Food Reflux Research Articles

Plication of the Ileocolic Valve to Prevent Food Reflux when an Ileocolon Flap is Used for Reconstruction of Esophagus and Voice

The advancement of microvascular bowel transfer has brought about good results in esophageal reconstruction. Within the last 10 years, the ileocolic flap has been advocated for simultaneous reconstruction of the esophagus and voice tube after total pharyngolaryngectomy. However, food reflux should be prevented to avoid aspiration.

Myasthenia gravis in a Boxer

HISTORY The patient presented with a three week history of vague signs, including exercise intolerance, hind limb weakness, cough and regurgitation/vomiting. These signs were insidious in onset, intermittent and had become progressively worse. There had been no response to empirical use of ranitidine, metoclopramide or NSAIDs, but the cough had responded to cephalexin. By the time of referral examination, she could not walk more than a few paces without collapsing, she was dyspnoeic and the coughing had recurred. Questioning did not enable the reflux of food to be differentiated as regurgitation or vomiting.

Dual-radionuclide simultaneous gastric emptying and bile transit study after gastric surgery with double-tract reconstruction

The physiology of gastrointestinal transfer function after proximal gastrectomy with bypass-tract reconstruction is not well understood. We applied a simultaneous dual-radionuclide method with a hepatobiliary imaging and gastric emptying study to evaluate physiologic alterations occurring after surgery. Nineteen patients with early gastric cancer, including 9 preoperative control patients and 10 who had proximal gastrectomy and double-tract reconstruction surgery were examined by dual-radionuclide hepatobiliary and gastric emptying studies (99mTc PMT and 111In DTPA). Retention fraction in the stomach at 3 minutes (R3) and 60 minutes (R60) and gastric emptying half-time (GET) were calculated. Bile reflux and mixture of bile and food were also evaluated. The retention fractions of R3 and R60 were significantly lower in the double-tract reconstruction group than those in the preoperative group. GET differed significantly between the double-tract and preoperative groups (20.7 min +/- 7.1 min and 36.2 min +/- 11.0 min, p = 0.0018). The mixture of bile and food was not good in the double-tract reconstruction group (p = 0.014 vs. preoperative). Patients with a large residual stomach showed slower initial emptying (p = 0.0068) and a better mixture of bile and food (p = 0.058) compared to those with a small residual stomach. The bile reflux was not significantly increased after surgery. The dual-radionuclide gastrointestinal and hepatobiliary imaging was feasible and could demonstrate characteristic transit patterns of the foods and bile in the double-tract reconstruction procedure. A larger residual stomach, if possible, is desirable to provide better transfer and mixing of bile and foods.

P0977 GASTROESOPHAGEAL REFLUX IN YOUNG ADULTS: ASSOCIATION WITH ITS DURING CHILDHOOD

Introduction: The Gastroesophageal reflux (GER) represents one of the main reasons for outpatient department consults in gastroenterology, general medicine and pediatrics. Although there are few epidemiologic studies correlating the occurrence of associated symptoms in both ages. Aim: Verifying the GER symptoms frequency in young adults, characterizing the predominant symptoms and correlating the GER occurrence in adults with presence of positive history during childhood. Methods: A survey including medical students and resident medical doctors was conducted in both sexes with questions about GER symptoms presence and frequency. The participants’ mothers filled in the previous data about childhood symptoms. The statistical analysis included the chi-square test an estimation of odds ratio. For all tests the values were considered statistically significant when p<0.05. Results: Complete answer was obtained in 211/300 investigations (70.3%). The GER history was positive in 98/211 (46.5%), 85 male and 126 female. GER has been characterized in 35/85 men (41.2%) and 63/126 women (50.0%). p= 0.207. The most prevalent symptoms were: post prandial plenitude (25.1%), heartburn (24.2%), eructation (22.8%), hiccups (13.7%), throat clearing (12.3%), nausea (11.9%), food reflux (11.4%), hoarseness (6.2%), chocking (5.7%), night coughing (3.7%) and vomits (0.5%). 87/98 of GER positive cases assembled 2 or more symptoms, and 31 at least 4 symptoms associated. The GER was present in childhood in 71 participants, among those 44 (62%) maintained the clinical feature during adulthood OR=2.60 p=0.001. Conclusion: 1) GER symptoms are frequent during adulthood. 2) There is no sex statistically predominance. 3) The majority of cases with GER positive history presented association of various symptoms. 4) There is a major chance of sustaining the GER symptoms during adult age when the history is positive during childhood.

Functional anatomy and physiology of the upper esophageal sphincter

Upper esophageal sphincter (UES) refers to the high-pressure zone located in between the pharynx and the cervical esophagus. The physiological role of this sphincter is to protect against reflux of food into the airways as well as prevent entry of air into the digestive tract. UES is a musculocartilaginous structure with its anterior wall being formed by the full extent of the posterior surface of the cricoid cartilage and arytenoid and interarytenoid muscles in the upper part. Posteriorly and laterally the cricopharyngeus (CP) muscle is a definitive component of the UES. CP has many unique characteristics: it is tonically active, has a high degree of elasticity, does not develop maximal tension at basal length, and is composed of a mixture of slow- and fast-twitch fibers, with the former predominating. These features enable the cricopharyngeus to maintain a resting tone and yet be able to stretch open by distracting forces, such as a swallowed bolus and hyoid and laryngeal excursion. CP, however, constitutes only the lower one third of the entire high-pressure zone. The thyropharyngeus (TP) muscle accounts for the remaining upper two thirds of the UES. The UES pressure is not entirely the result of myogenic activity, as a component of the pressure is the result of passive elasticity of the tissues. The opening of the UES involves relaxation of CP and TP muscles and forward movement of the larynx by the contraction of hyoid muscles. The UES function is controlled by a variety of reflexes that involve afferent inputs to the motorneurons innervating the sphincter. These physiological reflexes elicit either contraction or opening of the UES. Inability of the sphincter to open leads to difficulty in swallowing. Opening of the sphincter without associated CP relaxation leads to the clinical syndrome of cricopharyngeal bar.

Respiratory tract infections due to direct and reflux aspiration in children with severe neurodisability.

Lower respiratory tract infections in children with severe neurodisability are usually caused by aspiration of stomach contents from gastroesophageal reflux (GOR) or direct aspiration (DA) of food due to oral and pharyngeal motor problems. To determine the contributions and interactions of GOR and DA, oesophageal 24-hour pH monitoring and feeding videofluoroscopy were performed in 34 children (age range 7 months to 16 years, mean 7 years) who had severe physical and learning disabilities and who were slow feeders. Subjects were divided into three groups according to the frequency of their respiratory tract infections. Subjects in group 1 had no respiratory tract infections (N=10); five had GOR and none had DA. Subjects in group 2 had minor respiratory tract infections but had not received more than one course of antibiotics for this in the previous year (N=8); two had GOR alone, four had DA alone, and two had neither. All subjects in group 3 had recurrent respiratory tract infections (N=16); one had GOR alone, seven had DA alone, and eight had both GOR and DA. This study suggests that oral and pharyngeal motor problems are the major cause of respiratory tract infection in children with severe neurodisability. These problems lead to DA and, if GOR is present, to the aspiration of stomach contents. Those children with both DA and GOR are more likely to have severe respiratory tract infections which may lead to gastrostomy feeding (together with fundoplication). GOR without sufficient oral and pharyngeal motor problems to cause DA is less likely to cause respiratory tract infection in children with severe neurodisability.

Respiratory tract infections due to direct and reflux aspiration in children with severe neurodisability

Lower respiratory tract infections in children with severe neurodisability are usually caused by aspiration of stomach contents from gastroesophageal reflux (GOR) or direct aspiration (DA) of food due to oral and pharyngeal motor problems. To determine the contributions and interactions of GOR and DA, oesophageal 24‐hour pH monitoring and feeding videofluoroscopy were performed in 34 children (age range 7 months to 16 years, mean 7 years) who had severe physical and learning disabilities and who were slow feeders. Subjects were divided into three groups according to the frequency of their respiratory tract infections. Subjects in group 1 had no respiratory tract infections (N=10); five had GOR and none had DA. Subjects in group 2 had minor respiratory tract infections but had not received more than one course of antibiotics for this in the previous year (N=8); two had GOR alone, four had DA alone, and two had neither. All subjects in group 3 had recurrent respiratory tract infections (N=16); one had GOR alone, seven had DA alone, and eight had both GOR and DA. This study suggests that oral and pharyngeal motor problems are the major cause of respiratory tract infection in children with severe neurodisability. These problems lead to DA and, if GOR is present, to the aspiration of stomach contents. Those children with both DA and GOR are more likely to have severe respiratory tract infections which may lead to gastrostomy feeding (together with fundoplication). GOR without sufficient oral and pharyngeal motor problems to cause DA is less likely to cause respiratory tract infection in children with severe neurodisability.

Evaluation of esophageal bile reflux after total gastrectomy by gastrointestinal and hepatobiliary dual scintigraphy.

Conducting the qualitative evaluation of reconstruction methods is difficult because of their complexity. The aim of the present study was to compare esophageal bile and food reflux by performing gastrointestinal and hepatobiliary dual scintigraphy (GHDS) after various methods of reconstruction following total gastrectomy. Of 17 patients studied, 4 had undergone Roux-en-Y anastomoses (R-Y); 6, jejunal pouch-Y anastomoses (P-Y); and 7, jejunal pouch interposition (P-I). GHDS was performed 1 year after surgery using 111In-diethylene triamine pentaacetic acid administered orally, and 99mTc-pyridoxyl-5-methyl tryptophan administered intravenously. Imaging data from a gamma camera were stored in and processed by a data analyzer. Three patients who had undergone R-Y and one who had undergone P-I complained of heartburn, while one who had undergone R-Y, two who had undergone P-Y, and three who had undergone P-I complained of a feeling of fullness. Esophageal bile reflux was confirmed by GHDS in four of the patients who had undergone R-Y, one who had undergone P-Y, and four who had undergone P-I. Moreover, GHDS demonstrated food retention in two patients who had undergone R-Y, five who had undergone P-Y, and four who had undergone P-I. Weight loss was closely related to the esophageal reflux of bile or food which can be accurately detected by GHDS. Despite the absence of heartburn, patients diagnosed as having bile reflux by GHDS showed poor recovery of body weight.

Long-term quality of life after ablative intraoral tumour surgery

The aim of the present retrospective study was to determine the long-term quality of life of patients who had undergone intraoral tumour resection. 135 patients with a malignant tumour located in the floor of the mouth and the adjacent area were enrolled in the study. A standard questionnaire was used to determine the physical functional status, the psychological status and social functioning of cancer patients (Schipper et al., 1984). The results were related to the T-stage, the size and the location of the intraoral soft tissue defect, the mode of reconstruction and the postoperative interval. The results showed a significant correlation of the Functional Living Index-Cancer (FLIC) score with the Karnowsky-Index. The values were significantly lower in the higher T-stages. The location of the soft tissue defect, the type of soft tissue reconstruction and discontinuity resections of the mandible were crucial for postoperative quality of life, inasmuch as bilateral defects with loss of mandibular continuity and myocutaneous flap reconstructions showed significantly lower FLIC values. Reconstruction of mandibular continuity did not contribute to an increase in FLIC values. Dysphagia, reflux of food through the lips and nose during meals, decreased appetite and persistent pain significantly decreased the FLIC scores. It is concluded, that the FLIC is suitable for the determination of life quality in cancer patients since the score has shown the potential to reflect differences in postoperative life quality with regard to surgical procedures and functional sequelae.

Non-invasive detection of gastro-oesophageal reflux using an ambulatory system.

The aim of this study was the separate measurement of reflux of food and acid into the oesophagus in 37 healthy, ambulant subjects. This was performed by radiolabelling the food and monitoring its reflux with a small directional gamma detector, which was placed externally over the oesophagus, and connected to an ambulatory data recorder. The pH was measured with a conventional oesophageal pH electrode. This method permitted the separate characterisation of acid and neutral (food) components of gastro-oesophageal reflux. The gastric emptying characteristics of the test meal were also monitored by gamma scintigraphy in a separate experiment. The oesophageal pH fell below 4 for 3.2 + 8.6/-2.3% (mean (SD)) of the recording time. Food reflux alone occurred for 17.8 + 53.2/-13.8% of the recording time. Simultaneous food and acid reflux occurred for only 0.95 + 5.2/-1.2% of the time. Not every reflux event detected by a fall in pH was seen as an increase in counts as a result of reflux of food, and vice versa. This poor correlation of food and acid reflux implies incomplete mixing of food and acid in the stomach, and further shows the inadequacy of reflux diagnosis methods that depend on pH detection alone.

Indications for 24-hour gastric pH monitoring with single and multiple probes in clinical research and practice

The methodology of prolonged gastric pH monitoring has not yet been standardized with regard to the number and position of pH probes. Twenty-seven healthy volunteers and 11 patients affected by nonulcer dyspepsia have been submitted to 24-hr ambulatory simultaneous pH monitoring of the distal esophagus, fundus, and antrum. Fundic and antral pH profiles have been compared and causes of pH variations (pH > 4) identified. Both in healthy volunteers and dyspeptic patients, percentile curves of fundic and antral pH were statistically different in more than one of the daily periods considered (24-hr, postprandial, interdigestive, nocturnal). Percent time of duodenogastric reflux is significantly higher in the antrum than in the fundus in both groups. Modalities of gastric alkalinization secondary to food or duodenogastric reflux were different for the fundus and for the antrum both in healthy and dyspeptic subjects and between the two groups. These differences suggest that single and multiple pH monitoring of the stomach have different indications, and the position of the probes should vary according to the purpose of the test.

Temporary obturation of anterior residual clefts: Preliminary clinical report

In bilateral cleft lip and palate children, reflux of liquids and food into the nasal cavity, hypernasality and other speech deficiencies, displacement and risk of traumatic injuries to the premaxilla may be consequences of delayed surgical closure of the anterior palate. To address these problems, temporary obturation was undertaken with a newly designed orthopedic plate. The plate was well accepted by the ten consecutively treated patients and obturation was achieved in a clinical sense. The position of the premaxilla was corrected and maintained. Speech and intraoral air pressure were assessed. Both abilities improved with training and time after insertion of the plate.

Equine Cervical Esophagostomy: Complications Associated with Duration and Location of Feeding Tubes

SUMMARY Cervical esophagostomy for tube feeding was evaluated in 11 ponies. Minor complications responded to supportive therapy in 8 ponies. Two died of complications, and 1 pony had a permanent fistula because of persistent infection. There was a positive correlation between the duration of tube feeding and the event of closure of the esophageal stoma after the tube was removed. There was no difference in the frequency of complications related to duration of tube feeding. When the distal end of the feeding tube was located in the thoracic portion of the esophagus, instead of in the stomach, tubes were more readily dislodged. Reinsertion of some tubes was difficult or impossible to do and resulted in false passage of the tube into the mediastinal space, dissecting infections into the thorax, or both. Reflux of food around the tube occurred in ponies with the distal end of the feeding tube located in the stomach, but this was not associated with other complications.

Restoration of the alimentary tract after total gastrectomy using autosuture staplers

The first successful total gastrectomy was performed by Schlatter [I] in 1897. Schlatter restored digestive tract, continuity with an end-to-side esophagojejunostomy. For the next fifty years many ineffective surgical procedures were tried to correct the incapacitating esophagitis and malnutrition accompanying end-to-side esophagojejunostomy. In 1947 Orr [2] solved the problem of reflux esophagitis by dividing the jejunum below the ligament of Treitz and anastomosing the esophagus to the distal jejunum. The afferent jejunal limb was joined to the efferent jejunal limb below the anastomosis. In 1952 Hunt [3] introduced the creation of a jejunal pouch as a reservoir to improve absorption and correct the disabling problems of dumping and weight loss. The publication in 1962 of Lawrence’s most demonstrative case [4] clanged the bell that awakened the surT gical world to the importance of the Hunt pouch with the Orr Roux-en-Y alkaline diversion. In 1968 Scott, Gobbel, and Law, [5,6] further confirmed the value of the procedure with their experience. Paulino [7] noted that his patients with a Hunt-Lawrence pouch frequently had disagreeable symptoms of regurgitation. He evaluated these patients and discovered that they did not have esophagitis, but they did have reflux of food from the pouch into the esophagus. To correct the regurgitation, Paulino added the refinement of an isoperistaltic segment of jejunum between the esophagus and the jejunal pouch. Paulino reported excellent results in three patients. He sug-

Further experiences with jejunal gastrostomy.

An ideal permanent gastrostomy should allow for simple administration of food and also should prevent the reflux of food or the leakage of acid gastric chyme onto the anterior abdominal wall. Having become discouraged with many of the usual gastrostomy methods, particularly as related to the reflux of acid gastric chyme (Fig. 1), we sought a new method which would have the advantages of an ideal gastrostomy. Merendino and Dillard (1955) used an isolated loop of jejunum as a substitute sphincter between esophagus and stomach. One of the outstanding features of this operation has been the prevention of gastroesophageal reflux due, apparently, to the peristaltic action of the jejunal loop. It seemed to us that such a loop had a potential quality that would be useful in the construction of a permanent gastrostomy. On the basis of these considerations, a technique evolved using an isolated loop of jejunum between the

USE OF THE DEFUNCTIONALIZED LOOP OF JEJUNUM IN BILIARY AND PANCREATIC SURGERY

ON VARIOUS occasions it becomes necessary to perform anastomoses between the intestinal tract and the gallbladder, common duct, cysts of the common duct, pancreatic cysts and pancreatic fistulas. Direct anastomosis to the side of the duodenum or jejunum represents a simple type of procedure to allow discharge of the bile or pancreatic secretion into the intestine. Such a direct anastomosis would naturally allow reflux of food and intestinal content, at least to a mild degree, into the structure anastomosed with the intestine. It would appear that this reflux of food and irritating intestinal content might give rise to infection. In the majority of instances this does not occur, at least not to a detrimental degree, particularly when an operation such as cholecystoduodenostomy is performed as a palliative procedure for inoperable carcinoma of the head of the pancreas. To minimize the danger of infection, an anastomosis between the gallbladder and the