Distal Esophageal Segment Research Articles

Experience in the treatment of long-gap esophageal atresia by intraluminal esophageal stretching elongation.

To summarize the experience with intraluminal esophageal stretching elongation (ILESE) in the successful treatment of long-gap esophageal atresia (LGEA) at a single center. Clinical data of 68 neonates who underwent LGEA between February 2015 and January 2022 were retrospectively analyzed. Four patients died of multiple associated severe malformations and did not undergo ILESE. Esophageal anastomosis was successfully performed in 60 cases (93.75%) and failed in 4 cases (6.25%) treated with ILESE. The ILESE techniques, esophageal reconstruction, results, postoperative complications, and follow-up treatment were analyzed. The beginning time of performing ILESE preoperation was 53.4 ± 39.4 days after birth, and the age of esophageal reconstruction was 122.2 ± 70.3 days after birth in 60 cases. The gap length of proximal and distal esophageal segments which were evaluated the first time at admission was 4.8 ± 1.3 vertebral bodies, whereas the gap before anastomosis was -0.46 ± 0.90 vertebral bodies. Among the patients with esophageal primary-anastomosis, 55 received thoracoscopic surgery, and 5 underwent thoracotomy in the early stage. Of the 60 children with ILESE, 58 underwent end-to-end esophagostomy, of which 17 cases were combined with circular esophagotomy (livaditis), and 2 cases of esophageal lengthening were combined with the reversal of the ligulate loop of the proximal esophagus (flap). Overall, 59 cases were cured (98.3%), and 1 patient died of respiratory failure postoperatively. All patients were followed up for 7-96 months. Postoperative anastomotic leakage occurred in 16 patients (27.6%), all of whom were successfully treated conservatively. Anastomotic stenosis occurred in 49 cases (83.1%), all of which were successfully managed by non-surgical treatment, including 12.7 ± 9.3 times of esophageal balloon dilatation and 2 cases of stent dilatation. Gastroesophageal reflux occurred in 44 patients (74.6%), including associated or acquired esophageal hiatal hernia in 22 patients, and Nissen fundoplication was performed in 17 patients. ILESE is an effective method for prolonging the proximal and distal esophagus of the LGEA to reconstruct esophageal continuity using its esophageal tissue, with an efficacy rate of 93.75%. Postoperative anastomotic stricture and gastroesophageal reflux are common and require long-term, standardized follow-up and treatment.

The History and Legacy of the Foker Process for the Treatment of Long Gap Esophageal Atresia

Historically, children afflicted with long gap esophageal atresia (LGEA) had few options, either esophageal replacement or a life of gastrostomy feeds. In 1997, John Foker from Minnesota revolutionized the treatment of LGEA. His new procedure focused on “traction-induced growth” when the proximal and distal esophageal segments were too far apart for primary repair. Foker's approach involved placement of pledgeted sutures on both esophageal pouches connected to an externalized traction system which could be serially tightened, allowing for tension-induced esophageal growth and a delayed primary repair.Despite its potential, the Foker process was received with criticism and disbelief, and to this day, controversy remains regarding its mechanism of action - esophageal growth versus stretch. Nonetheless, early adopters such as Rusty Jennings of Boston embraced Foker's central principle that “one's own esophagus is best” and was instrumental to the implementation and rise in popularity of the Foker process. The downstream effects of this emphasis on esophageal preservation would uncover the need for a focused yet multidisciplinary approach to the many challenges that EA children face beyond “just the esophagus”, leading to the first Esophageal and Airway Treatment Center for children. Consequently, the development of new techniques for the multidimensional care of the LGEA child evolved such as the posterior tracheopexy for associated tracheomalacia, the supercharged jejunal interposition, as well as minimally invasive internalized esophageal traction systems. We recognize the work of Foker and Jennings as key catalysts of an era of esophageal preservation and multidisciplinary care of children with EA.

Effects of Microbeam Irradiation on Rodent Esophageal Smooth Muscle Contraction.

High-dose-rate radiotherapy has shown promising results with respect to normal tissue preservation. We developed an ex vivo model to study the physiological effects of experimental radiotherapy in the rodent esophageal smooth muscle. We assessed the physiological parameters of the esophageal function in ex vivo preparations of the proximal, middle, and distal segments in the organ bath. High-dose-rate synchrotron irradiation was conducted using both the microbeam irradiation (MBI) technique with peak doses greater than 200 Gy and broadbeam irradiation (BBI) with doses ranging between 3.5-4 Gy. Neither MBI nor BBI affected the function of the contractile apparatus. While peak latency and maximal force change were not affected in the BBI group, and no changes were seen in the proximal esophagus segments after MBI, a significant increase in peak latency and a decrease in maximal force change was observed in the middle and distal esophageal segments. No severe changes in physiological parameters of esophageal contraction were determined after high-dose-rate radiotherapy in our model, but our results indicate a delayed esophageal function. From the clinical perspective, the observed increase in peak latency and decreased maximal force change may indicate delayed esophageal transit.

Suture approximation of esophageal atresia leads to esophageal recanalization

Esophageal atresia is a congenital pathology in 1:4000 live newborns, which can occur isolated, associated with tracheoesophageal fistula or long gap (>2 vertebral bodies); the surgical objective is the ligation of the fistula and the esophageal anastomosis in the same surgery. However, this may not be possible in all cases [1]. The staged approach initially begins with the ligation of the tracheoesophageal fistula and gastrostomy, and definitive surgery focuses on the esophageal anastomosis. It is performed when the patient presents adequate clinical and anatomical conditions. Spontaneous recanalization of esophageal atresia is rare. The exact mechanism by which it occurs is unknown. Gastric reflux, being in contact with the esophageal distal end, generates inflammation and erosion of the wall, producing communication between the esophageal segments. We propose approximating the proximal and distal esophageal segments utilizing sutures produces an inflammatory process due to a foreign body generating a fistulous tract between the two esophageal components and esophageal recanalization [2]. We present two cases of esophageal recanalization to describe the clinical presentation, diagnostic and therapeutic approaches through imaging tests and endoscopy, contributing to the management of this unusual condition. • Esophageal atresia is a challenge; it presents variations in the location of the tracheoesophageal fistula and the length of the esophageal ends. It occurs isolated or associated with malformations. The pediatric surgeon must individualize treatment for each patient. • In all cases, extreme premature patients have hemodynamic alterations and fragile esophageal tissue, which do not allow performing a primary esophageal anastomosis. • Upper gastrointestinal endoscopy is a diagnostic and therapeutic resource in patients with spontaneous esophageal recanalization or the presence of a recurrent tracheoesophageal fistula.

A Comparative Study between Nissen's Fundoplication with or without Endoscopic Mucosal Resection in the Treatment of Barrett’s Oesophagus: a Meta-Analysis

Abstract Background It is already known that Barrett’s esophagus (BE) is a premalignant condition in which the normal squamous epithelium of the distal esophagus is replaced by columnar epithelium (intestinal metaplasia or gastric metaplasia) due to GERD. Most observers believe that there is a progression from intestinal metaplasia to low-grade dysplasia (LGD) to highgrade dysplasia (HGD) to cancer. The relative risk of developing esophageal adenocarcinoma in patients with BE appears to be 30-fold higher. Conventional therapies include medical treatment (profound acid inhibition), endoscopic treatment (like endoscopic mucosal resection) and surgical treatment (fundoplication). Methodology Types of studies: Published studies about the efficacy of Nissen’s Fundoplication with or without Endoscopic Mucosal Resection in the treatment of Barrett’s Oesophagus (carried out in the period between 2015 – 2020), types of participants Patients with clinically proven Barrett’s Oesophagus diagnosed by endoscopy and biopsy, types of interventions Nissen’s Fundoplication (Open or Laparoscopic) with or without Endoscopic Mucosal Resection, types of outcome measures Outcome of treatment in the form of Complete Remission of Columnar Metaplasia of the oesophageal mucosa or regression in recurrence rate as proved by follow-up endoscopy. Results The strategy of endoscopic therapy for Barrett’s metaplasia, dysplasia and/or intramucosal cancer along with fundoplication results in similar durability and recurrence rates when compared to patients being managed with PPIs following endoscopic therapy. However, fundoplication along with endoscopic therapy is superior to either of them alone in preventing further progression of disease and the development of cancer, particularly in refractory patients. Fundoplication is an important strategy along with endoscopic therapy for Barrett’s to achieve and maintain CR-IM, and to facilitate the eradication of persistent dysplasia. Conclusion Endoscopic mucosal resection after Nissen's Fundoplication is a safe modality, with high rate of success in complete eradication of BE in symptomatic GERD patients, especially those with severe anatomical impairment in distal esophageal segment. As a concurrent procedure, endoscopic procedures may be beneficial in the terms of reducing the early recurrence rates, which seems to be important issue during the management of BE. By doing synchronous endoscopic procedures and fundoplication, one might observe a true anatomy of esophagogastric junction in its entirety and might be able to truly observe the distal extent of columnar esophagus.

Meta-Analysis for Comparison between Antireflux Surgery With or Without Endoscopic Management of Barrett's Esophagus

Abstract Background: In patients with BE, anti-reflux surgery aims to sustainable control reflux symptoms and heal reflux induced esophageal mucosal inflammation and prevent progression of BE to adenocarcinoma. Endoscopic resection of visible lesions if any, followed by ablation of the rest of the BE epithelium is the current standard of care for management of BE with confirmed dysplasia. Although the current literature describes multiple endoscopic and anti-reflux techniques for the management of BE, there is no published evidence on the efficacy of anti-reflux surgery followed by endoscopic man-agement on the outcomes of BE. Aim of Study: The objective of this study was to compare between anti-reflux surgery with or without endoscopic man-agement of BE. Patients and Methods: In the present study, we searched Medline via PubMed, SCOPUS, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar. The search retrieved 2089 unique records. We then retained 57 potentially eligible records for full-texts screening. Finally, 6 studies were included. Results: In the present systematic review and meta-analysis, five studies reported the rates of recurrence. The overall effect estimates showed the rate of recurrence was 5.7% (95% CI 1.2-10.2%). In the present systematic review and meta-analysis, five studies reported the overall complica-tions rate. The overall effect estimates showed the overall complications rate was 7.3% (95% CI 4.1-10.6%), mainly stricture and perforation. Conclusion: Endoscopic procedures after anti-reflux surgery is a safe modality, with high rate of success in complete eradication of BE in symptomatic GERD patients, especially those with severe anatomical impairment in distal esophageal segment. As a concurrent procedure, endoscopic procedures may be beneficial in the terms of reducing the early recurrence rates, which seems to be important issue during the manage-ment of BE. By doing synchronous endoscopic procedures and fundoplication, one might observe a true anatomy of esophagogastric junction in its entirety and might be able to truly observe the distal extent of columnar esophagus.

Esophageal Compliance Quantifies Epithelial Remodeling in Pediatric Patients With Eosinophilic Esophagitis.

The management of eosinophilic esophagitis (EoE) relies on the severity of esophageal eosinophilia, yet there is poor evidence of its prediction of esophageal fibrotic remodeling and subsequent complications such as dysphagia, food impactions, or strictures. Functional luminal imaging planimetry (FLIP) has had limited use in pediatric patients to evaluate esophageal tissue mechanics. We aimed to standardize the FLIP technique and to measure esophageal compliance in children with EoE in comparison to controls. Subjects were enrolled into a prospective observational study and had FLIP performed at the time of endoscopy. We calculated esophageal distensibility and compliance for the total and segmental esophagus independently (ie, proximal, middle, and distal esophageal segments). We evaluated esophageal biopsies for eosinophilia and epithelial remodeling, calculated endoscopy scores, and documented patient symptoms. We enrolled 11 EoE and 12 controls subjects, aged 5 to 18 years old. While EoE subjects had lower esophageal compliance (P = 0.004) than controls, the difference in distensibility did not reach significance (P = 0.151). Epithelial remodeling severity was more strongly correlated with compliance than with distensibility. Epithelial remodeling scores ≥2 had a significant association with lower compliance both segmentally and in the entire esophagus (P = 0.029), but not with distensibility. Compliance measures were more sensitive in detecting subjects with remodeling score ≥2 than distensibility (79% vs 64%). Compliance is a more sensitive measure of esophageal epithelial remodeling in children compared to distensibility, and a more appropriate measure of esophageal tissue mechanics. Standardized placement of the FLIP catheter is important to accurately assess esophageal compliance.

Value of Multidetector Computed Tomography in the Assessment of Achalasia Subtypes and Detection of Pulmonary and Thoracic Complications

Objective: To evaluate multidetector computed tomography (MDCT) findings in patients with achalasia, to assess its role in differentiating subtypes in detecting lung involvement and extra-esophageal thoracic complications. Subjects and Methods: This clinical retrospective study included 51 patients with manometrically confirmed achalasia who underwent chest X-ray and MDCT in diagnostic work-up. Esophageal wall thickness and morphology, luminal dilatation, lung changes, and extra-esophageal manifestations were analyzed on MDCT by 2 readers. Wilcoxon, Kruskal-Wallis and Mann-Whitney test were used for assessing the differences among the achalasia subtypes, and intra-class correlation coefficients (ICC) assessing the inter-observer agreement between the measurements of 2 readers. Results: Fourteen (27.5%) patients had achalasia subtype I, 21 (60.8%) had subtype II while 6 (11.8%) had subtype III. Esophageal wall thickness of the esophageal body (EB) and distal esophageal segment (DES) as well as nodular/lobulated appearance of DES were found significantly more often in subtype III (p = 0.024, p < 0.001, p = 0.009, respectively). Esophageal dilatation gradually decreased from subtype I to III (p = 0.006). Chest X-ray revealed lung changes in 9 (17%) and MDCT in 21 (41%) patients (p = 0.001), most frequently in subtype I, with predominance of ground-glass opacities. Tracheal/carinal compression was detected in 27 (52.9%) and left atrial compression in 17 (33.3%) patients. Excellent inter-observer agreement was observed in measuring the EB and DES wall thickness, and diameter of EB (ICC 0.829, 0.901, and 0.922). Conclusion: MDCT is a useful tool for detecting lung and extra-esophageal thoracic complications in patients with achalasia, and could be a valuable additional imaging modality in the differentiation of achalasia subtypes.

Concurrent radiofrequency ablation and Nissen fundoplication

Endoscopic radiofrequency ablation (RFA) today represents a well-established, safe and effective procedure for the treatment of Barrett’s esophagus (BE). Choice of additional treatment to RFA emerges as an important clinical issue, due to the fact that recurrence of BE after complete eradication (CE) of intestinal metaplasia (IM) or dysplasia may occur. Concerning the data available so far, recurrence may occur due to insufficient reflux control with standard PPI’s regimen, while those with large hiatal hernia and long segment BE represent the subgroup of patients at highest risk for recurrence. Due to the anatomical deviation in distal esophageal segment proper ablation may be difficult in such patients. These patients can be treated by employing concurrent ARS and RFA. Concurrent ARS and RFA was proven to be safe, not time consuming, and it can be performed in conjunction with the basic rules of RFA procedure. Early results, in term of enhanced healing of treated epithelium, and possible reduction in number of ablation sessions needed to achieve CE of IM or dysplasia, are promising. To conclude, antireflux surgery may have important role in some patients undergoing RFA, especially those with significant hiatal hernia and anatomical impairment in distal esophageal segment.

Effects of Metoclopramide on Esophageal Motor Activity and Esophagogastric Junction Compliance in Healthy Volunteers.

Background/AimsProkinetic drugs such as metoclopramide are frequently used as second-line therapy for patients with gastroesophageal reflux disease. However, their beneficial effects remain unclear. Esophageal motor activities and compliance of the esophagogastric junction (EGJ) are important for prevention of gastroesophageal reflux. Although metoclopramide has been reported to increase lower esophageal sphincter (LES) pressure, its effects on EGJ compliance have not been evaluated. In the present study, we investigated the effects of metoclopramide on esophageal motor activities and EGJ compliance.MethodsNine healthy male volunteers without abdominal symptoms were enrolled. Peristaltic esophageal contractions and LES pressure were examined using high-resolution esophageal manometry, while EGJ compliance was evaluated with an endoluminal functional lumen-imaging probe. After obtaining baseline values for esophageal motor activities and EGJ compliance, metoclopramide (10 mg) was intravenously administered, then all measurements were repeated at 15 minutes after administration in each subject.ResultsFollowing administration of metoclopramide, mean resting LES pressure was significantly increased as compared with the baseline (13.7 ± 9.2 vs 26.7 ± 8.8 mmHg, P < 0.05). In addition, metoclopramide significantly augmented peristaltic contractions, especially in the distal esophageal segment (P < 0.05). On the other hand, distensibility index did not change after administration (4.5 ± 0.5 vs 4.1 ± 0.5 mm2/mmHg), suggesting no significant effect of metoclopramide on EGJ compliance.ConclusionsMetoclopramide augmented esophageal contractions without changing EGJ compliance in healthy adults.

Primary versus secondary achalasia: New signs on barium esophagogram.

Aim:To investigate new signs on barium swallow that can differentiate primary from secondary achalasia.Materials and Methods:Records of 30 patients with primary achalasia and 17 patients with secondary achalasia were reviewed. Clinical, endoscopic, and manometric data was recorded. Barium esophagograms were evaluated for peristalsis and morphology of distal esophageal segment (length, symmetry, nodularity, shouldering, filling defects, and “tram-track sign”).Results:Mean age at presentation was 39 years in primary achalasia and 49 years in secondary achalasia. The mean duration of symptoms was 3.5 years in primary achalasia and 3 months in secondary achalasia. False-negative endoscopic results were noted in the first instance in five patients. In the secondary achalasia group, five patients had distal esophageal segment morphology indistinguishable from that of primary achalasia. None of the patients with primary achalasia and 35% patients with secondary achalasia had a length of the distal segment approaching combined height of two vertebral bodies. None of the patients with secondary achalasia and 34% patients with primary achalasia had maximum caliber of esophagus approaching combined height of two vertebral bodies. Tertiary contractions were noted in 90% patients with primary achalasia and 24% patients with secondary achalasia. Tram-track sign was found in 55% patients with primary achalasia. Filling defects in the distal esophageal segment were noted in 94% patients with secondary achalasia.Conclusion:Length of distal esophageal segment, tertiary contractions, tram-track sign, and filling defects in distal esophageal segment are useful esophagographic features distinguishing primary from secondary achalasia.

Foker Technique for the Management of Pure Esophageal Atresia: Long-Term Outcomes at a Single Institution.

We present the short- and long-term outcomes in the management of pure long-gap esophageal atresia (LGEA) using the Foker technique (FT) of esophageal elongation by external axial traction at a single institution. All patients undergoing esophageal atresia (EA) repair with FT over a 10-year period were included in the study. Demographic data, birth weight, gestational age, associated anomalies, management, and short- and long-term outcomes were studied. Five patients (three males) were treated with FT in the study period, all with LGEA, with a mean birth weight of 1,926 g (range, 541-2,890 g). Four infants had associated anomalies. Primary repair after FT axial traction was achieved in four patients after a mean traction time of 13 days (range, 12-15 days). FT failed in one patient who had esophageal perforation from traumatic orogastric tube placement at birth and extensive matting of the esophagus at the time of FT attempt. The mean age at definitive esophageal anastomosis was 11.5 weeks (range, 8-14 weeks). In three of the five patients, traction sutures from the distal esophageal segment tore away, requiring a thoracotomy for replacement. One of the four patients had a confined leak at the anastomosis. All four patients developed strictures at the anastomosis, requiring serial dilations (mean 12 dilations, range 6-21 dilations), and three of those patients underwent a thoracotomy for stricture resection (two patients) or stricturoplasty (one patient). On long-term follow-up, all patients in whom a primary anastomosis was achieved had their gastrostomy closed and were on full oral feeds. FT was successful in achieving a primary anastomosis in 80% of the patients with LGEA, with a significant morbidity but favorable long-term outcomes.

A novel method of esophageal lengthening in a large animal model of long gap esophageal atresia

PurposeLong gap esophageal atresia remains a significant treatment challenge. We aimed to create the first large animal model of long gap esophageal atresia to test a degradable esophageal lengthening device. MethodsThe distal esophagus was divided 2cm above the gastroesophageal junction in 6 minipigs. A polycaprolactone (PCL) spring device was secured inside the distal esophageal segment, and the end was oversewn. Nonexpanding PCL tubes served as controls. An esophagogastric anastomosis was created to restore continuity. After 4weeks, the distal esophageal pouch was analyzed. ResultsThe distal esophageal pouch of experimental animals increased in length from 1.9 to 4.5cm. Control animals demonstrated no change. When comparing lengthened to native esophagus, there was no difference in the thickness of muscularis mucosa or muscularis propria. Mechanically lengthened esophagus showed mild to moderate superficial inflammation and fibrosis. There were no differences in the number of myenteric or submucosal ganglia. ConclusionWe created the first porcine model of long gap esophageal atresia and lengthened the distal esophagus with an internally placed device. This model may be used to explore novel therapies in the management of long gap esophageal atresia.

The effects of acute tension increase on rat esophageal muscle contractions: An in vitro study

In long-gap esophageal atresia surgeries, anastomoses can be tensioned by several traction methods in order to establish esophageal continuity. It is unclear whether the etiology of esophageal dysmotility after traction is related with esophageal atresia itself or tensioned esophagus. Therefore, we evaluated the effects of acute in vitro esophageal tension application on esophageal muscle contractility in rats. 26 Wistar rats weighing 250–300g were included to the study. After diethyl ether anesthesia, proximal segment (PS) and distal segment (DS) of esophagus were removed and suspended in an isolated organ bath kept at 37°C, Krebs–Henseleit solution. Rats were enrolled into four groups including control group (CG, n=14) without tension, 5g (5G, n=4), 15g (15G, n=4) and 25g (25G, n=4) tension groups. In all groups, contractile responses to electrical field stimulation (EFS), carbachol and KCl, and relaxation responses to serotonin were obtained. In CG, higher contractile responses were obtained in PS than DS after EFS. Both PS and DS showed higher contractile amplitudes in 5G with respect to that of CG, 15G and 25G (p<0.05). In 5G, contractile responses to carbachol were significantly increased in both PS and DS with respect to CG (p<0.05). However, contractile amplitudes in response to carbachol were decreased in PS when tension was increased to 15g and 25g. In DS, contractile responses in 15G and 25G were lower than 5G, and still higher than CG. Serotonin relaxation responses in PS were decreased when compared to CG at tension levels of 5g, 15g and 25g (p<0.05). In DS, responses to serotonin were also decreased in tension groups. PS had higher contraction amplitudes than DS when contractile responses were obtained by high K+ (p<0.05). Tension groups of both PS and DS showed increased contractions to high K+ compared to CG (p<0.05). Increased esophageal tension led to increase in cholinergic responses of smooth muscles as well as in EFS-induced skeletal muscle responses. On the other hand, relaxation responses induced by serotonin decreased. These data indicate that esophageal tension increase impairs esophageal motility in both segments.

Treatment and Follow-Up of Patients with Long-Gap Esophageal Atresia: 15 Years' of Experience from the Western Region of Sweden.

This retrospective study aims to report treatment results in patients with long-gap esophageal atresia (LGEA), gross A + B type, and discuss the value of different clinical findings and physiological tests in the follow-up. This retrospective observational study comprises all patients with LGEA admitted to our department between 1995 and 2010. A total of 16 patients were included. Their mean gestational age was 35(+2) weeks and their mean birth weight was 1,945 g (-2.5 standard deviation scores). No catch-up growth in height could be seen and they remained smaller than the average population during the study period. Gastrostomy was performed as the first surgical procedure. Overall, 11 of the 16 patients had a delayed primary anastomosis. Elongation of the distal esophageal segment was required in 3 of the 16 patients and a colonic interposition in 2 of the 16 patients. The median age at definitive surgery was 150 days. All the patients had gastroesophageal reflux after their definitive surgery. Three of the 16 patients required surgery due to aspiration and all 3 had a pathological lung clearance index (LCI) at multiple-breath washout (MBW). At the age of 1 or 7 years, the LCI was pathological in 4 of the 14 patients, and spirometry showed an obstruction in 9 of the 14 patients. LGEA is a severe congenital malformation, with severe morbidity. No mortality was seen. MBW could be a useful tool for the early detection of progressive pulmonary damage.

Selective inhibition of nitric oxide synthase causes increased muscle thickness in rat esophagus

AimAchalasia is a primary motor dysfunction of esophagus which can be created experimentally by nitric oxide synthase (NOS) inhibition. Although several theories have been suggested, mechanism of increased esophageal muscle thickness in achalasia is still unclear. An experimental study was performed to evaluate the esophageal muscle thickness after selective inhibition of NOS in rats. Materials and methodsWistar albino rats (n=18) weighing 150–200g of both sexes were included in the study. After anesthetization with ketamine hydrochloride, esophageal body and distal esophagus were sampled in control group (CG, n=6). In sham group (SG, n=6), intraperitoneal saline (1ml) injection was performed for 21days. l-NAME (l-nitroarginin metyl ester, selective inhibitor of NOS) group (LNAMEG, n=6) received 100mg/kg/d l-NAME intraperitoneally for 21days. The esophageal body and distal esophagus were removed for histopathological analysis in each group. All samples were evaluated for total and circular muscle thickness with hemotoxylene–eosine (HE) staining. ResultsNone of the samples showed pathologic finding in esophageal mucosa. There was no difference between CG and SG for total and circular muscle thickness in esophageal body and distal esophagus. LNAMEG had higher median levels of both total and circular muscle thickness than CG and SG in esophageal body (P<0.05). However, in distal esophageal segments, only total muscle thickness was statistically higher in LNAMEG than CG and SG (P<0.05). ConclusionSelective inhibition of NOS causes increased total smooth muscle thickness in esophageal body and distal esophagus. However, this effect could not detected in circular muscle in the distal esophagus. We suggest that NOS inhbition not only increases esophageal peristalsis but also causes muscle hypertrophy in esophagus.

Modified Scharli technique for the very long gap esophageal atresia

This modification of the Scharli technique which creates an isoperistaltic tube to overcome very long gap esophageal atresia involves retention of the short distal esophageal segment and creation of a neo-esophagus of tubularized gastric fundus of even calibre, similar to that of the upper esophageal segment. It has proved simple and effective in establishing esophageal continuity.

Effects of mosapride on esophageal motor activity and esophagogastric junction compliance in healthy volunteers

The effects of the prokinetic drug mosapride on esophageal motor activity vary at standard doses. In addition to esophageal motor activities, compliance of the esophagogastric junction (EGJ) is important for prevention of gastroesophageal reflux. However, the effects of mosapride on EGJ compliance have not been reported. Here, we investigated the effects of high-dose mosapride on esophageal motor activities and EGJ compliance. Nine healthy volunteers were enrolled in the study. Peristaltic esophageal contraction and lower esophageal sphincter pressures before and after administration of 40 mg mosapride were examined by high resolution esophageal manometry. Esophageal compliance was also investigated by intra-esophageal impedance planimetry (EndoFLIP(®)). High-dose mosapride augmented peristaltic contractions, especially in the distal esophageal segments (P < 0.05). The mean resting lower esophageal sphincter pressure was elevated from 25.0 mmHg before administration to 28.9 mmHg after (P < 0.05). In addition, mosapride significantly reduced EGJ compliance (P < 0.05). Mosapride at 40 mg augmented esophageal motor activities and reduced EGJ compliance in healthy volunteers.

Tu1788 Comparison of Post-Operative Physiology Parameters Between Asymptomatic and Symptomatic Patients After Anti-Reflux Surgery

Background: A TLESR is a major mechanism of acid reflux in healthy subjects and patients with reflux esophagitis and we have noticed that the amplitude of primary peristalsis and EGJ pressure, following a TLESR, is accompanied by a forceful contraction, when compared with before a TLESR. The aim of this study is to investigate whether or not primary peristalsis and EGJ pressure, when accompanied by a forceful contraction and following a TLESR, is a characteristic finding of a TLESR. Methods: 10 healthy subjects underwent esophageal high-resolution manometry with a 21-lumen perfused assembly, which monitored pressure in the pharynx, the upper esophageal sphincter, the esophageal body, LES and the proximal stomach. The EGJ was evaluated using ten side holes, spaced at 1-cm intervals. Recordings were then taken, in the sitting position, for 1 hour after a meal (692 kcal, 33 % fat). A TLESR is defined as previously described. Data were analyzed, using Trace! Software (Dr. G.S Hebbard, The Royal Melbourne Hospital, Australia). The contractile integral (CI) of the distal esophageal segment (D-CI: volume of the domain above 20 mmHg), excluding the EGJ segment, was measured both before and after a TLESR, and the CI of the EGJ (EGJCI) (volume of the domain above 0 mmHg), was measured for 8 seconds after primary peristalsis reached the EGJ, both before and after a TLESR. Results: 56 TLESRs were measured during the study. The D-CI (1603 mmHg s cm (1177-2120), median (interquartile range)) following a TLESR was significantly greater than before a TLESR (484 (323-1079)) and more than a 50% increase of D-CI in 35 (62.5%) of the 56 TLESRs was observed. The EGJCI (790 (465-1009)) following a TLESR was significantly greater than before a TLESR (238 (186-308)) and more than a 50% increase in the EGJ-CI in 48 (85.7%) of the 56 TLESRs was observed. Conclusions: The D-CI and the EGJ-CI following a TLESR, were significantly greater than before a TLESR and this tendency was evident in the EGJ-CI, although it can, at times, be difficult to evaluate a TLESR. If the focus is on a forceful contraction of primary peristalsis or on the EGJ, it may be easier to detect and evaluate a TLESR.

Tu1787 Primary Peristalsis and Esophagigastric Junction (EGJ) Pressure, Following a Transient Lower Esophageal Sphincter Relaxation (TLESR), Are Accompanied by a Forceful Contraction

Background: A TLESR is a major mechanism of acid reflux in healthy subjects and patients with reflux esophagitis and we have noticed that the amplitude of primary peristalsis and EGJ pressure, following a TLESR, is accompanied by a forceful contraction, when compared with before a TLESR. The aim of this study is to investigate whether or not primary peristalsis and EGJ pressure, when accompanied by a forceful contraction and following a TLESR, is a characteristic finding of a TLESR. Methods: 10 healthy subjects underwent esophageal high-resolution manometry with a 21-lumen perfused assembly, which monitored pressure in the pharynx, the upper esophageal sphincter, the esophageal body, LES and the proximal stomach. The EGJ was evaluated using ten side holes, spaced at 1-cm intervals. Recordings were then taken, in the sitting position, for 1 hour after a meal (692 kcal, 33 % fat). A TLESR is defined as previously described. Data were analyzed, using Trace! Software (Dr. G.S Hebbard, The Royal Melbourne Hospital, Australia). The contractile integral (CI) of the distal esophageal segment (D-CI: volume of the domain above 20 mmHg), excluding the EGJ segment, was measured both before and after a TLESR, and the CI of the EGJ (EGJCI) (volume of the domain above 0 mmHg), was measured for 8 seconds after primary peristalsis reached the EGJ, both before and after a TLESR. Results: 56 TLESRs were measured during the study. The D-CI (1603 mmHg s cm (1177-2120), median (interquartile range)) following a TLESR was significantly greater than before a TLESR (484 (323-1079)) and more than a 50% increase of D-CI in 35 (62.5%) of the 56 TLESRs was observed. The EGJCI (790 (465-1009)) following a TLESR was significantly greater than before a TLESR (238 (186-308)) and more than a 50% increase in the EGJ-CI in 48 (85.7%) of the 56 TLESRs was observed. Conclusions: The D-CI and the EGJ-CI following a TLESR, were significantly greater than before a TLESR and this tendency was evident in the EGJ-CI, although it can, at times, be difficult to evaluate a TLESR. If the focus is on a forceful contraction of primary peristalsis or on the EGJ, it may be easier to detect and evaluate a TLESR.