Mario Albertucci

Nissen fundoplication for gastroesophageal reflux disease. Evaluation of primary repair in 100 consecutive patients.

One hundred consecutive patients had a primary Nissen fundoplication for gastroesophageal reflux disease. None of the patients had previous gastaric or esophageal surgery or evidence of esophageal stricture or motility disorder. The primary symptom was persistent heartburn in 89 patients and aspiration in 11. An abnormal pattern of esophageal acid exposure was documented in all patients with 24-hour esophageal pH monitoring. By actuarial analysis, the operation was 91% effective in the control of reflux symptoms over a 10-year period. The incidence of postoperative symptomatic gas bloat and increased flatus was lower in patients with preoperative abnormal manometric measurements of the distal esophageal sphincter (p < 0.05). Three modifications in operative technique were made during the course of the study to minimize the side effects of the operation. First, enlarging the caliber of the bougie to size the fundoplication reduced the incidence of temporary swallowing discomfort from 83 to 39% (p < 0.01). Second, shortening the length of the fundoplication decreased the incidence of persistent dysphagia from 21 to 3% (p < 0.01). Third, mobilizing the gastric fundus for construction of the fundoplication increased the incidence of complete distal esophageal sphincter relaxation on swallowing from 31 to 71% (p < 0.05). This was done to prevent the delayed esophageal acid clearance secondary to incomplete sphincter relaxation observed after operation in five of 36 studied patients. It is concluded that by proper patient selection and the incorporation of the above surgical techniques, the Nissen fundoplication can re-establish a competent cardia and provide relief of reflux symptoms with minimal side effects.

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.

Drug-induced esophageal strictures

A retrospective study of 55 patients with a benign esophageal stricture showed that in 11 patients (20%) the cause was a drug-induced lesion due to potassium chloride (3), tetracyclines (3), aspirin (2), vitamin C (1), phenytoin (1), and quinidine (1). Five of the 11 patients would have been diagnosed as having a reflux etiology of their stricture if 24-hour esophageal pH monitoring was not performed. Six patients responded to dilatation and five patients required resection or bypass. A prospective study of 18 asymptomatic volunteers showed a high incidence of esophageal lodgment of a radiolabeled medicinal capsule, with subsequent dissolution and release of the isotope. This occurred most frequently in elderly subjects and was reduced by increasing the volume of water chaser. The sites of lodgment correspond to the location of the observed strictures in the patient population. An in vitro study showed that, when the causative drugs were mixed with saliva, dissolution occurred within 60 minutes and was associated with significant changes in pH. These investigations show that drug-induced esophageal strictures are more common than previously appreciated, and can be confused with a reflux etiology. Diagnosis is suggested by a history of drug ingestion, location of the stricture, and a normal esophageal acid exposure on 24-hour pH monitoring. The severity of the esophageal injury is variable and requires dilatation to resection for therapy.

Foreign body entrapment in the esophagus of healthy subjects—A manometric and scintigraphic study

Foreign body entrapment and mucosal injury caused by oral medications are increasingly reported to occur in the upper esophagus in apparently normal subjects. We performed esophageal manometry in 40 normal volunteers to determine whether a unique motility pattern in the upper third of the esophagus predisposes to entrapment of foreign bodies at this site; 18 normal volunteers also had transit scintigraphy of a gelatine capsule filled with a radionuclide. The esophageal body was divided into five consecutive segments starting proximally, with each segment corresponding to 20% of the total length. Amplitude, slope, and velocity of the esophageal contraction were markedly decreased in the second segment compared with the other segments. Entrapment and dissolution of a gelatine capsule occurred in 39% of volunteers in the proximal eosphagus correlating to the second segment, i.e., the segment with the lowest amplitude, slope, and velocity of esophageal contractions. The observation that wet swallows have greater amplitudes (P<0.01) and steeper slopes (P<0.05) than dry swallows explains why the occurrence of pill entrapment was reduced when taken with sufficient water. However, even with a water chaser of 120 mL, pill entrapment occurred at the second segment of the esophagus in 1 of 18 volunteers. The observed motility pattern in the proximal eosphagus provides a better explanation for the entrapment of foreign bodies at this site than compression of the esophagus by the left main stem bronchus, aortic arch, or left atrium as suggested by other investigators.

Pericardial Cells for Graft Seeding: Isolation, Culture and Identification

The purpose of this study was to determine the feasibility of using the pericardium as a source of endothelial cells. Nineteen pieces of fresh pericardium were obtained from nine mongrel dogs. Cells were prepared by collagenase digestion of the pericardium for 24 minutes followed by centrifugation. The cells were divided into three groups: The supernatant subjected to no further steps, Group I (N = 6); filtration through a 15 micron porous mesh, Group II (N = 6); and Percoll gradient separation with medium 199, Group III (N = 7). The cells obtained were cultured for seven days in tissue culture media. Yield (cells x 10(5)/gram fresh tissue) was determined with Methods I, II, and III, producing 32.4 +/- 25.9 (SD), 0.96 +/- 0.6 and 0.57 +/- 0.5, respectively (I vs II or III, p less than 0.01). Fibroblast contamination determined by phase contrast light microscopy was demonstrated in 6/6 cultures with Method I, 3/6 with II and 1/7 for III (I vs III, p less than 0.01). An assay for endothelial cells (Factor VIII) was positive in 2/6 cultures with Method I, 5/6 with II and 7/7 for III (I vs III, p less than 0.01). The pericardium is a suitable organ for procurement of endothelial cells. Though reducing yield, filtration and Percoll gradient separation allows for isolation of a relatively pure culture of endothelial cells.

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.

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).