Fumiaki Yano

Establishment of Surgically Induced Chronic Acid Reflux Esophagitis in Rats

BACKGROUND The purpose of the study was to establish an animal model of chronic acid reflux esophagitis which could be used for further investigations of the pathophysiology of reflux esophagitis. METHODS Esophagitis was produced by ligating the transitional region between the forestomach and the glandular portion with a 2-0 silk thread and covering the duodenum near the pylorus ring with a small piece of an 18Fr Nélaton catheter. The histologic features of the esophagus were examined, and the survival rate of these animals was investigated. Moreover, the effects of lansoprazole on this model was studied. RESULTS The 3-week survival rate was 90%, and esophagitis was noted in all rats. Esophagitis was found 2 or 3 cm above the esophagogastric junction in most cases and at 4.0+/-2.3 sites per animal. Histopathologically, there were increased thickness of the esophageal epithelium, elongation of the lamina propria papillae, which extended upward into the epithelium, marked inflammatory cell infiltration, interruption of the lamina muscularis mucosae, and increase of collagen fibers in the lamina propria and submucosa. These signs were in accord with the histologic features of typical chronic esophagitis. No signs of esophagitis were observed, except in one animal, in the rats given 1 mg/kg/day of lansoprazole. CONCLUSIONS This experimental rat model is considered useful as a model of chronic acid-type esophagitis for the evaluation of the pathophysiology of reflux esophagitis and the evaluation of drug efficacy.

Laparoscopic Heller myotomy and Dor fundoplication for the treatment of achalasia. Assessment in relation to morphologic type

BackgroundThe significance of laparoscopic Heller myotomy and Dor fundoplication (LHD) for the treatment of achalasia in relation to the severity of the lesion has not been sufficiently assessed.MethodsOf patients who were diagnosed with achalasia from August 1994 to February 2004, 55 individuals who underwent LHD served as subjects. The therapeutic effects of LHD were assessed in terms of operation time, intraoperative complications, postoperative hospital stay, and symptom improvement in relation to morphologic type (spindle type, Sp; flask type, Fk; and sigmoid type, Sig). Degree of symptomatic improvement was classified into four grades: excellent, good, fair, and poor.ResultsBreakdown of morphologic type was as follows: Sp, n = 29; Fk, n = 18; and Sig, n = 8. Excluding one patient for whom conversion to open surgery was required, median average operation time for 54 patients was 160 min. As to intraoperative complications, esophageal mucosal perforation was seen in nine of the 55 patients (16%); however, conversion to open surgery could be avoided by suturing the affected area. Moreover, intraoperative bleeding of at least 100 g was seen in five of the 55 patients (9%), with one Fk patient requiring conversion to open surgery and transfusion. Median postoperative hospital stay was 8 days. Degree of dysphagia relief was excellent in 45 patients (83%), good in eight patients (15%), and fair in one patient (2%). Excellent improvement was obtained in 90%, 88%, and 50% in Sp, Fk, and Sig patients, respectively. Reflux esophagitis was seen in two patients, and was treated with a proton pump inhibitor.ConclusionsThe results of the present study suggest that classification of morphologic type is a useful parameter in predicting postoperative outcome in achalasia. In order to achieve excellent symptomatic relief, surgery for achalasia should be recommended for but not limited to Sp and Fk types.

Preoperative dilatation does not affect the surgical outcome of laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia.

Background Laparoscopic Heller myotomy and Dor fundoplication are now widely performed for achalasia. In patients who have had dilatation in the past, inflammation between the esophageal mucosal and muscular layers may make it difficult to perform myotomy. Purpose We investigated the effects of preoperative dilatation on the surgical outcomes. Method : One hundred and twelve patients were divided into 2 groups: 37 patients with a past history of preoperative dilatation and 75 patients who had no history of preoperative dilatation. The operating time, intraoperative blood loss, days required to resume postoperative oral intake, postoperative hospital stay, improvement in dysphagia, and incidence of postoperative esophagitis were compared. Results The operating time, intraoperative blood loss, postoperative hospital stay, and improvement of dysphagia were no significant differences between these groups. Furthermore, there were no significant differences in the incidence of postoperative esophagiatis. Conclusions The therapeutic outcome of laparoscopic Heller myotomy and Dor fundoplication is not affected by preoperative pneumatic dilatation.

Immunohistochemical study of the muscularis externa of the esophagus in achalasia patients.

The etiology of achalasia is believed to be the neuropathy associated with chronic inflammation of the nerve plexus, but the cause of plexus inflammation is unknown. The purpose of this study was to evaluate the pathophysiology of achalasia by examining the muscularis externa of the esophagus. We used the muscularis externa of the esophagus of 62 patients with achalasia (median 44 years, male : female 32:30) who underwent surgical treatment (achalasia group) and of 10 patients (median 65.5 years, male : female 9:1) who underwent esophagectomy for thoracic esophageal cancer (control group) to perform immunohistochemical staining with S-100, CD43, c-kit (CD117), n-NOS, vasoactive intestinal polypeptide (VIP), and ubiquitin. The cell counts that were positive for S-100, n-NOS, VIP, and ubiquitin were significantly lower in the achalasia group compared with the control group (P < 0.001, P= 0.001, P < 0.001, and P= 0.001, respectively). There were no statistically significant differences with respect to CD43 and c-kit staining (P= 0.586 and P= 0.209, respectively). In conclusion, the pathophysiology of achalasia is therefore considered to be an impaired production of NO and VIP, which both affect interstitial cell of Cajal and smooth muscles, and this impairment is therefore considered to play a role in the pathophysiology of achalasia.

Therapeutic Effects of a Laparoscopic Heller Myotomy and Dor Fundoplication on the Chest Pain Associated with Achalasia

PurposeThe therapeutic effects of a laparoscopic Heller myotomy and Dor fundoplication (LHD) on the chest pain associated with achalasia were investigated.MethodsSixty-six patients who were diagnosed to have achalasia underwent LHD. The degree of dilatation was assessed based on the maximum horizontal diameter of the esophagus (Grades I–III). The type of dilatation was assessed based on the shape of the distal esophagus, namely, spindle type (Sp), flask type (Fk), and sigmoid type (Sig). The degree of improvement was classified into three grades as follows: A (complete disappearance), B (partial response), and C (unchanged).ResultsChest pain improved (A or B) in 22 patients (92%). The statistical results revealed that the improvement of postoperative A or B was significantly better in patients with Sp than in those with Fk or Sig (P = 0.0213). In addition, the results revealed that the improvement of postoperative A or B was significantly better in patients with grade I and grade II than in those with grade III (P = 0.004).ConclusionLHD is an effective therapeutic technique for the treatment of chest pain associated with achalasia. These results suggest that both the morphological type and esophageal dilatation are useful predictors for the improvement of chest pain after surgical therapy.

Prediction of recurrence after laparoscopic fundoplication for erosive reflux esophagitis based on anatomy-function-pathology (AFP) classification

BackgroundThe usefulness of the anatomy–function–pathology (AFP) score was examined to evaluate its prediction of recurrence after laparoscopic fundoplication for erosive reflux esophagitis.MethodsOf the patients undergoing laparoscopic fundoplication for erosive reflux esophagitis of Los Angeles classification grade A or higher from December 1994 to December 2004, 107 who underwent preoperative barium esophagogram, pH monitoring, and endoscopy were selected as subjects. The AFP score was calculated by A, F, and P factor grades of the AFP classification. By comparing patients with and without recurrence, the usefulness of the AFP score for predicting recurrence was examined.ResultsReflux esophagitis recurred in seven patients. No significant difference in age, sex, or A or F factor was observed between the groups, whereas a significant difference was observed in the P factor (p = 0.008). On the other hand, the mean AFP score in the recurrence group was 16.9 ± 5.3, whereas that in the nonrecurrence group was 8.9 ± 5.3 (p = 0.0021). Among the patients with a score of 17 points or more (n = 23), recurrence was found in 6 patients (26%). On the other hand, among the patients with a score lower than 17 points (n = 84), recurrence was found in 1 patient, but not in the remaining 83 patients (1%). Sensitivity was thus 85.7% (95% confidence interval [CI], 42.1–99.6), and specificity was 83% (95% CI, 74.2–89.8). The positive predictive value was 26.1% (95% CI, 10.2–48.4), and the negative predictive value was 98.8% (95% CI, 93.5–99.9). Multiple logistic regression analysis was performed, and receiver operating characteristics curves were obtained. The area under the curve for the AFP score was 0.8457, whereas that for the P factor was 0.7907 (p = 0.0045), suggesting that the AFP score may more accurately predict recurrence than the P factor.ConclusionThe AFP score may be useful for predicting postoperative recurrence. If surgery is performed when the AFP score is lower than 17 points, the likelihood of postoperative recurrence is expected to be very low.

Laparoscopic Collis gastroplasty and Nissen fundoplication for reflux esophagitis with shortened esophagus in Japanese patients.

Background There is an extremely small number of surgical cases of laparoscopic Collis gastroplasty and Nissen fundoplication (LCN procedure) in Japan, and it is a fact that the surgical results are not thoroughly examined. Purpose To investigate the results of LCN procedure for shortened esophagus. Patients and Methods The subjects consisted of 11 patients who underwent LCN procedure for shortened esophagus and followed for at least 2 years after surgery. The group of subjects consisted of 3 men and 8 women with an average age of 65.0±11.6 years, and an average follow-up period of 40.7±14.4 months. Esophagography, pH monitoring, and endoscopy were performed to assess preoperative conditions. Symptoms were clarified into 5 grades between 0 and 4 points, whereas patient satisfaction was assessed in 4 grades. The use of postoperative acid-reducing medication and the recurrence of esophagitis were also investigated. Results None of the patients experienced intraoperative complications, received transfusions, required conversion to open surgery, or died postoperatively. The average preoperative heartburn, regurgitation, and dysphagia scores were 2.36±1.29, 2.27±1.19, and 1.82±1.78 points, respectively. These scores improved after surgery to 0.55±1.21 (P=0.0063), 0.55±1.21 (P=0.0094), and 1.0±1.18 (P=0.1236) points, respectively. All patients had esophagitis preoperatively, which recurred in 3 patients (27%). In these 3 patients, acid-secreting mucosa was confirmed on the oral side of the wrap, by positive Congo-red staining. Hiatal hernia recurred in one patient, who also experienced recurrent esophagitis. Five patients received acid-reducing medication postoperatively. The degree of satisfaction was excellent in 2, good in 6 patients, fair in 2, and poor in 1 patient(s). Conclusions Although the LCN procedure can be performed safely, the outcome was not necessarily satisfactory. The LCN procedure requires avoidance of residual acid-secreting mucosa on the oral side of the wrapped neoesophagus. If acid-secreting mucosa remains, continuous acid suppression therapy should be employed postoperatively.

Data analyses and perspectives on laparoscopic surgery for esophageal achalasia.

In general, the treatment methods for esophageal achalasia are largely classified into four groups, including drug therapy using nitrite or a calcium channel blocker, botulinum toxin injection, endoscopic therapy such as endoscopic balloon dilation, and surgery. Various studies have suggested that the most effective treatment of esophageal achalasia is surgical therapy. The basic concept of this surgical therapy has not changed since Heller proposed esophageal myotomy for the purpose of resolution of lower esophageal obstruction for the first time in 1913, but the most common approach has changed from open-chest surgery to laparoscopic surgery. Currently, the laparoscopic surgery has been the procedure of choice for the treatment of esophageal achalasia. During the process of the transition from open-chest surgery to laparotomy, to thoracoscopic surgery, and to laparoscopic surgery, the necessity of combining antireflux surgery has been recognized. There is some debate as to which type of antireflux surgery should be selected. The Toupet fundoplication may be the most effective in prevention of postoperative antireflux, but many medical institutions have selected the Dor fundoplication which covers the mucosal surface exposed by myotomy. Recently, a new endoscopic approach, peroral endoscopic myotomy (POEM), has received attention. Future studies should examine the long-term outcomes and whether POEM becomes the gold standard for the treatment of esophageal achalasia.

Therapeutic Effects of Laparoscopic Fundoplication for Nonerosive Gastroesophageal Reflux Disease

PurposeSurgical treatments for nonerosive gastroesophageal reflux disease (NERD) have not been investigated sufficiently. We examined the results of laparoscopic fundoplication for patients with NERD.MethodsWe performed laparoscopic fundoplication for NERD in 22 patients. The severity of esophageal hiatal hernia, morphology of the cardiac orifice, and results of 24-hour continuous esophageal and gastric pH were evaluated. We used a four-point scale for the improvement rating of postoperative symptoms.ResultsThere were 20 patients (91%) with a sliding hiatal hernia, and 21 patients (95%) with a loose cardiac orifice. Seven patients had acid reflux with 4.0% or higher esophageal fraction of time pH below 4. The surgical techniques used were Nissen fundoplication in 10 patients and Toupet fundoplication in 12 patients. Improvement of postoperative heartburn was rated as excellent in 16 patients, good in 5, and fair in 1. The overall efficacy rating was 95%, and discontinuation of proton pump inhibitor (PPI) was possible in 21 patients.ConclusionOur results of performing laparoscopic fundoplication in patients with NERD were excellent. Even if abnormal acid reflux cannot be confirmed preoperatively, sufficient therapeutic efficacy can be expected for patients with esophageal hiatal hernia or a loose cardiac orifice.

Postoperative recurrence factors of GERD in the elderly after laparoscopic fundoplication

BackgroundAssessment of the outcomes of laparoscopic fundoplication in elderly patients with gastroesophageal reflux disease (GERD) is insufficient.MethodsOf the 256 patients with GERD who underwent surgery between December 1994 and December 2008, sufficient postoperative follow-up was completed in 205 patients. Of the 205 patients who were included in the study, 166 were younger than 70 years of age (mean, 49.2 ± 14.1 years; 108 men/58 women), and 39 patients were 70 years or older (mean, 74.8 ± 4.3 years; 11 men/28 women). Preoperative clinical conditions were assessed using the AFP classification. Recurrence was defined as postoperative recurrence of erosive esophagitis or evident hiatus hernia. Clinical conditions of cases with and without recurrence were compared to identify factors associated with the recurrence. Statistical analyses were performed using the Mann-Whitney U test.ResultsFive cases (13%) in the elderly patient group were judged to have a recurrence, all of whom had recurrent esophagitis and hernia. There was a significant difference in surgical procedures (P = 0.005) between the recurrence and nonrecurrence groups. There were 17 (10%) recurrent cases in the nonelderly patient group. In a comparison of the recurrence and nonrecurrence groups, there were signifi cant differences in age (P = 0.002), duration of symptoms (P = 0.029), A factor (P = 0.004), and AFP score (P = 0.007), but not in the surgical procedures.ConclusionsThe risk factors for recurrence were different between nonelderly patients and elderly patients. The laparoscopic Collis-Nissen methods should be indicated with caution in elderly GERD patients with a short esophagus.