Pharyngeal swallowing disorders: selection for and outcome after myotomy.

OBJECTIVE: To develop selection criteria based on the mechanical properties of pharyngoesophageal swallowing that indicate when patients with pharyngeal dysphagia will benefit from a myotomy. SUMMARY BACKGROUND DATA: The pathophysiology of pharyngoesophageal swallowing disorders is complex. The disorder is of interest to several medical specialists (gastroenterologists, otorhinolaryngologists, general and thoracic surgeons), which contributes to confusion about the entity. The management is compounded because it is most frequently seen in the elderly, is often associated with generalized neuromuscular disease, and occurs with a high prevalence of concomitant disease. The selection of patients for myotomy is difficult and of major importance to the quality of life of the affected patients. METHOD: One hundred seven patients without a Zenker diverticulum but with pharyngeal dysphagia underwent a detailed manometric assessment of the upper esophageal sphincter (UES). Cricopharyngeal opening was identified by the presence of a subatmospheric pressure drop before bolus arrival. Impaired pharyngoesophageal segment compliance resulting in a resistance to pharyngoesophageal flow was determined by measuring the intrabolus pressure generated by a 5-ml liquid bolus. RESULTS: Thirty-one of 107 patients underwent a myotomy (29%). Both impaired sphincter opening and increased intrabolus pressure predicted a good outcome. CONCLUSION: Myotomy is beneficial in patients with pharyngeal swallowing disorders and manometric evidence of defective sphincter opening and increased intrabolus pressure.     

Gastroesophageal reflux: a factor eliciting esophageal variceal hemorrhage?]

Following a hemorrhage, ten patients with esophageal varices were examined by means of gastroscopy and functional analysis of the esophagus with special regard to gastroesophageal reflux. A pathological gastroesophageal reflux was not confirmed. These results plus previously published findings lead to the assumption that reflux is of not importance in the initiation of esophageal variceal bleeding.     

Supradiaphragmatic correction of esophageal reflux strictures.

Intragastric pressure measurements and cineradiographic contrast studies were done in monkeys in order to determine the pressure at which esophageal reflux occurred. Antireflux operative procedures were performed above and below the diaphragm, and the results compared. The Nissen fundoplication proved to be the most effective type of mechanical antireflux valve and worked equally well placed above and below the diaphragm. Of 200 consecutive adult patients undergoing operative correction of esophageal reflux, 19 had severe esophageal strictures. Through a transthoracic approach, two patients had subdiaphragmatic Nissen fundoplications, one with adenocarcinoma of the esophagus had an esophageal resection, and 16 had supradiaphragmatic Nissen fundoplications; those 16 patients form the basis of this report. No patients died; superficial, temporary esophageal ulcerations developed in two. Follow-up times have ranged from six months to eight years; the results in all cases have been good. Experimental and clinical evidence supports the belief that this less radical approach is the treatment of choice in the management of severe esophageal strictures secondary to reflux esophagitis.     

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.     

Etiology and importance of alkaline esophageal reflux.

While an alkaline component to esophageal reflux disease is known to be present, little is known about its etiology and harmful effects. Simultaneous gastric and esophageal 24-hour pH monitoring was performed in 81 patients with foregut symptoms. The presence of a mechanically defective lower esophageal sphincter was determined by manometry and duodenogastric reflux by computer-assisted discriminant analysis of the gastric pH record. Heartburn, dysphagia, and regurgitation occurred more frequently in those with a mechanically defective sphincter (p < 0.05) and epigastric pain in those with duodenogastric reflux (p < 0.05). Esophagitis was more common and severe in those with a mechanically defective sphincter (p < 0.05). In these patients, the percentage of time over 24 hours that the esophageal pH was less than 4 was 40.5% in patients without duodenogastric reflux but only 10.2% in those with duodenogastric reflux (p < 0.005), suggesting acid damage in the former and alkaline damage in the latter. To establish the origin of the esophageal alkaline exposure, episodes of elevated fasting gastric pH greater than 4 lasting longer than 1 minute were searched for and identified in 45 patients. Esophageal pH tracings were compared for 30 minutes before and after these events. The esophageal pH was higher following these episodes in duodenogastric reflux patients (p < 0.05), suggesting a gastroduodenal origin of the esophageal alkalinization. This study shows that esophageal damage may be due to acid or alkaline reflux. The alkaline component of gastroesophageal reflux is important and should be considered in the evaluation of patients with foregut symptoms so that appropriate medical or surgical therapy can be instituted.     

Treatment of reflux esophagitis resulting in massive esophageal bleeding.

The complications that occur secondary to sliding hiatal hernia are reflux esophagitis with ulceration, stricture formation, and hemorrhage. We have treated seven patients for massive esophageal bleeding secondary to reflux esophagitis. All had endoscopic evidence of reflux esophagitis and a negative work-up for other sources of bleeding. All underwent Nissen fundoplication as the only mode of therapy for the bleeding esophagitis. No patient has bled again; healing of the esophagitis was evident six weeks after operation, as observed by gastrointestinal endoscopy. This operation prevents reflux, has minimal side-effects, and gives consistent results in the hands of the average trained gastrointestinal surgeon.     

Pharyngeal acid reflux in patients with single and multiple otolaryngologic disorders

OBJECTIVE: This study was designed to determine the prevalence and characteristics of pharyngeal acid reflux (PAR) events in single and multiple otolaryngologic disorders. METHODS: Sixty-seven patients with otolaryngologic symptoms and objective findings and 34 healthy control subjects were studied with an ambulatory 24-hour, 3-site pharyngoesophageal pH monitoring technique. Otolaryngologic diagnosis included isolated posterior laryngitis (PL) in 28 patients, isolated chronic rhinosinusitis (SIN) in 12, combined PL and SIN (PL+SIN) in 6, PL plus laryngotracheal stenosis (PL+LTS) in 12, and PL plus vocal cord nodules (PL+VCN) in 9. RESULTS: PAR events were documented in 68% of patients with PL, 34% of patients with SIN, 67% of patients with PL+SIN, 67% of patients with PL+LTS, 78% of patients with PL+VCN, and 21% of controls. The prevalence of PAR events in patients with isolated PL as well as those with PL combined with other disorders was significantly higher than that in patients without PL and that in controls. As a group, patients with PL had a greater number of PAR events and acid exposure time than other patients and controls. Distal and proximal esophageal reflux parameters were not significantly different among groups. CONCLUSIONS: The prevalence of PAR is significantly higher in patients with isolated PL compared to patients with other isolated otolaryngologic disorders and in controls. The prevalence of PAR in isolated otolaryngologic disorders other than PL is similar to that in healthy controls. The prevalence of PAR is significantly higher in patients with both PL and other otolaryngologic disorders than in controls and in patients with isolated otolaryngologic disorders.     

The combined Collis-Nissen operation for esophageal reflux strictures

This report evaluates the efficacy of the combined Collis-Nissen operation in achieving long-term reflux control in patients with reflux strictures. A Collis-Nissen procedure with dilation of a reflux stricture was performed in 64 adults. The strictures were mild (easily dilated) in 37, moderate (requiring some force to dilate) in 17, and severe (requiring very forceful dilation) in 10. Two strictures were perforated intraoperatively. There was 1 postoperative death, and 4 patients have been lost to follow-up. The remaining 59 patients have been followed from 2 to 120 months (average, 43 months) after operation. Subjectively, reflux is absent in 48 (81%), mild in 4 (7%), moderate in 5 (9%), and severe in 2 (3%). Objectively, intraesophageal pH studies show good or excellent reflux control in 94% at 1 year and 66% at 2 to 5 years. Dysphagia has been eliminated in 71%, is mild in 10%, moderate (requiring occasional dilation) in 12%, and severe (requiring regular dilations) in 7%. The combined Collis-Nissen operation provides good long-term reflux control and relief of dysphagia in most patients with reflux strictures. However, patients with reflux strictures after previous repairs are likely to have unsatisfactory results and may best be managed with resectional therapy. Resection may also ultimately prove to be a better option for patients with more severe strictures.     

Does surgery correct esophageal motor dysfunction in gastroesophageal reflux.

The high incidence of dysphagia in patients with symptomatic gastroesophageal reflux (GER) but no evidence of peptic stricture suggests esophageal motor dysfunction. Conventional methods for detecting dysfunction (radiologic and manometric examinations) often fail to detect abnormality in these patients. Radionuclide transit (RT), a new method for detecting esophageal motor dysfunction, was used to prospectively assess function in 29 patients with symptomatic GER uncomplicated by stricture before and three months after antireflux surgery (HILL). The preoperative incidence of dysphagia and esophageal dysfunction was 73% and 52%, respectively. During operation (Hill repair), intraoperative measurement of the lower esophageal sphincter pressure was performed and the LESP raised to levels between 45 and 55 mmHg. The preoperative lower esophageal sphincter pressure was raised from a mean of 8.6 mmHg, to mean of 18.5 mmHg after operation. No patient has free reflux after operation. Postoperative studies on 20 patients demonstrated persistence of all preoperative esophageal dysfunction despite loss of dysphagia. RT has demonstrated a disorder of esophageal motor function in 52% of patients with symptomatic GER that may be responsible for impaired esophageal clearance. This abnormality is not contraindication to surgery. The results indicate that construction of an effective barrier to reflex corrects symptoms of reflux, even in the presence of impaired esophageal transit. Radionuclide transit is a safe noninvasive test for assessment of esophageal function.     

Gastroesophageal reflux in esophageal scleroderma: diagnosis and implications.

Fifty-three patients with scleroderma were evaluated by history, barium swallow, and esophageal function tests. The most common esophageal symptoms were heartburn and dysphagia. Abnormal motility was seen radiologically in 43 patients, gastroesophageal reflux in only 9. Esophageal function tests demonstrated: (1) abnormal motility in 51 patients and lack of a distal esophageal high-pressure zone in 18; (2) moderate to severe gastroesophageal reflux in 38; and (3) abnormal acid-clearing ability in 50. Eleven patients, including 8 with peptic stricture, underwent the combined Collis-Belsey operation. Symptomatically, reflux was abolished in all and dysphagia in 10. Roentgenograms showed that regression of strictures was complete in 5 and partial in 3. Postoperative esophageal function tests in 9 patients demonstrated a competent distal esophageal valvular mechanism in 7. Gastroesophageal reflux, not impaired motility, is the major cause of esophageal symptoms in scleroderma. Its effecitve operative control is not contraindicated by systemic disease in these patients.     

Duodenoesophageal reflux and the development of esophageal adenocarcinoma in rats.

BACKGROUND. The carcinogenic effect of duodenoesophageal reflux, gastroesophageal reflux, and nitrosamines was studied in the rat esophagus. METHODS. Twenty male Sprague-Dawley rats underwent esophagogastroplasty to produce gastroesophageal reflux and 60 underwent duodenoesophageal anastomosis to produce duodenoesophageal reflux. Forty-three animals underwent no operation and acted as controls. Carcinogens known to produce squamous tumors in the rat esophagus (2,6-dimethylnitrosomorpholine [DMNM] or methyl-n-amylnitrosamine [MNAN]) were tested in each group. RESULTS. The rate of squamous carcinoma was 25% for rats with DMNM alone, 30% for rats with MNAN alone, and 20% for rats with induced gastroesophageal reflux plus DMNM. The rate of malignant change rose to 80% in rats with induced duodenoesophageal reflux and DMNM and 67% with duodenoesophageal reflux and MNAN. With duodenoesophageal reflux, 50% of tumors were adenocarcinoma, in contrast to 100% squamous differentiation of tumors in rats given the carcinogens with esophagogastroplasty or no operation. CONCLUSION. The presence of duodenoesophageal reflux increased the frequency and changed the histologic type of esophageal cancer in nitrosamine-treated rats. This indicates that duodenoesophageal reflux plays a role in the development of esophageal adenocarcinoma.     

Canadian Association of General Surgeons Evidence Based Reviews in Surgery. 6. "GERD" as a risk factor for esophageal cancer. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma.

Question: Is gastroesophageal reflux a risk factor for the development of esophageal adenocarcinoma? Design: A case control study. Setting: A population-based study in Sweden between 1994 and 1997. Participants: Cases included all patients with gastric or esophageal adenocarcinoma and half of all patients with esophageal squamous cell cancer, under the age of 80 years and living in Sweden between Dec. 1, 1994, and Dec. 31, 1997. Controls were selected randomly from among persons matched for age (within 10 yr) and sex in the entire Swedish population, through the use of a population register, which is computerized and updated continuously. Assessment of risk factors: Symptomatic reflux was assessed according to the severity of the symptoms (heartburn only, regurgitation only, heartburn and regurgitation combined, nightly symptoms), frequency and duration. Adjustment was made for age, sex, body mass index, smoking history, alcohol ingestion, socioeconomic status, intake of fruit and vegetables, overall energy intake, posture and the degree of physical activity both at work and during leisure. Main outcome measures: Gastric and esophageal adenocarcinoma and esophageal squamous cell cancer. Main results: Among participants with recurrent symptoms of reflux, as compared with those without such symptoms, the odds ratios were 7.7 (95% CI, 5.3–11.4) for development of esophageal adenocarcinoma and 2.0 (95% CI, 1.4–2.9) for adenocarcinoma of the cardia. The more frequent, more severe and longer duration the symptoms of reflux were, the greater was the risk. Among persons with long-standing, severe symptoms of reflux, the odds ratios were 43.5 (95% CI, 18.3–103.5) for development of esophageal adenocarcinoma and 4.4 (95% CI, 1.7–11.0) for adenocarcinoma of the cardia. The risk of esophageal squamous cell carcinoma was not increased with reflux (odds ratio, 1.1; 95% CI, 0.7–1.9). Conclusion: The study identified a strong and probably causal relation between symptomatic reflux as a strong risk factor for esophageal adenocarcinoma and a relatively weak risk factor for adenocarcinoma of the gastric cardia.     

Conservative surgical treatment of reflux esophagitis and esophageal stricture.

During a recent 3-year period, 17 consecutive patients were seen with advanced fibrotic esophageal strictures secondary to alkaline-acid-pepsin reflux. From detailed preoperative evaluations alone it was impossible to determine whether therapy should consist of excisional surgery, esophagogastroplasty or intra-operative dilatation with correction of reflux. Only at operation could the length, extent, degree and severity of the stricture be fully determined. Each of the 17 patients was treated by controlled dilatation, coupled with an antireflux procedure. This simplified approach proved successful on strictures thought preoperatively to be undilatable. It appears that this conservative approach is applicable to many advanced strictures and excisional and plastic procedures should be reserved for those cases that prove unyielding to intraoperative dilatation. The true appraisal of a reflux stricture and the choice of surgical procedure is best determined at the operating table.     

New techniques in measuring nonacidic esophageal reflux

New techniques in esophageal monitoring are allowing for better differentiation in the role of different gastric refluxates in esophageal mucosal damage and patient symptoms. The Bilitec 2001 (Synectics, Stockholm, Sweden) is a portable spectrophotometer that measures bilirubin as a surrogate marker for bile reflux and multichannel intraluminal impedance (MII) (Sandhill Scientific Inc, Highlands Ranch, CO) is a new technique allowing measurement of esophageal volume refluxate. Both techniques assess the role of nonacidic esophageal reflux. Despite their novel approach in assessing nonacid reflux, both methods have limitations. Future studies in this area, however, will prove beneficial in identifying their role in diagnosis and management of patients with suspected nonacid reflux disease.