Valentino Felice

Reliability of 24-hour home esophageal ph monitoring in diagnosis of gastroesophageal reflux

Twenty-four-hour home esophageal pH monitoring is proposed in order to study gastroesophageal reflux (GER) so that prolonged use of costly hospital equipment and staff can be curtailed and the diagnostic accuracy of the examination improved. Eighty-six patients affected by GER symptoms and 20 healthy volunteers underwent 24-hr home esophageal pH monitoring, x-rays, and endoscopy of the upper gastrointestinal tract to investigate reliability of outpatient recording. Fifteen more patients consecutively underwent out- and inpatient recording to detect possible differences between these methods in the two daily periods. Outpatient monitoring was well tolerated in 94.7% of the patients; 14.3% of them markedly reduced their routine activities. The range of normality of outpatient recording does not differ from that of inpatients. In the 15 patients who consecutively underwent out-and inpatient monitoring, no significant differences were reported. The sensitivity of 24-hr home esophageal pH recording is 0.85, the specificity 1, the accuracy for negative prediction 0.68, and the accuracy for positive prediction 1. The reliability of 24-hr home esophageal pH monitoring is comparable to inpatient recording. It allows hospital cost reduction and is also better tolerated by patients but has not greatly improved the diagnostic accuracy of the gastroesophageal reflux pH monitoring.

Ambulatory 24-hr pH monitoring of esophagus, fundus, and antrum

A method for outpatient 24-hr simultaneous recording of pH in the distal esophagus, fundus, and antrum was developed in order to detect acid, alkaline, alkalacid gastroesophageal reflux, and duodenogastric reflux and to study these phenomena in patients complaining of gastroesophageal reflux and dyspepsia related symptoms. Two hundred ninety-four studies were performed in 42 healthy volunteers and 237 patients. Three-probe ambulatory 24-hr esophagogastric pH monitoring applicability, tolerability, and capability to determine a relationship between symptoms which occurred during the tests, gastroesophageal reflux, and duodenogastric reflux episodes were assessed. Eighty-nine percent of the three-probe esophagogastric pH studies were easily performed. The examination was tolerated well by 86.1% of the patients and poorly by 13.9%. A temporal correlation between symptoms and pH activities was recognized in 61.3% when the esophageal tracing was considered (acid gastroesophageal reflux recording) and in 95.6% when the three pH traces were simultaneously interpreted. Alkalacid gastroesophageal reflux and duodenogastric reflux total percentage times were significantly higher in patients complaining of dyspeptic symptoms than in patients only affected by typical gastroesophageal symptoms. Three-probe 24-hr ambulatory esophagogastric pH monitoring is a simple, well-tolerated test that should be routinely adopted for the study of patients complaining of unclear upper gastrointestinal tract symptomatology.

Onset timing of delayed complications and criteria of follow-up after operation for esophageal achalasia

BACKGROUND The purpose of this study was to define the length of follow-up necessary to obtain definitive results of the Heller myotomy for the therapy of esophageal achalasia and the modalities of long-term follow-up. Insufficient myotomy, periesophageal scarring, and gastroesophageal reflux esophagitis are the most common late complications of operation for achalasia. Columnar-lined esophagus with or without dysplasia and cancer can further complicate postoperative reflux esophagitis. Because progressive worsening of results with time has been reported, we assessed the timing of appearance of these complications. METHODS Since 1973, 129 patients submitted to Heller myotomy were clinically and objectively followed up. Mean follow-up was 97.4 months (range, 12 to 268 months). Of 129 patients, 42 were followed up for less than 5 years (17 voluntary drop outs, 10 reoperations, 3 deaths, 12 in follow-up), 47 more than 5 years, 26 more than 10 years, 12 more than 15 years, and 2 more than 20 years. The timing of onset of symptoms and complications related to the myotomy were evaluated as was the development of dysplasia and cancer. RESULTS In 11 patients, severe dysphagia due to insufficient myotomy reappeared a mean of 12.4 months after the operation (range, 3 to 30 months). In 7 patients with periesophageal scarring, dysphagia recurred a mean of 18.8 months (range, 6 to 28 months) after the operation. Postoperative reflux esophagitis appeared in 22 patients a mean of 76.5 months (range 21 to 168 months) after the operation. Columnar-lined esophagus was detected in 8 patients a mean of 143.1 months (range, 85 to 230 months) after the operation. Mild to moderate dysplasia was found in 5 of 8 patients with columnar-lined esophagus a mean of 191.6 months after the operation (range, 152 to 287 months), and intramucosal adenocarcinoma was found in 1 patient with columnar-lined esophagus after 8 years. CONCLUSIONS Dysphagia secondary to insufficient myotomy and periesophageal scarring recurs early, not later than 3 years. Conversely, abnormal gastroesophageal reflux with related complications can appear more than 10 years postoperatively. Five years after the operation the follow-up should be primarily endoscopic and histologic. Results should withstand a follow-up of at least 10 years.

Clinical and surgical relevance of the progressive phases of intrathoracic migration of the gastroesophageal junction in gastroesophageal reflux disease

OBJECTIVE The pathophysiologic influence of progressive intrathoracic migration of the gastroesophageal junction axial to the esophagus on gastroesophageal reflux disease was investigated. METHODS A radiologic-manometric study was performed on hiatal insufficiency, concentric hiatus hernia, and short esophagus, the three radiologic steps of intrathoracic gastroesophageal junction migration, and on healthy volunteers. The distances between inferior and superior margins of the lower esophageal sphincter and the diaphragm were measured. Endoscopic, manometric, and pH-metric evaluations were performed after barium swallow in 38 patients with severe gastroesophageal reflux disease and sliding hiatus hernia with intraabdominally reducible gastroesophageal junction, in 35 patients with hiatal insufficiency, in 40 with concentric hiatus hernia, and in 19 with short esophagus. RESULTS The distance from the lower esophageal sphincter inferior margin to the diaphragm was different in healthy volunteers (-2.6 +/- 0.9 cm [standard deviation]) versus that in patients with hiatal insufficiency (-1.0 +/- 0.7 cm; p = 0.02), concentric hiatus hernia (-0.8 +/- 1.0 cm; p = 0.02), and short esophagus (4.0 +/- 2.5 cm; p = 0.0002), and in patients with short esophagus versus hiatal insufficiency (p = 0.0002) and concentric hiatus hernia (p = 0.0002). Lower esophageal sphincter tone was reduced between healthy volunteers (19 +/- 9.1 mm Hg [standard deviation]) and patients with sliding hiatus hernia (12 +/- 7.2 mm Hg;p = 0.02), hiatal insufficiency (10 +/- 5.9 mm Hg; p = 0.0001), concentric hiatus hernia (7 +/- 3.1 mm Hg; p = 0.00002), and short esophagus (7 +/- 3.7 mm Hg; p = 0.00003) and between concentric hiatus hernia versus sliding hiatus hernia (p = 0.007). Acid gastroesophageal reflux total time percent was increased between healthy volunteers (2.4% +/- 1.8% [standard deviation]) and patients with sliding hiatus hernia (12.8% +/- 7.8%;p = 0.02), hiatal insufficiency (17.2% +/- 15.8%; p = 0.0001), concentric hiatus hernia (24.0% +/- 19.6%;p = 0.00002), and short esophagus (26.1% +/- 19.6%;p = 0.00002) and between sliding hiatus hernia versus concentric hiatus hernia (p = 0.002) and short esophagus (p = 0.01). CONCLUSIONS Permanent gastroesophageal junction orad migration axial to the esophagus has greater pathophysiologic relevance on gastroesophageal reflux disease than sliding hiatus hernia with an intraabdominally reducible gastroesophgeal junction. Hiatal insufficiency, concentric hiatus hernia, and short esophagus are markers of progressively increasing irreversible cardial incontinence and therefore indications for surgical therapy.

Indications for 24-hour gastric pH monitoring with single and multiple probes in clinical research and practice

The methodology of prolonged gastric pH monitoring has not yet been standardized with regard to the number and position of pH probes. Twenty-seven healthy volunteers and 11 patients affected by nonulcer dyspepsia have been submitted to 24-hr ambulatory simultaneous pH monitoring of the distal esophagus, fundus, and antrum. Fundic and antral pH profiles have been compared and causes of pH variations (pH>4) identified. Both in healthy volunteers and dyspeptic patients, percentile curves of fundic and antral pH were statistically different in more than one of the daily periods considered (24-hr, postprandial, interdigestive, nocturnal). Percent time of duodenogastric reflux is significantly higher in the antrum than in the fundus in both groups. Modalities of gastric alkalinization secondary to food or duodenogastric reflux were different for the fundus and for the antrum both in healthy and dyspeptic subjects and between the two groups. These differences suggest that single and multiple pH monitoring of the stomach have different indications, and the position of the probes should vary according to the purpose of the test.

Gastroesophageal and Duodenogastric Reflux: Simultaneous Twenty-Four-Hour Home Recording with a Three-Probe System (3EGpH)

In our experience two-probe 24-h home esophagogastric pH-monitoring has shown to be very effective in identifying acid and non-acid gastroesophageal reflux (GER): almost 50% of patients resulted in being affected by abnormal non-acid reflux (particularly the “alkalacid” GER 4>pH<7 resulting from the mixing of gastric and duodenal contents) [1]. Moreover, gastric fundus percentage total reflux time with pH≧4 was higher in GER patients than in controls [1].

Results of Surgical Therapy of Achalasia with Three Different Techniques

From 1955 to date our group has adopted three different surgical techniques for the therapy of achalasia [1]. Until 1972 a long transabdominal esophagogastric myotomy (group AM) was performed in 72 patients. In 13 patients an antireflux procedure according to Lortat Jacob was also associated. A complete follow-up of these patients in 1972 showed that postoperative reflux was present in 41.1 %; the Lortat Jacob procedure had not reduced reflux. The second cause of failure in this group was periesophageal scarring (7.1 %). In order to avoid reflux and its serious complications, in 1973 we started to perform a transthoracic myotomy, limiting the incision on the stomach to only 1/2 cm [2]. However, our results were not satisfactory since the recurrence for insufficient myotomy was 20.8%. For these reasons, in 1979 we adopted a new technique, which consists of a long transabdominal esophagogastric myotomy with the addition of an anterior hemifun-duplication according to Dor [1]. In June 1986 a complete follow-up of the patients operated on from 1955 to June 1985 was completed to evaluate the results achieved with the three surgical techniques.

Twenty-Four-Hour Home Esophageal pH Monitoring (EpH) in the Diagnosis of Gastroesophageal Reflux: Is It Worthwhile?

Long-term home esophageal pH monitoring was utilized with the objective of avoiding drawn-out use of staff and costly hospital equipment and to better the effectiveness of diagnostic methodology. After having carried out long-term esophageal home pH monitoring in 90 patients presumably afflicted with gastroesophageal reflux (GER), we tried to assess the test reliability and sensitivity and to verify whether it is clinically trustworthy and useful in the physiopathological research of GER.