M. Baessato

Push-through intubation: Effective palliation in 409 patients with cancer of the esophagus and cardia

Between 1980 and 1989, 355 patients with cancer of the esophagus and 54 with cancer of the cardia underwent push-through intubation because of advanced tumor stage or medical contraindications to tumor resection. In 36 other patients (8.1%), the attempt at transtumoral intubation failed. The hospital mortality rate after intubation was 3.4%. The following complications were observed: hemorrhage in 2.0% of the patients, esophageal perforation in 4.9%, tube dislodgment in 12.7%, and tube obstruction in 4.4%. Early resumption of semisolid oral feeding was possible in 80% of the discharged patients. The actuarial 1-year survival rate was 7.7% and the median survival, 3.9 months. In conclusion, push-through intubation represents a valid therapeutic choice, which is indicated mainly for patients with a long, infiltrating, and circumferential stricture of the thoracic esophagus or cardia that is inoperable and for patients with an esophagorespiratory or esophagomediastinal fistula.

EARLY AND LONG-TERM RESULTS OF PNEUMATIC DILATION IN THE TREATMENT OF OESOPHAGEAL ACHALASIA.

SummaryBetween 1967 and 1989, 60 patients underwent pneumatic dilation of the cardia at our institution. Of these, 33 had not undergone any previous treatment (group 1), whereas 27 presented with recurrent dysphagia after a failure of surgical treatment (group 2). In this series there was no procedure-related mortality and a perforation occurred only in 1 patient who was treated conservatively. The mean follow-up was similar in both groups (44 and 49 months, respectively). The results of pneumatic dilation were either excellent or good in 61% of group 1 patients, and in 76% of group 2 patients. Reflux oesophagitis requiring medical therapy occurred in 1 group 2 patient. We conclude that pneumatic dilation is a safe and relatively effective procedure in patients with achalasia. Patients with a failed Heller myotomy seem to respond better than patients without previous surgery. However, the risk of gastro-oesophageal reflux after pneumatic dilation should not be underestimated.

Manometric Characteristics of the Distal Oesophageal Sphincter and Patterns of Gastro-Oesophageal Reflux in Healthy Volunteers and Patients

Three manometric characteristics of the distal oesophageal sphincter (DOS; pressure, length below the respiratory inversion point, i.e., abdominal length, and overall length) were investigated in 10 healthy volunteers and in 66 patients with typical symptoms of gastro-oesophageal reflux (GOR) disease. The aim of the work was to correlate the DOS deficiency with symptoms, endoscopic oesophagitis and with specific patterns of GOR as determined by means of 24-hour oesophageal pH monitoring. The results showed that patients with and without GOR disease cannot be separated solely on the basis of the standard manometric test, even adopting more parameters besides the traditional DOS pressure measurement. A functional defect of the DOS may be hypothesized for those patients with an apparently normal DOS on standard oesophageal manometry.

Gastro-Oesophageal Reflux in Italian Healthy Volunteers and Patients: Relationship between Gastro-Oesophageal Reflux, Endoscopic Oesophagitis and Symptoms

Prolonged pH monitoring of the distal oesophagus is considered the most sensitive test for detecting gastro-oesophageal reflux (GOR). Local patterns of GOR are needed because of its large diffusion in countries with different dietetic and behavioural habits and the use of the test in outpatients. 15 healthy volunteers and 30 patients affected by GOR disease were studied by means of a 24-hour oesophageal pH test. Moreover, the results obtained in the pathological group were compared with endoscopic findings and symptoms to find out whether there exists a relationship between pH test, oesophagitis and symptom severity. We found an average of 25 ± 17.3 reflux episodes/24 h; the percentage of acid exposure of the distal oesophagus was 1.6 ± 1.4; the percentage of acid exposure while the volunteers where recumbent was 0.81 ± 1.09: the number of reflux episodes longer than 5 min was 0.57 ± 1.04 and the duration of the longest episode was 4.5 ± 3 min in healthy subjects. There were no statistical differences compared with the values of healthy American subjects except for the percentage of acid exposure in supine position. This higher exposure of the distal oesophagus to the gastric refluxed juice could be explained by the different dietetic habits of the Italian volunteers, who ate late in the evening and went to bed in the postprandial phase. In the pathological group (identified by values greater than the mean plus 2 SD) no connection between the severity of oesophagitis and the severity of refluxes was observed. The pH test discriminated only symptomatic patients with or without oesophagitis but allowed no further division in this group to be made. The severity of the symptoms was related only to the percentage of acid exposure of the distal oesophagus in upright position. No relationship with the other parameters adopted was found. In conclusion, the 24-hour pH test is the test of choice for detecting and quantifying GOR disease. However, it is only a semiquantitative test and cannot be used for a prognosis of GOR disease development.

Reoperations After Complications or Failure of Antireflux Surgery

Antireflux operations are widely employed for relief of gastroesophageal reflux (GER) unresponsive to medical treatment. Whatever the adopted surgical technique is, long-term follow-up studies reveal that 10%–15% of patients still complain of symptoms which may or may not be related to the recurrence of GER [1]. Postlethwait [2] reports 9% of poor results after antireflux surgery on 4805 collected cases.

Long-term results of endoscopic dilation in patients with peptic esophageal strictures

The ideal management of patients with peptic esophageal strictures is not well defined at present. During the past two decades it has become apparent that most strictures can be successfully dilated and that dilation combined with standard antireflux repair can restore comfortable swallowing in the majority of the patients (12). Although dilation alone is considered an effective short-term therapy, the rate of stricture recurrence and the value of dilation plus medical treatment in the long-term management of these patients are still unknown.

Nissen Fundoplication: Intraoperative Manometry or Mechanical Calibration?

Intraoperative manometry was performed in 7 consecutive patients undergoing Nissen fundoplication for gastroesophageal reflux disease. The aim of the study was to assess the effectiveness of the technique of mechanical calibration of the fundoplication with a 60-french Maloney bougie. Results showed a statistically significant increase of lower esophageal sphincter pressure and length over preoperative values. The values remained stable at 1 week and 6 months after operation. No patient had postoperative dysphagia or abnormal esophageal acid exposure on 24-hour esophageal pH monitoring. We conclude that mechanical calibration of the Nissen fundoplication is very effective in constructing an adequate antirefiux barrier. Intraoperative manometry adds time to the operation, and the information gained is of little practical value.