Charles S. Winans

Quantitation of Lower Esophageal Sphincter Competence

Summary Normal subjects and patients with incompetent gastroesophageal sphincters have been studied by open-tipped catheter techniques. The two groups could not be separated on the basis of pressures measured by conventional methods. The best explanation for this failure is that the sphincters sealed the recording orifice. However, the addition of a constant external fluid infusion to the recording system prevented this sealing and allowed the recording of pressures which did appear to be related to the competence of the sphincter.

Cimetidine in the treatment of symptomatic gastroesophageal reflux: a double blind controlled trial.

The effectiveness of cimetidine for symptomatic relief in patients with chronic gastroesophageal reflux was studied in a multicenter, double blind clinical trial. Patients were entered into the study for a total of 8 weeks, receiving either cimetidine, 300 mg four times daily, or identical placebo tablets. Throughout the trial, frequent assessments were made of symptom severity and frequency, combined with careful measurement of antacid use. Esophagoscopy, esophageal acid sensitivity, and lower esophageal pressures were performed before and at the completion of the treatment period. Significant (P less than 0.05) decreases in symptom frequency and severity were noted throughout the study in the cimetidine-treated patients, as compared with the placebo group. This subjective improvement was corroborated by a concomitant decrease in antacid use, which was significantly (P less than 0.05) reduced in the cimetidine-treated group. In addition, significant improvement in esophageal acid sensitivity resulted from cimetidine therapy. No objective improvement in esophageal endoscopic appearance or sphincter pressures was noted. The results of this double blind trial indicate that cimetidine is more effective than the placebo for the relief of symptoms of gastroesophageal reflux.

Manometric asymmetry of the lower-esophageal high-pressure zone.

The lower-esophageal high-pressure zones (LEHPZ) of 10 normal subjects, 8 patients with hiatus hernia and one patient with progressive systemic sclerosis (PSS) were investigated using a special 8-lumen recording catheter, the lateral orifices of which were spaced at 45° intervals around the circumference of the catheter. While similar pressures were recorded from all orifices within the stomach and esophageal body, pressures within the LEHPZ were found to be related to spatial orifice position. In normal subjects, but not in patients with hiatus hernia, a significantly higher localized pressure was detected by orifices directed toward the left posterior quadrant of the circumference of the distal esophagus, while a lesser, rather uniform, pressure was recorded from the other three quadrants. From the PSS patient, who had severe gastroesophageal reflux, a LEHPZ was detected only in the left posterior quadrant. The results suggest that the recorded LEHPZ represents the summation of two factors: an intrinsic force possibly due to a physiologic loweresophageal sphincter and an extrinsic force possibly resulting from compression of the distal esophagus by the lateral margin of the diaphragmatic hiatus.

Surgical treatment of achalasia: results with esophagomyotomy and Belsey repair.

To address the controversy regarding the choice of operation for achalasia, the cases of 57 patients having operation, 38 for the first time (Group 1) and 19 with a previous procedure (Group 2), were reviewed. Surgical emphasis was on hiatal dissection to maximize exposure and use of the Belsey fundoplication to achieve cardiac competence without obstruction. Operative mortality was 1 (1.8%) of 57 patients. In group 1, 21 of the 38 had prior pneumatic dilations. All were treated with esophagomyotomy and a Belsey fundoplication. Clinical results are excellent or good in 30 (88%) of the 34 patients for whom follow-up is available, and are similar in patients with and without prior dilation. Lower esophageal sphincter (LES) pressure decreased from 22.3 to 7.7 mm Hg (p less than 0.001), and pH testing shows no reflux in any of 13 patients. In Group 2, previous operations were esophagomyotomy in 13, esophagomyotomy plus a Nissen fundoplication in 3, and a Nissen fundoplication only in 3. The initial operation failed because of inadequate myotomy in 6 patients, an obstructive Nissen fundoplication in 6, and reflux esophagitis in 7. In these 7 patients, acid reflux testing documented reflux due to cardiac incompetence and delayed clearance. Reoperations included takedown of a Nissen fundoplication in 6, esophagomyotomy and Belsey procedure in 15, Belsey procedure in 1, and resection plus colon interposition in 2. Clinical results are excellent or good in 12 (75%) of the patients with follow-up. These conclusions can be drawn. (1) Esophagomyotomy and Belsey fundoplication lowers LES pressure and provides good results with low risk, even after pneumatic dilation.(ABSTRACT TRUNCATED AT 250 WORDS)

Alteration of Lower Esophageal Sphincter Characteristics with Respiration and Proximal Esophageal Balloon Distention

By using the manometric recording catheter as both a measuring stick and a pressure detecting device, the location, length, and magnitude of the lower esophageal high pressure zone (HPZ) were studied in healthy human subjects. The HPZ was found to be located 1 to 3 cm more distal at end-inspiration than at end-expiration. In both phases of respiration the mean length (3 cm) and magnitude (22 mm Hg) of the resting HPZ were similar. An upward movement of the HPZ followed distention of the proximal esophagus by a balloon, accompanied by a 40% shortening of the HPZ and a 65% decrease in its magnitude. Whereas the movement of a sphincter segment relative to the recording orifice during the respiratory cycle can explain the pressure fluctuations within the resting HPZ, a combination of positional change and diminished sphincter tone best explains the fall in pressure within the HPZ after balloon distention and, probably, after swallowing. In addition, it is possible that sphincter length, as well as sphincter magnitude, is an important determinant of sphincter competence.

Randomized clinical trial of two colonoscopy preparation methods for elderly patients.

Colonic lavage with enemas or with Golytely are standard preparation methods for colonoscopy. Previous studies have demonstrated that Golytely has a statistically significant advantage in both adequacy of preparation and patient tolerance. To determine if these effects are present in the elderly, we performed a randomized clinical trial on 124 consecutive patients scheduled for colonoscopy who were greater than or equal to 75 years of age. Sixty-three patients were randomized to receive Golytely; 17 were inpatients, 33 were outpatients, and colonoscopy was canceled in 13. Sixty-one patients were randomized to receive the enema preparation; 17 were inpatients, 30 were outpatients, and colonoscopy was canceled in 14. For adequacy of the preparation, no differences were statistically significant, but the enema preparation was superior in outpatients while Golytely was superior in inpatients. Patients tolerated the enema preparation better, a finding present in both outpatients and inpatients. Contrary to previous reports of a significant advantage with Golytely, patients greater than or equal to 75 years old did not enjoy this advantage, but seemed to tolerate enemas better than Golytely with little difference in adequacy of the preparation.

Endoscopic diagnosis of esophageal inflammation

The histologic appearance of biopsy specimens, taken from the distal esophagus of 10 normal subjects and 57 patients with endoscopic evidence of esophagitis, has been reviewed. While only 10% of normal subjects demonstrated a polymorphonuclear leukocyte infiltrate of the mucosa or lamina propria, such an infiltrate was present in more than 80% of patients with an esophageal mucosa of abnormal appearance. Mononuclear cell infiltrates of the lamina propria were seen in both normal and esophagitis patients and their presence does not seem to be a useful criterion for the diagnosis of esophagitis. Careful inspection of the vascular pattern of the distal esophagus with the Olympus GIF endoscope is helpful in detecting cases of mild esophagitis, and a fine nodularity of the mucosa on close inspection is also a useful sign of esophageal inflammation.

Sarcomas arising after radiotherapy for peptic ulcer disease

SummaryTherapeutic gastric irradiation has been used to reduce peptic juice secretion in patients with peptic ulcer disease. Between 1937 and 1968 a total of 2049 patients received such therapy at the University of Chicago. Three of these patients are known to have developed sarcomas in the field of radiation. Two gastric leiomyosarcomas of the stomach were diagnosed 26 and 14 years after treatment and a malignant fibrous histiocytoma of the anterior chest wall was removed six years after gastric irradiation. Of 743 peptic ulcer patients treated without irradiation and constituted as a control group for the study of therapeutic gastric radiation, none is known to have developed sarcoma. As the incidence of sarcoma in these patient groups is known only from the tumor registry of the University of Chicago, other cases of sarcoma may exist in the groups. While an increased incidence of sarcoma has not been proven to occur in patients who received therapeutic gastric irradiation for peptic ulcer disease, the possibility of such a risk should be borne in mind by physicians caring for such patients.

Use of direct vision biopsy in the diagnosis of gastroesophageal malignancy

The technique of direct-vision endoscopic biopsy has been used in 185 cases to differentiate benign from malignant lesions of esophagus and stomach. No complications were encountered. Of 48 malignant lesions, 83.3% were correctly identified. No false positive interpretations were given to biopsy specimens from 137 benign lesions. Routine use of endoscopic biopsy improves substantially the accuracy of endoscopic diagnosis.

Discordance for achalasia in identical twins.

Twenty-year-old twin sisters, believed monozygotic on the basis of extensive blood grouping and cytogenetic studies, are reported. One twin demonstrated classical clinical, radiologic, and manometric features of achalasia, while similar studies in her sister documented perfectly normal esophageal motor function. Genetically determined damage to the esophageal parasympathetic innervation is, therefore, not a likely cause for the esophageal motor dysfunction in achalasia.