Distal Esophageal Segment Research Articles

Image-guided esophageal anastomosis in esophageal atresia

Infants with tracheoesophageal fistulas may present with complex cardiac disease that may obviate or disrupt a safe operative repair. Here we present a case of an infant who developed cardiac instability during esophageal atresia repair, precluding formal anastomosis after approximation of the distal and proximal esophageal segments. Postoperatively, anastomosis of the esophagus was achieved using an image-guided technique with subsequent dilation. This approach may provide an alternative approach for establishment of esophageal continuity in patients who are high-risk operative candidates.

Sa1362 Differences in Esophageal Motility Including Esophageal Peristaltic Transitional Zone Between Patients With Globus Sensation With and Without GERD

Background & Aims: High-resolution manometry (HRM) capable of pressure monitoring from the pharynx to the stomach together with pressure topography plotting represents an unquestionable evolution in esophageal manometry. HRM is useful in localizing and characterizing the transitional zone (TZ) that exists between the proximal and distal esophageal contractile segments. Although far less common than distal peristaltic or lower esophageal sphincter abnormalities, some studies suggested that TZ defects might be related to dysphagia. Globus sensation is a common symptom and gastroesophageal reflux disease (GERD) has been considered to be one of the important causes, although its pathogenesis is poorly understood. The aim of this study was to investigate differences in esophageal motility including TZ between patients with globus sensation related and unrelated to GERD. Methods: From September 2007 through March 2011, 128 consecutive patients (56 men, 72 women; mean age 53.2 years) who had globus sensation and/or heartburn occurring at least several times per week were recruited. After blood tests, ultrasonography, laryngoscope and endoscopy, 4 patients were excluded from the study because of organic disease. The remaining 124 patients underwent HRM. All patients completed a self-administered 7point Likert scale questionnaire about upper gastrointestinal symptoms before undergoing diagnostic tests. The clinical diagnosis of GERD was made when the Frequency Scale for Symptoms of GERD score was 8 points or higher. Results: Patients were divided into 3 groups: globus sensation with GERD (Group A) (26 men, 40 women; mean age 54.2 years), GERD only (Group B) (18 men, 4 women; mean age 51.3 years) and globus sensation only (Group C) (14 men, 14 women; mean age 54.9 years). As to the esophageal motility, the ratio of normal peristalsis in Group A was significantly lower than the Group C (65.2±4.8 % in Group A vs. 80.8±5.1% in Group C, P< 0.05). On the other hand, temporal prolongation (0.9±0.2 s in Group A vs. 2.6±0.2 s in Group C, P< 0.05) and spatial elongation of TZ (1.5±0.2 cm in Group A vs. 4.3±0.3 cm in Group C, P< 0.05) was significantly larger in Group C compared to those in Group A. Conclusions: This study showed that globus sensation related to GERD was associated with esophageal body dysfunction, while globus sensation unrelated to GERD was associated with coordination failure in TZ.

Beneficial effects of Ankaferd Blood Stopper on caustic esophageal injuries: an experimental model

Ankaferd Blood Stopper (ABS) is an herbal extract that enhances mucosal healing. The aim of this study was to investigate the efficacy of ABS on the healing of the esophagus and prevention of stricture development after esophageal caustic injuries in rats. The study included 50 rats. Rats were divided into five groups: group 1 (no injury, sham surgery), group 2 (injury + no ABS + study after 2 weeks of injury), group 3 (injury + ABS + study after 2 weeks of injury), group 4 (injury + no ABS + study after 4 weeks of injury), and group 5 (injury + ABS + study after 4 weeks of injury). Standard esophageal burn injury was created by applying 50% NaOH solution to distal esophagus of about 1.5 cm. To rats in the sham group, isotonic solution was given instead of NaOH. ABS (2 mL/day) was given via oral route to group 3 and 5 rats. Fourteen days (group 2 and 3) and 28 days (group 4 and 5) later, all the live rats were killed. The distal esophageal segments of all rats were removed and divided into two equal parts for biochemical and histopathological examination. Mortality rate, weight changes, inflammation, stenosis index (SI), and biochemical measurements were evaluated. The SI was found as 0.31 ± 0.03 in group 1, 0.533 ± 0.240 in group 2, 0.568 ± 0.371 in group 3, 0.523 ± 0.164 in group 4, and 0.28 ± 0.03 in group 5. The SI and inflammation in ABS-treatment group 5 was significantly lower than that in non-treatment group 4 (P= 0.005). There were no significant differences between inflammation and SI among other groups. The mortality rate was 14.2% in group 1, 37.5% in untreated group 2, 14.2% in ABS-treated group 3, 80% in untreated group 4, and 33.3% in ABS-treated group 5. The mortality rate in group 4 was significantly higher than other groups (P= 0.025). Decrease rates in mean body weights of the groups were as follows: group 1, 1%; group 2, 15%; group 3, 14%; group 4, 46%; and group 5, 15%. Biochemical tests other than albumin and creatinine were comparable among the groups. Treatment with ABS prevents inflammation, scar formation, weight loss, and mortality in esophageal caustic injuries. Additional studies to evaluate the clinical benefits of ABS in esophageal caustic injury are recommended.

Role of Corticotrophin-releasing Factor in the Stress-induced Dilation of Esophageal Intercellular Spaces

Corticotrophin-releasing factor (CRF) plays a major role in coordinating stress responses. We aimed to test whether blocking endogenous CRF activity can prevent the stress-induced dilation of intercellular spaces in esophageal mucosa. Eighteen adult male rats were divided into 3 groups: 1) a non-stressed group (the non-stressed group), 2) a saline-pretreated stressed group (the stressed group), 3) and an astressin-pretreated stressed group (the astressin group). Immediately after completing the experiments according to the protocol, distal esophageal segments were obtained. Intercellular space diameters of esophageal mucosa were measured by transmission electron microscopy. Blood was sampled for the measurement of plasma cortisol levels. Mucosal intercellular spaces were significantly greater in the stressed group than in the non-stressed group. Mucosal intercellular spaces of the astressin group were significantly smaller than those of the stressed group. Plasma cortisol levels in the stressed group were significantly higher than in the non-stressed group. Pretreatment with astressin tended to decrease plasma cortisol levels. Acute stress in rats enlarges esophageal intercellular spaces, and this stress-induced alteration appears to be mediated by CRF. Our results suggest that CRF may play a role in the pathophysiology of reflux-induced symptoms or mucosal damage.

A 47-Year-Old Woman With Dysphagia and Food Getting Stuck: What Is Your Impression?

A 47-year-old woman presented with dysphagia and food getting stuck for 6 months. There were no abnormal findings on esophagogastroduodenoscopy. She underwent a high-resolution manometry (HRM, version 2.0.1, Manoscan, Sierra Scientific Instruments, Los Angeles, CA, USA) with a 4.2 mm HRM catheter equipped with 36 pressure transducers spaced 1 cm apart. Ten swallows of 5 mL water was given to the patient in a supine position. Among the 10 swallows, 3 swallows revealed rapid contractile front velocity (CFV) (> 8 cm/sec) attributable to spasm on entire distal smooth muscle esophageal segment (S2 and S3) (Fig. 1A). In contrast, 7 swallows showed normal CFV ( 8 cm/sec) on S3 (Fig. 1B). What is your impression by the HRM plots? Figure 1 High-resolution manometry findings. (A) It illustrates a swallow with rapid contractile front velocity (CFV) attributable to spasm. The CFV of 30 and 50 mmHg isobaric contours parallel each other, indicating that no compartmentalized esophageal pressurization ... In the Chicago classification of distal esophageal motility disorders, distal esophageal spasm is defined when spasm (CFV > 8 cm/sec) is detected in ≥ 20% of swallows in distal esophageal segment.1 Distal esophageal segment is consisted of smooth muscle and composed with S2 and S3. When the spasms involve both S2 and S3, we can diagnose diffuse esophageal spasm by the Chicago classification. But, when only 1 segment of distal esophagus is involved by spasms, the diagnosis should be segmental esophageal spasm. Diffuse esophageal spasm is a quite rare disease according to a previous study.2 Among 400 patients, only 6 patients (1.5%) had a CFV > 8 cm/sec in ≥ 20% of swallows and met the criteria for a rapidly propagated contraction. In this case, the HRM plots are consistent with diffuse esophageal spasm.

Protective effects of ibuprofen against caustic esophageal burn injury in rats

The aim of this study was to investigate the efficacy of ibuprofen on the healing of esophagus and the prevention of stricture development after esophageal caustic injuries in rats. Rats were divided into three groups as: group 1(sham), group 2(esophageal burn injury), group 3(injury + ibuprofen). In groups 2 and 3, a standard esophageal burn injury was created by applying 10% NaOH solution to distal esophagus of about 3 cm. To rats in the sham group, isotonic solution was given instead of NaOH. Ibuprofen (90 mg/kg/day) was given via oral route to group 3 rats. Normal saline as placebo was given via the same route to rats in groups 1 and 2. 28 days later, all the live rats were killed. The distal esophageal segments of all rats were removed and divided into two equal parts for biochemical and histopathologic examination. In the tissue samples, biochemically hydroxyproline and histopathologically collagen content and stenosis indices were evaluated for efficacy of treatment. The hydroxyproline level (microg/mg wet tissue) in the groups was 1.54 +/- 0.08, 4.82 +/- 0.60, and 3.28 +/- 0.27, respectively. The hydroxyproline level increased significantly in group 2 compared with group 1 (P < 0.01). Although the hydroxyproline level was significantly increased in group 3 compared with group 1, it decreased significantly in group 3 compared with group 2 (P < 0.05) by treatment of ibuprofen. In group 3, the collagen content score (1.50 +/- 0.26) was significantly lower than in group 2 (2.62 +/- 0.37) (P < 0.05). The stenosis index was found as 0.37 +/- 0.02 in group 1, 0.84 +/- 0.02 in group 2, and 0.67 +/- 0.03 in group 3. The stenosis index in group 2 was significantly higher than group 1 and group 3 (P < 0.01). Although the stenosis index was significantly higher than in group 1, a significant decrease in stenosis index was found in group 3 compared with group 2, by ibuprofen treatment (P < 0.01). Based on these results, we concluded that the treatment with ibuprofen in acute phase esophageal burn injury has beneficial effects on healing of esophagus and may decrease the stricture formation. For these reasons, ibuprofen may effectively be used in the acute phase treatment of caustic esophagus injury and after esophageal dilatation procedures.

Caustic esophageal injury decreases the number of interstitial cells of Cajal in the rat esophagus

To evaluate the effect of caustic esophageal injury (CEI) on the number of interstitial cells of Cajal (ICC). Materials and methods: Wistar rats were divided into 3 groups: control, acid, and alkali induced CEI. CEI was performed by the injection of 1 mL of 10% hypochloric acid in the acid group, and 1 mL of 10% sodium hydroxide was injected into the alkali group. Distal esophageal segments were removed 24 h after injection. CEI was graded and the number of ICC were investigated (CD-117 staining). The number of ICC was compared in groups and correlated with CEI grades. Results: Typical histopathologic features of CEI were encountered in acid (mean grade: 0.25 ± 0.15), and in alkali (median: 2, range: 1.25-3) groups. The number of ICC was decreased in both the acid (mean: 12.8 ± 9.2) and alkali (median: 2, range: 0.0-4.0) groups with respect to the control group (mean: 30.5 ± 6.5) (P < 0.05). In addition, alkali group had a decreased number of ICC, when compared to the acid group (P < 0.05). Histopathologic grading showed an inverse correlation with number of ICC in both the acid (rs: 0.678) and alkali (rs: 0.759) groups. Conclusion: CEI decreases the number of ICC in the rat esophagus. Alkali caustics cause a higher grade of esophageal injury and a greater decrease in the number of ICC. Motility disorders after caustic ingestion may be related to the decreased number of ICC.

Mitomycin C decreases the rate of stricture formation in caustic esophageal burns in rats

Although the incidence of caustic ingestion is declining, the management of caustic esophageal strictures remains a challenge. Although many agents have been tried experimentally to treat strictures, few have gained clinical application. The aim of this study was to investigate the influence of mitomycin C (MMC), which inhibits fibroblastic proliferation in treating delayed caustic esophageal strictures. Forty-two rats were allocated into 3 groups. Caustic esophageal burns were created as described by Gehanno. Group A was instilled only with saline. Group B was injured with 10% NaOH and left untreated. Group C was injured and received topical MMC at 0.04% concentration in the fourth week. At 56 days, stenosis index (SI), collagen deposition, and hydroxyproline content (HP) were determined in distal esophageal segments. Statistical analyses were performed. The mean SI in group B was significantly higher than others (SI: 1.15 +/- 0.37 d/lum, P < .05). Collagen accumulation was highest in group B, followed by groups C and A, respectively. Collagen deposition in group C was statistically lower than group B (P < .018). The mean HP in group B was statistically higher than others (5.07 +/- 1.30 microg/mg tissue, P < .05), and similar between groups A and C (1.20 +/- 0.20, 1.91+/- 0.79, respectively, P = .73). In the current study, MMC treatment ameliorated caustic esophageal stricture as reflected in the significantly lower SI. We conclude that MMC application is effective in the treatment of caustic esophageal strictures.

Biochemical and histopathologic effects of omeprazole and vitamin E in rats with corrosive esophageal burns

The aim of the study reported here was to evaluate the biochemical and histopathologic effects of omeprazole and vitamin E in rats with corrosive esophageal burns. A total of 144 Wistar Albino rats were divided into 12 experimental groups (12 rats per group) and used in an animal study. Group I rats were given a laparotomy and received no treatment (control group), while groups II, III and IV received a laparotomy and were treated with omeprazole, vitamin E or omeprazole/vitamin E, respectively. Groups V-XII rats received a laparotomy and were given a caustic acid burn through acid instillation (1 ml caustic 10% sulphuric acid; groups V-VIII) or alkali instillation (corrosive 10% sodium hydroxide solution; groups IX-XII) into the isolated esophageal segment via a 22-Fr cannula for 2 min. Each group of rats subjected to caustic burn received either no treatment (groups V and IX) or were treated with omeprazole, vitamin E or omeprazole/vitamin E, respectively (remaining six groups). Omeprazole (20 mg/kg) or vitamin E (10 mg/kg) was administered to the rats intraperitoneally or intramuscularly, respectively. Seventy-two rats (50% of each group, n = 6) were killed immediately after the experimental treatment (acute phase). The remaining rats were kept under standard conditions for 21 days (late phase) before being killed. The distal esophageal segments were harvested from all animal and used in histopathologic and biochemical analyses. Compared to the controls (no caustic burn), rats receiving only the acid or alkali installation (and no subsequent treatment) had the highest mean malondialdehyde (16.9 and 15.8 micromol MDA/g protein, respectively) and hydroxyproline (5.9 and 5.7; mg HP/g wet tissue) levels of all groups. In comparison, rats treated with acid + omeprazole and/or vitamin E had relatively lower MDA (12.9 and 11.6 micromol/g protein, respectively) and HP levels (4.3 and 4.08 mg/g wet tissue, respectively). Similarly, rats treated with alkali + omeprazole and/or vitamin E had low levels of MDA (13.9 and 11.7 micromol/g protein, respectively) and HP (4.3 and 4.4 mg/g wet tissue, respectively). The glutathione (GSH) levels of acid-only- or alkali-only-treated rats were lower than those found in omeprazole- and/or vitamin E-treated rats. Based on these results, we conclude that vitamin E and omeprazole affect the biochemical and histopathologic parameters in rats receiving corrosive esophageal burn from acid and alkali. The effect of both substances was slightly greater in the acid-treated groups.

Intrinsic esophageal innervation in esophageal atresia without fistula

Esophageal atresia and tracheo-esophageal fistula (EA + TEF) are often associated with malformations of neural crest origin. Esophageal innervation is also derived from the neural crest and it is abnormal in EA + TEF in which there is motor dysfunction. Our aim was to examine the intrinsic esophageal innervation in children with isolated EA in which different embryogenic mechanisms might be involved. Specimens from the proximal and distal esophageal segments of 6/35 patients who had esophageal replacement for isolated EA between 1965 and 2006 were suitable for the study. They were sectioned and immunostained with anti-neurofilament (NF) and anti-S-100 antibodies. The muscle and neural surfaces on each section were measured with the assistance of image processing software. The surface of the ganglia and the number of neurons per ganglion were determined at high power microscopy. The findings were compared with those of six autopsy specimens from newborns dead of other diseases by means of standard statistical tests and a significance threshold of P < 0.05. Unmatched age/size of babies in isolated EA and control groups precluded comparison of the relative surfaces occupied by neural elements. Patients with pure EA had denser fibrilar network and larger ganglia than controls. The number of neurons/ganglion were similar in both groups although the cells from EA patients were larger. The findings were similar at both esophageal levels studied. In spite of methodologic biases, it seems that intrinsic esophageal fibrilar network is denser and the intramural ganglia larger with larger cells in patients with pure EA than in controls on both esophageal ends of the organ. These neural anomalies are only in part reminiscent of those described in regular EA/TEF but may as well explain esophageal dysfunction in patients with repaired isolated EA.

Autofluorescence Imaging and Narrow-Band Imaging for the Detection of Early Neoplasia in Patients with Barrett’s Esophagus

High-resolution endoscopy (HRE), magnifying endoscopy, auto-fluorescence endoscopy, and narrow-band imaging (NBI) are promising techniques that could improve the detection of early neoplasia and the efficacy of endoscopic surveillance in patients with Barrett's esophagus. HRE improves the detection of lesions by white light, and video autofluorescence imaging (AFI) may have additional value in terms of sensitivity. The strengths ofAFI are its high sensitivity and a high negative predictive value,while potential limitations are its moderate specificity and positive predictive value. NBI enhances the mucosal and vascular patterns (i. e. the mucosal morphology) without the need for chromoendoscopy. The mucosal morphology features may be used to distinguish early neoplasia from nondysplastic Barrett's esophagus. Magnification is required for optimal use of NBI,which is a limitation of this technique. NBI with magnifying endoscopy could, however, be used for targeted inspection of lesions detected first by HRE or AFI. This approach has been shown to reduce the false-positive rate associated with AFI while maintaining its high sensitivity. To date, AFI and NBI have been used separately in two different prototypes, but a prototype endoscope that incorporates all of these techniques has recently become available. It is expected that future refinement of the autofluorescence and narrow-band modules may further increase their diagnostic value and ultimately improve the effectiveness of surveillance of Barrett's esophagus.

Mitomycin C prevents strictures in caustic esophageal burns in rats

Caustic esophageal injuries lead to stricture formation. Although a number of agents have been tried experimentally to prevent strictures, few have gained clinical application. The purpose of this study was to investigate the effectiveness of Mitomycin C (MMC), which inhibits fibroblastic proliferation in preventing caustic esophageal strictures. Fifty-six rats were allocated into four groups. Caustic esophageal burns were created as described by Gehanno. Group A was instilled only with saline. Group B was injured and untreated. Groups C and D were injured and received topical MMC at 0.02 and 0.04% concentrations, respectively. At 28 days, stenosis index (SI), collagen deposition, and hydroxyproline content (HP) were determined in distal esophageal segments. Statistical analyses were done. Mean SI in Group B was significantly higher than others (P < 0.05). Mean SI was statistically higher in Group C than A and D and similar between groups A and D. The greatest accumulation of collagen was found in Group B, followed by Group C, D, and A, respectively. Collagen deposition in Group D was statistically lower than Group B (P < 0.01) and similar to Group C. Mean HP in Group B was statistically higher than others (P < 0.05), significantly higher in Group C than Group D (P = 0.047), and similar between Groups A and D (P = 0.73). MMC was effective in preventing strictures following experimental caustic esophageal injury, in a dose-dependent manner. We consider that it can gain clinical utilization with the establishment of effective mode, dose, and timing of therapy.

Mitomycin C prevents strictures in caustic esophageal burns in rats

<h3>Background</h3> Caustic esophageal injuries lead to stricture formation. Although a number of agents have been tried experimentally to prevent strictures, few have gained clinical application. The purpose of this study was to investigate the effectiveness of Mitomycin C (MMC), which inhibits fibroblastic proliferation in preventing caustic esophageal strictures. <h3>Material and methods</h3> Fifty-six rats were allocated into four groups. Caustic esophageal burns were created as described by Gehanno. Group A was instilled only with saline. Group B was injured and untreated. Groups C and D were injured and received topical MMC at 0.02 and 0.04% concentrations, respectively. At 28 days, stenosis index (SI), collagen deposition, and hydroxyproline content (HP) were determined in distal esophageal segments. Statistical analyses were done. <h3>Results</h3> Mean SI in Group B was significantly higher than others (<i>P</i> < 0.05). Mean SI was statistically higher in Group C than A and D and similar between groups A and D. The greatest accumulation of collagen was found in Group B, followed by Group C, D, and A, respectively. Collagen deposition in Group D was statistically lower than Group B (<i>P</i> < 0.01) and similar to Group C. Mean HP in Group B was statistically higher than others (<i>P</i> < 0.05), significantly higher in Group C than Group D (<i>P</i> = 0.047), and similar between Groups A and D (<i>P</i> = 0.73). <h3>Conclusion</h3> MMC was effective in preventing strictures following experimental caustic esophageal injury, in a dose-dependent manner. We consider that it can gain clinical utilization with the establishment of effective mode, dose, and timing of therapy.

Clamshell approach for cervical mediastinal esophageal reconstruction

Objectives: The thoracic inlet is a complex anatomic structure. Many vital structures ranging from vessels to organ systems traverse through here on their way from the chest into the neck. Access to reconstruct these areas can be quite difficult. The esophagus is a structure that stretches from the cervical region through the thoracic inlet into the mediastinum. Diseases or defects in the esophagus have traditionally been repaired by end-to-end anastomosis when a distal anastomosis is possible. Lesions where the distal esophagus is not accessible through a cervical approach often necessitate a total esophagectomy with a stomach pull-up. One approach, the clamshell approach, involves a median sternotomy and right thoracotomy with rotation of the anterior and lateral bony confinements of the thoracic inlet laterally. This provides access to the anterior mediastinum. Mobilization of the upper lung provides access to the posterior mediastinum. Methods: We present an interesting case of a gentleman with Boerhaave’s syndrome who had a diverting esophagostomy at the cervical thoracic level. The distal esophagus was allowed to retract into the chest. After he survived his initial insult, reconstruction was undertaken. Results: The distal esophagus could not be connected to the proximal esophagus. Using a clamshell approach, distal and proximal esophageal segments were isolated and a free jejeunal tissue transfer was undertaken. Anastomosis to the internal mammary vessels allowed reconstruction of the esophageal conduit. Conclusion: This poster will demonstrate the interesting complexity of the thoracic inlet with a photographic demonstration of the technical approach.

Deglutitive inhibition affects both esophageal peristaltic amplitude and shortening.

Deglutitive inhibition attenuates ongoing esophageal contractions if swallows are separated by short time intervals. This study aimed to determine whether esophageal shortening, mediated by longitudinal muscle, was similarly affected. Eight healthy subjects with two distal esophageal segments demarcated by mucosal clips and manometric recording sites positioned within those segments underwent concurrent manometry and fluoroscopy. Peristaltic amplitude and change in distal segment lengths were quantified during single swallows, paired swallows separated by progressively prolonged intervals, and a series of rapid repetitive swallows. During grouped swallows, deglutitive inhibition with complete attenuation of both the manometric contraction and segment shortening was evident with short-interval swallows and rapid-sequence swallows. No inhibition of either was evident with long-interval pairs. With intermediate interswallow intervals, the occurrence and degree of deglutitive inhibition between peristaltic amplitude and segment shortening were closely correlated. Deglutitive inhibition affects both the longitudinal and circular muscle layers of the esophageal wall, and the occurrence of inhibition evident in one layer is strongly correlated with the other.

Prevalence of intestinal metaplasia according to the length of the specialized columnar epithelium lining the distal esophagus in patients with gastroesophageal reflux

The diagnosis of Barrett's esophagus is based on the presence of intestinal metaplasia (IM) at the distal esophagus. The aim of this study was to determine the prevalence of IM in patients with symptoms of gastroesophageal reflux in whom endoscopically a segment of distal esophagus was covered by columnar epithelium (CE). In a prospective, descriptive and transversal study, 492 patients (33%) from 1480 patients with gastroesophageal reflux, in whom endoscopic evaluation demonstrated the presence of a short-segment CE measuring less than 3 cm or a long-segment CE measuring more than 3 cm, were evaluated. From each patient, several biopsy specimens were taken, which were stained with hematoxylin-eosin and Alcian blue pH 2.5. Out of 492 cases, 421 patients (86%) presented with a short-segment CE and 71 patients (14%) had a long-segment CE. Among these 71 cases, 38 had a 3-6 cm-length CE, 21 patients had a 6.1-10 cm-length CE and 12 patients had CE more than 10.1 cm in length. Endoscopic short-segment CE was six times more frequent than long-segment CE. The prevalence of IM was 35% among patients with short-segment CE and increased progressively according to the length of CE, being 100% in patients with > 10 cm in length. Therefore, true short-segment BE was three times more frequent during endoscopic studies than long-segment BE. Dysplasia in the metaplastic epithelium also increased parallel to the length of the CE. True BE (presence of IM at the columnar epithelium lining the distal esophagus), was present in 13.6% of all patients with symptoms of gastroesophageal reflux submitted to endoscopic evaluation. Short-segment BE is three times more frequent than long-segment BE, and endoscopic and bioptic evaluation is fundamental in all cases with gastroesophageal reflux who exhibit some segment of the distal esophagus lined by columnar epithelium, even if it is > or = 1 cm long.

An exclusively intraabdominal distal esophageal segment prevents primary delayed anastomosis in children with pure esophageal atresia

Purpose: The aim of this study was to evaluate the outcome of children with pure esophageal atresia (EA) managed by the strategy of delayed primary anastomosis and to find parameters to identify which of these children will have satisfactory esophageal growth to permit a successful primary esophageal anastomosis. Methods: Sixteen children with pure EA were treated by delayed anastomosis strategy from June 1992 to May 2001 at the Instituto da Criança-University of São Paulo Medical School. The treatment consisted of creating an early feeding gastrostomy, continuous upper pouch suction, and periodic radiologic/endoscopic assessments of the gap between the superior and inferior esophageal pouches. The first assessment was done 4 weeks after the initial gastrostomy. Subsequent assessments were done, when necessary, 4 to 10 weeks after the first one. Children with the gap between the pouches corresponding to 2 vertebral bodies or less were considered for primary repair. Results: The waiting period ranged from 8 to 14 weeks. Five children were considered for primary repair (31.3%). All of them had an end-to-end esophageal anastomosis performed without tension. Eleven children (68.7%) did not show significant esophageal growth after the waiting period and were not considered for primary esophageal anastomosis. Eight of them (50%) showed an entirely intraabdominal distal pouch at the first assessment. Conclusions: (1) Infants with an exclusively intraabdominal distal pouch at the first evaluation will not reach sufficient elongation of the pouches and should be considered early as a candidate for esophageal replacement. (2) Combined radiologic/endoscopic assessment and the measurement of the gap in terms of vertebral bodies is a practical and reliable method to predict the feasibility of primary anastomosis. (3) Using these criteria, primary anastomosis could be accomplished in less than a third of cases. J Pediatr Surg 37:1521-1525. Copyright 2002, Elsevier Science (USA). All rights reserved.

Effect of antioxidant therapy on collagen synthesis in corrosive esophageal burns.

To investigate the efficacy of antioxidant therapy on collagen synthesis in corrosive esophageal burns, 110 Sprague-Dawley rats were divided into five groups of 22 animals each. A standard esophageal caustic burn was produced by 1 ml of 10% sodium hydroxide solution for the rats in groups B to E; group A was instilled only with 0.9% saline after preparation of the distal esophageal segment. Group A animals (controls) were uninjured and untreated. Group B had untreated esophageal burns. Esophageal burns were treated in group C with vitamin E (10 mg/kg IM), in group D with vitamin C (10 mg/kg IP), and in group E with methylprednisolone (30 mg/kg IM) on each of 5 days. Eight rats from each group were killed 4 days after initiation of the study and the abdominal esophagus was studied for tissue malondialdehyde (MDA; micromol/g protein) levels. The other rats were killed 28 days after initiation of the study and determination of hydroxyproline (HP) (microg/g tissue) levels in esophageal tissue was performed for 8 rats in each group. Histopathologic evaluation was also performed in the other 6 rats from each group. MDA levels in esophageal tissue were significantly lower in groups C (9.24 +/- 2.62, P < 0.01) and group E (6.26 +/- 2.22, P < 0.001) than in group B (12.35 +/- 1.80). HP levels were significantly lower in groups A (0.75 +/- 0.21, P < 0.001), C (1.11 +/- 0.15, P < 0.01), and E (0.96 +/- 0.15, P < 0.001) than in group B (1.40 +/- 0.20). Histopathologically, collagen deposition in the submucosa and tunica muscularis was lower in groups C and E than in group B (P < 0.05, and 0.01, respectively). Our results demonstrate that treatment with antioxidant drugs such as vitamin E and methylprednisolone decreased tissue HP levels, and thus inhibited new collagen synthesis and stricture formation in rats with alkali-induced caustic esophageal burns.

Esophageal longitudinal muscle contraction: Another component of transient lower esophageal sphincter relaxation (tLESR)?

Background. Longitudinal muscle contraction is an integral part of primary peristalsis (PP). This study aimed to characterize longitudinal muscle contraction during tLESR. Method. 8 healthy subjects (4 males, 26_+1 yrs) had metal clips endoscopically affixed at O, +3, and + 8 cm relative to the squamocolumnar junction (SCJ), defining two distal esophageal segments. Axial clip movement was assessed by concurrent manometry and fluoroscopy during LES relaxation with PP, secondary peristalsis (SP) induced by esophageal air injection, and tLESR induced by gastric distension with 800ml of air through the manometric catheter. Segment lengths were measured at 0.5 s intervals during relaxation and the percentage change relative to the initial length was calculated. If a tLESR ended with PP or SP, only the earlier period was used. Maximal SCJ upward movement was measured at end expiration. Results (Table). Although significant shortening was evident in both segments with all three types of LES relaxation, the magnitude of distal segment shortening was least with tLESR and greatest with PP. On the other hand, the maximal degree of overall esophageal shortening durin 0 tLESR, evident by the SCJ excursion, was similar to that during PP suggesting a global effect on the esophagus. In three instances, the moment of LES opening and gas reflux was optimally imaged and SCJ excursion was 0.3-+0.1 cm prior to LES opening and 1.4-+0.7 cm immediately after the occurrence of an esophageal common cavity. Conclusions. Although the segmental pattern appears to be distinct from that seen during PP or SP, esophageal shortening (likely attributable to longitudinal muscle contraction) occurs during tLESR. However, elevation of the LES did not precede LES opening during tLESR suggesting that this is nut part of the opening mechanism, but rather a consequence of the esophageal distension induced by gas reflux.

Abnormal enteric nerve morphology in atretic esophagus of fetal rats with adriamycin-induced esophageal atresia.

Gastroesophageal reflux is common in children after successful repair of esophageal atresia (EA), and may be related to a congenital neuronal abnormality of the esophagus. This study employed a fetal rat model of adriamycin-induced EA to investigate whether the innervation of the esophagus is abnormal in EA. The fetal rats were divided into four groups: (1) normal controls; (2) a saline-injected controls; (3) adriamycin administered but without the development of EA; and (4) adriamycin-induced EA. The distal esophageal segments were immunostained with a general neural marker, protein gene product 9.5 (PGP). Immunoreactivity per cross-sectional area (/xsa) was measured with an image analyzer. The extent of the esophageal circumference encircled by PGP-stained nerve tissue was assessed. While there was no significant difference in PGP immunoreactivity/xsa between the groups, the near-complete ring of nerve tissue along the plane of the myenteric plexus was replaced by clusters of nerve tissue in the atretic group (normal vs EA, P = 0. 001, Mann-Whitney U test). The abnormal distribution of nerve tissue in the atretic esophagus may be contributing factor in the esophageal dysmotility seen in EA.