Werner K. H. Kauer

Mixed reflux of gastric and duodenal juices is more harmful to the esophagus than gastric juice alone. The need for surgical therapy re-emphasized.

Objective The authors goal was to determine the role of duodenal components in the development of complications of gastroesophageal reflux disease. Summary and Background Data There is a disturbing increase in the prevalence of complications, specifically the development of Barretts esophagus among patients with gastroesophageal reflux disease. Earlier studies using pH monitoring and aspiration techniques have shown that increased esophageal exposure to fluid with a pH above 7, that is, of potential duodenal origin, may be an important factor in this phenomenon. Methods The presence of duodenal content in the esophagus was studied in 53 patients with gastroesophageal reflux disease confirmed by 24‐hour pH monitoring. A portable spectrophotometer (Bilitec 2000, Synectics, Inc.) with a fiberoptic probe was used to measure intraluminal bilirubin as a marker for duodenal juice in the esophagus. Normal values for bilirubin monitoring were established for 25 healthy subjects. In a subgroup of 22 patients, a custom‐made program was used to correlate simultaneous pH and bilirubin absorbance readings. Results Fifty‐eight percent of patients were found to have increased esophageal exposure to gastric and duodenal juices. The degree of mucosal damage increased when duodenal juice was refluxed into the esophagus, in that patients with Barretts metaplasia (n = 27) had a significantly higher prevalence of abnormal esophageal bilirubin exposure than did those with erosive esophagitis (n = 10) or with no injury (n = 16). They also had a greater esophageal bilirubin exposure compared with patients without Barretts changes, with or without esophagitis. The correlation of pH and bilirubin monitoring showed that the majority (87%) of esophageal bilirubin exposure occurred when the pH of the esophagus was between 4 and 7. Conclusions Reflux of duodenal juice in gastroesophageal reflux disease is more common than pH studies alone would suggest. The combined reflux of gastric and duodenal juices causes severe esophageal mucosal damage. The vast majority of duodenal reflux occurs at a pH range of 4 to 7, at which bile acids, the major component of duodenal juice, are capable of damaging the esophageal mucosa.

Composition and concentration of bile acid reflux into the esophagus of patients with gastroesophageal reflux disease

BACKGROUND Reflux of duodenal contents into the esophagus of patients with gastroesophageal reflux disease has been suggested by pH and bilirubin monitoring but is rarely directly measured. A portable device has been developed and was used to collect and quantitate material refluxed into the esophagus under ambulatory conditions during a prolonged time period. The objective of this study was to use this device to quantitate the composition and concentration of bile acids refluxed into the esophagus of patients with gastroesophageal reflux disease. METHODS Esophageal aspiration was performed on 43 normal subjects and 37 patients with reflux disease during a 17-hour period. Aspiration was performed through a modified 16F Salem sump tube, positioned 5 cm above the lower esophageal sphincter and connected to a portable, battery powered pump that aspirated continuously at 100 mm Hg pressure. Validation studies showed that minimal amounts of saliva and swallowed liquids were aspirated and that gastric pressure was not altered. Postprandial, upright, and supine collections were performed. Total bile acids were assayed by a standard enzymatic assay; specific conjugated bile acids were analyzed by high-performance liquid chromatography. RESULTS There was no difference in the total aspiration volume between normal volunteers and patients with gastroesophageal reflux disease, although patients tended to have a higher volume in the supine and postprandial periods. Bile acids could be detected in 58% of normal subjects and 86% of patients (p < 0.003). The mean concentration of bile salt exposure (micromole per liter) was higher in patients during the postprandial and supine periods. The mean bile acid reflux rate (micromole per hour) during all three aspiration periods was significantly higher in patients. On a molar basis the composition of the bile acids was 60% glycocholic acid, 16% glycodeoxycholic acid, and 15% glycochenodeoxycholic acid. Taurocholic, taurodeoxycholic, taurochenodeoxycholic, and glycolithocholic acid constituted the remaining 10%. CONCLUSIONS Patients with reflux disease have an increased concentration of bile acids in their esophageal aspirates. Most of the exposure occurs during the postprandial and supine periods. A variety of bile acids were detected, most of which were in their glycine conjugated form.

A tailored approach to antireflux surgery.

Tailored surgical antireflux procedures were done in 104 patients during a 7-year period. Presenting symptoms included heartburn in 95 patients (91%), regurgitation in 83 patients (80%), and dysphagia in 61 patients (60%). Evaluation before operation included video barium esophagography, endoscopy, 24-hour esophageal pH monitoring, and esophageal motility studies. On the basis of anatomic and functional findings, the following procedures were performed: 15 laparoscopic and 49 open transabdominal Nissen fundoplications, 23 transthoracic Nissen fundoplications, seven Belsey partial fundoplications, and 10 Collis gastroplasty and Belsey partial fundoplications. The severity of symptoms was assessed before and after operation according to a previously published grading score. Eighty-five of the 104 patients (82%) were able to be contacted for a follow-up evaluation by means of a standardized questionnaire. Median length of follow-up was 4 years, with 40 patients having follow-up beyond 5 years. The tailored operation cured the symptoms of heartburn in 97%, regurgitation in 91%, and dysphagia in 92%. Ninety-eight percent of the patients reported that operation had cured their preoperative symptoms and 93% were satisfied with the outcome of the operation. To obtain optimal results, surgical treatment of gastroesophageal reflux disease should be tailored to the patients anatomic and functional assessments. For early, uncomplicated disease a transabdominal Nissen fundoplication is done, laparoscopically when expertise exists. Patients with complicated disease should undergo an open antireflux procedure tailored to specific anatomic or functional abnormalities.

Does duodenal juice reflux into the esophagus of patients with complicated GERD? Evaluation of a fiberoptic sensor for bilirubin.

BACKGROUND It is controversial whether duodenal juice can damage esophageal mucosa in patients with gastroesophageal reflux disease (GERD). The issue remains unresolved partly because of difficulties in detecting the presence of duodenal juice in the lower esophagus. OBJECTIVES AND METHODS This study utilized an in vitro portable spectrophotometer with a fiberoptic probe capable of detecting bile as a marker of duodenal juice. Absorbance/concentration curves were established with known bilirubin concentrations at pH 1.4 and pH 7.7. Esophageal pH and bilirubin absorbance were monitored in vivo over a 24-hour period in 20 healthy volunteers to determine the absorbance threshold for clinical use. The study population consisted of 21 patients with GERD. Four had no mucosal injury, 5 erosive esophagitis, and 12 Barretts esophagus. RESULTS The correlation between absorbance and bilirubin concentration was 0.98 and 0.99 for acid and alkaline environments, but bilirubin absorbance was 35% less in an acid environment. Using an absorbance threshold of 0.14, patients with GERD taken in toto had elevated esophageal exposure to bilirubin. No difference was observed in bilirubin exposure between reflux patients without mucosal injury and controls. Highest exposure occurred in patients with Barretts esophagus. An important observation was that esophageal bilirubin exposure frequently occurred during periods when the esophageal pH was in the normal range. CONCLUSIONS The fiberoptic probe accurately detects esophageal bilirubin as a marker of duodenal juice. Esophageal exposure to bilirubin is uncommon in normal subjects. Patients with erosive esophagitis and Barretts metaplasia have increased esophageal exposure to duodenal juice compared to normal subjects. Reflux of duodenal juice into the esophagus can occur when the esophageal pH is within its normal range and is undetectable by pH monitoring alone.

Alkaline gastroesophageal reflux: Assessment by ambulatory esophageal aspiration and pH monitoring☆☆☆

The pathophysiologic effect of duodenal contents in the refluxed gastric juice of patients with gastroesophageal reflux disease (GERD) is controversial. We evaluated the composition of the refluxed gastric juice in 43 normal volunteers and 52 patients with GERD using a newly developed device that allows ambulatory esophageal aspiration. The findings were correlated with the results of 24-hour esophageal pH monitoring and the presence of complications of GERD. Compared with bile concentrations in normal volunteers, the total bile acid concentration in the reflux aspirates was higher in patients with GERD (p < 0.01). There was a significant correlation between the bile acid concentration in the aspirates and the percentage of time the pH was above 7 on ambulatory 24-hour esophageal pH monitoring (r = 0.59, p = 0.006), and both were highest during the night (p < 0.01). The bile acid concentration and the percentage of time pH was greater than 7 were particularly increased in patients with strictures or Barretts esophagus (p < 0.01). Both an increased bile acid concentration in aspirates and the percentage of time with pH greater than 7 on pH monitoring were observed primarily in patients with a destroyed gastroduodenal barrier [status post Billroth II resection (BII), Billroth I resection (BI), or pyloroplasty] or after cholecystectomy. An increased bile acid concentration also occurred in a substantial number of patients without previous foregut surgery, although this did not usually result in an increase in the time that pH was above 7. These data suggest that contamination of the refluxed gastric juice with bile acids predisposes the patient to the development of strictures and Barretts esophagus. An increased time that pH is greater than 7 on esophageal pH monitoring indicates biliary reflux and occurs primarily after previous foregut surgery. A normal-time pH above 7 does, however, not exclude contamination of the refluxed gastric juice with duodenal contents.

Stent implantation as a treatment option in patients with thoracic anastomotic leaks after esophagectomy.

BackgroundIn patients with esophagectomy and gastric pull up for esophageal carcinoma anastomotic leaks are a well-known complication and a major cause of morbidity and mortality.ObjectiveWe evaluated stent implantation as a treatment option in patients with thoracic anastomotic leaks after esophagectomy.Methods269 patients with esophageal cancer (adenocarcinoma n = 212, squamous cell carcinoma n = 57) had undergone esophagectomy and gastric pull up with an intrathoracic anastomosis between January 1998 and December 2005. A thoracic anastomotic leak was clinically and endoscopically proven in 12 patients (4.5%). Endoscopic insertion of a self-expanding covered metal stent at the site of the anastomotic leak was performed in 10 patients; two patients were treated with fibrin glue.ResultsStents were successfully placed in all patients without complications. In all but one patient (n = 9) radiological examination showed complete closure of the leakage. In one patient the stent was endoscopically corrected and complete closure could be achieved thereafter. The stent could be removed after six weeks in five patients. Stent migration occurred in four patients. In all but one patient (n = 7) definitive leak occlusion was achieved. Two patients died during their hospital stayfor reasons not related to the stent placement.ConclusionStent implantation in patients with thoracic anastomotic leaks after esophagectomy is an easily available and effective treatment option with low morbidity, but stent migration does occur.

Esophageal replacement for end-stage benign esophageal disease.

The fact that esophageal resection and foregut reconstruction for benign disease can be performed with only a 2% mortality and minimal morbidity is encouraging news to patients who are crippled by the various manifestations of end-stage disease. The continuation of slow, anxious, and socially restricted alimentation or the maintenance of nutrition by enteral or parenteral means is unnecessary. The patient should be referred to a unit skilled in evaluating foregut function, performing esophageal replacement surgery, and caring for patients in the perioperative period. In our experience, the colon, when available, is the preferred conduit for esophageal replacement over the long term. Even though some subtle preoperative symptoms of foregut dysfunction may persist after surgery, the overall outcome is generally judged to be satisfactory. Indeed, patients can re-enter society and live a normal and fulfilled life after remedial surgery. Prolonged attempts at medical management of patients with severe derangements of esophageal structure and function are not warranted. Long-term esophageal replacement for severe end-stage benign disease can be accomplished with low mortality, a high degree of success, and a marked improvement in the quality of alimentation. Reconstruction restores the pleasure of eating and is viewed by the patient to be highly successful.

Emerging Concepts of Bile Reflux in the Constellation of Gastroesophageal Reflux Disease

RationaleReflux of gastric and duodenal contents in patients with gastroesophageal reflux disease (GERD) has been postulated as a major cause of complications, such as Barrett’s esophagus or malignant degeneration.FindingsWe present a summary of experimental, clinical, and immunohistochemical studies that show that acid and bile reflux are increased in patients who suffer from GERD, are the key factor in the pathogenesis of Barrett’s esophagus, and are possibly related to the development of esophageal adenocarcinoma.

4597 Interobserver variation in endosonographic cancer staging better results if endoscopy is included in the assessment.

Background and Aims : Whereas a multitude of literature exists on the accuracy of endoscopic ultrasonography (EUS) in cancer staging, data on reproducibility (interobserver variability, IOV) of this technique are sparse. We conducted a videotape evaluation of esophagogastric cancer cases who all had surgical confirmation. Methods : Well documented videotapes were selected of patients with esophageal and gastric cancer who underwent surgical resection between 1990-1996. After agreeing on EUS staging criteria by consensus on the basis of established and published criteria, 5 examiners independently looked at the full videotape sequences to diagnose the T and N category in 1997. Endoscopy videos were initially not made available. Thereafter, selected cases, where both endoscopy and EUS documentation were available, were again reviewed 1-2 years later (to avoid recognition of images) by 2 examiners (TR and HJD). Kappa values of >0.75 were regarded as excellent, 0.4-0.75 as fair/good and Results : Videotape sequences of 55 patients with esophageal and of 53 patients with gastric carcinoma were included in the IOV analysis. For T as well as for N staging, kappa values were poor in 50% of cases as outlined in the Table. In 62 selected cancer cases (esophageal cancer: n=30, gastric cancer: n=32), we compared the interobserver variability for the two main investigators only (HJD, TR): here, the kappa-value for T-staging of all categories T1-4 was 0.30 (poor), but increased to 0.48 (fair/good) when videotapes of endoscopic aspects were added in another analysis by HJD + TR. Conclusions : Reproducibility of EUS cancer staging results is rather poor, but can be significantly improved when endoscopy is added to the analysis. The factors influencing image analysis for scientific evaluation have to be studied further.