Endoscopic treatment of vesicoureteral reflux with collagen

Submucosal injection of bovine collagen (Zyplast) was performed in 1 boy, 41 girls, and 9 women with 79 refluxing ureters. Five ureters had grade IV reflux, while the others had grades I–III. All patients suffered from recurrent urinary tract infections. In 25 ureters a second injection was given. As a result of this treatment, reflux is absent in 86% of the ureters. Only 15 patients had urinary tract infections during the follow-up period (6–30 months). Collagen injections could gain great importance in the management of vesicoureteral reflux.     

Reflux nephropathy in the 1st year of life — the role of infection

The importance of infection and vesico-ureteric reflux in the development of reflux nephropathy is generally accepted. Widespread use of antenatal ultrasound scanning has identified dilated fetal urinary tracts, allowing prompt investigation and treatment in the early post-natal period; some of these children have vesico-ureteric reflux. This study compares renal parenchymal damage, demonstrated by uptake of technetium ^99m dimercaptosuccinic acid (DMSA) in two groups. The first included babies less than 6 months old who had presented with their first urinary tract infection and had vesico-ureteric reflux. The second included those in whom a dilated urinary tract had been identified at antenatal ultrasound and post-natal investigation revealed vesico-ureteric reflux, but who had no evidence of urinary tract infection. Renal damage was present in 68% of group 1 and 29% of group 2 when DMSA scanning was used to detect scarring (P = <0.05). Our results support the proposal that infection is a major factor in development of renal damage in patients with vesico-ureteric reflux. Identification by antenatal ultrasound scanning allows early therapeutic intervention before renal damage occurs. Offprint requests to: D. C. S. Gough     

全胃切除间置空肠变法空肠代胃术20例报告

报告全胃切除间胃空肠变法空肠代胃术２０例。方法：全胃切除并淋巴结扩清后，距屈氏韧带８０ｃｍ切断空肠及其系膜，肛侧端闭锁，于１５ｃｍ行空肠侧侧吻合，于３５ｃｍ用粗丝线结扎肠管并于结扎线上下各１ｃｍ缝合浆肌层一周形成中隔，于４０ｃｍ行食管空肠端侧吻合。空肠口侧与十二指肠端端吻合。优点：１）食物通过十二指肠符合生理。２）有效地防止返流性食管炎。３）如发生吻合瘘则有利于瘘的愈合。     

Randomized comparative study of omeprazole and famotidine in reflux esophagitis

BACKGROUND: Although proton pump inhibitors (PPI) and H2-receptor antagonists (H2-RA) are routinely used in the treatment of reflux esophagitis (RE), no consensus has been reached yet as to whether the first-choice drug should be PPI or H2-RA. In this study, the effects of omeprazole (OMP) and famotidine (FAM) on RE have been examined in a randomized comparative study. METHODS: Protocols of OMP 20 mg once daily or FAM 20 mg twice daily for 8 weeks were allocated to 56 cases with RE at random, using an envelope randomization method. Their efficacy in achieving healing was examined endoscopically and a relief from subjective symptoms was compared. RESULTS: Patient's background such as sex, age, recurrence, hiatal hernia, smoking and drinking habits, and complications, and the severity of esophagitis at the time of enrolment were not significantly different between the two groups. Healing in the OMP group and the FAM group was observed in 72 and 32% (P = 0.025) of patients at week 4 and 95 and 53% (P = 0.003) of patients at week 8, respectively. Subjective symptoms were relieved more frequently in the OMP group (at week 2, 67% compared with 29%, P = 0.005; at week 4, 95% compared with 55%, P = 0.009), but this superiority was not significant at week 8 (94% compared with 65%, P = 0.085). No serious adverse events occurred. CONCLUSIONS: Omeprazole provided quicker healing and a greater relief from subjective symptoms than did FAM in the treatment of RE, and was considered more suitable as a first-choice drug.     

Heller's myotomy without fundoplication: a series of 123 patients

INTRODUCTION: Surgical treatment of achalasia of lower oesophageal sphincter is Heller's myotomy, usually associated with a fundoplication due to an high risk of postoperative gastro-oesophageal reflux. The value of this fundoplication is discussed. The aim of this study was to evaluate retrospectively the results of Heller's myotomy without fundoplication but performed according to a precise technique preventing postoperative reflux. PATIENTS AND METHODS: Between 1975 and 1999, 123 patients underwent Heller's myotomy without systematic fundoplication. Diagnosis of achalasia was performed clinically and confirmed by investigations: baryum meal, fibroscopy and manometry. Myotomy was performed through an abdominal approach in 117 (95%) patients. Dissection preserved fixity of abdominal oesophagus in all cases, particularly its posterior meso. Myotomy was performed on abdominal oesophagus but not below the cardia. Posterior fundoplication was associated in 2 patients. RESULTS: One patient (0,8%) died from massive aspiration. Morbidity (1,6%) consisted in one peritonitis and one postoperative occlusion. At follow-up (mean = 5 years; range: 1-20), functional results were satisfying (excellent and good) in 112 (92%) patients. Seven patients (6%) developed postoperative reflux, including one who need surgical treatment. Dysphagia persisted in 3 patients (2%) who had to be reoperated. CONCLUSION: Results of this series show that systematic fundoplication is not necessary in Heller's myotomy for achalasia of lower oesophageal sphincter.     

Endoscopy in Patients Receiving Radiation Therapy to the Thorax

Radiation therapy for thoracic malignancies is often complicated by radiation-induced esophagitis. Symptoms of radiation esophagitis are nonspecific and include dysphagia, odynophagia, and chest pain. Patients receiving radiation therapy are also at risk for infectious esophagitis, which can be indistinguished clinically from radiation-induced esophagitis. We retrospectively reviewed data on patients who had esophagitis symptoms during or after thoracic radiation therapy and were referred for upper endoscopy. We sought to determine how often infectious esophagitis or cancer was present, as compared to radiation-induced esophagitis alone. Twenty-four upper endoscopies were performed on 16 patients over a three-year period to evaluate esophagitis symptoms. Forty-four percent of the patients endoscoped had infectious esophagitis or recurrent cancer diagnosed by endoscopy. No complications occurred from the procedures. Esophagoscopy is a safe procedure that should be considered, to exclude infection or cancer, in patients who develop esophagitis symptoms during or after thoracic radiation.     

Surgical physiology of esophagogastric junction. Selective testing is effective; some problems remain elusive

Summary When evaluating foregut symptoms which may originate from many sites, accurate diagnosis must be achieved by cost-effective and efficient diagnostic methods. Since all tests cannot be done routinely, invasive tests are mandatory only when the diagnosis is uncertain; testing which confirms the obvious is overly expensive and superfluous. This report describes selective preoperative diagnostic testing for patients with heartburn and dysphagia; endoscopy was used always, but radiography, manometry, and pH testing were done selectively. Hiatus hernia remains an elusive entity which resists easy definition. Methods: A total of 273 patients operations (185 with gastroesophageal reflux disease (GERD) and 88 with achalasia (ACHA) of the esophagus) were operated upon during a 15 year period. All heartburn patients had endoscopy; if erosive esophagitis was present and symptoms responded to medical treatment the diagnosis of GERD was made; manometry and pH studies were performed selectively. Esophagrams or other special X-Rays (spiral tomography) were performed often, but selectively, in preoperative patients and less commonly in postoperative patients. When indicated, fundoplication was performed for GERD and transabdominal cardiomyotomy with fundoplication for ACHA. Results (Tables 1, 2): Endoscopy was performed in all patients. Motility examinations (n = 248) and pH studies (n = 175) were helpful in defining operative candidates; 95% of GERD and ACHA operations were effective, and postoperative hiatus hernia or wrap disruption occurred rarely (2%). ACHA patients had minimal reflux, and one had reoperation for extrinsic stricture at the gastoesophageal junction. Unexpected hiatus hernia was found in 8–10% of both groups. Conclusions: Clinical judgment supported by selective diagnostic testing in GERD and ACHA effectively identified operative candidates. The role of hiatus hernia in causing symptoms in individual patients is largely unknown at present; further, there is no reliable noninvasive way of estimating the size of hernia in a single patient.     

铝碳酸镁不同给药方法对反流性食管炎的近期疗效观察

目的：铝碳酸镁（达喜）不同给药方法治疗反流性食管炎，通过进行胃镜观察疗效对比，探索反流性食管炎的治疗新方法。方法：将胃镜下诊断为Ⅱ级以上的RE患者106例，随机分成两组，治疗组采用铝碳酸镁溶于水，小口慢咽，对照组用铝碳酸镁片剂给药，按同等剂量治疗10 d复查胃镜。结果：治疗组总有效率显著高于对照组，经χ^2检验，两组总有效率有非常显著性差异（P〈0.01）。结论：采用铝碳酸镁水溶剂小口慢咽的给药方法，让药物与病灶局部充分接触是治疗反流性食管炎，尤其是Ⅱ级以上糜烂性食管炎非常有效的方法。     

Inflammatory esophagogastric polyp and fold in an adolescent

The case of a 13 year old boy with an inflammatory esophagogastric polyp and ulcerative colitis is described. Endoscopy revealed a typical polyp and gastric fold complex at the esophagogastric junction and a hiatal hernia. Histology of a biopsy specimen confirmed an inflammatory polyp covered by hyperplastic squamous and gastric foveolar epithelium. Continuous 24 hour esophageal manometry suggested gastroesophageal reflux, which may be related to the pathogenesis of the lesion. Follow-up endoscopy showed marked regression of the polyp with medication for reflux eosphagitis. This clinical entity is rare in childhood and adolescence, and the manifestations may not be readily recognized. Therefore, endoscopic biopsy is important in children with esophageal polyps. However, polypectomy is unnecessary except when malignancy is suspected or when symptoms persist.     

Primary vesicoureteral reflux in infants with a dilated fetal urinary tract

Vesicoureteral reflux (VUR) was recognized neonatally by voiding cystography in 25 of 117 infants with a dilated fetal urinary tract. There was a male preponderance (76%) and a high percentage (40%) of associated urinary malformations. Thirtynine refluxing units were studied. All grades of VUR were detected but gross dilating VUR dominated (59%). Spontaneous resolution was excellent in lower grades of VUR but was poor in gross VUR. Surgery was successfully performed in 13 renal units of nine patients with gross reflux [8], additional ipsilateral malformations [4], or pyelonephritis during antibiotic prophylaxis [1]. Segmental renal scars developed in four kidneys after urinary infections, and a diffuse parenchymal lesion was noted in nine kidneys even at birth. One boy with duplication had a non-functioning refluxing system. Our results in a small number of infants show differences to children with VUR detected after urinary infections and seem to support the existence of a congenital reflux nephropathy.