Segment Of Esophagus Research Articles

The Effect of Beta-Aminopropionitrile and Prednisolone on the Prevention of Fibrosis in Alkali Esophageal Burns: An Experimental Study

Objective. The aim of this study was to investigate the efficacy of beta-aminopropionitrile (BAPN) and prednisolone on the prevention of esophageal damage and stricture formation after caustic esophageal burn. Method. Twenty-eight rats were divided into four equal groups. In groups 1, 2, and 3, caustic esophageal burns were generated by applying NaOH to the 1.5 cm segment of the abdominal esophagus. Group 4 was for the sham. Normal saline to group 1, BAPN to group 2, and prednisolone to group 3 were administered intraperitoneally as a single daily dose. Results. Treatment with BAPN decreased the stenosis index (SI) and histopathologic damage score (HDS) seen in caustic esophageal burn rats. The SI in group 4 was significantly lower compared with groups 1, 2, and 3. Group 2 had the minimum SI value in corrosive burn groups. The differences related to SI between groups 1, 2, and 3 were not statistically significant. The HDS was significantly lower in group 4 compared with groups 1, 2, and 3. The HDS in group 2 was significantly lower compared with groups 1 and 3. Conclusion. This study demonstrated that BAPN was able to decrease the development of stenosis and tissue damage better than prednisolone.

Risk Factors in the Development of Esophageal Adenocarcinoma

It is assumed that esophageal adenocarcinoma is the end result of a stepwise disease process that transitions through gastroesophageal reflux disease (GERD) and Barrett's esophagus. The aim of this study was to examine at what stage known risk factors exert their influence toward the progression to cancer. We enrolled 113 consecutive outpatients without GERD, 188 with GERD, 162 with Barrett's esophagus, and 100 with esophageal adenocarcinoma or high-grade dysplasia (HGD). All patients underwent a standard upper endoscopy and completed a standardized questionnaire about their social history, symptoms, dietary habits, and prescribed medications. We used adjusted logistic regression analysis to assess risk factors between each two consecutive disease stages from the absence of reflux disease to esophageal adenocarcinoma. Overall, male gender, smoking, increased body mass index (BMI), low fruit and vegetable intake, duration of reflux symptoms, and presence of a hiatal hernia were risk factors for cancer/HGD. However, different combinations of risk factors were associated with different disease stages. Hiatal hernia was the only risk factor to be strongly associated with the development of GERD. For GERD patients, male gender, age, an increased BMI, duration of reflux symptoms, and presence of a hiatal hernia were all associated with the development of Barrett's esophagus. Finally, the development of cancer/HGD among patients with Barrett's esophagus was associated with male gender, smoking, decreased fruit and vegetable intake, and a long segment of Barrett's esophagus, but not with age, BMI, or a hiatal hernia. While some risk factors act predominantly on the initial development of reflux disease, others appear to be primarily responsible for the development of more advanced disease stages.

Barrett's Esophagus and Adenocarcinoma Risk

To establish the incidence and risk factors for progression to high-grade intraepithelial neoplasia (HG-IEN) or Barrett's esophageal adenocarcinoma (BAc) in a prospective cohort of patients with esophageal intestinal metaplasia [(BE)]. BE is associated with an increased risk of BAc unless cases are detected early by surveillance. No consistent data are available on the prevalence of BE-related cancer, the ideal surveillance schedule, or the risk factors for cancer. In 2003, a regional registry of BE patients was created in north-east Italy, establishing the related diagnostic criteria (endoscopic landmarks, biopsy protocol, histological classification) and timing of follow-up (tailored to histology) and recording patient outcomes. Thirteen centers were involved and audited yearly. The probability of progression to HG-IEN/BAc was calculated using the Kaplan-Meier method; the Cox regression model was used to calculate the risk of progression. HG-IEN (10 cases) and EAc (7 cases) detected at the index endoscopy or in the first year of follow-up were considered to be cases of preexisting disease and excluded; 841 patients with at least 2 endoscopies {median, 3 [interquartile range (IQR): 2-4); median follow-up = 44.6 [IQR: 24.7-60.5] months; total 3083 patient-years} formed the study group [male/female = 646/195; median age, 60 (IQR: 51-68) years]. Twenty-two patients progressed to HG-IEN or BAc (incidence: 0.72 per 100 patient-years) after a median of 40.2 (26.9-50.4) months. At multivariate analysis, endoscopic abnormalities, that is, ulceration or nodularity (P = 0.0002; relative risk [RR] = 7.6; 95% confidence interval, 2.63-21.9), LG-IEN (P = 0.02, RR = 3.7; 95% confidence interval, 1.22-11.43), and BE length (P = 0.01; RR = 1.16; 95% confidence interval, 1.03-1.30) were associated with BE progression. Among the LG-IEN patients, the incidence of HG-IEN/EAc was 3.17 patient-years, that is, 6 times higher than in BE patients without LG-IEN. These results suggest that in the absence of intraepithelial neoplastic changes, BE carries a low risk of progression to HG-IEN/BAc, and strict surveillance (or ablative therapy) is advisable in cases with endoscopic abnormalities, LG-IEN or long BE segments.

Transoral Endoscopic Resection of Esophageal Liposarcoma

A 63-year-old man presented with a 1-month history of dysphagia. Endoscopy showed the patient had a mass in the cervical esophagus. Multiple biopsy specimens were taken, which were inconclusive for a diagnosis. A positron-emission tomography scan showed a hypermetabolic lesion. A transoral endoscopic approach was used to resect the tumor. Final histologic examination revealed a completely resected low-grade liposarcoma.

Inhibitory actions of a local neural reflex on propulsive activity of the esophageal striated muscle portion in rats

The aim of the present study was to clarify functional roles of a local neural reflex in propulsive activity of the rat esophageal striated muscle. Firstly, we established a method for measuring the volume of fluid expelled from an isolated esophageal segment to evaluate propulsive activity. Electrical stimulation to vagus nerves induced propulsion of intraluminal solution in the esophageal segment. The vagally evoked propulsion was abolished in the presence of d-tubocurarine. Next, this quantitative method was applied to examine the functional roles of intrinsic nerves in the esophagus. Capsaicin, a stimulant of primary afferents, inhibited the vagally mediated propulsion. A nitric oxide synthase inhibitor or a selective tachykinin NK1 receptor antagonist significantly blocked the inhibitory effect of capsaicin. These findings suggest that the local neural reflex, which consists of tachykininergic and nitrergic neurons, might participate in modulation of propulsive activity in the striated muscle portion of the rat esophagus.

Esophageal pulse oximetry is more accurate and detects hypoxemia earlier than conventional pulse oximetry during general anesthesia

The esophagus is perfused directly by prominent arteries and may provide a more consistent tissue source for pulse oximetry. The goal of this study was to evaluate the sensitivity and accuracy of an esophageal pulse oximetry probe on patients during controlled hypoxemia in comparison to measurements obtained with conventional pulse oximetry (SpulseO(2)). Forty-five ASA I-II adult patients were included in this prospective observational study. Nellcor digital oximetric probes were placed on finger tips for SpulseO(2) before anesthesia. After tracheal intubation, an esophageal probe was placed in the lower segment of the esophagus for esophageal oximetric monitoring (SoesO(2)). All patients were disconnected from the breathing circuit to establish a controlled hypoxemia, and were re-connected to the breathing circuit and ventilated with 100% oxygen immediately when SoesO(2) dropped to 90%. Matched SoesO(2) and SpulseO(2) readings were recorded when SoesO(2) measurements were at 100%, 95%, 90% and the lowest reading. The time for SoesO(2) and SpulseO(2) to drop from 100% to 95%, 90% and return to 100% was recorded. Oxygen saturation from arterial blood samples (SartO(2)) was also measured at each time point respectively. The linear correlation coefficient of the regression analysis between SartO(2) and SoesO(2) was 0.954. The mean ± 2SD of the difference was 0.3% ± 4.3% for SoesO(2) vs. SartO(2) and 6.8% ± 5.6% for SpulseO(2) vs. SartO(2) (P < 0.001). The 95% confidence interval for the absolute difference between SoesO(2) and SartO(2) was 0.3% to 0.7% and 6.2% to 7.4% between SpulseO(2) and SartO(2). The time to reach 90% saturation measured with SoesO(2) was approximately 94 seconds earlier than the SpulseO(2) (P < 0.001). In conclusion, SoesO(2) is more accurate and enables earlier detection of hypoxemia when compared to conventional pulse oximetry during hypoxemia for patients undergoing general anesthesia.

In vitro sensitivity of rat esophagus to agonists in different alkaline mediums

AimAn in vitro study was performed to determine the in vitro sensitivity of rat esophagi to contracting and relaxing agonists in different alkaline mediums. Materials and MethodsTwenty-four Wistar rats weighing 200 to 250 g were included in the study. After inducing anesthesia with thiopental sodium (50 mg/kg), the rats were killed, and the distal esophagus (DE) and gastroesophageal junction (GEJ) were removed. Excised tissues were suspended under 0.6 g of resting tension in a tissue bath containing 10 mL of Tyrode solution at 37°C. The esophageal segments were divided into 4 groups, each with a different pH medium: 7.4, 7.6, 7.8, and 8. To evaluate the smooth muscle activity of the rat esophagus in different alkaline mediums, cholinergic agonist carbachol (a cholinergic agonosit) and KCl (which acts on calcium channels) were added to the organ baths to obtain concentration-dependent contraction responses. Relaxation responses were obtained using an adrenergic agonist, isoproterenole. Data obtained from different pH mediums were analyzed using Kruskal-Wallis nonparametric analysis of variance and post hoc Dunn's test. ResultsThe pH of the medium has no effect on the concentration-dependent contracting responses to carbachol in the DE, but responses obtained in pH 8 medium were significantly lower in the GEJ (P < .05). In pH 8 medium, concentration-dependent relaxation responses to isoproterenole were also significantly lower (P < .05). When contractile responses to KCl were evaluated, the groups with pH 7.6 and 7.8 medium were found to have higher responses in the DE segments than other groups (P < .05). However, the GEJ segments had lower contractile responses to KCl in pH 8 medium (P < .05). ConclusionAlthough different alkaline mediums caused no alteration in esophageal smooth muscle responses to cholinergic stimulation, GEJ responses were lower in pH 8 medium. Relaxation responses, owing to increased adrenergic activity, decreased when the pH of the medium was increased to 8. Calcium-dependent contractions caused by KCl decreased in both segments in pH 8 medium but increased in the DE in pH 7.6 medium.

Influence of Fundoplication on Remission and Recurrence of Intestinal Metaplasia after Ablation of Barrettʼs Esophagus

Purpose: Radiofrequency ablation (RFA) is an effective treatment for Barrett's dysplasia in conjunction with adequate acid reflux control. Fundoplication is a treatment option for persistent gastroesophageal reflux in spite of optimal pharmacotherapy. Our aim was to assess the effect of fundoplication in achieving complete remission of intestinal metaplasia (CRIM) and recurrence after successful RFA. Methods: We performed a retrospective cohort analysis of patients who underwent RFA for Barrett's dysplasia at a tertiary referral center from Jan. 2003 to Jun. 2012. All patients were on proton pump inhibitors following RFA. CRIM was defined as the absence of intestinal metaplasia (IM) in 2 consecutive endoscopies with biopsies. Recurrence was defined as the reappearance of IM with any grade of dysplasia after CRIM. Demographic and endoscopic factors associated with CRIM or recurrences were assessed by univariate and multivariate analyses. The effect of pre-RFA fundoplication to either time to CRIM or recurrence was assessed by Kaplan-Meier survival estimates. Results: A total of 206 patients were included in the analysis. There were 28 (13.6%) patients who had pre-RFA fundoplication. Patients were followed for 26.69 ±18.91 months after their first RFA session. Baseline characteristics are summarized in Table 1 which showed no significant difference between those with and without fundoplication. There was no association of fundoplication with either achieving CRIM (HR 0.93, 95% CI: 0.47-1.65) or recurrence (HR 0.99, 0.15-3.81) after controlling for age, number of RFA sessions, length of Barrett's esophagus (BE) segment and hiatal hernia in a multivariate Cox proportional hazards analysis. Figure 1 presents the Kaplan-Meier plot of patients with and without fundoplication in relation to CRIM. Time intervals for both CRIM (p=0.87) and recurrence (p=0.90) were not different between the two groups based on Mantel-Cox statistics.Table: Baseline characteristics of subjects with and without pre-RFA fundoplicationFigure: [62]Conclusion: In our cohort of patients, fundoplication was not associated with either time to CRIM or recurrence. Future studies with long term follow-up data and evidence of sufficient acid control, measured by pH impedance after fundoplication are needed to assess the effect of surgical reflux control on BE eradication following RFA. Disclosure: Dr. Wang - Consultant and research support from: Covidien (Barrx); Ninepoint Medical; CDX Diagnostics; Fujinon; Pinnacle Biologics; Ms. Lutzke - Research support: Covidien (Barrx); Fujinon; Ninepoint; Dr. Prasad Iyer - Research support: Takeda.

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.

Oesophageal pain: A tough nut to crack the role of high resolution manometry guided segmental oesophageal myotomy

Introduction: Oesophageal motility disorders (OMDs) are a recognized cause of pain in 25-33% of patients with non-cardiac chest pain. The understanding of these disorders based on standard multichannel oesophageal manometry has improved with high resolution oesophageal manometry (HROM). This could facilitate selection of treatment modality including identifying those suitable for surgical myotomy while preserving oesophageal function. Material and methods: This discussion is based on a 65 year old lady with a 17 year history of oesophageal pain due to Nutcracker oesophagus. Persistence of symptoms despite medical management using proton pump inhibitors, calcium channel blockers, nitrates, endoscopic pneumatic dilatation & Botulinum toxin injection prompted re-referral to our specialist unit and analysis of residual oesophageal function using HROM. This revealed a segment of nutcracker oesophagus in the mid oesophagus with significant supine reflux. Result: Surgical treatment with trans-hiatal open focused oesophageal myotomy with preservation of lower oesophageal sphincter and floppy Nissen fundoplication led to satisfactory and complete resolution of symptoms. Discussion: HROM provides a clearer classification of the functional abnormalities and their co-relation to symptoms. This allows application of the best available treatment modality including surgery to achieve symptomatic relief with preservation of residual oesophageal function. Conclusion: Limited evidence is currently available on the comparative benefits of available treatment modalities for OMDs. HROM provides greater insight into OMDs and the benefits of available treatment modalities allowing selection of optimal treatment modality and preserving oesophageal function while achieving relief of the patients distressing symptoms.

Effect of Feeding Regulation Measures for Establishing Esophageal Channel Function in Neoesophagus Created with a Nitinol Artificial Esophagus

Purpose This study attempted to observe the effect of feeding regulation measures (FRM) for the construction of an esophageal channel function in a neoesophagus using an artificial nitinol esophagus. Methods Experiments were divided among groups: group 1, receiving FRM; and group 2, the non-feeding regulation measures (NFRM) group. Results Ten pigs survived for 6 months without any complications such as anastomotic leakage. The shedding time of the artificial esophagus in group 1 was significantly delayed in comparison with group 2 (&gt;180 ± 0.0 days vs. 75.6 ± 27.1 days, respectively, p&lt;0.05). In group 1, the weight changes at 3 and 6 months postoperation were significantly different in comparison with preoperative values (t = 14.86, 9.17 &gt; 2.78, respectively; p&lt;0.05). In group 2, the weight changes at 3 and 6 months postoperation were significantly different in comparison with preoperative values (t = 7.95, 11.37 &gt; 2.78, respectively; p&lt;0.05). Conclusions FRM not only effectively delayed the shedding time of the artificial esophagus but also played a role in protecting the neoesophagus from stenosis, by functioned as a bougienage after artificial esophagus sloughing. Therefore, FRM is an effective way for establishing a stable eating channel in the neoesophagus when using a nitinol composite artificial esophagus to replace the resected segment of an intrathoracic esophagus.

Delayed primary anastomosis for management of long-gap esophageal atresia: a meta-analysis of complications and long-term outcome

Management of newborns with long-gap esophageal atresia (LGEA) remains a challenge for pediatric surgeons. Since spontaneous growth of the esophageal segments occurs without mechanical stretching, initial gastrostomy followed by delayed primary anastomosis (DPA) comprises treatment in most LGEA patients. This meta-analysis aimed to investigate the complications and long-term outcome in patients with LGEA managed by DPA. A systematic literature search was conducted for relevant articles published between 1981 and 2011, and a meta-analysis of complications and long-term outcome was performed. Forty-four articles presented data on 451 newborns with LGEA managed by DPA. Most common variants were pure LGEA (194/451) and LGEA with tracheoesophageal fistula (257/451). Initial gap lengths ranged from 1.9 to 7.0 cm. At the time of DPA, performed at a mean of 11.9 weeks (range 0.5-54.0), the gap had decreased to 0.5-3.0 cm. Mean follow-up was 5.5 years (range 0.5-27.0). Frequent complications were anastomotic leaks/strictures, gastroesophageal reflux (GER), esophagitis and dysphagia. Relative risk for strictures was significantly higher in patients who previously had a leak (p < 0.0001) or GER (p < 0.0001). Patients with GER also had a significantly higher risk for esophagitis (p = 0.0283) and dysphagia (p = 0.0174). The majority of patients could eat without swallowing difficulties at follow-up. DPA provides good long-term functional results. However, the high incidence of GER and associated strictures requires early intervention to prevent feeding problems.

No New Therapeutic Approach

In actual fact, achalasia affects the entire esophagus, which is paralyzed (chalasia=relaxation), much too long, and subject to muscular hypertrophy; esophageal folds are therefore lacking, as is correctly shown in the figure accompanying the article. Impedance manometry confirms the fact that the entire esophagus is affected: no spasmolytic drugs will help, the esophagus is passively closed, which is shown by the elastance pressure volume curve. The esophagus does not have a lower sphincter but a centimeter-long muscular elastic closure segment consisting of two spiral shaped tubes that are inconspicuously embedded in the muscle wall (and act as an extension splint/brace. The muscle fibers in the esophagus are arranged in an elongated spiral in an oval shape and transport food. If a botulinum toxin injection is carried out the endoscope penetrates into this long segment and unintentionally distends it. Botox paralyzes only skeletal muscles. In human beings, smooth muscles in a spiral arrangement are found in the distal esophagus (2). Myotomy always splits only the easily detachable, very thick outer layer of the elastic esophageal closure segment and not the thinner, inner layer that has grown together with the epithelium. The inner tube therefore remains paralyzed but does not act as an obstruction any longer. The studies do not provide any new treatment for achalasia, merely for reflux esophagitis—by tightening the slack closure mechanism. The existing comprehensive literature does not include the underlying etiology that explains all these disorders.

A modified Foker’s technique for long gap esophageal atresia

External traction using the Foker's technique enables elongation in the esophageal segments within days, and allows the primary repair of the long gap. This article presents our modified Foker's technique which was easily applicable for long-gap esophageal atresia.

Epidemiological investigation of Barrett's esophagus in patients with gastroesophageal reflux disease in Northwest China

ObjectiveTo investigate the prevalence and possible risk factors of Barrett's esophagus (BE) in patients with gastroesophageal reflux disease (GERD) in Northwest China. MethodsPatients older than 18 years who underwent regular health check-up or had upper gastrointestinal symptoms in the endoscopy centers of four major teaching hospitals located in four different provinces of Northwest China from September 2008 to February 2009 were included in the study. A face-to-face reflux diagnostic questionnaire including risk factors were taken and scale scores (Sc) were accumulated. Diagnostic criterion of GERD was Sc≥12 points. None of these subjects received anti-acid medication prior to their endoscopy done. Barrett's esophagus was diagnosed when specialized intestinal metaplasia was detected histologically. ResultsA total of 528 patients met the criteria of GERD, among which 32 patients (20 male and 12 female) were diagnosed with BE. BE was present in 6.06% with a mean age of 51.2±11.6 years, which was significantly older than patients with GERD without BE (46.6±13.3 years) (P<0.05). There were significant differences between BE and GERD patients regarding gender, age, hiatus hernia, smoking and alcohol consumption (P<0.05), while no significant difference regarding symptoms of GERD. There was significant difference between short segment Barrett's esophagus and long segment (65.6% vs 34.4%, P<0.05). ConclusionThe prevalence of BE was 6.06% in patients with GERD in northwest China and was dominated by SSBE. The potential risk factors of Barrett's esophagus were older age, male, esophageal hiatal hernia, smoking and alcohol consumption.

Fragmented esophageal smooth muscle contraction segments on high resolution manometry: a marker of esophageal hypomotility

Esophageal peristalsis consists of a chain of contracting striated and smooth muscle segments on high resolution manometry (HRM). We compared smooth muscle contraction segments in symptomatic subjects with reflux disease to healthy controls. High resolution manometry Clouse plots were analyzed in 110 subjects with reflux disease (50 ± 1.4 years, 51.5% women) and 15 controls (27 ± 2.1 years, 60.0% women). Using the 30 mmHg isobaric contour tool, sequences were designated fragmented if either smooth muscle contraction segment was absent or if the two smooth muscle segments were separated by a pressure trough, and failed if both smooth muscle contraction segments were absent. The discriminative value of contraction segment analysis was assessed. A total of 1115 swallows were analyzed (reflux group: 965, controls: 150). Reflux subjects had lower peak and averaged contraction amplitudes compared with controls (P < 0.0001 for all comparisons). Fragmented sequences followed 18.4% wet swallows in the reflux group, compared with 7.5% in controls (P < 0.0001), and were seen more frequently than failed sequences (7.9% and 2.5%, respectively). Using a threshold of 30% in individual subjects, a composite of failed and/or fragmented sequences was effective in segregating reflux subjects from control subjects (P = 0.04). Evaluation of smooth muscle contraction segments adds value to HRM analysis. Specifically, fragmented smooth muscle contraction segments may be a marker of esophageal hypomotility.

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.

Su1087 Heartburn and Condition of Distal Part of Esophagus in Pregnancy

Ineffective esophageal motility (IEM) has been observed in erosive and non-erosive reflux disease (NERD) patients and may account for delayed bolus transit and impaired esophageal reflux clearance. It has been demonstrated that conventional manometry findings cannot predict reflux clearance in GERD patients. High resolution manometry (HRM) allows an accurate analysis of esophageal motility. Distal contractile integral (DCI) integrates the length, contractile vigour, and duration of contraction of the first two segments of the distal esophagus. Aim: To assess the correlation between HRM findings and reflux clearance in GERD patients. Methods: Following a 3-week washout from PPI and/or H2 antagonists, HRM and 24-hour ambulatory multichannel pH-impedance (pH-MII) monitoring were performed in 37 consecutive GERD patients, with no evidence of hiatal hernia at endoscopy. Patients were analyzed in the supine position, a catheter with 36 solid state pressure sensors located at 1 cm intervals (MMS, HRIM, Enschede, The Netherlands) was used. Data were stored and analyzed using dedicated software. A total of 10 saline (5 ml) swallows, at 30sec intervals were analyzed in each subject. The pH-impedance assembly was positioned with the pH electrode at 5cm above the LES and impedance measuring segments at 3, 5, 7, 9, 15 and 17cm above LES (Sandhill Scientific, USA). Reflux episodes were classified according to standardized criteria. Mean reflux clearance time (RCT) and reflux exposure time (RET) were calculated using Bioview software analysis, after a manual analisys of each pH-MII tracing. DCI was calculated and correlated to RCT and RET values by means of linear regression analysis. HRM tracings were analyzed according to the Chicago classification. IEM was defined by the presence of hypothensive or absent peristaltic waves in >20% of deglutitions. Results: Of the 37 patients, 30 showed normal esophageal motility and 7 IEM. Mean DCI values were 1562 (95% CI, 1203-1921) mmHg*s−1*cm−1 in all patients and 182 (95% CI, 122-242) mmHg*s−1*cm−1 in the 7 patients with IEM (p<0.001). Mean RCT and RET were 12.2 sec. and 3.6% of total recording time in all 37 patients, 13.5 sec. and 6.5% in the 7 IEM patients. No correlation was found between DCI and mean RCT and RET (r= 0.3 and 0.25, respectively). Weak correlation was found between DCI and mean RCT in the subgroup of IEM patients (r= 0.65, p<0.05). Conclusions: failure of esophageal motility seems to play a weak role in the clearing of gastroesophageal reflux episodes. DCI is not correlated to impaired esophageal reflux clearing whose occurrence could depend on the balance between the magnitude of the motility weakness and of the flow resistance at esophago-gastric junction.

Comparison of the results of lymph node dissection via left versus right thoracotomy

Up to now surgical treatment has been still the most effective treatment for esophageal cancer. However, postoperative lymph node recurrence is still a frequent event and affects long term survival considerably. The aim of this study is to compare the results of lymph node dissection via left vs. right thoracotomies and to verify whether there is any essential difference in lymphadenectomy between these two approaches. Five hundred and fifty-nine cases with thoracic esophageal cancer were randomly selected from the database of esophageal cancer patients who underwent surgical treatment in our hospital between May 2005 and January 2011, including 282 cases through left thoracotomy and 277 cases through right thoracotomy. This series consisted of 449 males and 110 females with a mean age of 58.8 years (age range: 36 - 78 years). The pathological types were mainly squamous cell carcinoma (548 cases) and other rare types (11 cases). The data were analyzed and compared using Chi-square test. The P-value < 0.05 was considered as statistically significant. The actual 5-year survival rate was calculated based on the recent follow-up data of the patients who underwent surgery at least 5 years ago. The average number of dissected lymph nodes was 23.4 via left versus 24.6 via right thoracotomies. The overall lymph node metastasis rate was 48.9% via left thoracotomy and 53.8% via right thoracotomy, and 34.8% vs. 50.5% in the chest (P < 0.001), 29.1% vs. 17.7% in the abdomen (P = 0.001). The pathologically confirmed lymph node metastasis rate was 45.9%, 44.0% and 34.9% in the upper, middle and lower segments of thoracic esophagus, respectively. The lymph node metastasis rates detected via left and right thoracotomy in the stage T1 cases were 14.7% (5/34) vs. 42.9% (12/28) (P < 0.001), and in the stage T2 cases were 35.4% (17/48) vs. 52.8% (28/53) (P = 0.007); in the station of para-thoracic esophagus were 9.6% vs. 13.4%, in the left upper mediastinum were 2.1% vs. 7.6%, and in the right upper mediastinum were 1.4% vs. 26.0%, respectively. The preliminary actual 5-year survival rate was 38.2% in the cases via left thoracotomy vs. 42.1% in those via right thoracotomy. The results of this study demonstrate that lymph node dissection is more complete via right thoracotomy than via left thoracotomy, especially for the tracheoesophageal groove and para-recurrent laryngeal nerve nodes, which may eventually improve the survival of patients with esophageal cancer. Therefore, surgical treatment via right thoracotomy by Ivor-Lewis (two incisions) mode or Levis-Tanner (three incisions) mode with two-field or three-field complete lymph node dissection may become prevalent in the future.

P.19.3 ESOPHAGEAL HIGH RESOLUTION MANOMETRY FINDINGS DO NOT CORRELATE WITH CLEARANCE OF GASTRO-ESOPHAGEAL REFLUX IN GERD PATIENTS

Ineffective esophageal motility (IEM) has been observed in erosive and non-erosive reflux disease (NERD) patients and may account for delayed bolus transit and impaired esophageal reflux clearance. It has been demonstrated that conventional manometry findings cannot predict reflux clearance in GERD patients. High resolution manometry (HRM) allows an accurate analysis of esophageal motility. Distal contractile integral (DCI) integrates the length, contractile vigour, and duration of contraction of the first two segments of the distal esophagus. Aim: To assess the correlation between HRM findings and reflux clearance in GERD patients. Methods: Following a 3-week washout from PPI and/or H2 antagonists, HRM and 24-hour ambulatory multichannel pH-impedance (pH-MII) monitoring were performed in 37 consecutive GERD patients, with no evidence of hiatal hernia at endoscopy. Patients were analyzed in the supine position, a catheter with 36 solid state pressure sensors located at 1 cm intervals (MMS, HRIM, Enschede, The Netherlands) was used. Data were stored and analyzed using dedicated software. A total of 10 saline (5 ml) swallows, at 30sec intervals were analyzed in each subject. The pH-impedance assembly was positioned with the pH electrode at 5cm above the LES and impedance measuring segments at 3, 5, 7, 9, 15 and 17cm above LES (Sandhill Scientific, USA). Reflux episodes were classified according to standardized criteria. Mean reflux clearance time (RCT) and reflux exposure time (RET) were calculated using Bioview software analysis, after a manual analisys of each pH-MII tracing. DCI was calculated and correlated to RCT and RET values by means of linear regression analysis. HRM tracings were analyzed according to the Chicago classification. IEM was defined by the presence of hypothensive or absent peristaltic waves in >20% of deglutitions. Results: Of the 37 patients, 30 showed normal esophageal motility and 7 IEM. Mean DCI values were 1562 (95% CI, 1203-1921) mmHg*s−1*cm−1 in all patients and 182 (95% CI, 122-242) mmHg*s−1*cm−1 in the 7 patients with IEM (p<0.001). Mean RCT and RET were 12.2 sec. and 3.6% of total recording time in all 37 patients, 13.5 sec. and 6.5% in the 7 IEM patients. No correlation was found between DCI and mean RCT and RET (r= 0.3 and 0.25, respectively). Weak correlation was found between DCI and mean RCT in the subgroup of IEM patients (r= 0.65, p<0.05). Conclusions: failure of esophageal motility seems to play a weak role in the clearing of gastroesophageal reflux episodes. DCI is not correlated to impaired esophageal reflux clearing whose occurrence could depend on the balance between the magnitude of the motility weakness and of the flow resistance at esophago-gastric junction.