Karl H. Fuchs

Experimental and Clinical Results with Proximal End-to-end Duodenojejunostomy for Pathologic Duodenogastric Reflux

Existing Roux-en-Y bile diversion procedures for duodenogastric reflux coupled with distal gastric resection or antrectomy and vagotomy have varied success due to interruption of the physiologic relationships between stomach and duodenum, the reduction of the gastric reservoir, the side effects of vagotomy, and the effect of the Roux limb on gastric emptying. A new bile diversion procedure, suprapapillary Roux-en-Y duodenojejunostomy, was studied, which eliminates the need for gastric resection to prevent jejunal ulcers by preserving duodenal inhibition of gastric acid secretion and the protective effects of duodenal secretion on the surrounding mucosa. Experimentally, the incidence of jejunal ulceration was significantly decreased by the preservation of the proximal duodenum. Clinically, bile diversion by suprapapillary Roux-en-Y duodenojejunostomy alleviates symptoms of duodenogastric reflux disease without being ulcerogenic (in the presence of normal gastric secretion) or prolonging gastric emptying.

Influence of tumor position on accuracy of endorectal ultrasound staging.

Endorectal ultrasound is a well-established method of preoperative staging of rectal neoplastic lesions. PURPOSE: This study was undertaken to evaluate whether tumor site (in terms of height) and position (with respect to the rectal circumference) have an influence on the reliability of endoluminal ultrasound staging. METHODS: From January 1991 to May 1996, 154 consecutive patients with a total of 162 rectal tumors were examined preoperatively using endorectal ultrasound. Apart from staging all tumors using the uT/uN classification, tumor level and tumor position were recorded prospectively. Neoplasms were subdivided into low rectal (0–6 cm from the anal verge), mid rectal (7–12 cm), and higher lesions (>12 cm). Furthermore, the lumen was divided into an anterior, left lateral, posterior, and right lateral position, and all tumors, apart from circular lesions (n=9), were subclassified accordingly. RESULTS: Overall, we found 40 (25 percent) adenomas, 15 (9 percent) T1, 29 (18 percent) T2, 67 (41 percent) T3, and 11 (7 percent) T4 lesions. Overall accuracy was 78 percent. Staging accuracy for low rectal tumors (n=41) was 68 percent, whereas 76 and 88 percent of mid (n=96) and high (n=25) neoplasms were staged correctly, respectively. The difference was not statistically significant. With regard to position, 47 tumors were situated anteriorly (77 percent accuracy), 42 in the left lateral position (69 percent accuracy), 33 posteriorly (73 percent accuracy), and 31 in the right lateral position (81 percent accuracy). Differences did not reach statistical significance. CONCLUSION: Endorectal ultrasound is currently the best method for preoperative assessment of the depth of infiltration of rectal tumors. However, rectal anatomy seems to affect staging accuracy in the lower rectum because the structure of the ampulla recti renders endosonographic examination more difficult. In addition, endosonographic layers are less well defined at this level. Both factors contribute to a lower reliability and predictive value of endorectal ultrasound staging in the lower rectum, although statistical significance was not reached in this study. On the other hand, tumor position with respect to rectal circumference does not influence the predictive value of endorectal ultrasound.

EAES recommendations for the management of gastroesophageal reflux disease

BackgroundGastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett’s esophagus, and enteroesophageal and duodenogastroesophageal reflux.MethodsThe European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session.ResultsRecommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD.ConclusionsSince the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.

Computerized identification of pathologic duodenogastric reflux using 24-hour gastric pH monitoring.

Duodenogastric reflux is a naturally occurring sporadic event, the incidence, occurrence, and detrimental effects of which have been difficult to assess. The reliability of 24-hour gastric pH monitoring to detect duodenogastric reflux was studied. Central to the use of pH monitoring for this purpose is confidence in its ability to measure and display pH data in a way that reflects changes in the gastric pH environment with sufficient sensitivity. To test this the gastric pH of 10 dogs was measured in the fasting state, after feeding, and after pentagastrin stimulation. The antrum was more alkaline in the fasting state (p less than 0.01) and the display of data by frequency distribution graph was sensitive enough to reflect induced pH changes. To test the consistency of gastric pH at a given position, simultaneous 24-hour gastric monitoring was performed in 12 normal subjects with two probes placed at either 5 or 10 cm below the lower esophageal sphincter. Only at the 5-cm position did the two probes read within 1 pH unit of each other more than 90% of the time. Based on these principles, gastric pH monitoring was performed 5 cm below the lower esophageal sphincter in 30 normal subjects and 11 patients, fulfilling Ritchies clinical criteria for pathologic duodenogastric reflux. The data obtained was arranged into 71 variables and subjected to discriminant analysis. Sixteen variables were identified, each with a corresponding coefficient to be used as a multiplier to derive a score. A score of more than +2.2 indicated a high probability of pathologic duodenogastric reflux. The test was applied to a validation population consisting of 10 additional normal subjects and 10 patients meeting Ritchies criteria. All normal subjects had a normal score and all but one (90%) of the patients had an abnormal score. When compared to O-diisopropyl iminodiacetic acid (DISIDA) scintigraphy in another group of 22 normal subjects and 60 patients, 24-hour gastric pH monitoring was superior in the detection of pathologic duodenogastric reflux. The study shows how the application of computer technology can be used to diagnose pathologic duodenogastric reflux in patients with complex foregut complaints.

Comparison of different J-pouches vs. straight and side-to-end coloanal anastomoses: experimental study in pigs.

PURPOSE: Functional results after low anterior resection with straight coloanal anastomosis are poor. Although certain functional aspects are improved with coloanal J-pouch anastomosis, evacuation difficulties are encountered in some of these patients. The aim of the study was to investigate the functional results of different reconstruction methods after low anterior resection in a standardized pig model. METHODS: Thirty-two adult Göttinger mini pigs were randomly assigned either to straight end-to-end (Group 1), side-to-end (Group 2), small (4-cm limb length) J-pouch (Group 3), or large (8-cm limb length) J-pouch (Group 4) coloanal anastomosis after low rectal excision. The animals were investigated 12 weeks after the operation by measuring neorectal compliance and ceruletide-induced defecation. Eight pigs without operation were used as controls (Group 5). RESULTS: Compliance was lowest in Groups 1 and 2, which were significantly different compared with both pouch designs and controls. Neorectal compliance of pigs with either small or large pouches did not differ significantly compared with one another or controls. Defecation was significantly impaired in pigs with a large pouch compared with all other groups. Pigs with side-to-end anastomoses had as rapid an evacuation as animals with straight coloanal reconstruction. CONCLUSION: Coloanal J-pouch reconstruction adequately restores reservoir capacity after low anterior resection of the rectum. From a functional point of view, side-to-end is not superior to straight coloanal anastomosis. Compared with small pouches, a large pouch design does not lead to better neorectal compliance in the pig model, whereas pouch evacuation seems to be considerably compromised.

Quantification of the Duodenogastric Reflux in Gastroesophageal Reflux Disease

The dual presence of gastroesophageal and duodenogastric reflux disease has been investigated by combined esophageal and gastric 24-h pH monitoring on the premise that alkalinity in the stomach reflects duodenal regurgitation and acidity in the esophagus reflects gastric regurgitation (Little et al. 1979; DeMeester 1985, Del Genio et al. 1985). The experience showed that this concept was applicable to gastroesophageal but not duodenogastric reflux for the following reasons: 1. In contrast to the esophagus, where a pH threshold of 4 is widely accepted as a border between health and disease (Emde et al. 1986), a clear-cut border cannot be established in the stomach. 2. An unspecified amount of duodenogastric reflux is physiological. 3. Alkaline changes in the gastric pH environment can result from other causes than regurgitation of duodenal contents such as a reduction in gastric acid secretion, dilution of intraluminal fluid by increased mucus production, and ingestion of food or fluid.

Esophageal Sphincters in Health and Disease

Abstract Introduction: The esophagus is a muscular tube connecting the mouth with the stomach. The main function of the esophagus is the transport of fluids and food to ensure regular nutrition of the body. At the proximal and distal end of the tube, special boundaries are necessary to fulfill complex functional tasks such as swallowing, belching, and vomiting and allowing breathing and coughing, while preventing substantial reflux of gastric contents into the esophagus. Structures and Function in Health and Disease: This chapter focuses on the upper esophageal sphincter (UES) and the lower esophageal sphincter (LES). The complex functions of the two sphincters are regulated and influenced by nerval innervations, pressure systems, hormonal and chemical influences, and external and possible psychological factors. The functional assessment is usually performed by radiographic studies and manometric techniques. There are many disorders that can cause cervical or oropharyngeal dysphagia. This includes myogenic, neurogenic, iatrogenic, mechanical, and psychogenic causes, as well as idiopathic dysfunctions of the UES. The LES structure is incorporated in the distal esophagus. The major function is the proximal closure of the gastric reservoir to prevent reflux of substantial amounts of gastric contents back into the esophagus. This is important because gastric juice can be toxic for the esophageal mucosa. The major functional finding at the distal esophagus is a high-pressure zone. The most frequent failure of the LES is a weakening causing increased gastroesophageal reflux.

Concomitant Duodenogastric and Gastroesophageal Reflux: The Role of Twenty-Four-Hour Gastric pH Monitoring

Duodenogastric reflux can occur in patients with gastroesophageal reflux disease (Pellegrini et al. 1978; Little et al. 1984; DeMeester 1985a). Its presence is suggested symptomatically by epigastric pain, nausea, and vomiting in addition to heartburn and regurgitation; endoscopically by a large bile lake or evidence of gastritis; and functionally by a normal 24-h esophageal pH monitoring test in a patient with a mechanically defective lower esophageal sphincter (LES), i.e., LES pressure less than 6 mmHg, LES overall length 2 cm or less, and LES intraabdominal length 1 cm or less (Toye and Williams 1965; Ritchie 1984; DeMeester 1985 b).

278. Oesophagitis-Hiatushernie, eine Kontroverse? Neue Perspektiven in der Refluxkrankheit

SummaryIn this study the diagnostic accuracy of the current investigations regarding gastroesophageal reflux disease was evaluated. Ninety subjects (45 healthy volunteers and 45 patients with the disease) underwent radiography, esophagoscopy, 24-h esophageal pH monitoring, and manometry of the lower esophageal sphincter. Morphologic investigations such as radiography and esophagoscopy showed limited sensitivity (78% vs 62%). The highest accuracy found was 24-h pH monitoring with 96% sensitivity and specificity. Manometry of the sphincter can select patients with a mechanically insufficient sphincter with an accuracy of 87%. The diagnostic workup should include functional studies.ZusammenfassungUm die diagnostische Trefferquote verschiedener Untersuchungen der gastro oesophagealen Refluxkrankheit zu evaluieren, wurden 90 Testpersonen (45 gesunde Probanden und 45 Patienten mit der Erkrankung) in dieser Studie untersucht. Radiographie, Endoskopie, 24-h-pH-Metrie und die Manometrie des unteren oesophagealen Sphincters wurden getestet. Die morphologischen Untersuchungen, Radiographie und Endoskopie erreichten nur begrenzte Sensitivität (78% resp. 62%). Die höchste Sensitivität (96%) und Spezifität (96%) hatte die 24-h-pH-Metrie. Die Manometrie selektiert Patienten mit einem mechanisch insuffizienten Sphincter mit einer Trefferquote von 87%.

142. Ergebnisse der selektiv-proximalen Vagotomie beim Ulcus ventriculi Typ III

SummaryThirty-eight of 49 patients operated on for a prepyloric gastric ulcer (1978–1983) had a selective proximal vagotomy combined with excision of the ulcer. By march 1985, 12 recurrent ulcers had been found (31.2%). Including the patients with recidivist ulcers without significant complaints, only 51.5% of the patients were evaluated as Visick I or II. Eight of 12 females had a recurrent ulcer, but only 2 of them had hypersecretion; only 4 of 26 males had a recurrence (2 patients with normal gastric secretion). As a result, we perform primary resection in females with normal acid output.ZusammenfassungDas präpylorische Magenulcus wurde 1978–1983 mit einer selektiv-proximalen Vagotomie und Ulcusexcision behandelt (n=38). Es traten bisher 12 Rezidive auf (31,2%). In der Visick-Einschätzung (n=33) waren die Ergebnisse unter Einbeziehung der symptomarmen Rezidive nur 51,5% der Patienten als sehr gut und gut zu bezeichnen. Von 11 Frauen wiesen 8 ein Rezidiv auf, davon 5 mit normaler Säuresekretion, von 26 Männern nur 4 (2 mit normaler Saftanalyse). Wir haben hieraus die Konsequenz gezogen, Frauen mit normaler Säuresekretion primär zu resezieren.