Prior Gastric Surgery Research Articles

Gastroparesis: A Review of Current Diagnosis and Treatment Options.

Gastroparesis (GP) is a chronic neuromuscular disorder of the upper gastrointestinal tract. The incidence of GP is not well described; however, the number of individuals affected by symptoms of GP in the United States is estimated to be over 4 million. The etiology of GP is diverse. Approximately 25% of cases are associated with diabetes, whereas nearly 50% are classified as idiopathic; many of these latter cases likely represent a postinfectious process. Connective tissue disorders, autoimmune disorders, prior gastric surgery, ischemia, and medications make up the vast majority of the remaining cases. The pathophysiology of GP is also diverse. Abnormalities in fundic tone, antroduodenal dyscoordination, a weak antral pump, gastric dysrhythmias, and abnormal duodenal feedback all contribute to delays in gastric emptying and symptom expression. Characteristic symptoms of GP include nausea, vomiting, epigastric pain, early satiety, and weight loss. The diagnosis of GP is made using a combination of characteristic symptoms in conjunction with objective evidence of delayed gastric emptying in the absence of mechanical obstruction. Once the diagnosis is made, treatment options include dietary modification, medications to accelerate gastric emptying, antiemetic agents, gastric electrical stimulation, and surgery. In the following sections we will provide an overview of the health care impact of GP, describe the underlying pathophysiology, and review treatment options using an evidence-based approach.

Laparoscopic Repair of Paraesophageal Hernias with a Falciform Ligament Buttress

BackgroundButtressing the crura in paraesophageal hernia (PEH) repairs with synthetic mesh may be associated with erosions and dysphagia, while biologic buttresses are expensive and do not decrease long-term recurrence rates. This study documents outcomes following laparoscopic PEH repairs using the falciform ligament as a buttress. MethodsThis is a prospective study of laparoscopic PEH repairs with a falciform ligament buttress. Preoperatively and at 6 months follow-up, medications, radiologic studies and symptom scores were recorded. Patients included had a hiatal defect greater than 5 cm, while recurrent PEH or prior gastric surgery patients were excluded. ResultsThirty-four patients were included with a mean age of 61 years, and 33 patients completed postoperative evaluation with a mean follow-up of 7.1 months. The mean symptom severity decreased from 11.24±1.71 to 3.24 ± 0.84, mean symptom frequency decreased from 11.62±1.70 to 3.45 ± 0.85, and mean total symptom score decreased from 22.85±3.40 to 6.69±1.69 (p < 0.0001). Three patients had recurrences on the upper gastrointestinal (UGI) series. Only one required reoperation. ConclusionsLaparoscopic PEH repair with a falciform ligament buttress is a viable option. Ongoing follow-up will demonstrate the utility of this approach to decrease morbidity and recurrence rates for paraesophageal hernia repairs.

201: Prevalence of prior gastric bypass surgery among obese pregnant women and associated adverse pregnancy outcomes

201: Prevalence of prior gastric bypass surgery among obese pregnant women and associated adverse pregnancy outcomes

A Case of Gastroplasty Presenting With Weight Gain and Abdominal Pain Due to a Defect Leading to Surgical Separation of the Proximal Stomach

Introduction: Vertical banded gastroplasty is a common procedure for the treatment of morbid obesity. We present a case of vertical banded gastroplasty in which there was a defect that led to the surgical separation of the proximal stomach. This separation led to weight gain and abdominal pain with increased heartburn. A very pleasant 62-year old female who had vertical banded gastroplasty presented with increased abdominal pain, heartburn, and progressive weight gain of 42 lbs in the past 3 months. An upper GI series was done which revealed a defect in the prior gastric surgery area separating the proximal stomach. The barium contrast used for the study passed through both sides of the proximal stomach, indicating a defect. Subsequently, an upper endoscopy was done and it confirmed the defect in original vertical banded gastroplasty. The patient was sent for surgical repair of the defect. Conclusion: In patients who have had vertical banded gastroplasty, complications such as surgical separation of the gastroplasty can lead to progressive weight gain, increased heart burn and abdominal pain.Figure 1Figure 2Figure 3

A Rare Stomach Lesion: Gastritis Cystica Profunda

Gastritis cystica profunda is described as gastric glands covered with normal gastric mucosa that locate submucosally and form cystic expansion. Its etiology is not clear, but the most important cause is prior gastric surgery. There is no agreed treatment because of its rarity. A 44-year-old female patient was admitted to hospital with complaints of abdominal pain and vomiting. We found a 2-cm mass in the wall of the stomach as a result of investigations. The patient was operated on with a preliminary diagnosis of gastric cancer. Surgeon performed excision of the total mass only. Pathological examination of the mass revealed that it was gastritis cystica profunda. Gastritis cystica profunda is a rare lesion of the stomach, and can be confused with other gastric pathologies. Preoperative diagnosis is important because it can prevent unnecessary resections. Gastritis cystica profunda should be kept in mind in the differential diagnosis of gastric submucosal masses.

Etiologies of Dyspepsia among a Chinese Population: One Hospital-Based Study

Background and Methods: Dyspepsia refers to a collection of upper gastrointestinal symptoms, and the causes may be either organic or functional. The aim of this study was to investigate the etiologies of dyspepsia among a Chinese population in Taiwan. Patients who underwent upper endoscopy for symptoms of dyspepsia were retrospectively analyzed between January and December 2008. Exclusion criteria included cirrhosis with varices, heart-burn sensation as the main symptom, gastrointestinal bleeding, hepatobiliary abnormalities, prior gastric surgery, and use of anti-acid medication for more than 2 months. Patients were classified according to the findings of upper endoscopy. Results: Data from the medical records of 2062 patients were collected and retrospectively analyzed. Normal endoscopic findings, gastritis, gastric ulcers, duodenal ulcers, reflux esophagitis and esophageal or gastric malignancy accounted for 1174 (56.9%), 215 (10.4%), 254 (12.3%), 194 (9.4%), 182 (8.8%) and 43 (2.1%) cases, respectively. The overall ratio of H. pylori infection was 28.4%. The ratio was the highest in duodenal ulcers and the lowest in reflux esophagitis. A significantly higher ratio of patients with gastric ulcers had a history of aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) usage. Conclusion: Patients with organic dyspepsia, compared to those with functional dyspepsia, were older, male, and had a higher H. pylori infection ratio, a positive relationship with aspirin or NSAIDs usage, and more risk factors. These findings demonstrate that upper endoscopy has a high diagnostic yield in patients in this group.

An Evidence-Based Approach to the Management of Functional Dyspepsia Associated With Helicobacter pylori Infection.

BackgroundFunctional dyspepsia is defined as at least a 3-month history of dyspepsia without structural explanation for the symptoms, and it accounts for most cases of dyspepsia. We designed this study to investigate functional dyspepsia among a Chinese population in Taiwan.MethodsData from the medical records of 1,143 adult patients who underwent transoral upper endoscopy for symptoms of dyspepsia in our hospital were retrospectively analyzed between January 2008 and December 2008. Exclusion criteria were structural gastrointestinal and hepatobiliary abnormalities, prior gastric surgery or history of chronic medication use.ResultsPatients were mainly in the third and fourth decades of life. More female patients were noted than male patients (ratio 2:1). The rate of Helicobacter pylori infection was 18.5%. The rate of response to therapeutic agents, including proton pump inhibitors, H2-receptor antagonists and prokinetic agents, ranged from 69% to 77% among all cases. Patients who underwent H. pylori eradication therapy (88.8%) had a significantly higher rate of symptom improvement than those without H. pylori infection (77.5%).ConclusionCases with functional dyspepsia have the characteristics of middle age, female predominance, a relatively lower H. pylori infection rate and a positive response to H. pylori eradication therapy.

Coconut Bezoars in Patients with Prior Bariatric Surgery: Report of Two Cases

Purpose: Phytobezoars are concretions that are formed in the GI tract from undigested vegetable matter. Risk factors for bezoar formation include gastroparesis, use of high-dose antacids, high intake of vegetables/citric fruits and prior gastric surgery. Bezoars are especially noted to form in patients with vagotomy and pyloroplasty, or Billroth 2. There are fewer reports of bezoars in bariatric surgery patients. Coconut is an unusual source of bezoar formation, and only one case of coconut bezoar has been described in a bariatric patient. We present two cases of coconut bezoars in patients with prior bariatric surgery; one in a gastric bypass patient and one in a lap band patient. A 47-year-old female with a history Roux-en-Y gastric bypass seven years ago presented with four days of nausea and vomiting after eating corn bread with coconut. CT scan revealed an approximately 3-cm, fat density material at the gastrojejunal anastomosis. Upper endoscopy revealed a coconut bezoar in the gastric pouch. The bezoar was broken into small pieces with a snare and flushed through the anastomosis into the jejunum. The entire bezoar was cleared from the stomach. The patient had resolution of symptoms and was able to tolerate a liquid diet. A 37-year-old female with a history of Lap band placement three years ago presented with nausea and vomiting after eating half a coconut. Her lap band was deflated but her symptoms persisted. CT scan revealed a 2 cm x 2.2 cm fat density material located just above the gastric band. Upper endoscopy revealed a coconut bezoar above the gastric lap band. The bezoar was broken up with a snare and pushed into the stomach below the lap band. The patient experienced resolution of her symptoms and was able to resume her normal diet. We report the first case of a coconut bezoar in a lap band patient and only the second case report in a patient with a prior Roux-en Y gastric bypass surgery. Bariatric surgery should be recognized as a possible risk factor for bezoar formation. Bariatric patients should avoid intake of significant amounts of coconut, as it may predispose to bezoar formation.

Acute Liver and Multi-organ Failure Secondary to Intentional Iron Overdose

Introduction: Intentional iron overdoses are rare in adults, but have severe consequences. We report two patients with multi-organ system failure occurring rapidly after large quantity oral iron ingestions. Case Discussion: A 26-year-old woman was transferred from an outside hospital (OSH) for acute liver failure (ALF): 48 hours prior, she had intentionally ingested a large amount of iron supplements. At initial presentation, she had nausea, gastrointestinal bleeding and normal liver enzyme levels. She then developed abdominal pain, tender hepatomegaly, elevated liver enzymes and coagulopathy (see table). No asterixis or encephalopathy was present. Deferoxamine, N-acetylcysteine (NAC) and dialysis were initiated. She progressed to coma, shock, brainstem herniation and death. Case B: A 35-year-old woman with prior gastric bypass surgery, hypertension, iron deficiency anemia and previous suicide attempt was transferred from an OSH with ALF after intentionally ingesting 300 iron pills the evening before. She developed nausea, vomiting, diarrhea and abdominal pain. Initially, she was hypertensive, had a tender abdomen, but no asterixis. Acute kidney injury (AKI) and severe acidosis were managed with intravenous fluids and, eventually, dialysis. She also received a proton pump inhibitor, NAC, polyethylene glycol laxative and deferoxamine. She recovered after 16 days, with liver enzymes and INR near normal. However, she remained dialysis-dependent on discharge, and subsequently has been lost to follow-up. Acetaminophen adducts were negative, and no radio-opaque pills were identified on abdominal x-ray (KUB) in either case. Discussion: Iron overdose causes rapid onset multi-organ failure with high mortality. Iron-induced oxidative damage results from hepatocyte exposure to high quantities of non-transferrin bound iron via the portal venous system, resulting in excessive free radical production. Peak serum iron levels occur 4-6 hours after ingestion. Bowel irrigation is indicated if tablets are identified on KUB. IV deferoxamine should be administered early if systemic signs such as metabolic acidosis are present. NAC can be given empirically. AKI is thought to be from direct mitochondrial injury and lactic acidosis. In case B, survival may, in part, have been due to the history of gastric bypass surgery, which may have limited absorption. These patients were enrolled in the Acute Liver Failure Study Group registry, supported by U-01-58369-014 from NIDDK.Table 5: Liver function tests

Endoscopic Management of a Rare Case of Duodenal Phytobezoar Resulting in Small Bowel Ulceration with a Visible Vessel

Introduction: Bezoars are collections of indigestible material that accumulate in the GI tract. Found in less than 1% of patients (pts) undergoing EGD, bezoars are rarely seen. We report a case and the endoscopic management of a duodenal phytobezoar that resulted in duodenal ulceration with a visible vessel. Case: A 63-year-old male with a history (hx) of diabetes mellitus (DM) presented to our hospital with a 2-week hx of epigastric pain. Physical exam was normal; however, contrasted CT imaging showed dilated first and second duodenal segments and the proximal duodenum appeared to be filled with multiple soft tissue density fragments. EGD discovered a large duodenal phytobezoar comprised of several rounded boulder appearing and shaped food particles. Using a combination of rat tooth and roth net, pieces were removed from the bulb and from the pt. As the phytobezoar was methodically and endoscopically taken apart and removed one large duodenal ulcer were visualized. A 10 mm x 8 mm ulcer with an adherent clot was seen along the posterior wall. The clot was removed and the visible vessel was cauterized with a 10 Fr gold probe. Biopsies from the edge of the ulcer were taken and significant for chronic duodenitis. Discussion: Bezoars are usually located in the stomach and are classified based on their composition and the three most common types of bezoars are phytobezoars (vegetable matter), trichobezoars (hair-life fibers), and medication bezoars (pharmacobezoars). Phytobezoars, the most common type, occur due to the continued ingestion of large amounts of insoluble and indigestible fibers such as cellulose and fruit tannin. Patients can either be asymptomatic or can have pain, vomiting, weight loss and early satiety. Phytobezoars can cause cause gastric outlet obstruction, pancreatitis, jaundice, and bleeding. The majority of pts with bezoars have a predisposing factor that decreases gastric emptying. Approximately 70% of pts have a hx of prior gastric surgery. Gastroparesis and DM have been implicated in bezoar formation. To diagnose bezoars, an EGD is the gold standard as plain films and contrast studies detect only 25% of bezoars discovered on EGD. For small bezoars, conservative medical management is often sufficient including liquid diet, prokinetic agent, and chemical dissolution with either cellulose, acetylcysteine, or Coca-Cola. For larger bezoars, endosopic treatment with endoscopic removal via fragmenting the bezoar with water jet, mechanical electrohydraulic, or injection of enzyme solutions should be attempted. If conservative management fails, pts often require surgery. Once bezoar formation occurs, there is a 14% recurrence rate.

Revisional bariatric surgery: perioperative morbidity is determined by type of procedure

Revisional bariatric procedures are on the rise. The higher complexity of these procedures has been reported to lead to increased risk of complications. The objective of our study was to compare the perioperative risk profile of revisional bariatric surgery with primary bariatric surgery in our experience. A prospectively maintained database of all patients undergoing bariatric surgery by three fellowship-trained bariatric surgeons from June 2005 to January 2013 at a center of excellence was reviewed. Patient demographics, type of initial and revisional operation, number of prior gastric surgeries, indications for revision, postoperative morbidity and mortality, length of stay, 30-day readmissions, and reoperations were recorded. These outcomes were compared between revisional and primary procedures by the Mann-Whitney or Chi square tests. Of 1,556 patients undergoing bariatric surgery, 102 patients (6.5%) underwent revisional procedures during the study period. Indications for revisions included inadequate weight loss in 67, failed fundoplications with recurrent gastroesophageal reflux disease in 29, and other in 6 cases. Revisional bariatric procedures belonged into four categories: band to sleeve gastrectomy (n = 23), band to Roux-en-Y gastric bypass (n = 25), fundoplication to bypass (n = 29), and other (n = 25). Revisional procedures were associated with higher rates of readmissions and overall morbidity but no differences in leak rates and mortality compared with primary procedures. Band revisions had similar length of stay with primary procedures and had fewer complications compared with other revisions. Patients undergoing fundoplication to bypass revisions were older, had a higher number of prior gastric procedures, and the highest morbidity (40%) and reoperation (20%) rates. In experienced hands, many revisional bariatric procedures can be accomplished safely, with excellent perioperative outcomes that are similar to primary procedures. As the complexity of the revisional procedure and number of prior surgeries increases, however, so does the perioperative morbidity, with fundoplication revisions to gastric bypass representing the highest risk group.

Tu1306 Endoscopic Removal of Sutures or Staples Relieves Symptoms and AIDS Healing of Anastomotic Ulcers in Post Gastric Surgery Patients

Symptomatic patients with a prior gastric surgery often have endoscopic findings such as marginal ulcers, anastomotic strictures or fistulae. Some of these findings are thought to be due to ischemia likely from a tight surgical staple or suture (foreign body). Redundant suture or exposed staples are common endoscopic findings in post-surgical anatomy.

Gastritis Cystica Profunda: A Rare Gastric Tumor Masquerading as a Malignancy

Introduction: Gastritis cystica profunda (GCP) is a rare tumor which occurs more commonly in patients with prior gastric surgery. The nonspecific symptoms and radiographic appearance of this tumor mimic that of other hyperproliferative conditions making diagnosis difficult without definitive surgical resection. This report provides a comprehen-sive review of GCP and all GCP cases reported to date. Methods: A comprehensive literature search (1972-2011) was conducted with all reported GCP cases analyzed. Keywords searched included gastritis cystica profunda, submucosal cysts of the stomach, and heterotopic submucosal gastric glands. Results: Thirty-seven GCP cases have been reported since 1972, which includes 29 (78%) men and 8 (21%) women (M:F ratio, 3.6:1). The overall mean age was 60.5 years (range, 39 - 81 years) with 55.6 years (range, 39 - 79) and 62.2 years (range, 39 - 81 years) in women and men, respectively. 65% (N = 24) had prior gastric surgery. 62% (N = 23) of GCP tumors were located in the body; 24% (N = 9) in the fundus; 8% (N = 3) in the antrum; or 6% (N = 2) in the cardia of the stomach. GCP was an incidental finding in 19% of patients. Complete excision was performed most often (73%) followed by endomucosal resection (18%), and polypectomy (4.5%). One patient underwent surveillance (4.5%). Conclusions: GCP is a rare gastric tumor, which is difficult to diagnose preoperatively and masquerades as a malignancy. GCP is more common in men and typically presents with nonspecific symptoms. Although a benign lesion, GCP may represent an intermediate histology in the malignant progression to gastric neoplasia. To date, there have been no reports of local recurrence or distant metastasis following definitive surgical excision, which remains the standard of care.

Inpatient capsule endoscopy leads to frequent incomplete small bowel examinations

To examine the predictive factors of capsule endoscopy (CE) completion rate (CECR) including the effect of inpatient and outpatient status. We identified 355 consecutive patients who completed CE at Rush University Medical Center between March 2003 and October 2005. Subjects for CE had either nothing by mouth or clear liquids for the afternoon and evening of the day before the procedure. CE exams were reviewed by two physicians who were unaware of the study hypotheses. After retrospective analysis, 21 cases were excluded due to capsule malfunction, prior gastric surgery, endoscopic capsule placement or insufficient data. Of the remaining 334 exams [264 out-patient (OP), 70 in-patient (IP)], CE indications, findings, location of the patients [IP vs OP and intensive care unit (ICU) vs general medical floor (GMF)] and gastrointestinal transit times were analyzed. Statistical analysis was completed using SPSS version 17 (Chicago, IL). Chi-square, t test or fisher exact-tests were used as appropriate. Multivariate logistic regression analysis was used to identify variables associated with incomplete CE exams. The mean age for the entire study population was 54.7 years. Sixty-one percent of the study population was female, and gender was not different between IPs vs OPs (P = 0.07). The overall incomplete CECR was 14% in our study. Overt obscure gastrointestinal bleeding (OGB) was significantly more common for the IP CE (P = 0.0001), while abdominal pain and assessment of IBD were more frequent indications for the OP CE exams (P = 0.002 and P = 0.01, respectively). Occult OGB was the most common indication and arteriovenous malformations were the most common finding both in the IPs and OPs. The capsule did not enter the small bowel (SB) in 6/70 IPs and 8/264 OPs (P = 0.04). The capsule never reached the cecum in 31.4% (22/70) of IP vs 9.5% (25/ 264) of OP examinations (P < 0.001). The mean gastric transit time (GTT) was delayed in IPs compared to OPs, 98.5 ± 139.5 min vs 60.4 ± 92.6 min (P = 0.008). Minimal SB transit time was significantly prolonged in the IP compared to the OP setting [IP = 275.1 ± 111.6 min vs OP = 244.0 ± 104.3 min (P = 0.037)]. CECR was also significantly higher in the subgroup of patients with OGB who had OP vs IP exams (95% vs 80% respectively, P = 0.001). The proportion of patients with incomplete exams was higher in the ICU (n = 7/13, 54%) as compared to the GMF (n = 15/57, 26%) (P = 0.05). There was only a single permanent SB retention case which was secondary to a previously unknown SB stricture, and the remaining incomplete SB exams were due to slow transit. Medications which affect gastrointestinal system motility were tested both individually and also in aggregate in univariate analysis in hospitalized patients (ICU and GMF) and were not predictive of incomplete capsule passage (P > 0.05). Patient location (IP vs OP) and GTT were independent predictors of incomplete CE exams (P < 0.001 and P = 0.008, respectively). Incomplete CE is a multifactorial problem. Patient location and related factors such as severity of illness and sedentary status may contribute to incomplete exams.

Transoral Incisionless Fundoplication: Initial Experience in Patients Referred to an Integrated Academic Institution

Transoral incisionless fundoplication is a new treatment for patients with gastroesophageal reflux disease. We present our initial experience with 10 patients undergoing this procedure with varying past surgical histories. All procedures were performed under general nasotracheal anesthesia. RAND-36 and Visual Analog Scale symptom scores were collected at pre and postoperative appointments for a mean of 9.2 months. The mean procedure time was 68 minutes. There were no intraoperative or postoperative complications. Patients with prior pancreaticoduodenectomy had observed reduced working space due to prior distal gastrectomy and required additional insufflation due to no pyloric resistance to insufflation of the small bowel. The patient with prior fundoplication required additional time and force for fastener penetration of the resultant scar from the partially disrupted fundoplication. All patients were discharged within 23 hours of the procedure. Throughout the follow-up period, patients reported gradual changes in medication requirements and symptom scores. There were no late complications. Transoral incisionless fundoplication is technically safe in well-selected patients including those with prior esophageal and gastric surgery.

Gastric Emptying of Solids and Liquids for Evaluation for Gastroparesis

Gastric emptying scintigraphy (GES) of solids is typically used to evaluate for gastroparesis. The purpose of this study was to determine the value of simultaneously measuring gastric emptying of liquids and solids for assessing patients for delayed gastric emptying. A total of 596 patients at our institution from September 2007 to January 2010 underwent GES with assessment of both solid and liquid gastric emptying. An EggBeaters® with jam sandwich meal radiolabeled with Tc-99 m was used for solid GES and water radiolabeled with In-111 for liquid GES. Inclusion criteria (no medications affecting gastric motility in 48 h prior to test; no prior gastric surgery) was met by 449 patients. Liquid gastric emptying was significantly correlated to solid gastric emptying: 30 min (r=0.652, P<0.001), 60 min (r=0.624, P<0.001) and 120 min (r=0.766, P<0.001). Interestingly, 60 patients, of which 57 were nondiabetic, had normal solid GES but delayed liquid emptying and represented 26% of the 228 patients with normal solid GES. Gastric retention of solids was mildly correlated with nausea, vomiting, loss of appetite, early satiety and feeling excessively full after meals. Gastric emptying of liquids was associated with early satiety and loss of appetite. Gastric emptying of liquids correlates well with gastric emptying of solids. When evaluating patients for gastroparesis, assessment of gastric emptying of liquids in addition to solids may help identify additional patients with delayed gastric emptying, particularly non-diabetic patients where 26% with normal solid emptying may have delayed emptying of liquids. Symptoms of gastroparesis, however, are primarily associated with delayed gastric emptying of solids.

Helicobacter pylori Testing in Patients with Funcional Dyspepsia: What Factors Dictate the Practice?

Purpose: Both functional dyspepsia (FD) and peptic ulcer disease (PUD) are associated with Helicobacter pylori (Hp) colonization. While Hp eradication is beneficial in patients with PUD, the same approach does not always reduce symptoms in FD patients. Despite this uncertainty, Rome III guidelines for FD recommend obtaining gastric biopsies for Hp testing in FD patients undergoing esophagogastroduodenoscopy (EGD). The extent to which this practice is performed is unknown. Methods: We evaluated the practice of obtaining gastric biopsies during EGD in dyspeptic patients with no endoscopic pathology (FD), compared this to patients with endoscopically confirmed PUD, and assessed the predictors of obtaining biopsies. All EGDs performed for evaluation of dyspepsia in adults at an urban hospital during the previous 29 months were identified and reviewed. Demographic and clinical information was extracted along with endoscopic and pathologic findings. Hp colonization was confirmed by histology. Results: A total of 1010 patients (618 women, mean age 50) underwent EGD. FD was diagnosed in 853 (84.5%) while 35 (3.5%) had PUD. The percentage of FD patients who had gastric biopsies taken did not differ significantly from patients with PUD (86.5% vs. 94.3%; p=0.37). Amongst those in which biopsies were obtained, the prevalence of Hp was 45.4% in FD compared to 60.6% in PUD patients (p=0.23). Within the FD cohort, there were significant ethnic differences in biopsy frequencies: Asians 91.7%, Hispanics 86.1%, African Americans 78.6%, and Caucasians 77.6%; p=0.016. FD patients born outside the U.S. were more likely to have biopsies taken than those born in the U.S. (87.2% vs. 65.7%; p=0.01). FD patients in whom gastropathy was noted endoscopically were more likely to have biopsies taken than those without gastropathy (95.7% vs. 63.4%; p<0.001). Neither patient age (p=0.08), gender (p=0.10), language (p=0.35), history of prior gastric surgery (p=0.34), history of prior Hp testing (p=0.39), nor the level of experience of the endoscopist (p=0.14) was predictive of whether or not biopsies would be obtained in the setting of FD. In multivariate logistic regression analysis controlling for age, gender, and ethnicity, both non-U.S. birth (OR 5.7 CI 1.7-18.8; p=0.005) and endoscopic gastropathy (OR 16.5 CI 8.4-32.5; p<0.001) remained significant predictors of obtaining biopsies. Conclusion: While the majority of patients with FD undergoing EGD had gastric biopsies taken, several factors were predictive of this practice including non-U.S. country of birth and the presence of endoscopic gastropathy. Further evaluation of the endoscopic assessment of FD patients may help provide important practice quality improvement measures.

Esophagectomy without thoracotomy: 25 years of experience over 750 patients

ObjectiveThis study aimed to review and evaluate our experience in 750 patients, who underwent transhiatal esophagectomy (THE) and analyze our data. Special attention was paid to some strategies, which we developed in the course of time, regarding the postoperative management of these patients and formulation of improved guidelines.Patients and methodsThis is a retrospective analysis of all THE operations performed between January 1981 until May 2007 in 750 patients: 60 patients (8%) had benign lesions, while 690 (92%) had malignant ones (5.2% of malignancies were located in the upper esophagus, 7.4% in the middle esophagus, 19% in the lower esophagus, and 68.4% at the cardioesophageal junction). THE and esophageal reconstruction were performed at the same operation in all patients. The stomach was our esophageal substitute of first choice with the colon and jejunum being acceptable alternatives in patients with prior gastric surgery and those necessitating synchronous gastrectomy for cancer invasion. A gastric tube was used as an esophageal substitute in 624 patients (83.2%), the whole stomach in 70 (9.4%), the colon in 43 (5.73%), and a jejunal loop in 13 (1.73%).ResultsThe overall in-hospital mortality rate was 2.93% (22 patients). There was no intraoperative death. Major complications included atelectasis or pneumonia (4.8%), pleural effusion (22.7%), myocardial infarction (0.5%), recurrent laryngeal nerve paralysis (1.33%), and three tracheal lacerations (0.4%). The anastomotic leak rate decreased gradually over time from 29.4% to 11.1% in the last 6 years. The average intraoperative blood loss was 315 ml and 82% of the patients did not receive any blood transfusion. Late functional results were good or excellent in 93%. The average length of hospital stay was 11 days and intensive care unit stay was 2.3 days. The actuarial 5-year survival rate after THE for carcinoma was 21%.ConclusionTHE is a safe and effective method of esophageal resection with low morbidity and mortality rates and good functional results when performed by experienced surgeons. We believe that our strategies concerning the way of dissecting the cervical esophagus, avoidance of performing pyloromyotomy, the delayed removal of the cervical drain and the delayed advance to oral feeding have reduced, noticeably, morbidity and mortality in our series.

Role of Endoscopic Therapy Plus Intravenous Proton Pump Inhibitor in Uremic Patients with High-Risk Peptic Ulcer Bleeding. Preliminary Report of a Case-Controlled Study

Background: The combination of endoscopic therapy and intravenous proton pump inhibitor (PPI) in treating peptic ulcer bleeding (PUB) has been shown to reduce re-bleeding rate. PUB patients with uremia are prone to re-bleed. Aim: To compare the efficacy of endoscopic therapy and subsequent intravenous PPI in high-risk PUB patients with or without uremia. Methods: Uremic and non-uremic patients having high-risk (adherent clot, NBVV and oozing) PUB were enrolled. We excluded cases with COPD, CAD, liver cirrhosis, bleeding tendency, pregnancy, gastric cancer, prior gastric surgery, and recent use of anti-secretory agents within one week. All patients received a successful endoscopic therapy with epinephrine injection (1: 10000, 5-15 ml) plus intravenous omeprazole, 40mg bolus followed by 40mg infusion every 12 hrs for 3 days. The primary outcomes including re-bleeding, need of surgery, all-cause mortality and secondary outcomes including units of blood transfusion, hospital stay, and complication were analyzed. The study was approved by the ethical committee of Ton-Yen General Hospital, Hsin-Chu, Taiwan. Results: From September 1999 to December 2006, a total of 64 patients (uremia: 31 and non-uremia: 33) were included. Their demographic data such as age, gender, personal and past medical history, and presenting symptoms were similar in both groups. The endoscopic features including gastric content, ulcer size, stigmata of recent hemorrhage, and the amount of injected epinephrine were comparable between both groups. The uremic group had more re-bleeding episodes (8/31 vs 1/33, p=0.009, OR(95%CI): 11.31(1.30-95.25)), all-cause mortality (4/31 vs 0/33, p=0.033, OR(95%CI): 1.148 (1.003-1.315)), units if blood transfusion after endoscopic therapy (mean (SD): 4.55(3.39) vs 1.91(1.72), p<0.001), hospital stay (day, median(range): 5 (2-48) vs 3(2-7), p<0.001), and complications during hospitalization (9/31 vs 0/33, p=0.001, OR(95%CI): 1.409 (1.125-1.176)). The need of surgery was not significantly different in both groups (1/31 vs. 0/33, p=0.298). Conclusion: Endoscopic therapy with epinephrine injection plus IV PPI has a limited value in uremic patients with high-risk PUB patients.

Measurement of gastric pH in ambulatory esophageal pH monitoring

Ambulatory esophageal pH monitoring is the method used most widely to quantify gastroesophageal reflux. The degree of gastroesophageal reflux may potentially be underestimated if the resting gastric pH is high. Normal subjects and symptomatic patients undergoing 24-h pH monitoring were studied to determine whether a relationship exists between resting gastric pH and the degree of esophageal acid exposure. Normal volunteers (n = 54) and symptomatic patients without prior gastric surgery and off medication (n = 1,582) were studied. Gastric pH was measured by advancing the pH catheter into the stomach before positioning the electrode in the esophagus. The normal range of gastric pH was defined from the normal subjects, and the patients then were classified as having either normal gastric pH or hypochlorhydria. Esophageal acid exposure was compared between the two groups. The normal range for gastric pH was 0.3-2.9. The median age of the 1,582 patients was 51 years, and their median gastric pH was 1.7. Abnormal esophageal acid exposure was found in 797 patients (50.3%). Hypochlorhydria (resting gastric pH >2.9) was detected in 176 patients (11%). There was an inverse relationship between gastric pH and esophageal acid exposure (r = -0.13). For the patients with positive 24-h pH test results, the major effect of gastric pH was that the hypochlorhydric patients tended to have more reflux in the supine position than those with normal gastric pH. There is an inverse, dose-dependent relationship between gastric pH and esophageal acid exposure. Negative 24-h esophageal pH test results for a patient with hypochlorhydria may prompt a search for nonacid reflux as the explanation for the patient's symptoms.