Jörg Theisen

Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate

BACKGROUND Recent studies based on symptomatic outcomes analyses have shown that laparoscopic repair of large type III hiatal hernias is safe, successful, and equivalent to open repair. These outcomes analyses were based on a relatively short followup period and lack objective confirmation that the hernia has not recurred. The aim of this study was to compare the outcomes of laparoscopic and open repair of large type III hiatal hernia using both symptomatic evaluation and barium study to assess the integrity of the repair. STUDY DESIGN Fifty-four patients underwent repair of a large type III hiatal hernia between 1985 and 1998. The surgical approach was laparotomy in 13, thoracotomy in 14, and laparoscopy in 27. An antireflux procedure was included in all patients. Symptomatic outcomes were assessed using a structured questionnaire at a median of 24 months and was complete in 51 of 54 patients (94%). A single radiologist, without knowledge of the operative procedure, assessed the integrity of the repair using video esophagram. Videos were performed at a median of 27 months (35 months open and 17 laparoscopic) and were completed in 41 of 54 patients (75%). RESULTS Symptomatic outcomes were similar in both groups with excellent or good outcomes in 76% of the patients after laparoscopic repair and 88% after an open repair. Reherniation was present in 12 patients and was asymptomatic in 7. A recurrent hernia was present in 12 of the 41 patients (29%) who returned for a followup video esophagram. Forty-two percent (9 of 21) of the laparoscopic group had a recurrent hernia compared with 15% (3 of 20) of the open group (p < 0.001 log-rank value on recurrence-free followup). CONCLUSIONS Laparoscopic repair of type III hiatal hernias is associated with a disturbingly high (42%) prevalence of recurrent hernia. More than half such recurrences have few, if any, symptoms.

Occult Esophageal Adenocarcinoma: Extent of Disease and Implications for Effective Therapy

OBJECTIVE The need for esophagectomy in patients with Barretts esophagus, with no endoscopically visible lesion, and a biopsy showing high-grade dysplasia or adenocarcinoma has been questioned. Recently, endoscopic techniques to ablate the neoplastic mucosa have been encouraged. The aim of this study was to determine the extent of disease present in patients with clinically occult esophageal adenocarcinoma to define the magnitude of therapy required to achieve cure. METHODS Thirty-three patients with high-grade dysplasia (23 patients) or adenocarcinoma (10 patients) and no endoscopically visible lesion underwent repeat endoscopy and systematic biopsy followed by esophagectomy. The surgical specimens were analyzed to determine the biopsy error rate in detecting occult adenocarcinoma. In those with cancer, the depth of wall penetration and the presence of lymph node metastases on conventional histology and immunohistochemistry staining was determined. The findings were compared with those in 12 patients (1 with high-grade dysplasia, 11 with adenocarcinoma) who had visible lesions on endoscopy. RESULTS The biopsy error rate for detecting occult adenocarcinoma was 43%. Of 25 patients with cancer and no visible lesion, the cancer was limited to the mucosa in 22 (88%) and to the submucosa in 3 (12%). After en bloc esophagectomy, one patient without a visible lesion had a single node metastasis on conventional histology. No additional node metastases were identified on immunohistochemistry. The 5-year survival rate after esophagectomy was 90%. Patients with endoscopically visible lesions were significantly more likely to have invasion beyond the mucosa (9/12 vs. 3/25, p = 0.01) and involvement of lymph nodes (5/9 vs. 1/10, p = 0.057). CONCLUSIONS Endoscopy with systematic biopsy cannot reliably exclude the presence of occult adenocarcinoma in Barretts esophagus. The lack of an endoscopically visible lesion does not preclude cancer invasion beyond the muscularis mucosae, cautioning against the use of mucosal ablative procedures. The rarity of lymph node metastases in these patients encourages a more limited resection with greater emphasis on improved alimentary function (esophageal stripping with vagal nerve preservation) to provide a quality of life compatible with the excellent 5-year survival rate of 90%.

Suppression of gastric acid secretion in patients with gastroesophageal reflux disease results in gastric bacterial overgrowth and deconjugation of bile acids

The aim of this study was to test the hypothesis that gastric bacterial overgrowth is a side effect of acid suppression therapy in patients with gastroesophageal reflux disease (GERD) and that the bacteria-contaminated gastric milieu is responsible for an increased amount of deconjugated bile acids. Thirty patients with GERD who were treated with 40 mg of omeprazole for at least 3 months and 10 patients with GERD who were off medication for at least 2 weeks were studied. At the time of upper endoscopy, 10 ml of gastric fluid was aspirated and analyzed for bacterial growth and bile acids. Bacterial over-growth was defined by the presence of more than 1000 bacteria/ml. Bile acids were quantified via high-performance liquid chromatography. Eleven of the 30 patients taking omeprazole had bacterial over-growth compared to one of the 10 control patients. The median pH in the bacteria-positive patients was 5.3 compared to 2.6 in those who were free of bacteria and 3.5 in the control patients who were off medication. Bacterial overgrowth only occurred when the pH was >3.8. The ratio of conjugated to unconjugated bile acids changed from 4:1 in the patients without bacterial overgrowth to 1:3 in those with bacterial growth greater than 1000/ml. Proton pump inhibitor therapy in patients with GERD results in a high prevalence of gastric bacterial overgrowth. The presence of bacterial overgrowth markedly increases the concentration of unconjugated bile acids. These findings may have implications in the pathophysiology of gastroesophageal mucosal injury.

Prevalence and location of nodal metastases in distal esophageal adenocarcinoma confined to the wall: Implications for therapy

OBJECTIVE The purpose of this study was to characterize the prevalence and location of regional lymph node metastases in adenocarcinoma confined to the esophagal wall, to determine the extent of dissection required, and to investigate the applicability of nonoperative therapy. METHODS Histologic evaluation of the resected specimens after en bloc esophagogastrectomy with mediastinal and abdominal lymphadenectomy was performed on 37 patients with adenocarcinoma confined to the esophageal wall. Follow-up was complete in all patients (median 24 months). RESULTS Fifteen patients (41%) had intramucosal tumors. Twelve (32%) had submucosal tumors and 10 (27%) had muscular invasion. The prevalence of regional lymph node metastases (15/37 patients, 41%) increased progressively with depth of tumor invasion, with involved nodes identified in 80% of patients with muscular invasion. Lymph node metastases were also more common at distant node stations in intramuscular tumors (5/10, 50%). Actuarial survival for the entire group was 63% at 5 years. Recurrence was identified in 6 of the 37 patients (16%), with the risk of recurrence correlating with tumor depth. CONCLUSIONS Tumor depth is a strong predictor of the probabilities of regional lymph node metastases, the likelihood of involvement of distant node groups, and the risk of recurrence. Patients with invasion of the muscular wall are at particularly high risk. En bloc esophagectomy with mediastinal and abdominal lymphadenectomy has the highest likelihood of achieving an R0 resection. The long-term survival and low recurrence rate achieved with an en bloc esophagectomy emphasizes the importance of an aggressive lymph node dissection to remove all potentially involved nodes.

The extent of Barrett's esophagus depends on the status of the lower esophageal sphincter and the degree of esophageal acid exposure

OBJECTIVE The purpose of this study was to assess whether the extent of intestinal metaplasia is related to the severity of the gastroesophageal reflux disease. METHODS A total of 556 consecutive patients with symptoms suggestive of foregut disease had upper gastrointestinal endoscopy with extensive biopsies from the gastroesophageal junction and the esophagus. All patients had esophageal motility and 24-hour pH monitoring. In 411 patients, cardiac-type mucosa was identified; in 147 patients, the cardiac-type mucosa showed intestinal metaplasia. They were divided into 3 groups based on the extent of intestinal metaplasia commonly seen clinically: long segments (>3 cm), short segments (<3 cm), and limited to the gastroesophageal junction. The duration of symptoms, the status of the lower esophageal sphincter, the degree of esophageal acid exposure, and the time to clear a reflux episode were assessed in each group. RESULTS The presence of intestinal metaplasia in cardiac-type mucosa was associated with the hallmarks of gastroesophageal reflux disease. The extent of intestinal metaplasia correlated strongly with the degree of esophageal acid exposure (r = 0.711; P <.001) and inversely with the lower esophageal sphincter pressure (r = 0.351; P <.001) and length (r = 0. 259; P =.002). Patients with a long segment of intestinal metaplasia (>3 cm) had longer duration of symptoms (16 years) than those patients with a segment of intestinal metaplasia less than 3 cm (10 years; P =.048) or those patients with intestinal metaplasia limited to the gastroesophageal junction (10 years; P =.01). CONCLUSION The extent of intestinal metaplasia, that is, Barretts esophagus, is related to the status of the lower esophageal sphincter and the degree of esophageal acid exposure.

Physiologic Basis for the Treatment of Epiphrenic Diverticulum

ObjectiveTo quantitate and characterize the motility abnormalities present in patients with epiphrenic diverticula and to assess the outcome of surgical treatment undertaken according to these abnormalities. Summary Background DataThe concept that epiphrenic diverticula are complications of esophageal motility disorders rather than primary anatomic abnormalities is gradually becoming accepted. The inconsistency in identifying motility abnormalities in patients with epiphrenic diverticula is a major obstacle to the general acceptance of this concept. MethodsThe study population consisted of 21 consecutive patients with epiphrenic diverticula. All patients underwent videoesophagography, upper gastrointestinal endoscopy, and esophageal motility studies. The diverticula ranged in size from 3 to 10 cm and were predominantly right-sided. Seventeen patients underwent transthoracic diverticulectomy or diverticulopexy with esophageal myotomy and an antireflux procedure. The length of the myotomy was determined by the extent of the motility abnormality. Transhiatal esophagectomy was performed in one patient with multiple diverticula. Two patients declined surgical treatment and another patient died of aspiration before surgery. Symptomatic outcome was assessed via a questionnaire at a median of 24 months after surgery. ResultsThe primary symptoms were dysphagia in 5 (24%) patients, dysphagia and regurgitation in 11 (52%) patients, and pulmonary symptoms in 5 (24%) patients. The median duration of the primary symptoms was 10 years. Esophageal motility abnormalities were identified in all patients. An esophageal motor disorder was diagnosed only by 24-hour ambulatory motility testing in one patient, and 24-hour ambulatory motility testing clarified the motility diagnosis in five other patients. The most common underlying disorder was achalasia, which was detected in nine (43%) patients. A hypertensive lower esophageal sphincter was diagnosed in three patients, diffuse esophageal spasm in five, “nutcracker” esophagus in two, and a nonspecific motor disorder in two patients. One patient had an intraoperative myocardial infarction and died. Two patients had persistent mild dysphagia after surgery. The remaining patients had complete relief of their primary symptoms. ConclusionsThere is a high prevalence of named motility disorders in patients with epiphrenic diverticula, and this condition is associated with the potential for lethal aspiration. Twenty-four-hour ambulatory motility testing can be helpful if the results of the stationary examination are normal or indefinite. Resection of the diverticula and a surgical myotomy of the manometrically defined abnormal segment results in relief of symptoms and protection from aspiration.

Manometry of the lower esophageal sphincter: inter- and intraindividual variability of slow motorized pull-through versus station pull-through manometry.

The purpose of this study was to evaluate the interindividual and intraindividual variability of slow motorized pull-through lower esophageal sphincter (LES) manometry compared to standard station pull-through LES manometry to measure LES overall length, abdominal length, and pressure and to report normal values for the slow motorized pull-through method. The slow motorized pull-through had significantly smaller coefficient of variation, indicating closer agreement between different examiners in analyzing a given tracing. The correlation coefficients for each parameter in normal subjects and symptomatic patients was significantly higher when using slow motorized pull-through for both patients and normal subjects for all three parameters. The 5th percentile of normal values obtained from 41 volunteers for LES overall length, abdominal length, and pressure was 2.7 cm, 1.4 cm, 5.1 mm Hg, respectively. The results indicate that the slow motorized pull-through method is more reproducible than the standard station pull-through method both between different observers and when the same examiner measures the same tracing on two different occasions.

Perforating Barrett's ulcer resulting in a life-threatening esophagobronchial fistula

Perforating benign ulcer is a very rare complication of Barretts esophagus. This report presents the management of a patient with a Barretts ulcer that penetrated into the left mainstem bronchus resulting in a life-threatening bronchial esophageal fistula. This rare complication was successfully managed by using a staged surgical approach, which combined the principles used for treating benign esophagorespiratory fistulas and perforating Barretts ulcers.

Esophageal adenocarcinoma--is Barrett's truly to blame?

Aiming to support the hypothesis that Barrett’s esophagus is the precursor of most adenocarcinomas of the esophagus and cardia, the authors determined a biochemical profile typical of Barrett’s esophagus and esophageal adenocarcinoma. They evaluated the expression of the small intestinal proteins sucrase-isomaltase (SI) and crypt cell antigen (CCAg) in Barrett’s esophagus, in its putative precursor tissues, and in esophageal-cardial adenocarcinomas without Barrett’s esophagus. Tissue samples were obtained by endoscopic biopsy or from surgical resected specimens. Five normal stomach samples were used for negative controls and five jejunum specimens for positive controls. Furthermore, five samples of peptic esophagitis and squamous cell carcinoma were analyzed. All specimens were stained with hematoxylin and eosin and Barrett’s esophagus was classified according to the presence of dysplasia and the type of metaplasia (cardiac and intestinal). Adenocarcinomas of the esophagus were classified using the Siewert-classification. For detection of the two intestinal proteins the authors used an indirect immunofluorescence technique with mouse monoclonal antibodies. The sections were analyzed with laser confocal microscopy imaging. Of the Barrett’s mucosa specimens, 93% showed a positive staining for SI and 89% for CCAg regardless of the type of metaplasia present. The expression of SI and CCAg was also independent of the coexistence of dysplasia or the presence of associated adenocarcinoma. Furthermore there was no statistical difference in SI and CCAg expression between specimens from adenocarcinoma with or without Barrett’s tissue and between tumors located in the esophagus and cardia. In peptic esophagitis or squamous cell carcinoma no expression of SI or CCAg was detected. The authors conclude that Barrett’s esophagus and adenocarcinoma of the esophagus have a similar biochemical phenotype and that these esophageal injuries probably originate from pre-existing Barrett’s esophagus, and furthermore that these data support the concept of a pluripotent stem cell for the development of Barrett’s esophagus and subsequently for adenocarcinoma of the esophagus and cardia. (Am J Gastroenterol 1999;94:1103–1104.

SURGICAL AND MEDICAL THERAPIES FOR GERD—CAN WE SEE INTO THE FUTURE?

Isolauri J, Luostarinen M, Viljakka M, et al. Long-Term Comparison of Antireflux Surgery Versus Conservative Therapy for Reflux Esophagitis Ann Surg 1997;225:295–9ABSTRACTThe authors studied the symptomatic and endoscopic outcome of patients who were treated for gastroesophageal reflux disease (GERD) with erosive esophagitis. The aim was to clarify the course of erosive esophagitis in GERD treated with an antireflux procedure or conservatively and furthermore to assess possible predictive factors of the long-term outcome. Included in this study were 105 of 120 patients who were consecutively referred for reflux symptoms to a gastroenterological department of a teaching hospital. The diagnosis was made symptomatically and endoscopically. Patients who were not relieved of symptoms or who had continued esophagitis underwent antireflux surgery. Conservative treatment included a modified lifestyle (elevated bedhead, avoidance of drugs or food, which reduced lower esophageal sphincter pressure, no smoking, no late evening meals) and medication (antacids, alginates, H2 antagonists). Thirty-seven patients underwent surgical treatment and 68 patients were treated conservatively. The median follow-up time was 10.9 yr (range 9–13.4) for all patients. The evaluation included a detailed, standardized interview, and an endoscopy with biopsy done by an investigator who was not involved previously. After the initial questionnaire, the patients assessed their symptoms with a self-scoring test. Compared to the conservatively treated group, the surgical patients initially had more severe disease. This was represented by a symptom score for heartburn and regurgitation and an endoscopic grade of esophagitis according to the Savary-Miller esophageal grading, which was mainly between 1 and 2 in the medical group and between 2 and 3 among the surgical patients, respectively. There was no mortality or morbidity in the group who underwent surgery. The follow-up evaluation showed that 84% of the surgery group were symptom-free or had only occasional heartburn, and 89% had healing of the esophagitis. For the conservatively treated group, the figures were 53% and 45%, respectively. In total, 57% of the conservative group had some objective sign of ongoing GERD, and 21% were still taking H2 antagonists or omeprazole regularly. Fifty-five percent had erosive esophagitis at follow-up endoscopy and eight new cases of Barretts metaplasia were found. Within the surgical group, 12 patients were found to have Barretts esophagus, five at referral time and seven new cases at follow-up. The authors conclude that in terms of symptoms and signs of erosive esophagitis in GERD, surgery was superior to conservative therapy and more cost-effective. No factors were found to predict the course of the disease.