Roberta Barbera

Abnormal sensitivity to duodenal lipid infusion in patients with functional dyspepsia.

Background and objectives: Patients with functional dyspepsia exhibit increased sensitivity to gastric distension (mechanoreceptors) and to meals rich in fat (chemoreceptors). The aim of this study was to test whether these patients were abnormally sensitive to intraduodenal lipid, and whether this stimulus altered gastric mechanosensitivity. Methods and design: Experiments were conducted on 10 patients and 10 healthy controls. The stomach was distended with a flaccid bag during duodenal infusion of either 10% Intralipid or 0.9% saline. Intragastric pressure was recorded continuously, and the participants were asked to report gastric sensations of fullness and discomfort. Results: Intragastric pressure profiles during distension were similar in patients and controls. Lipid decreased intragastric pressure and reduced phasic contractility. Patients showed enhanced sensitivity to gastric distension compared with controls during both saline and lipid infusions. In the controls, threshold volumes for fullness and discomfort were higher during lipid than saline infusion. In the patients, the sensation of fullness occurred at lower volumes during lipid infusion, whereas discomfort occurred at similar volumes but lower intragastric pressures. Most patients experienced nausea and bloating and three patients vomited during lipid infusion, but remained asymptomatic during saline infusion. Controls reported no symptoms during either infusion. Conclusion: Dyspeptic patients have increased sensitivity to both gastric distension and intraduodenal lipid. In contrast to controls, lipid sensitizes their stomachs to distension.

Anorectal dysfunction and delayed colonic transit in patients with progressive systemic sclerosis

We studied 14 unselected patients with progressive systemic sclerosis (PSS), six with constipation, and eight with normal bowel habits. A control group, matched for age and sex, comprised six patients with idiopathic constipation and seven healthy subjects. Anorectal manometry was performed with perfused catheters and segmental colonic transit was measured by a radiopaque marker technique. The resting pressure of the anal canal was significantly reduced in PSS with constipation (P<0.05). The rectoanal inhibitory reflex was detected in only one PSS patient with constipation, but was present in seven of eight PSS patients with normal bowel habits and in all controls (P<0.01). Total and right colonic transit times were significantly delayed in PSS with constipation and in patients with idiopathic constipation (P<0.05). In patients with PSS, colonic transit was delayed and anal sphincter function was impaired in constipated patients, suggesting involvement of both the colon and the anorectum by the disease.

Endoluminal Fundoplication (ELF) for GERD Using EsophyX: a 12-Month Follow-up in a Single-Center Experience

BackgroundSeveral endoscopic antireflux therapies have been proposed to reduce the need for chronic medical therapy or laparoscopic fundoplication for gastroesophageal reflux disease (GERD). Aim of this study was to evaluate the short- and mid-term clinical results of endoluminal fundoplication (ELF) with EsophyX™.Patients and MethodsFrom June 2006 to April 2008, 20 patients were enrolled in the study. All the ELFs were performed under general anesthesia.ResultsThe mean duration of the procedure was 63xa0min (range 38–105). A median of 14 fasteners was placed. There were no major intraoperative complications. Two patients developed early complications and were treated conservatively. Four patients underwent, within the first year post-ELF, a laparoscopic fundoplication because of persistence of symptoms. One patient was lost to follow-up between 6 and 12xa0months. Among the other 15 patients who completed 12xa0months follow-up, the GERD health-related quality of life score decreased from a median of 40 to a median of 10 (pu2009<u20090.05), and seven patients were still off proton pump inhibitor. An improvement in esophageal acid exposure was recorded in 16.6% of patients, while in 66.7%, it worsened.ConclusionsELF induced improvement of GERD symptoms and patients quality of life in a subgroup of patients with a reduced need for medication. However, it did not significantly change esophageal acid exposure in these patients. The need for revisional standard laparoscopic fundoplication was high.

Sensations induced by medium and long chain triglycerides: role of gastric tone and hormones

BACKGROUND The relative roles of gastric relaxation and the neuroendocrine signals released by the small intestine in the perception of nutrient induced sensations are controversial. The different effects of long chain (LCT) and medium chain (MCT) triglyceride ingestion on perception, gastric relaxation, and hormonal release may help to elucidate the mechanisms underlying nutrient induced sensations. AIMS To compare the effects of intraduodenal LCT and MCT infusions on perception, gastric tone, and plasma gut hormone levels in healthy subjects. SUBJECTS Nine fasting healthy volunteers. METHODS The subjects received duodenal infusions of saline followed by LCTs and MCTs in a randomised order on two different days. The sensations were rated on a visual analogue scale. Gastric tone was measured using a barostat, and plasma gut hormone levels by radioimmunoassay. RESULTS LCT infusion increased satiation scores, reduced gastric tone, and increased the levels of plasma cholecystokinin, gastric inhibitory polypeptide, neurotensin, and pancreatic polypeptide. MCT infusion reduced gastric tone but did not significantly affect perception or plasma gut hormone levels. LCTs produced greater gastric relaxation than MCTs. CONCLUSIONS The satiation induced by intraduodenal LCT infusion seems to involve changes in gastric tone and plasma gut hormone levels. The gastric relaxation induced by MCT infusion, together with the absence of any significant change in satiation scores and plasma hormone levels, suggests that, at least up to a certain level, gastric relaxation is not sufficient to induce satiation and that nutrient induced gastric relaxation may occur through cholecystokinin independent mechanisms.

Persistent dysphagia after laparoscopic fundoplication for gastro‐esophageal reflux disease

Persistent postoperative dysphagia is a potentially severe complication of fundoplication for gastroesophageal reflux disease (GERD). The aim of this retrospective study was to analyze our experience of laparoscopic fundoplication for GERD in 276 consecutive patients, to determine the frequency of postoperative dysphagia and assess treatments and outcomes. There was no relation between preoperative dysphagia, present in 24 patients (8.7%), and postoperative DeMeester grade 2 or 3 dysphagia, present in 25 patients (9.1%). Ten (3.6%) patients had clinically significant postoperative dysphagia, eight (2.9%) underwent esophageal dilation, with symptom improvement in five. Four (1.4%) of our patients (two with failed dilation) and 11 patients receiving antireflux surgery elsewhere, underwent re-operation for persistent dysphagia 12 months (median) after the first operation. DeMeester grade 0 or 1 dysphagia was obtained in 10/13 evaluable patients. Our experience is fully consistent with that of the recent literature. Redo surgery is necessary in only a small fraction of operated patients with GERD with good probability of resolving the dysphagia. Best outcomes are obtained when an anatomical cause of the dysphagia is documented preoperatively.

Acid clearance and oesophageal sensitivity in patients with progressive systemic sclerosis.

This study examined the hypothesis that impaired oesophageal peristalsis was associated with delayed oesophageal clearance of acid in patients with progressive systemic sclerosis (PSS), some of whom are thought to have impaired oesophageal sensitivity to acid. Sixteen patients with PSS had: (a) oesophageal manometry and endoscopy; (b) acid perfusion of the oesophagus with simultaneous measurement of intraoesophageal pH during perfusion and for the next 10 minutes; (c) 22 hour monitoring of intraoesophageal pH; and (d) an evaluation of reflux symptoms during and after perfusion and during overnight pH monitoring. By oesophageal manometry, eight patients had normal peristalsis and eight patients had impaired peristalsis. Oesophageal endoscopy was unremarkable in patients with normal peristalsis, whereas all patients with impaired peristalsis had oesophagitis. The time needed to clear the oesophagus of perfused acid was shorter (p < 0.01) in patients with normal peristalsis and acid clearance time was significantly correlated (p < 0.01) with acid exposure time during overnight pH monitoring. During and after oesophageal perfusion, the nature, duration, and severity of symptoms did not differ between the groups, but overnight symptoms lasted longer (p < 0.05) in patients with impaired peristalsis. It is concluded that in PSS: (1) Impaired oesophageal motility delayed the clearance of acid and increased the exposure time to acid. (2) Acid clearance time is a useful parameter of impaired oesophageal motor function. The assessment of acid clearance time can be used as an alternative to overnight pH monitoring, to assess the impairment of oesophageal acid clearance. (3) Oesophageal sensitivity to acid was preserved in patients with impaired peristalsis and oesophagitis. (4) Reflux symptoms lasted longer in patients with prolonged oesophageal acid exposure but were still reported for a small fraction of the total acid exposure time. Thus, reflux symptoms reflect poorly prolonged exposure of the oesophagus to acid and are not a reliable guide to acid injury of the oesophagus in PSS.

Oesophageal acid clearance in patients with systemic sclerosis: Effect of body position

Objective: To test the effect of body position on oesophageal acid clearance time in patients with systemic sclerosis. Design and methods: Fifteen consecutive patients with systemic sclerosis and six healthy subjects underwent oesophageal manometry and an acid clearance test in three body positions (supine, recumbent at 30° and seated at 90°) in randomized order. Results: In healthy subjects the body position did not affect acid clearance time, whereas in patients the oesophagus cleared mainly by gravity. In patients the acid clearance time was significantly longer in the supine than in the seated position (P<0.05). Nine patients did not have a detectable peristaltic wave in the distal oesophagus. In the other six oesophageal peristalsis was still detectable but contractions had reduced amplitude and often had double and triple peaks; also in this subgroup the acid clearance time recorded in the supine position was prolonged. Conclusions: In systemic sclerosis gravity plays a major role in oesophageal acid clearance time. The finding of delayed acid clearance in a supine patient may suggest initial oesophageal involvement in the disease.

Nissen fundoplication after failure of endoluminal fundoplication: short-term results.

BackgroundEndoluminal fundoplcation (ELF) with EsophyX™ is a new attractive investigational procedure for the control of gastroesophageal reflux disease (GERD). The aim of this work is to evaluate the short-term results of Nissen fundoplication (NF) after failure of ELF.MethodDuring the period April 2007–January 2010, nine patients previously treated with ELF for GERD were submitted to laparoscopic NF for persistent reflux.ResultsAll patients were symptomatic for GERD, had a pathological esophageal acid exposure at multichannel intraluminal impedance (MII pH/24xa0h), and all of them were on proton pump inhibitor. Mean duration of the NF was 85xa0min (range, 56–104). There were no intraoperative complications. One patient had a postoperative mild peritoneal bleeding treated conservatively. After a mean follow-up of 24.9xa0months (4–34), all patients are asymptomatic for reflux. Two patients have a mild or moderate dysphagia at follow-up. Five patients underwent MII pH/24xa0h 1xa0year after surgery. Mean total reflux time was 0.3%, and acid reflux percent time was 0.ConclusionsPatients with persistent symptomatic reflux after a failing ELF can still undergo NF with good results; the endoluminal procedure does not seem to modify the results of the laparoscopic procedure, although an increased incidence of dysphagia pos-NF may be observed.