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Motility and function of the gastroesophageal junction following different laparoscopic approaches in antireflux surgery.clinical implications
S8
Abstracts
Conclusions: (1) BE occurs in at least 9 –10% of all subgroups coming to endoscopy. (2) Pts with all types of pulmonary/ENT Sx have a similar prevalence of BE as Pts with typical GER Sx. (3) BE occurs half as often with dyspepsia Sx or ulcer Sx than it does with typical GER Sx, yet the prevalence is high enough to consider routine biopsy of the SC junction during EGD. 22 MOTILITY AND FUNCTION OF THE GASTROESOPHAGEAL JUNCTION FOLLOWING DIFFERENT LAPAROSCOPIC APPROACHES IN ANTIREFLUX SURGERY.CLINICAL IMPLICATIONS Pietro Dusio, Marcello Spampinato, Emma Gay and Luigi Locatelli*. Gastroenterology and Endoscopy Motility Unit, Ospedale Valdese, Torino, Italy and Surgery, Ospedale Valdese, Torino, Italy. Purpose: Aim of this work was to determine the post operative function of gastroesophageal junction after different fundoplication techniques in GERD patients, and whether different approaches could affect the clinical outcome,in order to improve the surgical results.Recently we decided to fix the Nissen valve to the esophagus, avoiding possible slippage. Motility and clinical aspects were comparated among different techniques. Methods: 34 patients treated with different laparoscopic approaches, underwent a functional assessment and a clinical evaluation after funduplications, in order to discover possible reasons of disfunction .16 Floppy Nissen (FN) with the section of short vessels and a floppy valve, 13 Floppy Nissen with fixation of the valve to the esophagus on both sizes, according to Dellemagne (FND) and 5 Nissen Rossetti (NR ) were investigated.They underwent a pre and post operative manometry, post operative clinical examination, endoscopy and XRs check. Results: The post operative manometry showed in all cases normal neo LES pressure while the neo LES relaxations showed two different patterns. A: more than 80% of complete relaxations with normal lenght in 18 cases (7 FN, 9 FND, 2 NR). B: Not complete relaxations with short lenght in 16 cases (9 FN, 4 FND, 3 NR). 5 patients who had shown pre operative hypoperistalsis (2 FN and 3 FND),at the post operative manometry showed unvaried hypoperistalsis in 4 cases and a slight improvement in 1. Normal peristalsis was demonstrated in the remaining patients. 5 patients showed severe disphagia after surgery (4 FN, and 1 NR). In 2 cases disphagia disappeared after several endoscopies and in 3 became sporadic and was treated with medical therapy.Only 1 FND case showed transient disphagia. Conclusions: It appears that neo LES relaxations patterns,whether complete with normal lenght or not, do not affect the clinical outcome in the FN and NR groups.FND patients who had demonstrated poor incidence of disphagia, showed an increased good rate of complete neo LES relaxations. Different techniques do not affect post operative peristalsis findings.The valve fixations may offer a good pattern of neo LES relaxations and a good long lasting functional result. 23 ACHALASIA PRESENTING AFTER OPERATIVE AND NONOPERATIVE TRAUMA Rupa N. Shah, M.D., James L. Izanec, M.D., David M. Friedel, M.D.*, Peter Axelrod, M.D., Henry P. Parkman, M.D. and Robert S. Fisher, M.D. Gastroenterology, Temple University Hospital, Philadelphia, PA. Purpose: The purpose of this study was to assess the association of operative and nonoperative trauma as a factor in the development of achalasia. Methods: Clinical records were retrospectively screened over a 6 year period for the diagnosis of achalasia. Control patients had symptoms of dysphagia but with normal manometry and endoscopy. Charts were screened for symptoms (including duration) and history of preceding operative and nonoperative events. Results: Achalasia was diagnosed in 64 patients (37 F, 27 M; mean age 54 years). 16/64 patients (25%– 10 F, 6 M; mean age 55 years) had a history
AJG – Vol. 97, No. 9, Suppl., 2002
of trauma to the upper GI tract before the onset of symptoms (10 patients with operative trauma, 6 patients with nonoperative trauma). 48 patients (75%– 27 F, 21 M, mean age 54 years) reported no prior trauma. In contrast, in the control group with dysphagia and normal manometry, 7/73 patients (9.5%– 53F, 20M; mean age 45 years) had a history of trauma (5 surgeries, 2 motor vehicle accidents {MVAs}) before onset of symptoms (2 ⫽ 5.90, p ⬍ 0.02 vs. the control group). All nonoperative trauma cases were MVAs. The postoperative trauma achalasia group included 4 patients who underwent cardiac surgery and 6 patients who underwent surgery involving the gastroesophageal (GE) junction (2 bariatric surgery, 1 Nissen fundoplication, 1 Billroth II with vagotomy, 1 repair of distal esophageal perforation, and 1 repair of congenital tracheo– esophageal fistula). The postoperative trauma normal manometry group included 2 patients with cardiac bypass, 2 patients with Nissen fundoplications, and 1 patient who had thyroid surgery. The predominant symptom in all patients was dysphagia. Interestingly, the trauma achalasia patients had more chest pain (RR ⫽ 4.50, p ⫽ 0.012) but less regurgitation (RR ⫽ 0.51, p ⫽ 0.010) than the nontrauma achalasia patients. The average duration of symptoms prior to diagnosis was similar in each group. Conclusions: Achalasia can occur after operative and nonoperative trauma. In this retrospective study, 25% of patients with achalasia had a history of operative or nonoperative trauma to the thorax, compared to only 9.5% of dysphagia patients with normal manometry. These results suggest that some patients with achalasia may have neuropathic esophageal dysfunction related to vagal nerve damage from prior trauma.
24 BARRETT’S ESOPHAGUS GENOMIC STUDY GROUP: PROGRESS TO DATE Teresa G. Zais, Yvonne Romero*, Thomas Smyrk, Alan Cameron, Enrique Vazquez–Sequeiros, Lawrence Burgart, Mary Fredericksen, Linda Wadum, Raghuram Reddy, Daniel Schaid, Kenneth Wang and Gloria Petersen. Gastroenterology–Hepatology, Mayo Foundation, Rochester, MN; Anatomic Pathology, Mayo Foundation, Rochester, MN; Surgical Pathology, Mayo Foundation, Rochester, MN; Family Ascertainment Core, Mayo Foundation, Rochester, MN; Biostatistics, Mayo Foundation, Rochester, MN and United States and 6Health Sciences Research, Mayo Foundation, Rochester, MN. Purpose: The Barrett’s Esophagus Genomic Study group is a multidisciplinary collaborative team comprised of 143 private–practice and academic physicians from institutions throughout the US, South America and Europe, aimed at jointly collecting kindreds in which 3 or more members have long segment Barrett’s esophagus for genomic analysis. The aims of this report are to provide an update on kindreds collected to date and to request the aid of American College of Gastroenterology physicians in identifying additional families. Methods: BE defined as endoscopically visualized salmon– colored mucosa extending above the top of the gastric folds which on biopsy have intestinal metaplasia with goblet cells. Patients with BE, with/or without esophageal adenocarcinoma (ACA), asked to list all first– degree relatives. Patient demographics, clinical information, and a validated Reflux Symptoms Questionnaire (RSQ) collected. BE and ACA diagnoses confirmed by review of slides and endoscopic reports from all relatives endoscoped in the past. Endoscopy performed on consenting relatives not previously scoped. Collaborating non–Mayo physicians referred high penetrance BE families for review. Results: To date, 589 families have been identified. 367 (62%) BE index patients agreed to participate, 90 (25%) with concomitant ACA, listing all first– degree relatives. 1248 of 1925 (65%) adult living relatives completed RSQ’s and medical release forms. 151 non–Mayo endoscopy reports and pathology slides reviewed. 244 relatives scoped at Mayo. To date, 60 (16%) families have been identified, having at least two members with BE, with or without ACA; 39 families with at least 2 members; 28 families with at least 3 members, and 3 families with at least 4 first– degree family members with BE.
Abstracts
Conclusions: (1) BE occurs in at least 9 –10% of all subgroups coming to endoscopy. (2) Pts with all types of pulmonary/ENT Sx have a similar prevalence of BE as Pts with typical GER Sx. (3) BE occurs half as often with dyspepsia Sx or ulcer Sx than it does with typical GER Sx, yet the prevalence is high enough to consider routine biopsy of the SC junction during EGD. 22 MOTILITY AND FUNCTION OF THE GASTROESOPHAGEAL JUNCTION FOLLOWING DIFFERENT LAPAROSCOPIC APPROACHES IN ANTIREFLUX SURGERY.CLINICAL IMPLICATIONS Pietro Dusio, Marcello Spampinato, Emma Gay and Luigi Locatelli*. Gastroenterology and Endoscopy Motility Unit, Ospedale Valdese, Torino, Italy and Surgery, Ospedale Valdese, Torino, Italy. Purpose: Aim of this work was to determine the post operative function of gastroesophageal junction after different fundoplication techniques in GERD patients, and whether different approaches could affect the clinical outcome,in order to improve the surgical results.Recently we decided to fix the Nissen valve to the esophagus, avoiding possible slippage. Motility and clinical aspects were comparated among different techniques. Methods: 34 patients treated with different laparoscopic approaches, underwent a functional assessment and a clinical evaluation after funduplications, in order to discover possible reasons of disfunction .16 Floppy Nissen (FN) with the section of short vessels and a floppy valve, 13 Floppy Nissen with fixation of the valve to the esophagus on both sizes, according to Dellemagne (FND) and 5 Nissen Rossetti (NR ) were investigated.They underwent a pre and post operative manometry, post operative clinical examination, endoscopy and XRs check. Results: The post operative manometry showed in all cases normal neo LES pressure while the neo LES relaxations showed two different patterns. A: more than 80% of complete relaxations with normal lenght in 18 cases (7 FN, 9 FND, 2 NR). B: Not complete relaxations with short lenght in 16 cases (9 FN, 4 FND, 3 NR). 5 patients who had shown pre operative hypoperistalsis (2 FN and 3 FND),at the post operative manometry showed unvaried hypoperistalsis in 4 cases and a slight improvement in 1. Normal peristalsis was demonstrated in the remaining patients. 5 patients showed severe disphagia after surgery (4 FN, and 1 NR). In 2 cases disphagia disappeared after several endoscopies and in 3 became sporadic and was treated with medical therapy.Only 1 FND case showed transient disphagia. Conclusions: It appears that neo LES relaxations patterns,whether complete with normal lenght or not, do not affect the clinical outcome in the FN and NR groups.FND patients who had demonstrated poor incidence of disphagia, showed an increased good rate of complete neo LES relaxations. Different techniques do not affect post operative peristalsis findings.The valve fixations may offer a good pattern of neo LES relaxations and a good long lasting functional result. 23 ACHALASIA PRESENTING AFTER OPERATIVE AND NONOPERATIVE TRAUMA Rupa N. Shah, M.D., James L. Izanec, M.D., David M. Friedel, M.D.*, Peter Axelrod, M.D., Henry P. Parkman, M.D. and Robert S. Fisher, M.D. Gastroenterology, Temple University Hospital, Philadelphia, PA. Purpose: The purpose of this study was to assess the association of operative and nonoperative trauma as a factor in the development of achalasia. Methods: Clinical records were retrospectively screened over a 6 year period for the diagnosis of achalasia. Control patients had symptoms of dysphagia but with normal manometry and endoscopy. Charts were screened for symptoms (including duration) and history of preceding operative and nonoperative events. Results: Achalasia was diagnosed in 64 patients (37 F, 27 M; mean age 54 years). 16/64 patients (25%– 10 F, 6 M; mean age 55 years) had a history
AJG – Vol. 97, No. 9, Suppl., 2002
of trauma to the upper GI tract before the onset of symptoms (10 patients with operative trauma, 6 patients with nonoperative trauma). 48 patients (75%– 27 F, 21 M, mean age 54 years) reported no prior trauma. In contrast, in the control group with dysphagia and normal manometry, 7/73 patients (9.5%– 53F, 20M; mean age 45 years) had a history of trauma (5 surgeries, 2 motor vehicle accidents {MVAs}) before onset of symptoms (2 ⫽ 5.90, p ⬍ 0.02 vs. the control group). All nonoperative trauma cases were MVAs. The postoperative trauma achalasia group included 4 patients who underwent cardiac surgery and 6 patients who underwent surgery involving the gastroesophageal (GE) junction (2 bariatric surgery, 1 Nissen fundoplication, 1 Billroth II with vagotomy, 1 repair of distal esophageal perforation, and 1 repair of congenital tracheo– esophageal fistula). The postoperative trauma normal manometry group included 2 patients with cardiac bypass, 2 patients with Nissen fundoplications, and 1 patient who had thyroid surgery. The predominant symptom in all patients was dysphagia. Interestingly, the trauma achalasia patients had more chest pain (RR ⫽ 4.50, p ⫽ 0.012) but less regurgitation (RR ⫽ 0.51, p ⫽ 0.010) than the nontrauma achalasia patients. The average duration of symptoms prior to diagnosis was similar in each group. Conclusions: Achalasia can occur after operative and nonoperative trauma. In this retrospective study, 25% of patients with achalasia had a history of operative or nonoperative trauma to the thorax, compared to only 9.5% of dysphagia patients with normal manometry. These results suggest that some patients with achalasia may have neuropathic esophageal dysfunction related to vagal nerve damage from prior trauma.
24 BARRETT’S ESOPHAGUS GENOMIC STUDY GROUP: PROGRESS TO DATE Teresa G. Zais, Yvonne Romero*, Thomas Smyrk, Alan Cameron, Enrique Vazquez–Sequeiros, Lawrence Burgart, Mary Fredericksen, Linda Wadum, Raghuram Reddy, Daniel Schaid, Kenneth Wang and Gloria Petersen. Gastroenterology–Hepatology, Mayo Foundation, Rochester, MN; Anatomic Pathology, Mayo Foundation, Rochester, MN; Surgical Pathology, Mayo Foundation, Rochester, MN; Family Ascertainment Core, Mayo Foundation, Rochester, MN; Biostatistics, Mayo Foundation, Rochester, MN and United States and 6Health Sciences Research, Mayo Foundation, Rochester, MN. Purpose: The Barrett’s Esophagus Genomic Study group is a multidisciplinary collaborative team comprised of 143 private–practice and academic physicians from institutions throughout the US, South America and Europe, aimed at jointly collecting kindreds in which 3 or more members have long segment Barrett’s esophagus for genomic analysis. The aims of this report are to provide an update on kindreds collected to date and to request the aid of American College of Gastroenterology physicians in identifying additional families. Methods: BE defined as endoscopically visualized salmon– colored mucosa extending above the top of the gastric folds which on biopsy have intestinal metaplasia with goblet cells. Patients with BE, with/or without esophageal adenocarcinoma (ACA), asked to list all first– degree relatives. Patient demographics, clinical information, and a validated Reflux Symptoms Questionnaire (RSQ) collected. BE and ACA diagnoses confirmed by review of slides and endoscopic reports from all relatives endoscoped in the past. Endoscopy performed on consenting relatives not previously scoped. Collaborating non–Mayo physicians referred high penetrance BE families for review. Results: To date, 589 families have been identified. 367 (62%) BE index patients agreed to participate, 90 (25%) with concomitant ACA, listing all first– degree relatives. 1248 of 1925 (65%) adult living relatives completed RSQ’s and medical release forms. 151 non–Mayo endoscopy reports and pathology slides reviewed. 244 relatives scoped at Mayo. To date, 60 (16%) families have been identified, having at least two members with BE, with or without ACA; 39 families with at least 2 members; 28 families with at least 3 members, and 3 families with at least 4 first– degree family members with BE.