Fernando P. P. Vicentine

Postprandial proximal gastric acid pocket and gastric pressure in patients after gastric surgery

Background  An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been demonstrated in normal individuals (NI) and patients with gastro‐esophageal reflux disease (GERD). The role of gastric anatomy and gastric motility in the physiology of the PPGAP remains elusive. This study aims to analyze the correlation of PPGAP with proximal gastric pressure after gastric surgery.

High-Resolution and Conventional Manometry in the Assessment of the Lower Esophageal Sphincter Length

Dear Editor: High-resolution manometry (HRM) is a revolutionary tool in the field of esophageal function tests. It is a valuable and incomparable instrument to assess the esophageal sphincters and segmental defects of esophageal body peristalsis due to a “panoramic” and simultaneous view from the pharynx to the stomach. Furthermore, it is quicker, more comfortable, and does not share some of the limitations of conventional manometry such as motion artifacts. Ayazi et al. from DeMeester group recently presented an elegant paper on the value of HRM in the assessment of the lower esophageal sphincter (LES) in comparison to the conventional manometry. The authors reported an overestimation of the LES length with HRM. The paper raises two questions: (1) Which manometry is better to evaluate LES length?; (2) How should HRM assess LES length? When two methods are compared, the choice for which one should be considered the gold standard test may be sometimes difficult. Period of existence is not a guarantee that the older method is better. Ayazi et al. concluded in their study that HRM is associated to errors in the evaluation of the borders of the LES leading to detriment of accuracy in LES assessment. As a new method, HRM should be interpreted with open mind and new eyes. Old concepts must not necessary be valid for its interpretation. In regards to the evaluation of the borders of the LES and consequently of its length, motion artifacts must be carefully taken in consideration. It is known that LES is mobile with respiration (Fig. 1). This mobility is easily seen on HRM contours. It appears that the LES has a synchronous movement with the diaphragm, descending in average 0.85 cm during inspiration. Two points can explain the overestimation of the LES found. First, the borders of the LES must be defined in a fixed point, ignoring the oscillation seem on the HRM contours. If the borders are defined by the distance between its maximum and minimum amplitude, the amplitude of movement will be counted twice, as noticed on Fig. 3 of the referred paper. Second, this very group from the University of Southern California has educated all of us that the LES is defined by a constant rise in baseline of at least 2 mmHg. If we look at the area where the LES is intermittently present, a conventional manometry plot will not show a plateau of basal pressure expected for a sphincter, and it will not be incorporated in the calculation for the LES length (Fig. 2). In regards to pH catheter placement, also a concern of the authors, we recommend the use of the upper border of the area where the LES is constantly present F. A. M. Herbella : F. P. P. Vicentine : J. C. Del Grande Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil

Postprandial proximal gastric acid pocket and gastroesophageal reflux disease.

An unbuffered layer of acidity that escapes neutralization by food has been demonstrated in volunteers and gastroesophageal reflux disease patients. This postprandial proximal gastric acid pocket (PPGAP) is manometrically defined by the presence of acid reading (pH<4) in a segment of the proximal stomach between nonacid segments distally (food) and proximally (lower esophageal sphincter or distal esophagus). The PPGAP may have important clinical implications; however, it is still poorly understood. Gastric anatomy and physiology seem to be important elements for PPGAP genesis. Gastric operations and acid suppression medications may decrease distal - proximal intragastric acid reflux and help control gastroesophageal reflux.

LIVER TRANSPLANTATION FOR CARCINOMA HEPATOCELLULAR IN SÃO PAULO: 414 CASES BY THE MILAN/BRAZIL CRITERIA

ABSTRACT Background: The criterion of Milan (CM) has been used as standard for indication of liver transplantation (LTx) for hepatocellular carcinoma (HCC) worldwide for nearly 20 years. Several centers have adopted criteria expanded in order to increase the number of patients eligible to liver transplantation, while maintaining good survival rates. In Brazil, since 2006, the criterion of Milan/Brazil (CMB), which disregards nodules <2 cm, is adopted, including patients with a higher number of small nodules. Aim: To evaluate the outcome of liver transplantation within the CMB. Methods: The medical records of patients with HCC undergoing liver transplantation in relation to recurrence and survival by comparing CM and CMB, were analyzed. Results: 414 LTx for HCC, the survival at 1 and 5 years was 84.1 and 72.7%. Of these, 7% reached the CMB through downstaging, with survival at 1 and 5 years of 93.1 and 71.9%. The CMB patient group that exceeded the CM (8.6%) had a survival rate of 58.1% at five years. There was no statistical difference in survival between the groups CM, CMB and downstaging. Vascular invasion (p<0.001), higher nodule size (p=0.001) and number of nodules >2 cm (p=0.028) were associated with relapse. The age (p=0.001), female (p<0.001), real MELD (p<0.001), vascular invasion (p=0.045) and number of nodes >2 cm (p<0.014) were associated with worse survival. Conclusions: CMB increased by 8.6% indications of liver transplantation, and showed survival rates similar to CM.

Motilidade esofágica após derivação gástrica em Y-de-Roux para obesidade mórbida: achados à manometria de alta resolução

BACKGROUND: Bariatric operations may alter esophageal motility; however, there is a paucity of studies of the esophageal motility with high resolution manometry. AIM: To study patients after Roux-en-Y gastric bypass for morbid obesity with high resolution motility. METHODS: Were included 18 asymptomatic patients (17 women, mean age 53 years) after undergoing to Roux-en-Y gastric bypass for morbid obesity. All patients underwent high resolution motility after a mean follow-up of three years after the operation. RESULTS: The mean pressure of the lower esophageal sphincter was 18±13 (range 0-51) mmHg. Seven (39%) patients had a hypotonic sphincter and one (5%) hypertonicity. Sphincter relaxation was abnormal in one patient. Total and abdominal lower esophageal sphincter length was 4±1 (1-7) cm e 2±1 (0-3) cm, respectively. Esophageal body distal amplitude (average measurements at 3 and 7 cm above the lower esophageal sphincter) was 77±22 (40-120) mmHg. One (5%) patient had hypocontractility. Peristaltic waves were found in 95±0% (60-100). The upper esophageal sphincter basal pressure was 118±82 (33 - 334) mmHg; one (5%) patient (5%) had a hypotonic upper sphincter and eight (44%) hypertonicity. CONCLUSION: After gastric bypass in Roux-en-Y occurs significant lower esophageal sphincter hypotonia and upper esophageal sphincter hypertonia.

Postprandial proximal gastric acid pocket in patients after distal gastrectomy

Background  An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been noticed in the majority of normal individuals and patients with gastroesophageal reflux disease. The role of gastric anatomy, specifically the antrum, in the physiology of the PPGAP is not yet fully elucidated. This study aims to analyze the presence of PPGAP in patients submitted to distal gastrectomy.

High-resolution Manometry Findings in Patients After Sclerotherapy for Esophageal Varices.

Background/Aims Endoscopic therapy for esophageal varices may lead to esophageal dysmotility. High-resolution manometry is probably the more adequate tool to measure esophageal motility in these patients. This study aimed to evaluate esophageal motility using high resolution manometry following eradication of esophageal varices by endoscopic sclerotherapy. Methods We studied 21 patients (11 women, age 52 [45–59] years). All patients underwent eradication of esophageal varices with endoscopic sclerotherapy and subsequent high resolution manometry. Results A significant percentage of defective lower esophageal sphincter (basal pressure 14.3 [8.0–20.0] mmHg; 43% hypertonic) and hypocontractility (distal esophageal amplitude 50 [31–64] mmHg; proximal esophageal amplitude 40 [31–61] mmHg; distal contractile integral 617 [403–920] mmHg · sec · cm; 48% ineffective) was noticed. Lower sphincter basal pressure and esophageal amplitude correlated inversely with the number of sessions (P < 0.001). No manometric parameter correlated with symptoms or interval between last endoscopy and manometry. Conclusions Esophageal motility after endoscopic sclerotherapy is characterized by: (1) defective lower sphincter and (2) defective and hypotensive peristalsis. Esophageal dysmotility is associated to an increased number of endoscopic sessions, but manometric parameters do not predict symptoms.

High Resolution Manometry Findings in Patients With Esophageal Epiphrenic Diverticula

The pathophysiology of esophageal epiphrenic diverticula is still uncertain even though a concomitant motility disorder is found in the majority of patients in different series. High resolution manometry may allow detection of motor abnormalities in a higher number of patients with esophageal epiphrenic diverticula compared with conventional manometry. This study aims to evaluate the high resolution manometry findings in patients with esophageal epiphrenic diverticula. Nine individuals (mean age 63 ± 10 years, 4 females) with esophageal epiphrenic diverticula underwent high resolution manometry. A single diverticulum was observed in eight patients and multiple diverticula in one. Visual analysis of conventional tracings and color pressure plots for identification of segmental abnormalities was performed by two researchers experienced in high resolution manometry. Upper esophageal sphincter was normal in all patients. Esophageal body was abnormal in eight patients; lower esophageal sphincter was abnormal in seven patients. Named esophageal motility disorders were found in seven patients: achalasia in six, diffuse esophageal spasm in one. In one patient, a segmental hypercontractile zone was noticed with pressure of 196 mm Hg. High resolution manometry demonstrated motor abnormalities in all patients with esophageal epiphrenic diverticula.