7.5%) or number of reflux episodes, although the numbers of long reflux episodes (2.3–4.7) and weak acid reflux episodes were significantly increased (15.4–55.2). DeMeester and GSAS scores were not significantly changed. There was no significant difference in patients with preexisting reflux. However, for patients without preexisting reflux, acid exposure time increased significantly (1.3%–6.7%), as did DeMeester scores (5.8–24.5) and the numbers of long reflux episodes (.1–4.4) and weakly acidic episodes (22.1–89.2).ConclusionSG was associated with increased intragastric pressures, without changes in esophageal motility or acid exposure. For patients without preexisting reflux, there were increases in acid exposure time, long reflux episodes, weakly acidic reflux episodes, and DeMeester score.     

Characterization of reflux events after fundoplication using combined impedance-pH recording

BACKGROUND: Laparoscopic fundoplication effectively controls symptoms of gastro-oesophageal reflux disease (GORD) and decreases acid reflux, but its impact on non-acid reflux is not known. The aim of the study was to characterize reflux events after fundoplication using oesophageal combined multichannel intraluminal impedance (MII)-pH monitoring, to demonstrate its efficacy on acid as well as non-acid reflux events. METHODS: Thirty-six patients in whom ambulatory MII-pH recording was performed after laparoscopic fundoplication were reviewed retrospectively. There were 23 symptomatic and 13 asymptomatic patients, whose results were compared with those of 72 healthy volunteers. RESULTS: Oesophageal acid exposure was low in all but one operated patient, and there was no difference between those with and without symptoms. The median number of reflux events over 24 h was lower after fundoplication (11 in operated patients compared with 44 in healthy volunteers; P < 0.001). Almost all reflux events were non-acid after surgery whereas acid reflux episodes were predominant in healthy volunteers. Proximal reflux events were less common in operated patients. Non-acid reflux events were significantly associated with symptoms after surgery in some patients. CONCLUSION: Fundoplication restores a competent barrier for all types of reflux. Reflux events are mostly non-acid after surgery, and such events may be positively correlated with symptoms.     

Investigation of oesophageal reflux symptoms after gastric surgery with combined pH and bilirubin monitoring

BACKGROUND: Little is known about the role of bile in gastro-oesophageal reflux disease in patients with previous gastric surgery. This has partly been due to a lack of suitable techniques for identifying bile reflux objectively. METHODS: Some 28 patients with reflux symptoms and previous gastric surgery underwent oesophageal manometry, and 24-h ambulatory oesophageal pH and bilirubin monitoring. RESULTS: A wide variety of operations had been performed, most commonly Pólya gastrectomy (seven patients), vagotomy and pyloroplasty (six) and vagotomy and gastrojejunostomy (four). Three patients had isolated acid reflux, eight had isolated bile reflux, six had combined acid and bile reflux, and 11 patients had no reflux. Two-thirds of heartburn symptoms were not associated with reflux. However, one-quarter were associated with acid reflux and only 7 per cent with bile reflux. Erosive oesophagitis was present in five patients: two with combined acid and bile reflux, and three with isolated bile reflux. CONCLUSION: Acid and/or bile reflux can be present after a wide variety of gastric operations. Symptoms are more frequently associated with acid reflux than with bile reflux. Erosive oesophagitis can occur in the presence of isolated bile reflux. Combined pH and bilirubin monitoring determines the nature of the refluxate, and may help in the management of these patients.     

The Influence of Laparoscopic Adjustable Gastric Banding on Gastroesophageal Reflux

Background: Laparoscopic adjustable gastric banding (LAGB) influences gastroesophageal reflux. Methods: 26 patients undergoing gastric banding were assessed by a questionnaire for symptom analysis, 24-hour pH monitoring, endoscopy and barium swallows, preoperatively, at 6 weeks and at 6 months after operation. Results: Gastric banding had minimal effect on heartburn scores, but regurgitation and belching scores increased significantly during follow-up. Use of acid-reducing drugs decreased significantly at 6 weeks and increased significantly at 6 months. Pathological reflux was present in 13 of the 26 patients preoperatively. At 6 months pathological reflux was found in only 6 of these 13 patients, but 4 of the 13 patients with preoperative normal reflux patterns had developed pathological reflux. 6 months after the operation esophagitis had disappeared in 6 patients and was increased in 9 patients. In 9 patients, a pouch was found at 6 months. Pouch formation was significantly correlated with the presence of pathological reflux, esophagitis and the use of acid-reducing medication. Preoperative presence of a hiatal hernia did not influence pouch formation or pathological reflux. Conclusion: LAGB decreases gastroesophageal reflux if there is no pouch formation during follow-up.     

Surgical treatment of reflux in neurologically impaired child

Ninety-three consecutive patients with neurologically impaired bladders were evaluated for vesicoureteral reflux. Of 22 patients found to have reflux, 3 had spontaneous remission of reflux, 8 were maintained on suppressive antibiotic therapy, and 11 required ureteral reimplantation. A total of 14 refluxing renal units underwent ureteroneocystostomies. Twelve of 14 have had no postoperative reflux. The remaining two renal units are now free of reflux following augmentation cystoplasty. The modified Hutch ureteroneocystostomy is particularly suited for use in patients with neuropathic bladders, in that no submucosal tunnel is necessary. The operative technique is described.     

Clinical and hemodynamical findings in legs with previous surgery of the great saphenous vein: role of the small saphenous vein

AIM: To assess the role of small saphenous vein (SSV) reflux in patients with a long history of varicose disease and previous stripping of the great saphenous vein (GSV). METHODS: Consecutive patients with a history of GSV stripping 5-19 years earlier were enrolled in this prospective clinical study. A total of 101 legs of 75 consecutive patients fulfilled the study criteria: previous stripping of GSV from ankle to groin at least 5 years earlier, no history of thromboembolism and no previous surgery of deep veins or SSV. All patients were studied clinically using standardized classifications: clinical class, clinical disability score (CDS) and venous clinical scoring system (VCSS). Colour flow duplex imaging (CFDI) was used to assess reflux in deep and superficial veins. Details of prior surgery were evaluated. RESULTS: Overall, SSV reflux was noted in 28 (28%) of the legs, recurrent GSV (rGSV) in the thigh in 41 (41%), reflux in tributaries alone in 28 (28%) and a combination of SSV and rGSV reflux in 4 (3%). Segmental deep reflux was measured in 23 (23%) of the legs; the prevalence of deep reflux was significantly higher in complicated than in uncomplicated legs (12% versus 47%; P<0.05). Deep reflux was more frequently associated with SSV reflux than with rGSV reflux (50% versus 22%; P<0.05). The prevalence of SSV with or without deep reflux increased from 17% to 50% (P<0.05) when uncomplicated (C2-3) and complicated (C4-6) legs were compared. A similar increase was not seen in the legs with rGSV (39% versus 44%; P>0.05). SSV reflux without deep reflux was observed in 25% of the legs with complicated (C4-6) disease, whereas the prevalence of SSV reflux was low (9%) in uncomplicated (C2-3) legs. VCSS was higher in the legs with SSV reflux than in those with rGSV reflux. CDS scores tended to be higher in the SSV reflux group than in the legs with rGSV reflux or tributary reflux alone. After exclusion of deep reflux, the results remained at the same level. CONCLUSION: Small saphenous vein (SSV) reflux is common in legs with recurrent varicose veins and previous stripping of the GSV. SSV reflux alone is frequent in complicated legs, and SSV reflux is typically associated with segmental deep reflux. Clinical and hemodynamical findings stress the role of SSV reflux in this selected venous population.     

MYOTOMY FOR ACHALASIA: TO WRAP OR NOT TO WRAP?*

One of the potential consequences of carrying out a Heller's myotomy for achalasia is gastro-oesophageal reflux. Whether it is frequent or severe enough to warrant the routine addition of a fundoplication to the operation is debated. In this prospective series of all patients undergoing a myotomy using a minimally invasive method the incidence of gastro-oesophageal reflux disease is examined. It was found that in 124 patients who had been followed for at least 6 months, whereas mild heartburn was common (51 patients; 41%), in only 10 patients (8.2%) was a proton pump inhibitor required and there were no patients whose reflux was not controlled using standard medical treatment. Peptic oesophagitis was an infrequent endoscopic finding with only 3 of 40 patients with no or mild heartburn having mild oesophagitis and no patient on a proton pump inhibitor having active peptic oesophagitis. These findings suggest that the addition of a fundoplication to a Heller's myotomy to prevent gastro-oesophageal reflux disease is not essential.     

The Integrity of Esophagogastric Junction Anatomy in Patients with Isolated Laryngopharyngeal Reflux Symptoms

Background  Distortion of esophagogastric junction anatomy in patients with gastroesophageal reflux disease produces permanent dilation of the gastric cardia proportional to disease severity, but it remains unclear whether this mechanism underlies reflux in patients with isolated laryngopharyngeal reflux symptoms. Method  In a prospective study, 113 patients were stratified into three populations based on symptom complex: laryngopharyngeal reflux symptoms, typical reflux symptoms, and both laryngopharyngeal and typical symptoms. Subjects underwent small-caliber upper endoscopy in the upright position. Outcome measures included gastric cardia circumference, presence and size of hiatal hernia, and prevalence of esophagitis and Barrett’s esophagus within each group. Results  There were no differences in gastric cardia circumference between patient groups. The prevalence of Barrett’s esophagus was 20.4% overall and 15.6% in pure laryngopharyngeal reflux patients. Barrett’s esophagus patients had a greater cardia circumference compared to those without it. In the upright position, patients with isolated laryngopharyngeal reflux display the same degree of esophagogastric junction distortion as those with typical reflux symptoms, suggesting a similar pathophysiology. Conclusion  This indicates that, although these patients may sense reflux differently, they have similar risks as patients with typical symptoms. Further, the identification of Barrett’s esophagus in the absence of typical reflux symptoms suggests the potential for occult disease progression and late discovery of cancer. Funding:  This work was supported in part by NIH grants UL1 RR024140 and K23 DK066165 (BAJ)     

Pharyngeal ph monitoring in 222 patients with suspected laryngeal reflux

To determine the existence of and characterize gastroesophagopharyngeal reflux in patients with symptoms of airway irritation, we monitored pharyngeal pH over a 24-hour period in 222 consecutive patients. Pharyngeal reflux was defined as a drop in pH to less than 4 at the pharyngeal sensor, which occurred simultaneously with acidification of the distal esophagus. Patients were divided into two groups: those with pharyngeal reflux (PR+) and those without (PR-). The Mann-Whitney U test and Student’s t test were used to assess intergroup comparisons. Episodes of pharyngeal reflux (range 1 to 36, average 4.4) were identified in 90 PR+ patients (40%). No pharyngeal reflux was identified in the remaining 132 patients (PR-). Episodes of pharyngeal reflux were rapidly cleared (average duration 1.5 minutes), and occurred while in the upright position in 77 (86%) of 90 patients and while in the supine position in 11 (12%) of 90 patients. Twenty-three patients (25%) experienced symptoms in association with an episode of pharyngeal reflux. In the distal esophagus, the percentage of time the pH was below 4 during the upright position and the total percentage of time the pH was below 4 were greater in PR+ patients (6.4% and 5.8%, respectively) when compared to PR-patients (2.6% and 2.6%, respectively). Laryngoscopic findings did not distinguish PR+ from PR- patients. Pharyngeal reflux occurs most commonly in the upright position and can be identified in more than 40% of patients thought to have acid-induced laryngeal symptoms. Even though these episodes are short lived and rapidly cleared, symptoms occur concomitantly in 25% of patients with proven pharyngeal reflux. Patients with laryngeal symptoms and documented pharyngeal reflux have greater amounts of esophageal reflux when compared to patients with laryngeal symptoms and no demonstrable pharyngeal reflux. Supported in part by a grant from U.S. Surgical, a division of Tyco Healthcare Group LP. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 21–24, 2000.     

Surgical Management of Grades III and IV Primary Vesicoureteral Reflux in Children With and Without Acute Pyelonephritis as Breakthrough Infections: A Comparative Analysis

Purpose

Although high grade vesicoureteral reflux associated with breakthrough infection may be an indication for surgical intervention, it remains uncertain whether acute pyelonephritis as breakthrough infection is a risk for renal scar formation and whether surgery performed without it has any advantage. We assessed the results of antireflux surgery for high grade vesicoureteral reflux in children with and without acute pyelonephritis as breakthrough infections.

Materials and Methods

A total of 33 boys and 27 girls (102 refluxing units) less than 3 years old with grades III and IV vesicoureteral reflux who underwent surgical management because of breakthrough infections were retrospectively studied in a 3-year period. Of the 60 patients 30 (group 1) presented with breakthrough infections of acute pyelonephritis, although they were maintained on prophylactic antibacterials. The remaining 30 patients (group 2) underwent surgery without acute pyelonephritis as the breakthrough infections. There was no renal scar formation at the diagnosis of vesicoureteral reflux in either group. Patients with renal scars were excluded from study. There was no significant difference in patient gender (p = 0.795) or distribution of bilateral vesicoureteral reflux (p = 0.781) in the groups. Group 1 patients were significantly younger at the diagnosis of vesicoureteral reflux (p = 0.006).

Results

Although 55 patients presented with a febrile urinary tract infection at the diagnosis of vesicoureteral reflux, the infection was not significantly related to the development of renal scars (p = 0.066). Of the 55 patients 12 presented with acute pyelonephritis as the initial episode of urinary tract infection. The presence of acute pyelonephritis at the diagnosis of vesicoureteral reflux was also not significantly related to renal scar formation (p = 0.207). Postoperative urinary tract infections developed in 34 patients but there was no significant correlation between postoperative urinary tract infections and renal scar formation (p = 0.235). At followup 17 group 1 and 7 group 2 patients (29 renal units) were found to have renal scars.

Conclusions

Renal scars were significantly more common in younger children with than without acute pyelonephritis as breakthrough infections (p = 0.010). Although breakthrough infections in high grade reflux may be an indication for antireflux surgery, the most appropriate results were achieved when acute pyelonephritis was not a breakthrough infection.     

Gastroesophageal Reflux Disease and Antireflux Surgery—What Is the Proper Preoperative Work-up?

Background

Many surgeons feel comfortable performing antireflux surgery (ARS) on the basis of symptomatic evaluation, endoscopy, and barium esophagography. While esophageal manometry is often obtained to assess esophageal peristalsis, pH monitoring is rarely considered necessary to confirm the diagnosis of gastroesophageal reflux disease (GERD).

Aims

The aim of this study was to analyze the sensitivity and specificity of symptoms, endoscopy, barium esophagography, and manometry as compared to pH monitoring in the preoperative evaluation of patients for ARS.

Patients and Methods

One hundred and thirty-eight patients were referred for ARS with a diagnosis of GERD based on symptoms, endoscopy, and/or barium esophagography. Barium esophagography, esophageal manometry, and ambulatory 24-h pH monitoring were performed preoperatively in every patient.

Results

Four patients were found to have achalasia and were excluded from the analysis. Based on the presence or absence of gastroesophageal reflux on pH monitoring, the remaining 134 patients were divided into two groups: GERD+ (n?=?78, 58 %) and GERD? (n?=?56, 42 %). The groups were compared with respect to the incidence of symptoms, presence of reflux and hiatal hernia on esophagogram, endoscopic findings, and esophageal motility. There was no difference in the incidence of symptoms between the two groups. Within the GERD+ group, 37 patients (47 %) had reflux at the esophagogram and 41 (53 %) had no reflux. Among the GERD? patients, 17 (30 %) had reflux and 39 (70 %) had no reflux. A hiatal hernia was present in 40 and 32 % of patients, respectively. Esophagitis was found at endoscopy in 16 % of GERD+ patients and in 20 % of GERD? patients. Esophageal manometry showed no difference in the pressure of the lower esophageal sphincter or quality of peristalsis between the two groups.

Conclusions

The results of this study showed that (a) symptoms were unreliable in diagnosing GERD, (b) the presence of reflux or hiatal hernia on esophagogram did not correlate with reflux on pH monitoring, (c) esophagitis on endoscopy had low sensitivity and specificity, and (d) manometry was mostly useful for positioning the pH probe and rule out achalasia. Ambulatory 24-h pH monitoring should be routinely performed in the preoperative work-up of patients suspected of having GERD in order to avoid unnecessary ARS.     

MANAGEMENT OF ECTOPIC URETEROCELE ASSOCIATED WITH RENAL DUPLICATION: A COMPARISON OF PARTIAL NEPHRECTOMY AND ENDOSCOPIC DECOMPRESSION

PURPOSE: We compared the efficacy of primary endoscopic decompression versus partial nephrectomy for treating ectopic duplex ureteroceles. MATERIALS AND METHODS: We retrospectively reviewed the records of patients with renal duplication and upper pole ectopic ureterocele. Patients were classified according to the initial radiological evaluation. The operation performed was arbitrarily chosen by the surgeon. RESULTS: A total of 54 patients had unilateral upper or bilateral upper pole ureterocele with no associated vesicoureteral reflux. Partial nephrectomy was performed in 26 patients, of whom 4 (15%) required additional surgery for new onset ipsilateral lower pole reflux. Endoscopic decompression was performed in 28 patients, of whom 18 (64%) required additional treatment due to reflux into the ipsilateral lower pole ureter and ureterocele in 9, reflux into the ureterocele only in 4, ipsilateral lower pole reflux only in 3 and persistent ureterocele obstruction in 2 (p<0.01). An ectopic ureterocele with vesicoureteral reflux into 1 or more moieties was identified in 111 patients, including 56 of 67 (84%) treated with partial nephrectomy and 37 of 44 (84%) treated with endoscopy who have persistent reflux or required further surgery for reflux resolution. CONCLUSIONS: In patients with an ectopic ureterocele and no vesicoureteral reflux partial nephrectomy should be considered the treatment of choice. However, when the initial cystogram reveals vesicoureteral reflux, partial nephrectomy and endoscopic ureterocele decompression have identical definitive cure rates of only 16%. The majority of the latter patients require continued observation and/or additional surgery for managing persistent reflux.