食管癌贲门癌术后残余食管黏膜上肿瘤坏死因子-α和环氧化酶-2表达的意义

目的 连续观察食管癌贲门癌术后酸反流( acid reflux)、十二指肠胃食管反流(DGER)变化及其对残余食管黏膜环氧化酶-2(COX-2)、肿瘤坏死因子(TNF-α)表达的影响作用.方法 在术后不同时间段内对32例食管癌和贲门癌术后患者进行24小时pH和胆红素监测、电子胃镜、免疫组织学检查.结果 术后反流性食管炎的发生率和DeMeester评分随着时间的延长逐渐升高(P＜0.05).COX-2、TNF-α在正常食管黏膜基底细胞的胞浆内不表达或呈弱阳性表达;术后残余食管黏膜呈阳性表达.Barrett化生上皮细胞胞浆内COX-2、TNF-α的表达水平呈强阳性.残余食管黏膜发生反流性食管炎的TNF-α表达水平明显高于无发生者(P =0.0274),而COX-2的表达水平在残余食管黏膜有无发生反流性食管炎之间差别无统计学意义(P=0.7403).结论 食管癌贲门癌术后酸反流程度和反流性食管炎的发生率随着时间的延长而增加.食管黏膜上的COX-2、TNF-α表达是胃食管反流发生的早期变化,同时COX-2的表达可作为反应胃食管反流发生的分子标记.TNF-α的持续表达可能参与反流性食管炎的发病机制.     

胃食管吻合术后胃食管反流的研究

目的 研究食管癌和贲门癌术后不同位置的食管胃吻合口和时间因素对胃食管反流程度的影响。方法 对39例食管癌和贲门癌术后病人进行24h食管pH监测、电子胃镜检查，其中食管胃弓上吻合组（A组）21例，弓下吻合组（B组）18例。结果 （1）A组DeMeester评分和反流性食管炎评分均明显低于B组（P〈0．05）。（2）随着时间的推移A组和B组DeMeester评分无明显的改变（P〉0．05）。结论 不同位置的食管胃吻合口影响胃食管反流程度，食管胃吻合口位置越高胃食管反流和反流性食管炎程度越轻。时间因素对胃食管反流程度无明显的影响。     

黏膜瓣式食管胃吻合术抗反流的食管动力学研究

目的寻找一种实用有效的抗反流食管胃吻合术式。方法将食管癌和贲门癌患者464例随机分为黏膜瓣式食管胃吻合术组(A组,175例)、器械食管胃吻合术组(B组,151例)和单纯手工缝合食管胃一层吻合术组(C组,138例)。应用同位素测定胃食管反流指数和24h监测pH值,进行3组间的食管运动功能比较。结果同位素测定胃食管反流指数显示,A组反流阳性率为0,B组为33.3%,C组为6.7%。食管运动功能及24h监测pH显示,A组检测各项指标均接近正常值,B、C组与正常值比较,差异具有统计学意义(P<0.05)。结论黏膜瓣式食管胃吻合术式具有优异的抗反流功能,并能有效地防止食管癌、贲门癌术后反流性食管炎的发生。     

两种弓上食管胃吻合术后胃食管反流的比较

目的比较食管癌手术行"隧道式"式和器械式两种经主动脉弓上食管胃吻合方式术后胃食管反流的状况。方法对两组患者,"隧道式"吻合术组21例,器械吻合方式组35例,术后3个月行24 h食管pH监测;胃镜检查反流性食管炎的程度,并进行分级和评分。结果24小时pH监测显示,两组各项指标均高于正常值,但隧道组各项指标均低于器械式吻合组,差异有统计学意义:DeMeester评分和超过5 min的反流次数、pH低于4的总时间、以及pH<4的时间百分数(P<0.01)、24 h反流的次数和最长的反流时间(P<0.05);胃镜检查结果显示:器械组反流性食管炎的发生率为65.7%(23/35),明显高于隧道组为38.1%(8/21),两组反流性食管炎分级及反流性食管炎评分比较差异有统计学意义(P<0.01),器械组高于隧道组。结论两种吻合方式术后均有胃食管反流,弓上隧道式食管胃吻合术患者术后反流性食管炎的发生率和反流程度均小于器械吻合术式。     

间置空肠肌黏膜瓣成形在贲门癌术后抗反流中的应用

目的寻找一种能有效对抗贲门癌术后反流性食管炎的消化道重建术式. 方法将62例贲门癌患者分为两组,实验组30例,贲门癌手术采用间置空肠附加肌黏膜瓣成形消化道重建;对照组32例,采用"常规"食管-残胃套叠吻合.应用同位素测定胃食管反流指数,24小时食管pH监测及临床反流症状评定方法进行对比分析. 结果同位素胃食管反流指数测定显示,实验组反流阳性率为0%,对照组为93.33%.24小时食管pH测定显示,实验组Demeester评分为2.01±2.21,对照组为103.40±91.35,两组比较差别具有显著性意义(P<0.01).反流临床症状评定结果实验组无1例出现反流症状,而对照组24例(75%)出现反流症状. 结论间置空肠肌黏膜瓣成形术式具有优异的抗反流功效,能有效地防止贲门癌术后反流性食管炎的发生.     

食管胃壁内吻合术对抗反流作用的临床研究

目的 探讨食管胃壁内吻合术重建贲门功能对预防食管下段癌、食管胃交界癌术后反流性食管炎的作用.方法 回顾性分析2002年1月至2008年10月西安交通大学医学院第二附属医院对66例食管下段癌、食管胃交界癌患者(研究组)施行胸腔食管胃壁内吻合术的临床资料.同期行器械吻合的65例患者为对照组.两组术后情况进行比较,采用X~2和t检验统计分析.结果 (1)反流程度:研究组3例为Ⅰ度,63例为0度;对照组16例为0度,23例为Ⅰ度,19例为Ⅱ度,7例为Ⅲ度.两组比较差异有统计学意义(X~2=137.3,P<0.05).(2)钡餐透视:研究组12例有少量钡剂反流,对照组有41例钡剂反流,两组比较差异有统计学意义(X~2=27.4,P<0.05).(3)胃镜检查:研究组9例黏膜改变,对照组46例黏膜改变,两组比较差异有统计学意义(X~2=43.5,P<0.05).(4)食管括约肌压力:研究组食管下括约肌压力为(3.4±0.8)kPa,食管上括约肌压力为(7.4±1.7)kPa;对照组分别为(2.5±0.6)kPa、(4.2±0.8)kPa.两组比较差异有统计学意义(t=4.98,11.59,P<0.05).结论 食管胃壁内吻合术能够部分达到贲门功能重建的作用,可较好预防反流性食管炎的发生.     

腹腔镜手术治疗反流性食管炎的应用与评价

胃食管反流病（gastroesophageal reflux disease，GERD）的并发症包括食管炎、消化性食管狭窄、食管溃疡及Barrett化生。因酸（碱）反流导致的食管黏膜破损称为反流性食管炎（reflux esophagitis，RE）。RE可导致一系列的临床症状如烧心感、反酸、胸骨后灼痛等，严重时可出现吞咽痛及出血、Barrett食管的改变，甚至导致食管癌的发生。     

食管胃垂瓣吻合在贲门癌术后抗反流的临床研究

目的评价食管胃垂瓣吻合术式在贲门癌术后抗反流的作用。方法将40例贲门癌患者随机分成研究组和手术对照组,每组20例,吻合方式分别采用食管胃垂瓣吻合术和传统食管胃吻合方式。在术后3个月分别采用24 h pH监测及胃镜检查,观察术后胃食管反流情况。另选10例健康人设为正常对照组。结果术后近期研究组及手术对照组pH各项监测指标均高于正常对照组(P0.05),手术对照组高于研究组(P0.05);两组反流性食管炎分级及组织学食管黏膜炎症程度均高于正常对照组(P0.05),而手术对照组高于研究组(P0.05)。结论食管胃垂瓣吻合术后也有一定的反流现象,但和传统手术相比,食管胃垂瓣吻合术具有明显抗反流作用。     

上消化道重建中的抗反流设计

反流性食管炎(reflux esophagitis,RE)和反流性胃炎(refluxgastritis,RG)是上消化道术后的主要远期并发症之一,是导致患者术后不适的重要原因。临床表现为上腹胀痛、恶心、呕吐、烧心、胸骨后疼痛和消化不良等,对生活质量影响较大,而且胆汁反流还可能与癌变有关。反流性胃食管炎的发生率不同学者报道的差异较大,近端胃切除后采用食管残胃吻合的RE发生率在50%~70%,Shibuya等[1]报道为71.5%,其中75.6%为重度食管炎。Yuasa等[2]报道食管切除术后用胃代食管重建者,在颈部食管行24h pH监测和胆红素测定,28%有胃酸反流,44%有胆汁反流,胃镜检查…     

食管癌切除附加抗反流术后残余食管黏膜上环氧化酶-2的表达

目的探讨食管癌切除附加改良Nissen折叠术后残余食管黏膜上环氧化酶-2(COX-2)表达的意义。 方法对2013年12月—2015年7月徐州医科大学附属徐州市立医院胸外科收治的50例食管中下段癌患者按照随机对照试验原则分为抗反流吻合组和常规吻合组。常规吻合组实施食管癌切除食管胃常规吻合术,抗反流吻合组在实施常规吻合基础上附加改良Nissen折叠术,术后42例患者参加随访,并以10名无反流症状的健康志愿者为对照组。行胃镜检查观察残余食管黏膜形态学改变和黏膜活检,采用real-time PCR检测残余食管黏膜上COX-2基因的表达。 结果抗反流吻合组反流性食管炎的发生率为45%,常规吻合组为68.2%,两组间反流性食管炎的发生率无明显差别(P＝1.313),而抗反流组反流性食管炎评分明显低于常规吻合组(P＝0.038)。正常对照组食管黏膜上COX-2呈现低水平表达,两组在胃镜下检查残余食管黏膜是否发生反流性食管炎的COX-2相对表达量均高于正常对照组(P＝0.031,P＝0.016),而两组间无明显差别(P＝0.137)。常规吻合组和抗反流吻合组残余食管黏膜上COX-2的相对表达量均高于对照组(P＝0.002,P＝0.047),而抗反流吻合组残余食管黏膜上COX-2表达明显低于常规吻合组(P＝0.036)。 结论食管癌切除附加改良Nissen折叠术具有抗反流的效果,检测残余食管黏膜上COX-2的表达变化是反应食管癌术后胃食管反流的灵敏指标,也可能是一种评估抗反流吻合效果的新方法。     

Is duodeno-gastro-esophageal reflux just a bystander of acid reflux?

BACKGROUND & AIM: Duodeno-gastro-esophageal reflux (DGER) as measured with bilirubin monitoring is observed in many patients with reflux disease especially in Barrett's esophagus. As acid suppression is an effective therapy of reflux disease, DGER is frequently just considered as a bystander of acid reflux. To define the importance of DGER, reflux of duodenal contents was evaluated by bilirubin monitoring in the stomach. METHODS: 100 patients with reflux disease were evaluated (62 m, 38 f, 50 (12) years). 26 patients had Barrett's esophagus, 57 had esophagitis and 17 non- erosive reflux disease (pH pos.). All patients were evaluated with simultaneous 24-hour bilirubin monitoring in the esophagus and stomach. Results were compared to 35 measurements of healthy volunteers in the esophagus and 41 measurements in the stomach. RESULTS: Normal values: DGER - Exposure time esophagus > 11.8 % using an absorbance value > 0.14, duodenogastric reflux (DGR) - Exposure time stomach >24.8 % using an absorbance value > 0.25. 56 % of the patients had DGER, 41 % had DGR. 29 of the 41 patients with DGR had DGER (71 %), while 27 of the 56 patients with DGER had physiologic duodenogastric reflux (48 %). DISCUSSION: About 30 % of the patients with reflux disease show DGER combined with excessive DGR. Therefore, DGER is not just a bystander of acid reflux. The excessive DGR in some patients adds additional potentially dangerous substances to the esophageal reflux.     

Duodenogastric reflux potentiates the injurious effects of gastroesophageal reflux

Experimental studies have shown that the severity of esophageal mucosal injury in gastroesophageal reflux disease is related to the reflux of both gastric and duodenal juice. The purpose of this study was to determine whether duodenal juice potentiates esophageal injury in patients with reflux disease or, inf act, causes no harm allowing acid and pepsin to do the damage. A total of 148 consecutive patients who had no previous gastric or esophageal surgery underwent endoscopy and biopsy, manometry, and 24-hour esophageal pH and bilirubin monitoring. Esophageal injury was defined by the presence of erosive esophagitis, stricture, or biopsy-proved Barrett's esophagus. Exposure to duodenal juice, identified by the absorbance of bilirubin, was defined as an exposure time exceeding the ninety-fifth percentile measured in 35 volunteers. To separate the effects of gastric and duodenal juice, patients were stratified according to their acid exposure time. One hundred patients had documented acid reflux on pH monitoring, and in 63 of them it was combined with reflux of duodenal juice. Patients with combined reflux (50 of 63) were more likely to have injury than patients without combined reflux (22 of 37; P < 0.05). When the acid exposure time was greater than 10%, patients with injury (n = 40) had a greater exposure to duodenal juice (median exposure time 17.2% vs. 1.1%, P = 0.006) than patients without injury (n = 5), but there was no difference in their acid exposure (16.9% vs. 13.4%). Patients with dysplasia of Barrett's epithelium (n = 9) had a greater exposure to duodenal juice (median exposure time 30.2% vs. 7.2%, P = 0.04) compared to patients without complications (n = 25), whereas acid exposure was the same (16.4% vs. 15%). Duodenal juice adds a noxious component to the refluxed gastric juice and potentiates the injurious effects of gastric juice on the esophageal mucosa.     

Acid and nonacid gastroesophageal reflux after single anastomosis gastric bypass. An objective assessment using 24-hour multichannel intraluminal impedance-pH metry

Background

Single anastomosis gastric bypass (SaGB) was introduced in 2001 as an alternative to “loop” gastric bypass. It was considered as a procedure that would eliminate alkaline reflux and associated esophagitis.

Symptoms are a poor indicator of reflux status after fundoplication for gastroesophageal reflux disease: role of esophageal functions tests

BACKGROUND: If a patient develops foregut symptoms after a fundoplication, it is assumed that the operation has failed, and acid-reducing medications are often prescribed. Esophageal function tests (manometry and pH monitoring) are seldom performed early in the management of these patients. HYPOTHESIS: In patients who are symptomatic after fundoplication for gastroesophageal reflux disease, a symptom-based diagnosis is not accurate, and esophageal function tests should be performed routinely before starting acid-reducing medications. DESIGN: Prospective study. SETTING: University hospital.Patients and METHODS: One hundred twenty-four patients who developed foregut symptoms after laparoscopic fundoplication (average, 17 months postoperatively) underwent esophageal manometry and pH monitoring. Sixty-two patients (50%) were taking acid-reducing medications. MAIN OUTCOME MEASURES: Postoperative symptoms, use of antireflux medications, grade of esophagitis, esophageal motility, and DeMeester scores. RESULTS: Seventy-six (61%) of the 124 patients had normal esophageal acid exposure, while the acid exposure was abnormal in 48 patients (39%). Only 20 (32%) of the 62 patients who were taking acid-reducing medications had reflux postoperatively. Regurgitation was the only symptom that predicted abnormal reflux. CONCLUSIONS: These results show that (1) symptoms were due to reflux in 39% of patients only; (2) with the exception of regurgitation, symptoms were an unreliable index of the presence of reflux; and (3) 68% of patients who were taking acid-reducing medications postoperatively had a normal reflux status. Esophageal function tests should be performed early in the evaluation of patients after fundoplication to avoid improper and costly medical therapy.     

Lack of correlation between gastroesophageal reflux disease symptoms and esophageal lesions after sleeve gastrectomy

Background

The postoperative development or worsening of gastroesophageal reflux disease (GERD) represents the major drawback of laparoscopic sleeve gastrectomy (SG). A GERD diagnosis is often based only on symptoms and proton pump inhibitors (PPI) intake, while objective tests like esophagogastroduodenoscopy and pH measurements are performed less frequently.

腹腔镜食管裂孔疝修补术联合改良DOR胃底折叠术治疗食管裂孔疝合并胃食管反流病的临床疗效

目的探讨腹腔镜食管裂孔疝修补术联合改良DOR胃底折叠术治疗食管裂孔疝（HH）合并胃食管反流病患者的临床疗效。 方法选择2016年1月至2019年1月河北北方学院附属第二医院收治的108例食管裂孔疝合并胃食管反流病患者开展回顾性研究，按照不同手术方式将患者分为2组，每组患者54例。对照组行常规开腹手术，联合组行腹腔镜食管裂孔疝修补术联合改良DOR胃底折叠术，比较2组患者术前及术后6个月反流时间、反流次数、DeMeester评分、食管下括约肌压力及Gerd Q量表评分。 结果2组术前反流时间、反流次数、DeMeester评分、食管下括约肌压力及Gerd Q量表评分比较，差异无统计学意义（P>0.05）；2组患者术后6个月反流症状与术前比较，均得到明显改善，差异有统计学意义（P<0.05）；2组术后反流时间、反流次数、DeMeester评分、食管下括约肌压力及Gerd Q量表评分比较，差异有统计学意义（P<0.05）。联合组患者的手术时间、术中出血量及术后住院时长均明显优于对照组，差异有统计学意义（P<0.05）。 结论腹腔镜食管裂孔疝修补术联合改良DOR胃底折叠术对HH合并胃食管反流病患者效果显著，有利于患者身体快速恢复，微创、安全且近期疗效满意。     

Effect of pyloric drainage procedures on gastric passage and bile reflux after esophagectomy with gastric conduit reconstruction

BACKGROUND AND AIMS: Controversy still exists about the need for pyloric drainage procedures (pyloroplasty or pyloromyotomy) after esophagectomy with esophagogastrostomy and vagotomy. Although pyloric drainage may prevent postoperative delayed gastric emptying, it may also promote bile reflux into the oesophagus. We analysed pyloric drainage methods for their potential effect on gastric outlet obstruction and bile reflux in patients undergoing esophagectomy. MATERIALS AND METHODS: One hundred and ninety-eight patients with esophageal carcinoma were treated by transthoracal esophagectomy with gastric conduit reconstruction either with pyloromyotomy (group II, n = 118), pyloroplasty (group III, n = 34) or without pyloric drainage (group I, n = 46) between January 2000 and December 2004. The postoperative gastrointestinal passage by radiological investigation, anastomotic leakage rate, mortality and incidence of gastroesophageal reflux by endoscopy within the first postoperative year were retrospectively analysed. RESULTS: Patient demographics and the types of surgical procedures did not differ between the three groups. There was no difference in hospital mortality, anastomotic leakage rate, gastrointestinal passage and postoperative hospital stay between the three groups. However, more patients with pyloric drainage showed bile reflux (I = 0% vs II+III=14.9%, p = 0.069) and reflux esophagitis (I = 10.3% vs II+III = 34.5%, p < 0.05) compared to patients without pyloric drainage. On the multivariate analysis, pyloric drainage and the anastomotic height were independent and were significant risk factors associated with postoperative reflux esophagitis. CONCLUSION: Pyloric drainage after esophagectomy with gastric conduit reconstruction should be omitted because it does not improve gastric emptying and may favour biliary reflux esophagitis.     

The role of esophageal motility and hiatal hernia in esophageal exposure to acid

Background: The pathogenesis of gastroesophageal reflux disease (GERD) is multifactorial. This study evaluates the relationship between esophageal exposure to acid, the presence or absence of a hiatal hernia, and manometric indicators of esophageal motility. Methods: A total of 51 patients with foregut symptoms were evaluated with upper gastrointestinal series or endoscopy, 24-h pH testing, and esophageal manometry. The DeMeester score was used to distinguish patients with physiologic reflux (DeMeester score <14.72) FROM PATIENTS WITH PATHOLOGIC REFLUX (DEMEESTER SCORE >14.72). Results: Patients with physiologic reflux had fewer hypotensive contractions and a smaller percentage of uncoordinated and hypotensive contractions combined, as compared to patients with pathologic reflux. The amplitude of distal esophageal contractions was greater in patients with physiologic reflux. Also, patients with a hiatal hernia had a higher incidence of pathologic reflux, regardless of the lower esophageal sphincter pressure. Conclusion: Patients with pathologic reflux have abnormal acid exposure associated with pump failure of the esophagus and/or a mechanical defect of the cardia associated with a hiatal hernia.     

Mixed reflux of gastric and duodenal juices is more harmful to the esophagus than gastric juice alone. The need for surgical therapy re-emphasized.

OBJECTIVE: The author's goal was to determine the role of duodenal components in the development of complications of gastroesophageal reflux disease. SUMMARY AND BACKGROUND DATA: There is a disturbing increase in the prevalence of complications, specifically the development of Barrett's esophagus among patients with gastroesophageal reflux disease. Earlier studies using pH monitoring and aspiration techniques have shown that increased esophageal exposure to fluid with a pH above 7, that is, of potential duodenal origin, may be an important factor in this phenomenon. METHODS: The presence of duodenal content in the esophagus was studied in 53 patients with gastroesophageal reflux disease confirmed by 24-hour pH monitoring. A portable spectrophotometer (Bilitec 2000, Synectics, Inc.) with a fiberoptic probe was used to measure intraluminal bilirubin as a marker for duodenal juice in the esophagus. Normal values for bilirubin monitoring were established for 25 healthy subjects. In a subgroup of 22 patients, a custom-made program was used to correlate simultaneous pH and bilirubin absorbance readings. RESULTS: Fifty-eight percent of patients were found to have increased esophageal exposure to gastric and duodenal juices. The degree of mucosal damage increased when duodenal juice was refluxed into the esophagus, in that patients with Barrett's metaplasia (n = 27) had a significantly higher prevalence of abnormal esophageal bilirubin exposure than did those with erosive esophagitis (n = 10) or with no injury (n = 16). They also had a greater esophageal bilirubin exposure compared with patients without Barrett's changes, with or without esophagitis. The correlation of pH and bilirubin monitoring showed that the majority (87%) of esophageal bilirubin exposure occurred when the pH of the esophagus was between 4 and 7. CONCLUSIONS: Reflux of duodenal juice in gastroesophageal reflux disease is more common than pH studies alone would suggest. The combined reflux of gastric and duodenal juices causes severe esophageal mucosal damage. The vast majority of duodenal reflux occurs at a pH range of 4 to 7, at which bile acids, the major component of duodenal juice, are capable of damaging the esophageal mucosa.