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Pharyngeal pH monitoring in 200 patients with suspected laryngeal reflux
AI060 SSAT ABSTRACTS
GASTROENTEROLOGY Vot. 118, No.4
3807
3897
LYMPH NODE MICROINVOLVEMENT IN ADENOCARCINOMA OF THE GASTRO-ESOPHAGEAL JUNCTION. Marcus Feith, Hubert J. Stein, James Mueller, M. Werner, J. Ruediger Siewert, Dept of Surg, Tech Univ Muenchen, Munich, Germany; Dept of Pathology, Tech Univ, Munich, Germany. Introduction: In the past decade there has been a alarming rise in the incedence of adenocarcinoma of the gastro-esophageal junction in western countries. There at present time still much discrepancies in the classification of tumors of the gastro-esophageal junction.We investigated possible differences and the prognostic impact of lymph node microinvolvement and micrometastases in adenocarcinoma of the gastro-esophageal junction . Material and methods: We examined in 3987 lymph nodes of 145 ROresected adenocarcinoma of the gastro-esophageal junction with irnmunhistochemical techniques (antibody cocktail AEl/AE3 and antibody BerEP4) the incidence of micrometastases and microinvolvement. Micrometastases were defined as single tumor cells or cellclusters smaller than 0.2mm in diameter with stromal reaction, classified as microinvolvement when the stromal reaction was missed. Results: In 90 (2.3%) of the lymph nodes microinvolvement and in 106 (2.7%) micrometastases were detectable.Of the 145 investigated patients, 75 were classified as pNO and 70 patients had lymph node metastases in standard histological examination. In contrast to the pNO patients showed the pN + patients significant more micrometastases (17.3% vs. 60%); p<0.05). The presence of lymph node micrometastases correlated with the pT-stade and the non-intestinal classification according to Lauren. Patients with true cardia carcinoma and subcardial carcinoma showed a significant higher rate of micrometastases than adenocarcinoma of the distal esophagus (24.4% vs. 6.7%; p<0.05). The survival analysis showed a significant difference between pNO staged patients with micrometastases compared to patients without micrometastases. The microinvolvement was without impact on survival. Conclusion: In contrast to adenocarcinoma of the distal esophagus, patients with true cardia carcinoma and subcardial carcinoma had a higher incidence of micrometastases. This request a more specialized classification of adenocarcinoma of the gastro-esophageal j unction and supports the different surgical extension and lymphadenectomy in this tumor entities.
LONG·TERM PROSPECTIVE FOLLOW-UP ( > 10 YEARS) AF· TER VERTICAL BANDED GASTROPLASTY (VBG), Bruno M. Balsiger, Keith A. Kelly, Juan L. Poggio, Jane Mai, Michael G. Sarr, Mayo Clin, Rochester, MN; Mayo Clin, Scottsdale, AZ. Long-term follow-up (> 10 yr) after VaG is almost nonexistent. AIM: To determine long-term outcome after VaG in a group of 73 patients studied prospectively. HYPOTHESIS: VaG is not a durable effective bariatric procedure. METHODS: 73 consecutive patients with morbid obesity (55 women, 18 men; mean age 40, range: 22-71 yr) underwent VBG from 1985-1989 and were followed prospectively. Follow-up to date, death or subsequent bariatric reoperation was 99% obtained in 70 of the 71 patients still alive. RESULTS: Weight (x:tSEM) preoperatively was 137:t3 kg and decreased to 114:t3 kg 10 or more yr postoperatively. Body mass index (BMI) decreased from 49:t I to 4l:t 1. Only 17 of 72 patients (23%) lost and maintained the loss of at least half of their excess body weight (EBW) at latest follow-up and only 9 of 58 ( 15%) reached a final weight of < 50% above ideal body weight with the VaG alone. Vomiting of once or more per week continues to occur in 22% and heartburn in 18%. Fourteen patients have undergone conversion of VBG to Roux-en-Y gastric bypass (10 pts) or other procedures (4 pts) because of inadequate weight loss in 13 patients, only 2 of whom had staple line dehiscence, gastroesophageal reflux in 5, and frequent vomiting in 4. BMI decreased from 43:t I at time of conversion to another bariatric procedure to 32:t 1 at follow-up 7.5:t0.3 yr later. SUMMARY: Only 23% of patients after VBG have maintained a weight loss of at least 50% EBW; 20% underwent bariatric reoperation with good results. CONCLUSIONS: VBG is not an effective durable bariatric operation; potential implications to laparoscopic gastric banding , which establishes a similar gastric partitioning, are worrisome concerning the durability of this "new" operation .
3808 THE MUTAGENIC POTENTIAL OF DUODENO-GASTRO ESOPHAGEAL REFLUX. Jorg Theisen, Peter W. Laird, Reginald V. Lord, Michael Hughes, Kristen A. Skinner, Jeffrey A. Hagen, Steve R. DeMeester, Peter F. Crookes, Cedric G. Bremner, Tom R. DeMeester, Jeffrey H. Peters, Univ of Southern CA, Los Angeles, CA. Objective: Duodeno-gastric-esophageal reflux disease is directly linked to Barren' s esophagus and to the development of esophageal adenocarcinoma. Despite this link little is known about the mutagenic potential of refluxed material on the esophageal mucosa. We hypothesize that the reflux of gastric and duodenal content causes mutations in esophageal mucosa in vivo. Methods: 11 Sprague DawleylBig Blue Fl lad transgenic rats underwent esophago-duodenostorny (ED) to surgically create duodenogastric-esophageal reflux. 12 non-operated rats served as negative (n=5) and as positive (n=7/methyl-N-amyl-nitrosamine MNAN i.p.) controls. The animals were sacrificed at 16 weeks following operation or injection, the entire esophageal mucosa was harvested and mutation frequency determined via standard Big Blue Mutagenesis Assay. Results: Gross esophagitis was evident in all operated animals. The frequency of lac! mutations in esophageal mucosal cells of animals with ED was significantly higher, nearly 2-fold, than that of non-operated animals. Nitrosamine administration resulted in nearly 20-fold increase of lad mutation frequency. (Table 1.) Conclusion: This is the first demonstration of mutagenic potential of reflux material on the esophagus. Correlation of the mutational spectra with that observed in genes of patients with esophageal adenocarcinoma may link this animal study to human esophageal cancer. Table. 1
Mutation Frequency x 10"'
Control
ED
MNAN
(n=5) 5.9 [4.9-6.6J
(n=ll) 9.9' [6.8-1411
(n=7) 112' [1 01-122J
·p<0.05versus control. Dataare shown asmedians and inlerquartileranges
3898 PHARYNGEAL PH MONITORING IN 200 PATIENTS WITH SUSPECTED LARYNGEAL REFLUX. Thomas R. Eubanks, Pablo E. Omelanczuk, Nicole Maronian, Allen Hillel, Charles E. Pope, Carlos A. Pellegrini, Univ of Washington, Seattle, WA. We monitored pharyngeal pH over 24 hours to determine the degree of esophago-pharyngeal reflux in 200 consecutive patients (128 women and 72 men) with symptoms of airway irritation not explained by other etiologies. Chronic cough was present in 63% of these patients, hoarseness in 39%. and chronic throat clearing in 12%. Sixty (30%) patients complained of heartburn. All patients were studied using a specially designed catheter with 4 pH sensors to provide simultaneous esophageal (distal, middle and upper) and pharyngeal (1.5 em above the upper esophageal sphincter) pH monitoring. Pharyngeal reflux was defined as a drop in the proximal (pharyngeal) channel to a pH < 4 that occurred simultaneously with acidification of the distal esophagus. Patients were divided into two groups: those in whom pharyngeal reflux was noted (PR+) and those in whom it was not (PR-). The Mann-Whitney U test and student t test were used to assess inter-group comparisons. One or more pharyngeal reflux episodes (range 1-36, average 5) were identified in 84 (42%) patients (PR + ). No pharyngeal reflux was identified in the remaining 116 patients (PR-). Pharyngeal reflux episodes were characterized by their brevity (duration < 4 min) and complete clearance. They occurred only during the upright position in 71 (85%) ofPR+ patients and predominantly during the upright position in the remaining 13 (15%). Twenty-one (25%) of the 84 PR+ patients experienced cough in association with an episode of pharyngeal reflux. Table 1 compares the standard distal esophageal physiologic measurements between the PR- and PR + groups (mean and std deviation). Our study shows that pharyngeal reflux: (a) does occur, (b) is characterized by brief episodes that occur primarily in the upright position, and, (c) can be identified in over 40% of patients thought to have acid-induced laryngeal symptoms. Furthermore, in 25% of these patients symptoms occur in association with the episode of reflux. Patients with laryngeal symptoms and pharyngeal reflux have a less competent sphincter and greater amounts of reflux as determined by standard parameters than those without pharyngeal reflux. Group PRo PR+ ·p
LES Pressure
Upright Reflux
DeMeester
17.9(9.4) 14.1 ' (6.1)
3.2% (4.5) 5.5%' (5.7)
11.8(15.7] 21.r (21 .2)
GASTROENTEROLOGY Vot. 118, No.4
3807
3897
LYMPH NODE MICROINVOLVEMENT IN ADENOCARCINOMA OF THE GASTRO-ESOPHAGEAL JUNCTION. Marcus Feith, Hubert J. Stein, James Mueller, M. Werner, J. Ruediger Siewert, Dept of Surg, Tech Univ Muenchen, Munich, Germany; Dept of Pathology, Tech Univ, Munich, Germany. Introduction: In the past decade there has been a alarming rise in the incedence of adenocarcinoma of the gastro-esophageal junction in western countries. There at present time still much discrepancies in the classification of tumors of the gastro-esophageal junction.We investigated possible differences and the prognostic impact of lymph node microinvolvement and micrometastases in adenocarcinoma of the gastro-esophageal junction . Material and methods: We examined in 3987 lymph nodes of 145 ROresected adenocarcinoma of the gastro-esophageal junction with irnmunhistochemical techniques (antibody cocktail AEl/AE3 and antibody BerEP4) the incidence of micrometastases and microinvolvement. Micrometastases were defined as single tumor cells or cellclusters smaller than 0.2mm in diameter with stromal reaction, classified as microinvolvement when the stromal reaction was missed. Results: In 90 (2.3%) of the lymph nodes microinvolvement and in 106 (2.7%) micrometastases were detectable.Of the 145 investigated patients, 75 were classified as pNO and 70 patients had lymph node metastases in standard histological examination. In contrast to the pNO patients showed the pN + patients significant more micrometastases (17.3% vs. 60%); p<0.05). The presence of lymph node micrometastases correlated with the pT-stade and the non-intestinal classification according to Lauren. Patients with true cardia carcinoma and subcardial carcinoma showed a significant higher rate of micrometastases than adenocarcinoma of the distal esophagus (24.4% vs. 6.7%; p<0.05). The survival analysis showed a significant difference between pNO staged patients with micrometastases compared to patients without micrometastases. The microinvolvement was without impact on survival. Conclusion: In contrast to adenocarcinoma of the distal esophagus, patients with true cardia carcinoma and subcardial carcinoma had a higher incidence of micrometastases. This request a more specialized classification of adenocarcinoma of the gastro-esophageal j unction and supports the different surgical extension and lymphadenectomy in this tumor entities.
LONG·TERM PROSPECTIVE FOLLOW-UP ( > 10 YEARS) AF· TER VERTICAL BANDED GASTROPLASTY (VBG), Bruno M. Balsiger, Keith A. Kelly, Juan L. Poggio, Jane Mai, Michael G. Sarr, Mayo Clin, Rochester, MN; Mayo Clin, Scottsdale, AZ. Long-term follow-up (> 10 yr) after VaG is almost nonexistent. AIM: To determine long-term outcome after VaG in a group of 73 patients studied prospectively. HYPOTHESIS: VaG is not a durable effective bariatric procedure. METHODS: 73 consecutive patients with morbid obesity (55 women, 18 men; mean age 40, range: 22-71 yr) underwent VBG from 1985-1989 and were followed prospectively. Follow-up to date, death or subsequent bariatric reoperation was 99% obtained in 70 of the 71 patients still alive. RESULTS: Weight (x:tSEM) preoperatively was 137:t3 kg and decreased to 114:t3 kg 10 or more yr postoperatively. Body mass index (BMI) decreased from 49:t I to 4l:t 1. Only 17 of 72 patients (23%) lost and maintained the loss of at least half of their excess body weight (EBW) at latest follow-up and only 9 of 58 ( 15%) reached a final weight of < 50% above ideal body weight with the VaG alone. Vomiting of once or more per week continues to occur in 22% and heartburn in 18%. Fourteen patients have undergone conversion of VBG to Roux-en-Y gastric bypass (10 pts) or other procedures (4 pts) because of inadequate weight loss in 13 patients, only 2 of whom had staple line dehiscence, gastroesophageal reflux in 5, and frequent vomiting in 4. BMI decreased from 43:t I at time of conversion to another bariatric procedure to 32:t 1 at follow-up 7.5:t0.3 yr later. SUMMARY: Only 23% of patients after VBG have maintained a weight loss of at least 50% EBW; 20% underwent bariatric reoperation with good results. CONCLUSIONS: VBG is not an effective durable bariatric operation; potential implications to laparoscopic gastric banding , which establishes a similar gastric partitioning, are worrisome concerning the durability of this "new" operation .
3808 THE MUTAGENIC POTENTIAL OF DUODENO-GASTRO ESOPHAGEAL REFLUX. Jorg Theisen, Peter W. Laird, Reginald V. Lord, Michael Hughes, Kristen A. Skinner, Jeffrey A. Hagen, Steve R. DeMeester, Peter F. Crookes, Cedric G. Bremner, Tom R. DeMeester, Jeffrey H. Peters, Univ of Southern CA, Los Angeles, CA. Objective: Duodeno-gastric-esophageal reflux disease is directly linked to Barren' s esophagus and to the development of esophageal adenocarcinoma. Despite this link little is known about the mutagenic potential of refluxed material on the esophageal mucosa. We hypothesize that the reflux of gastric and duodenal content causes mutations in esophageal mucosa in vivo. Methods: 11 Sprague DawleylBig Blue Fl lad transgenic rats underwent esophago-duodenostorny (ED) to surgically create duodenogastric-esophageal reflux. 12 non-operated rats served as negative (n=5) and as positive (n=7/methyl-N-amyl-nitrosamine MNAN i.p.) controls. The animals were sacrificed at 16 weeks following operation or injection, the entire esophageal mucosa was harvested and mutation frequency determined via standard Big Blue Mutagenesis Assay. Results: Gross esophagitis was evident in all operated animals. The frequency of lac! mutations in esophageal mucosal cells of animals with ED was significantly higher, nearly 2-fold, than that of non-operated animals. Nitrosamine administration resulted in nearly 20-fold increase of lad mutation frequency. (Table 1.) Conclusion: This is the first demonstration of mutagenic potential of reflux material on the esophagus. Correlation of the mutational spectra with that observed in genes of patients with esophageal adenocarcinoma may link this animal study to human esophageal cancer. Table. 1
Mutation Frequency x 10"'
Control
ED
MNAN
(n=5) 5.9 [4.9-6.6J
(n=ll) 9.9' [6.8-1411
(n=7) 112' [1 01-122J
·p<0.05versus control. Dataare shown asmedians and inlerquartileranges
3898 PHARYNGEAL PH MONITORING IN 200 PATIENTS WITH SUSPECTED LARYNGEAL REFLUX. Thomas R. Eubanks, Pablo E. Omelanczuk, Nicole Maronian, Allen Hillel, Charles E. Pope, Carlos A. Pellegrini, Univ of Washington, Seattle, WA. We monitored pharyngeal pH over 24 hours to determine the degree of esophago-pharyngeal reflux in 200 consecutive patients (128 women and 72 men) with symptoms of airway irritation not explained by other etiologies. Chronic cough was present in 63% of these patients, hoarseness in 39%. and chronic throat clearing in 12%. Sixty (30%) patients complained of heartburn. All patients were studied using a specially designed catheter with 4 pH sensors to provide simultaneous esophageal (distal, middle and upper) and pharyngeal (1.5 em above the upper esophageal sphincter) pH monitoring. Pharyngeal reflux was defined as a drop in the proximal (pharyngeal) channel to a pH < 4 that occurred simultaneously with acidification of the distal esophagus. Patients were divided into two groups: those in whom pharyngeal reflux was noted (PR+) and those in whom it was not (PR-). The Mann-Whitney U test and student t test were used to assess inter-group comparisons. One or more pharyngeal reflux episodes (range 1-36, average 5) were identified in 84 (42%) patients (PR + ). No pharyngeal reflux was identified in the remaining 116 patients (PR-). Pharyngeal reflux episodes were characterized by their brevity (duration < 4 min) and complete clearance. They occurred only during the upright position in 71 (85%) ofPR+ patients and predominantly during the upright position in the remaining 13 (15%). Twenty-one (25%) of the 84 PR+ patients experienced cough in association with an episode of pharyngeal reflux. Table 1 compares the standard distal esophageal physiologic measurements between the PR- and PR + groups (mean and std deviation). Our study shows that pharyngeal reflux: (a) does occur, (b) is characterized by brief episodes that occur primarily in the upright position, and, (c) can be identified in over 40% of patients thought to have acid-induced laryngeal symptoms. Furthermore, in 25% of these patients symptoms occur in association with the episode of reflux. Patients with laryngeal symptoms and pharyngeal reflux have a less competent sphincter and greater amounts of reflux as determined by standard parameters than those without pharyngeal reflux. Group PRo PR+ ·p
LES Pressure
Upright Reflux
DeMeester
17.9(9.4) 14.1 ' (6.1)
3.2% (4.5) 5.5%' (5.7)
11.8(15.7] 21.r (21 .2)