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Jeon D. Comment on " Twenty-four-hour pH monitoring of gastric conduit in post-esophagectomy patients: correlation with clinical and endoscopic parameters in a prospective cohort study from India". JOURNAL OF MINIMALLY INVASIVE SURGERY 2025; 28:64-65. [PMID: 40534517 DOI: 10.7602/jmis.2025.28.2.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2025] [Accepted: 06/10/2025] [Indexed: 06/22/2025]
Affiliation(s)
- Dongjae Jeon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Jain V, Varshney VK, Soni SC, Selvakumar B, Varshney P, Agarwal L, Agarwal A, Birda CL. Twenty-four-hour pH monitoring of gastric conduit in post-esophagectomy patients: correlation with clinical and endoscopic parameters in a prospective cohort study from India. JOURNAL OF MINIMALLY INVASIVE SURGERY 2025; 28:81-88. [PMID: 40534520 DOI: 10.7602/jmis.2025.28.2.81] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2024] [Revised: 02/12/2025] [Accepted: 04/15/2025] [Indexed: 06/22/2025]
Abstract
Purpose Esophagectomy for malignancy leads to decreased gastric conduit acidity due to bilateral vagotomy and fundic gland area reduction. However, reflux symptoms occur. The changes in pH of gastric conduit and esophageal remnant post-esophagectomy were studied and correlated clinically, endoscopically and with Helicobacter pylori positivity. Methods We studied 20 patients prospectively undergoing esophagectomy for malignancy from January 2022 to December 2023. The patients underwent pre- and postoperative clinical assessment, 24-hour pH monitoring, and esophagoduodenoscopy with H. pylori testing and analysis. Results Postoperatively, the total percent (%) time pH <4 was nonsignificantly increased to 17.95% (p = 0.754) in the esophageal remnant and significantly decreased to 53.5% (p = 0.012) in the stomach. Postoperatively, the H. pylori-positive patients had a non-significantly higher total % time pH <4 in the esophageal remnant than H. pylori-negative patients (29.47 ± 33.54 vs. 6.44 ± 11.58, p = 0.064) and slightly lower total % time pH <4 in the stomach (53.30 ± 46.08 vs. 53.71 ± 31.20, p = 0.982). The total % time pH <4 in the gastric conduit was significantly correlated with the esophageal remnant (p = 0.002), showing a correlation coefficient of 0.629. Conclusion There is a significant increase in gastric conduit pH post-esophagectomy with increased exposure to the esophageal remnant mucosa proportional to gastric acidity. H. pylori infection does not affect gastric aciditiy and acid reflux after esophagectomy.
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Affiliation(s)
- Vishu Jain
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, India
| | - Vaibhav Kumar Varshney
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, India
| | - Subhash Chandra Soni
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, India
| | - B Selvakumar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, India
| | - Peeyush Varshney
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, India
| | - Lokesh Agarwal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, India
| | - Ashish Agarwal
- Department of Gastroenterology, All India Institute of Medical Sciences, Jodhpur, India
| | - Chhagan Lal Birda
- Department of Gastroenterology, All India Institute of Medical Sciences, Jodhpur, India
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Chen C, Fan X, Li B, Hua R, Gu H, Guo X, Yang Y, Li S, Sun Y, Li C, Li Z. Comparative Outcomes of Ileocolon Graft Versus Gastric Conduit Reconstruction in Esophageal Cancer: A Propensity-Matched Analysis of Survival, Quality of Life, and Perioperative Risks. Ann Surg Oncol 2025:10.1245/s10434-025-17516-1. [PMID: 40419713 DOI: 10.1245/s10434-025-17516-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2025] [Accepted: 05/03/2025] [Indexed: 05/28/2025]
Abstract
BACKGROUND Esophagectomy with ileocolon graft (ICG) reconstruction serves as the standard surgical approach for esophageal cancer when gastric conduit (GC) is unavailable, yet comparative outcome data between these techniques remain scarce. This study evaluates survival, quality of life (QoL), and surgical risks between these approaches. PATIENTS AND METHODS A single-center cohort compared ICG (n = 95 after propensity score matching) and GC (n = 95) in patients with esophageal cancer. Operative outcomes, complications, survival, and QoL (assessed via EORTC QLQ-C30/OES18) were analyzed. RESULTS The 3-year overall survival [hazard ratio (HR):1.26, 95% confidence interval (CI) 0.81-1.96; p = 0.47] and recurrence-free survival (HR: 1.29, 95% CI 0.85-1.95; p = 0.09) were comparable. ICG patients exhibited significantly fewer reflux symptoms (p < 0.001) and less nausea/vomiting (p = 0.017), with better QoL scores. However, ICG required longer operative times (398.2 vs. 259.3 min; p < 0.001), greater blood loss (178.9 vs. 149.5 mL; p = 0.038), and higher reoperation rates (12 vs. 2; p = 0.005). Postoperatively, ICG was associated with extended hospital stays (15.9 vs. 11.8 days; p < 0.001), increased graft necrosis (4 vs. 0; p = 0.043), and a trend toward thromboembolism (3 vs. 0; p = 0.081). The 30-day mortality (2 vs. 0; p = 0.115) and long-term complications were similar between groups. CONCLUSIONS ICG and GC offer equivalent long-term survival, but ICG reduces reflux and improves QoL despite higher perioperative complexity. ICG represents a viable alternative for esophageal reconstruction when symptom control and QoL are prioritized.
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Affiliation(s)
- Chunji Chen
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinyi Fan
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bin Li
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rong Hua
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haiyong Gu
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xufeng Guo
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yang Yang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Saiqi Li
- Department of Intensive Care Unit, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yifeng Sun
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chunguang Li
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Zhigang Li
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Pollmann L, Linnemann J, Pollmann NS, Jürgens C, Schmeding M. Preoperative proton pump inhibitor therapy and anastomotic leak after esophagectomy-a new perspective. Langenbecks Arch Surg 2025; 410:157. [PMID: 40366457 PMCID: PMC12078452 DOI: 10.1007/s00423-025-03727-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2025] [Accepted: 05/01/2025] [Indexed: 05/15/2025]
Abstract
PURPOSE Proton pump inhibitors (PPIs) are indispensable in the treatment of gastro-esophageal reflux disease and peptic ulcers or for the prevention of stress ulcers after major abdominal surgery. However, long-term PPI therapy leads to several side effects such as delayed gastric emptying and distinct changes in mucosal histology. Therefore, this retrospective study aims to evaluate the impact of preoperative PPI therapy on the anastomotic leak rate after esophagectomy. METHODS A retrospective, single-center analysis was conducted for all patients treated with esophagectomy and gastric conduit reconstruction between January 2016 and November 2024. Preoperative treatment with PPIs, as well as patient comorbidities, histopathological findings and surgical techniques were noted. Subsequently, a group-wise comparison was carried out for the differences in anastomotic leak rate and postoperative complications in patients with and without preoperative PPI therapy. Finally, a multivariate logistic regression analysis was conducted for the occurrence of anastomotic leak. RESULTS A total of 229 patients were included in the study. The group-wise comparison revealed a significantly higher rate of anastomotic leaks and postoperative complications in patients with preoperative PPI therapy compared to those without. The multivariate logistic regression analysis indicated a 2.5-fold increased risk of anastomotic leaks in patients with preoperative PPI therapy compared to patients without. CONCLUSION Preoperative PPI therapy may represent a modifiable risk factor for the development of anastomotic leaks after esophagectomy. Further prospective, interventional studies are necessary to verify the results. TRIAL REGISTRATION The study was retrospectively registered in the German clinical trial database (Application number DRKS00035536, Registration date 03.12.2024).
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Affiliation(s)
- Lukas Pollmann
- Department of General and Visceral Surgery, Klinikum Dortmund gGmbH, Dortmund, Witten/Herdecke University, Beurhausstraße 40, 44137, Dortmund, Germany.
| | - Jonas Linnemann
- Department of General and Visceral Surgery, Klinikum Dortmund gGmbH, Dortmund, Witten/Herdecke University, Beurhausstraße 40, 44137, Dortmund, Germany
| | - Nicola S Pollmann
- Department of General-, Visceral and Transplant Surgery, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Claudius Jürgens
- Department of General and Visceral Surgery, Klinikum Dortmund gGmbH, Dortmund, Witten/Herdecke University, Beurhausstraße 40, 44137, Dortmund, Germany
| | - Maximilian Schmeding
- Department of General and Visceral Surgery, Klinikum Dortmund gGmbH, Dortmund, Witten/Herdecke University, Beurhausstraße 40, 44137, Dortmund, Germany
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Tankel J, Patel D, Nevo Y, Najmeh S, Spicer J, Mulder D, Mueller C, Ferri L, Cools-Lartigue J. Postoperative Outcomes and Quality of Life After Left Thoracoabdominal Esophagogastrectomy: Contrasting Esophagogastrostomy with Esophagojejunostomy. Ann Surg Oncol 2023; 30:8182-8191. [PMID: 37436604 DOI: 10.1245/s10434-023-13733-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/17/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Following left thoracoabdominal (LTA) esophagogastrectomy, gastrointestinal continuity can be re-established via esophagogastrostomy or esophagojejunostomy. We explored how the method of reconstruction impacted postoperative outcomes and quality of life (QoL). METHODS From January 2007 to January 2022, patients undergoing LTA were identified from a single center's prospectively maintained database. Following esophagogastrectomy or extended total gastrectomy, an esophagogastrostomy (GAS) or Roux-en-Y esophagojejunostomy (R-Y) was fashioned. Postoperative outcomes were compared according to the method of reconstruction. The Functional Assessment of Cancer Therapy-Esophagus (FACT-E) questionnaire compared QoL. RESULTS Of the 147 LTA patients identified, 135 (92%) were included-97 GAS (72%) and 38 R-Y patients (28%). R-Y patients had more ypT3/4 lesions (97% vs. 61%, p ≤ 0.001) and a similar incidence of ypN+/M+ disease. Anastomotic leaks were more common among GAS patients (17% vs. 3%, p = 0.023), however grade 3/4 complications (26.6% vs. 19.4%, p = 0.498), reoperation, intensive care admission, hospital representation and readmission were similar. FACT-E data were available for 68/97 (70%) GAS patients and 22/38 (58%) R-Y patients, with scores for 80/21/24/18/23/24 patients at baseline/preoperatively/1 month/3-6 months/1-3 years/3+ years postoperatively, respectively. Comparing between the groups, the scores were similar at each timepoint. FACT-E improved between baseline and preoperatively (79, 34-124 vs. 102, 81-123, p = 0.027). Only at 3+ years were postoperative scores equivalent to preoperative values. GAS patients had more reflux and esophagitis >6 months postoperatively (54% vs. 13%, p = 0.048; 62% vs. 0%, p ≤ 0.001). CONCLUSION While the type of reconstruction did not affect QoL, it did affect the postoperative course.
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Affiliation(s)
- James Tankel
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Devangi Patel
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Yenonatan Nevo
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Sara Najmeh
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Jonathan Spicer
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - David Mulder
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Carmen Mueller
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Lorenzo Ferri
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Jonathan Cools-Lartigue
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada.
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Krishnan U, Dumont MW, Slater H, Gold BD, Seguy D, Bouin M, Wijnen R, Dall'Oglio L, Costantini M, Koumbourlis AC, Kovesi TA, Rutter MJ, Soma M, Menzies J, Van Malleghem A, Rommel N, Dellenmark-Blom M, Wallace V, Culnane E, Slater G, Gottrand F, Faure C. The International Network on Oesophageal Atresia (INoEA) consensus guidelines on the transition of patients with oesophageal atresia-tracheoesophageal fistula. Nat Rev Gastroenterol Hepatol 2023; 20:735-755. [PMID: 37286639 DOI: 10.1038/s41575-023-00789-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 06/09/2023]
Abstract
Oesophageal atresia-tracheoesophageal fistula (EA-TEF) is a common congenital digestive disease. Patients with EA-TEF face gastrointestinal, surgical, respiratory, otolaryngological, nutritional, psychological and quality of life issues in childhood, adolescence and adulthood. Although consensus guidelines exist for the management of gastrointestinal, nutritional, surgical and respiratory problems in childhood, a systematic approach to the care of these patients in adolescence, during transition to adulthood and in adulthood is currently lacking. The Transition Working Group of the International Network on Oesophageal Atresia (INoEA) was charged with the task of developing uniform evidence-based guidelines for the management of complications through the transition from adolescence into adulthood. Forty-two questions addressing the diagnosis, treatment and prognosis of gastrointestinal, surgical, respiratory, otolaryngological, nutritional, psychological and quality of life complications that patients with EA-TEF face during adolescence and after the transition to adulthood were formulated. A systematic literature search was performed based on which recommendations were made. All recommendations were discussed and finalized during consensus meetings, and the group members voted on each recommendation. Expert opinion was used when no randomized controlled trials were available to support the recommendation. The list of the 42 statements, all based on expert opinion, was voted on and agreed upon.
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Affiliation(s)
- Usha Krishnan
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, New South Wales, Australia.
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.
| | - Michael W Dumont
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Hayley Slater
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Benjamin D Gold
- Children's Center for Digestive Health Care, GI Care for Kids, LLC, Atlanta, GA, USA
| | - David Seguy
- University of Lille, Reference Centre for Rare Oesophageal Diseases, CHU Lille, Lille, France
- Department of Nutrition, CHU Lille, Lille, France
| | - Mikael Bouin
- University of Montreal, CHUM Research Center (CRCHUM), Montréal, Quebec, Canada
| | - Rene Wijnen
- Department of Paediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Luigi Dall'Oglio
- Digestive Surgery and Endoscopy Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Anastassios C Koumbourlis
- Division of Pulmonary & Sleep Medicine, Children's National Medical Center, Washington, DC, USA
- George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Thomas A Kovesi
- Deptartment of Paediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- The University of Ottawa, Ottawa, Ontario, Canada
| | - Michael J Rutter
- Division of Paediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Otolaryngology, University of Cincinnati, Cincinnati, OH, USA
| | - Marlene Soma
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Otolaryngology, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Jessica Menzies
- Department of Nutrition and Dietetics, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | | | - Nathalie Rommel
- Department of Gastroenterology, Department of Neurogastroenterology and Motility, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, ExpORL, Deglutology, University of Leuven, Leuven, Belgium
| | - Michaela Dellenmark-Blom
- Department of Paediatric Surgery, The Queen Silvia Children's hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Vuokko Wallace
- Department of Psychology, University of Bath, Bath, UK
- Department of Psychology, University of Eastern Finland, Joensuu, Finland
| | - Evelyn Culnane
- Transition Support Service, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Graham Slater
- EAT Oesophageal Atresia Global Support Groups e.V., Stuttgart, Germany
| | - Frederic Gottrand
- University of Lille, Reference Centre for Rare Oesophageal Diseases, CHU Lille, Lille, France
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, CHU Lille, Lille, France
- Institute for Translational Research in Inflammation INFINITE, Inserm Faculté de Médecine, Université de Lille, Lille, France
| | - Christophe Faure
- Division of Paediatric Gastroenterology & Oesophagus Development and Engineering Lab, Sainte-Justine Hospital, Montréal, Quebec, Canada
- Université de Montréal, Montréal, Quebec, Canada
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Columnar epithelium morphology after esophagectomy: clinical insight into the development of Barrett's esophagus. Esophagus 2020; 17:392-398. [PMID: 32383128 DOI: 10.1007/s10388-020-00742-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/27/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND The presence of Barrett's mucosa in the esophageal remnant is a result of post-esophagectomy anastomotic site exposure to gastric acid and is regarded as a human model of Barrett's esophagus onset. Here, we attempted to clarify the relationship between duodenogastric reflux and formation of columnar epithelium by following the changes over time after esophagectomy. METHODS A total of 96 patients underwent esophagectomy due to superficial cancer from April 2000 to March 2018 were included in this study. Cases were divided into two groups according to the reconstruction technique after esophagectomy as either the gastric pull-up (Ga) group and ileocolonic interposition (Ic) group. Previously obtained endoscopic pictures of the cases were reviewed retrospectively and chronologically. RESULTS There were 24 cases of columnar epithelium in the Ga group (42%) and 1 in the Ic group (2.6%) (P < 0.01) with 32 reflux cases (56%) in the Ga group and 1 (2.6%) in the Ic group (P < 0.01). Reflux precedes the development of columnar epithelium in both the Ga- and Ic groups. Multivariate analysis revealed surgical technique (odds ratio 10.6, 95% CI 1.2-97.5, P = 0.037) and reflux (odds ratio 4.5, 95% CI 1.3-15.6, P = 0.0017) as risk factors. CONCLUSIONS The development of columnar epithelium was preceded by reflux comprising principally gastric acid and was strongly associated with a strong inflammatory state.
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Comparison of the incidences of anastomotic leakage when PDSII or LACLON are used in esophago-gastric conduit handsewn anastomosis after esophagectomy. Sci Rep 2020; 10:15616. [PMID: 32973231 PMCID: PMC7518418 DOI: 10.1038/s41598-020-72619-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 08/12/2020] [Indexed: 11/22/2022] Open
Abstract
The incidence of anastomotic leakage after esophagectomy remains around 10%. It was previously reported that PDSII rapidly loses tensile strength at pH 1.0 and pH 8.5. By contrast, LACLON degradation is reportedly insensitive to pH. We therefore compared LACLON with PDSII for esophago-gastric conduit, layer-to-layer, handsewn anastomosis. Between January 2016 and January 2020, 90 patients who received posterior mediastinal gastric conduit reconstruction with layer-to-layer handsewn anastomosis (51 using PDSII and 39 using LACLON) at Akita University Hospital were enrolled. The incidence of anastomotic leakage was significantly lower in the LACLON (2.6%, 1/39 patients) than PDSII group (15.7%, 8/51 patients) (p = 0.0268). Multivariable logistic analysis showed the risk of anastomotic leakage was significantly greater with PDSII than LACLON (odds ratio 11.01; 95% CI 1.326–277.64; p = 0.024). The percentages of time the pH was higher than 8 on the gastric conduit side of the anastomosis were 3.1%, 5.7%, 20.9% and 80.5%, respectively, in the four most recent patients. The present study showed that pH at the anastomosis soon after esophagectomy tends to be alkaline rather than acidic, which raises the possibility that this alkalinity facilitates the deterioration of surgical sutures including PDSII.
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Cho JH. Reflux Following Esophagectomy for Esophageal Cancer. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:217-221. [PMID: 32793455 PMCID: PMC7409890 DOI: 10.5090/kjtcs.2020.53.4.217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/09/2020] [Accepted: 07/11/2020] [Indexed: 02/04/2023]
Abstract
Gastroesophageal reflux is a common problem after gastroesophageal resection and reconstruction, despite the routine prescription of proton pump inhibitors (PPIs). Resection of the lower esophageal sphincter and excision of the vagus nerve are generally thought to be the main factors that interfere with gastric motor function. However, physiological studies of reflux symptoms after esophagectomy are still lacking. Gastroesophageal reflux occurs frequently after esophagectomy, but there is no known effective method to prevent it. Therefore, in order to manage gastroesophageal reflux after esophagectomy, strict lifestyle modifications and gastric acid suppression treatment such as PPIs are needed, and further clinical studies are required.
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Affiliation(s)
- Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Gupta JI, Corbett JR, Murthy VL, Weinberg RL. What is this image? 2019: Image 5 result : Gastroesophageal reflux: An unexpected cause of chest pain identified by review of planar images and coregistered SPECT-CT images. J Nucl Cardiol 2019; 26:367-369. [PMID: 30719654 DOI: 10.1007/s12350-019-01627-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
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Watanabe K, Hikichi T, Nakamura J, Hashimoto M, Takagi T, Suzuki R, Sugimoto M, Kikuchi H, Konno N, Takasumi M, Sato Y, Irie H, Obara K, Ohira H. Clinical Outcomes and Adverse Events of Endoscopic Submucosal Dissection for Gastric Tube Cancer after Esophagectomy. Gastroenterol Res Pract 2019; 2019:2836860. [PMID: 30944559 PMCID: PMC6421774 DOI: 10.1155/2019/2836860] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 01/23/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIM The clinical outcomes of endoscopic submucosal dissection (ESD) for gastric tube cancer (GTC) after esophagectomy remain unclear. The aim of this study was to evaluate the clinical outcomes and safety of ESD for GTC. PATIENTS AND METHODS Twenty GTC lesions in 18 consecutive patients who underwent ESD between February 2008 and June 2018 were included in this retrospective study. The endpoints were the treatment outcomes of ESD (i.e., en bloc resection rate, complete en bloc resection rate, and curative resection rate), the adverse events following ESD, and the long-term outcomes. RESULTS The en bloc resection rate was 100%, while the complete en bloc resection rate and curative resection rate were 80% each. Adverse events were observed in 16.7% (3/18) of patients: one postoperative bleeding, 1 intraoperative perforation that required emergency surgery, and 1 pyothorax that required chest drainage. The 1-, 3-, and 5-year overall survival rates were 100%, 70.9%, and 70.9%, respectively. Although local recurrence was detected in 1 case of noncurative resection, no GTC- or ESD-related deaths were observed. CONCLUSION ESD for GTC was feasible and acceptable to enable en bloc resection and to prevent cancer death. However, ESD for GTC should be performed more carefully than common gastric ESD because serious adverse events specific to the gastric tube may occur.
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Affiliation(s)
- Ko Watanabe
- Department of Endoscopy, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Japan
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Japan
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Japan
| | - Minami Hashimoto
- Department of Endoscopy, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Japan
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Japan
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Japan
| | - Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Japan
| | - Hitomi Kikuchi
- Department of Endoscopy, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Japan
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Japan
| | - Naoki Konno
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Japan
| | - Mika Takasumi
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Japan
| | - Yuki Sato
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Japan
| | - Hiroki Irie
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Japan
| | - Katsutoshi Obara
- Department of Advanced Gastrointestinal Endoscopy, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University School of Medicine, 1 Hikarigaoka, Fukushima, Japan
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12
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Kim D, Min YW, Park JG, Lee H, Min BH, Lee JH, Rhee PL, Kim JJ, Zo JI. Influence of esophagectomy on the gastroesophageal reflux in patients with esophageal cancer. Dis Esophagus 2017; 30:1-7. [PMID: 28881892 DOI: 10.1093/dote/dox106] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 07/26/2017] [Indexed: 12/11/2022]
Abstract
This study aims to assess the influence of esophagectomy with gastric transposition on the gastroesophageal reflux (GER) and gastric acidity in patients with esophageal cancer. Data on 53 esophageal cancer patients who underwent 24-hour impedance-pH monitoring after esophagectomy were retrospectively analyzed. We used a solid-state esophageal pH probe in which the esophageal pH sensor is placed 1.5 cm distal to the upper esophageal sphincter and the gastric pH sensor is located 15 cm distal to the esophageal pH channel. 24-hour impedance-pH monitoring data and other clinical data including anastomosis site stricture and incidence of pneumonia were collected. We defined pathologic reflux with reference to known normative data. Stricture was defined when an intervention such as bougienage or balloon dilatation was required to relieve dysphagia. The esophageal and gastric mean pH were 5.47 ± 1.51 and 3.33 ± 1.64, respectively. The percent time of acidic pH (<4) was 6.66 ± 12.49% in the esophagus and 70.53 ± 32.19% in the stomach. Esophageal pathologic acid reflux was noticed in 32.1%, 20.8%, and 35.8% during total, upright, and recumbent time, respectively. Esophageal pathologic bolus reflux was noted in 83.0%, 77.4%, and 64.2% during total, upright, and recumbent time, respectively. Gastric acidity increased with time after esophagectomy. Esophageal acid exposure time correlated with intragastric pH. However, esophageal pathologic acid reflux was not associated with anastomosis site stricture or pneumonia. In conclusion, GER frequently occurs after esophagectomy. Thus, strict lifestyle modifications and acid suppression would be necessary in patients following esophagectomy.
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Affiliation(s)
| | | | | | | | | | | | | | | | - J I Zo
- Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Impact of the Level of Anastomosis on Reflux Esophagitis Following Esophagectomy with Gastric Tube Reconstruction. World J Surg 2017; 41:804-809. [PMID: 27798723 DOI: 10.1007/s00268-016-3786-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Among patients who undergo gastric tube reconstruction after esophagectomy, it is generally accepted that the incidence of reflux esophagitis (RE) is significantly lower in patients with neck anastomosis than in those with intrathoracic anastomosis. However, the true impact of the level of anastomosis on RE currently remains unclear. METHODS We examined 53 patients with thoracic esophageal cancer underwent radical esophagectomy with gastric tube reconstruction and neck anastomosis. The level of anastomosis was assessed by measuring the distance from the sternal notch to the stapled ring by computed tomography. The relative level of anastomosis was calculated by the distance from the sternal notch to the most caudal side of the stapled ring (mm)/height (cm). RESULTS The relative level of anastomosis in 30 (56.6%) patients showed <0, which indicated that anastomosis in these patients was located at a lower level than the sternal notch. The mean relative level of anastomosis was significantly lower in patients with RE (grade A to D) than in those without RE (grade N) (-0.062 vs. -0.012 mm/cm, respectively; p = 0.043). RE was more severe with a lower relative level of anastomosis (p for trends = 0.044). CONCLUSIONS The level of anastomosis in patients with gastric tube reconstruction following esophagectomy was associated with the incidence of RE. The displacement of anastomosis into the thoracic cavity was detected in approximately half of the patients with neck anastomosis. RE was more severe with a lower level of anastomosis, even in patients with neck anastomosis.
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14
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Deldycke A, Van Daele E, Ceelen W, Van Nieuwenhove Y, Pattyn P. Functional outcome after Ivor Lewis esophagectomy for cancer. J Surg Oncol 2015; 113:24-8. [PMID: 26525826 DOI: 10.1002/jso.24084] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 10/21/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Little is known on functional outcome after Ivor Lewis esophagectomy (ILE) with intrathoracic anastomosis. METHODS Patients who underwent ILE were identified from a prospective database. Clinicopathological data were retrieved and compared with functional outcome data based on patient self-assessment by a standard questionnaire. Predictive factors for selected functional complaints were identified with logistic regression analyses. RESULTS Three hundred and twenty-two patients (80.4% male, mean age 62 years) were studied. Indications for surgery were adenocarcinoma (62.4%), squamous cell carcinoma (28%), and HG Barrett dysplasia (7%). Preoperative chemoradiation (CRT) was administered to 42.5% of patients. Anastomotic leakage occurred in 5.6% and was associated with higher age and diabetes mellitus. Functional symptoms identified were reflux (39%), delayed gastric emptying (37%), dumping (21.4%), and anastomotic stenosis (16%). In the multivariate models, anastomotic stenosis was associated with smaller stapler diameter and presence of esophagitis. Postoperative reflux was associated with higher BMI, whereas dumping was predicted by female gender and age. The quality of life questionnaires revealed a good general health status in 82% of the patients. CONCLUSIONS Functional complaints after ILE consist of reflux, delayed gastric emptying, dumping, and dysphagia, and are affected by age, gender, BMI, diabetes mellitus, and stapler diameter.
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Affiliation(s)
- Annelies Deldycke
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Elke Van Daele
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Yves Van Nieuwenhove
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
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15
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Pochini CDC, Gagliardi D, Saad Júnior R, Almeida RFD, Corsi PR. Esophagectomy with gastroplasty in advanced megaesophagus: late results of omeprazole use. Rev Col Bras Cir 2015; 42:299-304. [DOI: 10.1590/0100-69912015005006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 01/20/2015] [Indexed: 11/21/2022] Open
Abstract
Objective: To analyze the late results of advanced Chagasic megaesophagus treatment by esophagectomy associated with the use of proton pump inhibitor (omeprazole) as for the incidence of esophagitis and Barrett's esophagus in the remaining stump. Methods : We studied patients with advanced megaesophagus undergoing esophagectomy and transmediastinal esophagogastroplasty. Patients were divided into three groups: A (20) with esophageal replacement by full stomach, without the use of omeprazole; B (20) with esophageal replacement by full stomach, with omeprazole 40 mg/day introduced after the first postoperative endoscopy and maintained for six years; and C (30) with esophageal replacement by gastric tube with use of omeprazole. Dysphagia, weight loss and BMI were clinical parameters we analyzed. Upper gastrointestinal endoscopy was performed in all patients, and determined the height of the anastomosis, the aspect of the mucosa, with special attention to possible injuries arising from gastroesophageal reflux, and the patency of the esophagogastric anastomosis. Results : We studied 50 patients, 28 males (56%) and 22 (44%) females. All underwent endoscopy every year. In the first endoscopy, erosive esophagitis was present in nine patients (18%) and Barrett's esophagus, in four (8%); in the last endoscopy, erosive esophagitis was present in five patients (8%) and Barrett's esophagus in one (2%). When comparing groups B and C, there was no evidence that the manufacturing of a gastric tube reduced esophagitis and Barrett's esophagus. However, when comparing groups A and C, omeprazole use was correlated with reduction of reflux complications such as esophagitis and Barrett's esophagus (p <0.005). Conclusion : The use of omeprazole (40 mg/day) reduced the onset of erosive esophagitis and Barrett's esophagus during the late postoperative period.
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16
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Gallo G, Zwaveling S, Van der Zee DC, Bax KN, de Langen ZJ, Hulscher JBF. A two-center comparative study of gastric pull-up and jejunal interposition for long gap esophageal atresia. J Pediatr Surg 2015; 50:535-9. [PMID: 25840058 DOI: 10.1016/j.jpedsurg.2014.05.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 04/09/2014] [Accepted: 05/13/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE When restoration of the anatomical continuity in case of long gap esophageal atresia (LGEA) is not feasible, esophageal replacement surgery becomes mandatory. The aim of this paper is to critically compare the experience of two tertiary referral centers in The Netherlands performing either gastric pull-up (GPU) or jejunal interposition (JI). METHODS Retrospective chart review of all the patients with LGEA who underwent GPU in the University Medical Center Groningen and JI in the University Medical Center Utrecht. Main endpoints were short term morbidity, mortality and long term functional outcome (digestive functioning and growth). Descriptive analyses conducted using Mann-Whitney U test for continuous variables and Fisher's exact test for categorical variables. RESULTS Nine children underwent GPU and 15 JI. Median age (years) at last follow up was fourteen (GPU) and eight (JI). One patient died, 10 years after JI. No grafts were lost. Perioperative anastomotic complications were reported more often after JI (73% vs. 22%, p=0.03). However reintervention rate was the same in both groups (33%). Among long term outcomes, functional obstruction was not registered after GPU, while it was recorded in 46% after JI (p=0.02). No other significant differences were found apart from some tendencies concerning full oral nutrition and gastroesophageal reflux (GPU>JI). CONCLUSION Comparative data from this study reveal no mortality but significant morbidity in both groups. No graft was lost. Although not statistically different as a result of small patient numbers, clinically important differences regarding gastrointestinal system were noted. Growth should be monitored closely in both groups.
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Affiliation(s)
- Gabriele Gallo
- Department of Pediatric Surgery, University Medical Center Groningen, Groningen, The Netherlands.
| | - Sander Zwaveling
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - David C Van der Zee
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Klaas N Bax
- Department of Pediatric Surgery, Sophia Children's Hospital, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Zacharias J de Langen
- Department of Pediatric Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan B F Hulscher
- Department of Pediatric Surgery, University Medical Center Groningen, Groningen, The Netherlands
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Imanningsih N, Muchtadi D, Wresdiyati T, - K. ACIDIC SOAKING AND STEAM BLANCHING RETAIN ANTHOCYANINS AND POLYPHENOLS IN PURPLE Dioscorea alata FLOUR. JURNAL TEKNOLOGI DAN INDUSTRI PANGAN 2013. [DOI: 10.6066/jtip.2013.24.2.121] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Nakabayashi T, Mochiki E, Kamiyama Y, Kato H, Kuwano H. Impact of gastropyloric motor activity on the genesis of reflux esophagitis after an esophagectomy with gastric tube reconstruction. Ann Thorac Surg 2013; 96:1833-8. [PMID: 23998403 DOI: 10.1016/j.athoracsur.2013.06.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 05/28/2013] [Accepted: 06/06/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reflux esophagitis is a significant problem in patients after an esophagectomy with gastric tube reconstruction. The pathogenesis of reflux esophagitis is not fully understood. The aim of the present study was to evaluate whether gastropyloric motility influences the pathogenesis of reflux esophagitis after an esophagectomy. METHODS Thirty esophagectomized patients were assessed by endoscopy and manometry. The patients were classified into 3 groups according to the postoperative period as follows: Group 1 (less than 12 months), group 2 (12 to 24 months), and group 3 (more than 24 months). Gastropyloric motor activity was quantified by calculating the motility index, which is equivalent to the area under the contractile waves. RESULTS Reflux esophagitis was observed in 80% of group 1, 80% of group 2, and 30% of group 3. The severity of reflux esophagitis decreased with time. Contractions of the gastric body were not observed in any of the patients. The antral motility index in group 3 was significantly greater than that in groups 1 and 2. The pyloric motility index progressively increased. The severity of reflux esophagitis is significantly associated with gastropyloric motor activity. CONCLUSIONS The severity of reflux esophagitis decreases with time, coupled with recovery of antropyloric motor activity. Gastropyloric motor activity plays an important role in the genesis of reflux esophagitis after an esophagectomy.
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Affiliation(s)
- Toshihiro Nakabayashi
- Department of Surgery, Gunma Prefectural Cardiovascular Center, Maebashi, Japan; Department of General Surgical Science, Gunma University, Graduate School of Medicine, Maebashi, Japan.
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Wu S, Chen M, Wei L, Chen Z. Embedded cervical esophagogastrostomy: a simple and convenient method using a circular stapler after esophagectomy for esophageal carcinomas. Ann Surg Oncol 2013; 20:2984-90. [PMID: 23645482 PMCID: PMC3732760 DOI: 10.1245/s10434-013-2991-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Indexed: 01/13/2023]
Abstract
Background Cervical esophagogastrostomy is currently the most common method for esophageal reconstruction after esophagectomy. The advantages and disadvantages of hand-sewn, linear-stapled, or circular-stapled anastomoses have been subject to debate in recent years. We explored a new method of end-to-side anastomosis using a circular stapler that embeds the anastomosis and the remaining esophageal tissue into the gastric cavity to reduce the occurrence of anastomotic leakage and to prevent gastroesophageal reflux. Methods In 127 patients with esophageal carcinomas, end-to-side anastomoses with esophageal embedding were performed by connecting the anvil and body of the circular stapler inside the stomach before firing and embedding the anastomosis and remaining esophagus into the stomach after esophagectomy. Retrospective investigations on postoperative complications such as leakage, stricture, and gastroesophageal reflux were conducted. Results A total of 123 patients (96.9 %) had successful surgery, and 4 patients (3.3 %) developed anastomotic leakage, with the total morbidity of 20 of 123 (16.3 %) and in-hospital mortality of 1 of 123 (0.8 %). The incidence of stricture (<1 cm) affected 14 of 123 patients (11.4 %). Eight patients underwent dilatation treatment as a result of severe dysphagia (6.5 %). Half of the patients [62 of 123 (50.4 %)] experienced postoperative heartburn, 11 of 123 patients (8.9 %) experienced acid regurgitation, and 16 of 123 patients (13.0 %) experienced nocturnal cough. Conclusions Embedded cervical esophagogastrostomy with circular stapler is a simple and convenient method, with low incidence of anastomotic leakage and a good antireflux effect.
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Affiliation(s)
- Sen Wu
- Center of Thoracic Tumor, Henan Provincial People's Hospital, Zhengzhou, China.
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20
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Park SY, Lee HS, Jang HJ, Lee JY, Joo J, Zo JI. The role of one-year endoscopic follow-up for the esophageal remnant and gastric conduit after esophagectomy with gastric reconstruction for esophageal squamous cell carcinoma. Yonsei Med J 2013; 54:381-8. [PMID: 23364971 PMCID: PMC3575976 DOI: 10.3349/ymj.2013.54.2.381] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
PURPOSE After esophagectomy and gastric reconstruction for esophageal cancer, patients suffer from various symptoms that can detract from quality of life. Endoscopy is a useful diagnostic tool for evaluating patients after esophagectomy. This observational study was performed to investigate the correlation between symptoms and endoscopic findings one year after esophageal surgery and to assess the clinical usefulness of one-year endoscopic follow-up. MATERIALS AND METHODS From 2001 to 2008, 162 patients who underwent esophagectomy with gastric reconstruction were endoscopically examined one year after operation. RESULTS Patients suffered from the following symptoms: nocturnal cough (n=10), regurgitation (n=7), cervical heartburn (n=3), lump sensation (n=2), dysphagia (n=20) and odynophagia (n=22). Eighty-five (52.5%) patients had abnormal findings on endoscopic examination. Twelve (7.4%) patients had reflux esophagitis, and 37 (22.8%) patients had an anastomotic stricture. Only stricture-related symptoms were correlated with the finding of anastomotic strictures (p<0.001). Two patients had recurrences at the anastomotic sites, and four patients had regional lymph node recurrences with gastric conduit invasion visualized by endoscopy. Newly-developed malignancies in the esophageal remnant or hypopharynx that were not detected by clinical symptoms and imaging studies were reported in two patients. CONCLUSION One year after esophagectomy, endoscopic findings were not correlated with clinical symptoms, except those related to stricture. Routine endoscopic follow-up is a useful tool for identifying latent functional and oncological lesions.
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Affiliation(s)
- Seong Yong Park
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun-Sung Lee
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hee-Jin Jang
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
- Department of Systems Biology, The University of Texas MD Anderson Cancer Center, TX, USA
| | - Jong Yeul Lee
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jungnam Joo
- Cancer Biostatistics Branch, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jae Ill Zo
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
- Department of Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
Esophagectomy remains the gold standard curative therapy for the treatment of esophageal cancer. Despite 125 years of evolution, esophagectomy remains a demanding procedure associated with a 5% to 10% mortality and a 50% morbidity rate. Knowledge of the multitude of techniques possible for performing this complex procedure, as well as the host of associated complications, is vital for the practitioner aspiring to treat this challenging disease.
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Affiliation(s)
- Daniel Raymond
- Thoracic & Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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22
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Nakabayashi T, Mochiki E, Kamiyama Y, Kuwano H. Gastric motor activity in gastric pull-up esophagectomized patients with and without reflux symptoms. Ann Thorac Surg 2012; 94:1114-7. [PMID: 22884594 DOI: 10.1016/j.athoracsur.2012.05.120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 05/28/2012] [Accepted: 05/31/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients frequently experience reflux symptoms of heartburn and regurgitation after a gastric pull-up esophagectomy. The pathogenesis of reflux symptoms is not fully understood. The gastrointestinal tract exhibits a temporally coordinated cyclic motor pattern, termed interdigestive migrating motor contraction, during the interdigestive state. Phase III of interdigestive migrating motor contraction is important in cleaning indigestible solids and basal secretions. Impairment of phase III may result in reflux symptoms of heartburn and regurgitation. The present study evaluated whether gastropyloroduodenal motility after gastric pull-up esophagectomy influences the pathogenesis of reflux symptoms. METHODS Gastropyloroduodenal motility was recorded by manometry in 20 patients after a gastric pull-up esophagectomy. Esophagectomized patients were questioned about the presence of heartburn or regurgitation, or both. RESULTS Of 20 patients, 8 (40%) were considered the symptomatic group. Phase III, in which contractions originating from the antrum migrate to the pylorus and then move to the duodenum, was observed in only 1 of 8 patients. In the asymptomatic group, phase III was observed in 8 of 12 patients. A significant correlation was found between the presence of reflux symptoms and the paucity of phase III activity (p=0.02). CONCLUSIONS The presence of reflux symptoms after gastric pull-up esophagectomy is significantly associated with the paucity of gastric phase III. Gastric motor activity is important in the occurrence of reflux symptoms.
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Affiliation(s)
- Toshihiro Nakabayashi
- Department of Surgery, Gunma Prefectural Cardiovascular Center, Gunma University, Graduate School of Medicine, Maebashi, Japan.
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Nishimura K, Tanaka T, Tsubuku T, Matono S, Nagano T, Murata K, Aoyama Y, Yanagawa T, Shirouzu K, Fujita H. Reflux esophagitis after esophagectomy: impact of duodenogastroesophageal reflux. Dis Esophagus 2012; 25:381-5. [PMID: 21967617 DOI: 10.1111/j.1442-2050.2011.01268.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Reflux esophagitis (RE) is a known complication disturbing patients' quality of life after esophageal resection. It is generally recognized that bile reflux as well as acid reflux cause RE. However, the clinical influence of acid and bile reflux, and Helicobacter pylori (H. pylori) infection on RE in the cervical esophagus after esophagectomy is not yet clarified. Sixty patients who underwent cervical esophagogastrostomy following esophagectomy were enrolled in this study. They underwent examination for H. pylori infection, endoscopic examination, and continuous 24-hour pH and bilirubin monitoring, at 1 month after surgery. The influence of acid and/or bile reflux, H. pylori infection, and others on the development of RE were investigated. RE was observed in 19 patients (32%) at 1 month after esophagogastrostomy, mild RE in 16 (27%), and severe RE in 3 (5%). The percentage of time duration of both acid and bile reflux into the cervical esophagus was higher in patients with RE than in those without (P = 0.027, P < 0.001). A significant difference in %time pH < 4 acid reflux was found between mild RE and severe RE (P = 0.014), and a statistical difference in %time abs. > 0.14 between non-RE and mild RE (P = 0.017). Acid and/or bile reflux was observed in 31 patients (52%), acid-only reflux in 6 (10%), bile-only reflux in 15 (25%), and acid-and-bile reflux in 10 (17%). Severe RE was observed only in patients having acid-and-bile reflux. On the univariate analysis, no infection of H. pylori, acid reflux, and bile reflux were determined to be the influencing factors to RE among the clinical factors including age, gender, route of esophageal reconstruction, H. pylori infection, and acid-and-bile reflux. In the subanalysis using the logistic model, there were significant correlations between bile reflux and RE irrespective of the presence of H. pylori infection (P = 0.016, P = 0.007). On the other hand, there was a significant correlation between acid reflux and RE only in patients without H. pylori infection (P = 0.039). In the early period after esophagogastrostomy, bile reflux could cause RE irrespective of H. pylori infection, while acid reflex could cause RE only in patients without H. pylori infection. There is a possibility that bile reflux plays an important role in the development of RE after esophagectomy.
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Affiliation(s)
- K Nishimura
- Department of Surgery Biostatistics Center, Kurume University, Kurume, Fukuoka, Japan
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Miura M, Motoyama S, Hinai Y, Niioka T, Endo M, Hayakari M, Ogawa JI. Influence of CYP2C19 and ABCB1 polymorphisms on plasma concentrations of lansoprazole enantiomers after enteral administration. Xenobiotica 2011; 40:630-6. [PMID: 20528170 DOI: 10.3109/00498254.2010.494201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
An intraoral annihilation enteric-coated preparation of lansoprazole is often administered via intestinal fistula. The purpose of this study was to determine the plasma concentrations of lansoprazole enantiomers after enteral administration in subjects with cytochrome P4502C19 (CYP2C19) and ABCB1 C3435T genotypes. Fifty-one patients who underwent a curative oesophagectomy for oesophageal cancer were enrolled in this study. After a single enteral dose of racemic lansoprazole (30 mg), plasma concentrations of lansoprazole enantiomers were measured 4 h post-dose (C(4h)). There were significant differences in the C(4h) of (R)- and (S)-lansoprazole and the R/S-enantiomer ratio for three CYP2C19 genotype groups (*1/*1, *1/*2 ± *1/*3, and *2/*2 ± *2/*3 ± *3/*3 (poor metabolizers (PMs)), but not the ABCB1 C3435T genotypes. In a stepwise forward selection multiple regression analysis, the C(4h) of (R)- and (S)-lansoprazole were associated with CYP2C19 PMs (p = 0.0005 and < 0.0001 respectively) and age (p = 0.0040 and 0.0121 respectively), while the R/S-enantiomer ratio was associated with CYP2C19*1/*1 (p = 0.0191) and CYP2C19 PMs (p = 0.0426). Direct administration to the jejunum is unaffected by residence time in the stomach and the gastric emptying rate. With enteral administration, CYP2C19 phenotyping of patients using the lansoprazole R/S enantiomer index at C(4h) could be possible.
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Affiliation(s)
- Masatomo Miura
- Department of Pharmacy, Akita University Hospital, Akita, Japan.
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Ubukata H, Nakachi T, Tabuchi T, Nagata H, Takemura A, Shimazaki J, Konishi S, Tabuchi T. Gastric tube perforation after esophagectomy for esophageal cancer. Surg Today 2011; 41:612-9. [PMID: 21533931 DOI: 10.1007/s00595-010-4476-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Accepted: 12/13/2010] [Indexed: 12/11/2022]
Abstract
We searched for cases of perforation of the gastric tube after esophagectomy for esophageal cancer by reviewing the literature. Only 13 cases were found in the English literature, and serious complications were seen in all cases, especially in cases of posterior mediastinal reconstruction. However, in the Japanese literature serious complications were also frequently seen in retrosternal reconstruction. Gastric tubes are at a higher risk of developing an ulcer than the normal stomach, including an ulcer due to Helicobacter pylori infection, insufficient blood supply, gastric stasis, and bile juice regurgitation. H. pylori eradication and acid-suppressive medications are important preventive therapies for ordinary gastric ulcers, but for gastric tube ulcers the effects of such treatments are still controversial. We tried to determine the most appropriate treatment to avoid serious complications in the gastric tubes, but we could not confirm an optimal route because each had advantages and disadvantages. However, at least in cases with severe atrophic gastritis due to H. pylori infection or a history of frequent peptic ulcer treatment, the antesternal route is clearly the best. Many cases of gastric tube ulcers involve no pain, and vagotomy may be one of the reasons for this absence of pain. Therefore, periodic endoscopic examination may be necessary to rule out the presence of an ulcer.
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Affiliation(s)
- Hideyuki Ubukata
- Fourth Department of Surgery, Tokyo Medical University Ibaraki Medical Center, 3-20-1 Chuo, Ami, Inashiki, Ibaraki, 300-0395, Japan
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Akiyama T, Inamori M, Akimoto K, Iida H, Endo H, Hosono K, Ikeda T, Sakamoto Y, Fujita K, Yoneda M, Koide T, Takahashi H, Tokoro C, Goto A, Abe Y, Kobayashi N, Kubota K, Saito S, Moriya A, Rino Y, Imada T, Nakajima A. Gastric surgery is not a risk factor for erosive esophagitis or Barrett's esophagus. Scand J Gastroenterol 2010; 45:403-8. [PMID: 20085437 DOI: 10.3109/00365520903536507] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The role of gastric acid reflux is difficult to separate from that of pancreatic-biliary reflux in the pathogenesis of erosive esophagitis (EE) and Barrett's esophagus (BE). Gastric surgery patients provide a good model for both significant pancreatic-biliary reflux and marked gastric acid inhibition. We assessed the risk of EE and BE after distal gastrectomy in a case-controlled study. MATERIAL AND METHODS One hundred and sixty patients (121 men, 39 women; median age 68 years; range 32-86 years) with distal gastrectomies (Billroth-I) and 160 sex- and age-matched controls with intact stomachs were enrolled. The presence of EE and BE were diagnosed based on the Los Angeles Classification and the Prague C & M Criteria, respectively. A conditional logistic regression model with adjustments for potential confounding factors was used to assess the associations. RESULTS According to the multivariate analyses, patients with distal gastrectomies tended to have inverse associations with the risks of EE and BE, and the inverse association with the risk of BE reached a significant level. CONCLUSIONS Distal gastrectomy is not a risk factor for the development of EE and BE. This lack of a positive association between distal gastrectomy and EE and BE may suggest that pancreatic-biliary reflux with a limited amount of acid is not sufficient to damage the esophageal mucosa.
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Affiliation(s)
- Tomoyuki Akiyama
- Department of Gastroenterology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
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Nishimura K, Tanaka T, Tanaka Y, Matono S, Murata K, Shirouzu K, Fujita H. Reflux esophagitis and columnar-lined esophagus after cervical esophagogastrostomy (following esophagectomy). Dis Esophagus 2010; 23:94-9. [PMID: 19664076 DOI: 10.1111/j.1442-2050.2009.00998.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Reflux esophagitis (RE) and columnar-lined esophagus (CLE) are frequently observed after esophagectomy. The incidence of these conditions according to time and to the route of esophageal reconstruction after esophagectomy remains unknown. The aim of this study was to clarify any changes and differences of the incidence of RE and CLE in patients who underwent gastric tube reconstruction after esophagectomy. A hundred patients who underwent cervical esophagogastrostomy after resection of the thoracic esophagus were included in this study. We reviewed their endoscopic findings at 1 month, at 1 year and at 2 years after surgery, and compared the incidence rates of RE and CLE with the passage of time and among the three reconstruction routes; a subcutaneous route, a retrosternal route, and a posterior mediastinal route. The incidence rate of RE was 42%, 37% and 38%, at 1 month, 1 year and at 2 years after surgery, respectively. There was no significant difference in the incidence of RE according to the time after surgery. The incidence rate of severe RE (Grade C and D in the Los Angeles Classification) was 9% percent at 1 month after surgery, 18% at 1 year after surgery and 22% at 2 years after surgery, significantly increasing with passage of time. The incidence rate of CLE was 0% at 1 month after surgery, 14% at 1 year after surgery and 40% at 2 years after surgery, significantly increasing with passage of time. No difference was observed in the incidence of RE and that of CLE among the three routes of esophageal reconstruction. Severe RE and CLE increase with passage of time after cervical esophagogastrostomy. Therefore, careful endoscopic follow-up is necessary for such patients irrespective of the route of esophageal reconstruction.
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Affiliation(s)
- K Nishimura
- Department of Surgery, Kurume University School of Medicine, Kurume 830-0011, Japan
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Nishimura K, Fujita H, Tanaka T, Tanaka Y, Matono S, Murata K, Umeno H, Shirouzu K. Endoscopic classification for reflux pharyngolaryngitis. Dis Esophagus 2010; 23:20-6. [PMID: 19549209 DOI: 10.1111/j.1442-2050.2009.00994.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The quality of life in patients who have undergone surgery for esophageal cancer is frequently disturbed by postoperative gastroesophageal reflux disease or pharyngolaryngeal reflux disease. Recently, there have been many reports on gastroesophageal reflux disease after esophagectomy, and only a few on pharyngolaryngeal reflux disease. There is not yet any convenient endoscopic classification of reflux pharyngolaryngitis. We designed a new classification for reflux pharyngolaryngitis based on endoscopic findings. Our new classification consists of the five grades from 0 to IV based on (i) the extent and severity of erythema and/or edema in the pharynx and the larynx, and (ii) the extent and severity of granulation or scarring stenosis in the vocal cords. Ninety-three patients after cervical esophagogastrostomy after esophagectomy (the CEG group) and 28 patients after intrathoracic esophagogastrostomy (the TEG group) were reviewed in this study. We investigated the relation between the severity of reflux pharyngolaryngitis and clinical symptoms in these patients, and the correlation between this new classification of reflux pharyngolaryngitis and the Los Angeles classification of reflux esophagitis. Reflux esophagitis was more severe in the TEG group than in the CEG group, while there was no difference in the grading of reflux pharyngolaryngitis between the two groups. The pharyngolaryngeal symptoms and F-scale scores were not correlated with the severity of reflux pharyngolaryngitis in each group. The grading of reflux pharyngolaryngitis and that of reflux esophagitis was correlated in each group (P<0.001 in the CEG group and P=0.002 in the TEG group). We proposed a new endoscopic classification of reflux pharyngolaryngitis. The new classification of reflux pharyngolaryngitis correlated fairly well with the Los Angeles classification of reflux esophagitis, although this classification did not correlate with the clinical symptoms in patients who underwent esophagectomy. Follow-up attention including upper endoscopy should be paid to reflux pharyngolaryngitis in patients after esophagogastrostomy as well as reflux esophagitis, because there is often a lack in symptoms regardless of high incidence of pharyngolaryngitis.
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Affiliation(s)
- K Nishimura
- Department of Surgery, Kurume University School of Medicine, Fukuoka, Japan.
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Comparison of gastroesophageal reflux in 100 patients with or without prior gastroesophageal surgery. J Gastroenterol 2009; 44:650-8. [PMID: 19434363 DOI: 10.1007/s00535-009-0055-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Accepted: 02/23/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE The role of duodenogastroesophageal reflux (DGER) in gastroesophageal reflux disease (GERD) remains controversial. Few studies of reflux have compared patients with an intact stomach to those without intact stomach after gastroesophageal surgery. This study aimed to investigate differences of the refluxate between patients with and without prior gastroesophageal surgery and to assess the role of DGER in GERD. METHODS One hundred patients (34% with reflux symptoms) were divided into four groups: 23 with an intact stomach, and 27, 42, and 8 with esophagectomy followed by gastric tube reconstruction, distal gastrectomy, and total gastrectomy, respectively. Reflux symptoms were evaluated, and endoscopy and simultaneous 24-h monitoring of esophageal pH and bilirubin were performed. RESULTS Of 44 patients with increased DGER but without increased acid reflux, three had severe reflux esophagitis and seven had Barrett's esophagus. DGER was most frequent under weakly acidic conditions in the intact stomach, esophagectomy, and distal gastrectomy groups. Pure acid reflux and DGER at any pH were elevated in GERD patients with an intact stomach, while weakly acidic and alkaline DGER were elevated in GERD patients after gastrectomy. Esophagectomy patients had reflux with the combined characteristics of those in the intact stomach and gastrectomy groups. Weakly acidic or alkaline DGER was correlated with symptoms and esophageal mucosal changes in gastrectomy patients. CONCLUSION The refluxate causing GERD differed between patients with and without prior gastroesophageal surgery. Weakly acidic or alkaline DGER may cause both symptoms and esophageal mucosal damage.
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30
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Kim HK, Choi YH, Shim JH, Cho YH, Baek MJ, Sohn YS, Kim HJ. Endoscopic evaluation of the quality of the anastomosis after esophagectomy with gastric tube reconstruction. World J Surg 2009; 32:2010-4. [PMID: 18553190 DOI: 10.1007/s00268-008-9664-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The morbidity and mortality of anastomotic complications after esophagectomy have gradually decreased in recent years. However, swallowing difficulties and reflux continue to burden patients jeopardizing their quality of life. In the present study we performed endoscopic evaluation of the outcomes of esophagogastrostomy by analyzing the presence of anastomotic stenosis and reflux esophagitis. METHODS A retrospective analysis was carried out on 74 patients who underwent esophagogastrostomy after esophagectomy by one surgeon between January 1995 and December 2004. Fifty-three patients had an endoscopic examination during follow-up (29 +/- 23.6 months, range = 5-111 months). Reflux esophagitis and stenosis at the anastomostic site were analyzed according to the surgical technique used and the location of the esophagogastrostomy. RESULTS The mean age at the time of repair was 60.3 +/- 8.87 (range = 39-81) years. Cervical anastomosis was performed in 26 patients and intrathoracic anastomosis in 27 patients. No significant statistical difference in the frequency of anastomotic stenosis was observed between the two groups (p = 0.829); reflux esophagitis was noted in three patients in the cervical anastomosis group and in 14 patients in the intrathoracic anastomosis group (p = 0.041). For all patients, 23 received a hand-sewn esophagogastric anastomosis and 30 a circular stapled one. There was no significant statistical difference in anastomotic stenosis (p = 0.689) and reflux esophagitis (p = 0.879) in comparisons between the two groups. CONCLUSION Cervical anastomosis resulted in a better outcome for esophagogastrostomy by lowering the risk of reflux esophagitis; this outcome might improve the patient's quality of life.
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Affiliation(s)
- Hyun Koo Kim
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University Guro Hospital, 97 Guro-Dongkil, Guro-Ku, Seoul 152-703, Korea
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Miura M, Motoyama S, Hinai Y, Niioka T, Hayakari M, Ogawa JI, Suzuki T. Correlation between R/S enantiomer ratio of lansoprazole and CYP2C19 activity after single oral and enteral administration. Chirality 2009; 22:635-40. [DOI: 10.1002/chir.20810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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da Rocha JRM, Ribeiro U, Sallum RAA, Szachnowicz S, Cecconello I. Barrett's esophagus (BE) and carcinoma in the esophageal stump (ES) after esophagectomy with gastric pull-up in achalasia patients: a study based on 10 years follow-up. Ann Surg Oncol 2008; 15:2903-9. [PMID: 18618179 DOI: 10.1245/s10434-008-0057-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2008] [Revised: 05/29/2008] [Accepted: 05/29/2008] [Indexed: 12/17/2022]
Abstract
BACKGROUND Subtotal esophagectomy and gastric pull-up with cervical anastomosis is the main treatment for advanced achalasia. This surgical technique has been associated to esophagitis and also Barrett's epithelium following esophagectomy. AIM To analyze late clinical, endoscopic, and pathologic findings in the esophageal stump (ES) mucosa after subtotal esophagectomy in patients treated for advanced chagasic achalasia. METHODS 101 patients submitted to esophagectomy and cervical gastroplasty were followed-up prospectively for a mean of 10.5 +/- 8.8 years. All patients underwent clinical, endoscopic and histopathological evaluation every 2 years. Gastric acid secretion was also assessed. RESULTS The incidence of esophagitis in the esophageal stump (45.9% at 1 year; 71.9% at 5 years, and 70.0% at 10 years follow-up); gastritis in the transposed stomach (20.4% at 1 year, 31.0% at 5 years, and 40.0% at 10 or more years follow-up), and the occurrence of ectopic columnar metaplasia and Barrett's Esophagus in the ES (none until 1 year; 10.9% between 1 and 5 years; 29.5% between 5 and 10 years; and 57.5% at 10 or more years follow-up), all rose over time. Gastric acid secretion returns to its preoperative values 4 years postoperatively. Esophageal stump cancer was detected in the setting of chronic esophagitis in five patients: three squamous cell carcinomas and two adenocarcinomas. CONCLUSION (1) Esophagitis and Barrett's esophagus in the esophageal stump rose over time. (2) These mucosal alterations and the development of squamous cell carcinoma and adenocarcinoma are probably due to exposure to duodenogastric reflux, and progressively higher acid output in the transposed stomach.
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Affiliation(s)
- Julio Rafael Mariano da Rocha
- Department of Gastroenterology, University of São Paulo Medical School, Rua Oscar Freire, 1546 Apto 171, 05409-010, São Paulo, SP, Brazil,
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Abstract
Gastric interposition is usually considered the reconstruction of choice following esophageal resection. However, a number of reports show that esophagectomy followed by a gastric transplant is associated with poor quality of life and significant reflux esophagitis in the esophageal remnant. The aim of this work is to review the factors affecting the mucosa of the esophageal remnant when using the stomach. A Medline was conducted. Additional references and search pathways were sourced from the references of reviewed articles. Reflux disease is considered an unavoidable consequence of esophageal resection followed by gastric interposition. Mucosal damage from acid and bile exposure in the esophageal remnant affects approximatively 50% of these patients. There is usually no correlation between symptoms and the presence of mucosal damage in the remaining esophagus. Endoscopy and endoscopic biopsies are the only reliable methods to document the status of the mucosa. When present, reflux esophagitis shows a progression from inflammation to erosions and to the development of columnar lined metaplasia. Esophageal and gastric function, gastric drainage operation, level of the anastomosis, route of reconstruction, and patients' position after the operation have all been shown to influence the severity and extent of damage in the esophageal remnant. Prevention and treatment of esophagitis in the remaining esophagus are discussed. When the stomach is used as a substitute to reconstruct the esophagus whether for malignant or benign conditions, an in vivo model of reflux diseases is created. Studies using this model may help clarify molecular and cellular events that lead to irreversible insult on the esophageal mucosa. Improvement to the reconstruction itself must be sought to favor better results with the gastric transplant.
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Affiliation(s)
- X B D'Journo
- Department of Surgery, Université de Montréal, Thoracic Surgery Division, Quebec, Canada
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Proton Pump Inhibitors Relieve and Prevent Symptoms Related to Gastric Acidity after Esophagectomy. World J Surg 2007; 32:246-54. [DOI: 10.1007/s00268-007-9325-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Mori N, Fujita H, Sueyoshi S, Aoyama Y, Yanagawa T, Shirouzu K. Helicobacter pylori infection influences the acidity in the gastric tube as an esophageal substitute after esophagectomy. Dis Esophagus 2007; 20:333-40. [PMID: 17617883 DOI: 10.1111/j.1442-2050.2007.00718.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
It is commonly considered that acidity in a gastric tube used as an esophageal substitute after esophagectomy decreases due to truncal vagotomy. However, there have been few, if any, studies on the factors influencing the acidity in the gastric tube. It is well known that Helicobacter pylori (H. pylori) plays an important role in acid secretion of the stomach. The aim of this study was to investigate whether or not H. pylori infection also influenced the acidity in the gastric tube as an esophageal substitute. We investigated the changes in the levels of gastric acidity and the status of H. pylori infection from the preoperative period to 1 year after surgery. In 65 Japanese patients who underwent resection of esophageal cancer followed by reconstruction using a gastric tube, 24-h gastric pH monitoring and examination of H. pylori infection using the 13C-urea breath test and biopsy specimen obtained from the gastric mucosa under upper gastrointestinal endoscopy were performed pre- and postoperatively. Twenty-seven among the 65 patients underwent the same examinations at 1 year after surgery. The levels of postoperative gastric acidity and at 1 year after surgery were significantly lower than that of preoperative gastric acidity (P = 0.031, P = 0.001, respectively). There was no difference in the levels of gastric acidity between 1.5 months and 1 year after surgery (P = 0.282). The levels of gastric acidity in the stomach and in the gastric tube were significantly influenced by H. pylori infection, while age, gender, and past history of peptic ulcer showed no influence. The level of gastric acidity in patients who had H. pylori infection pre- and postoperatively were significantly lower than that in patients who had no H. pylori infection pre- and postoperatively (P < 0.0001). H. pylori infection was indicated to be an important factor influencing the levels of gastric acidity in the reconstructed esophagus as well as in the stomach before surgery.
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Affiliation(s)
- N Mori
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan.
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Yamamoto S, Makuuchi H, Shimada H, Chino O, Nishi T, Kise Y, Kenmochi T, Hara T. Clinical analysis of reflux esophagitis following esophagectomy with gastric tube reconstruction. J Gastroenterol 2007; 42:342-5. [PMID: 17530357 DOI: 10.1007/s00535-007-2011-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2006] [Accepted: 01/17/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recently, the rate of postoperative long-term survival has increased in cases of esophageal cancer. We report on our analysis of postoperative reflux esophagitis (RE) at Tokai University. METHODS We enrolled 48 patients who underwent gastric tube reconstruction after esophagectomy. The diagnosis of RE was confirmed by endoscopy. RESULTS Of the 48 patients, 28 (58.3%) were found to have RE. Among the 28 patients with RE, only four (14.3%) reported symptoms. The distribution of the severity of RE according to the Los Angeles classification in the patients was as follows: grade M, 1 (3.6%); grade A, 2 (7.1%); grade B, 6 (21.4%); grade C, 17 (60.7%); and grade D, 2 cases (7.1%). Barrett's epithelium was detected in 9 of the 28 patients (31%) with RE and in 3 of the 20 (15%) patients with no evidence of RE. CONCLUSIONS To detect the presence of RE as well as monitor for recurrence and development of metachronous cancer, we consider it important to perform endoscopy regularly over the long term. As Barrett's epithelium is frequently encountered, care should be exercised to detect the specialized columnar epithelium showing dysplastic changes.
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Affiliation(s)
- Soichiro Yamamoto
- Department of Surgery, Tokai University School of Medicine, Bohseidai, Isehara, Kanagawa 259-1193, Japan
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Maruyama K, Motoyama S, Okuyama M, Sato Y, Hayashi K, Minamiya Y, Ogawa JI. Esophagotracheal fistula caused by gastroesophageal reflux 9 years after esophagectomy. World J Gastroenterol 2007; 13:801-3. [PMID: 17278207 PMCID: PMC4066017 DOI: 10.3748/wjg.v13.i5.801] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Fistula between digestive tract and airway is one of the complications after esophagectomy with lymph node dissection. A case of esophagotracheal fistula secondary to esophagitis 9 years after esophagectomy and gastric pull-up for treatment of esophageal carcinoma is described. It was successfully treated with transposition of a pedicled pectoralis major muscle flap.
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Affiliation(s)
- Kiyotomi Maruyama
- Department of Surgery, Akita University School of Medicine, 1-1-1 Hondo, Akita 010-8543, Japan.
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Mabrut JY, Collard JM, Baulieux J. Le reflux biliaire duodéno-gastrique et gastro-œsophagien. ACTA ACUST UNITED AC 2006; 143:355-65. [PMID: 17285081 DOI: 10.1016/s0021-7697(06)73717-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This study reviews current data regarding duodenogastric and gastroesophageal bile reflux-pathophysiology, clinical presentation, methods of diagnosis (namely, 24-hour intraluminal bile monitoring) and therapeutic management. Duodenogastric reflux (DGR) consists of retrograde passage of alkaline duodenal contents into the stomach; it may occur due to antroduodenal motility disorder (primary DGR) or may arise following surgical alteration of gastoduodenal anatomy or because of biliary pathology (secondary DGR). Pathologic DGR may generate symptoms of epigastric pain, nausea, and bilious vomiting. In patients with concomitant gastroesophageal reflux, the backwash of duodenal content into the lower esophagus can cause mixed (alkaline and acid) reflux esophagitis, and lead, in turn, to esophageal mucosal damage such as Barrett's metaplasia and adenocarcinoma. The treatment of DGR is difficult, non-specific, and relatively ineffective in controlling symptoms. Proton pump inhibitors decrease the upstream effects of DGR on the esophagus by decreasing the volume of secretions; promotility agents diminish gastric exposure to duodenal secretions by improving gastric emptying. In patients with severe reflux resistant to medical therapy, a duodenal diversion operation such as the duodenal switch procedure may be indicated.
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Affiliation(s)
- J Y Mabrut
- Service de Chirurgie Générale, Digestive et de Transplantation Hépatique, Hôpital de la Croix-Rousse - Lyon.
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