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PubMed1988

Esophageal motility disorders.

Esophageal motility disorders consist of a complex array of disturbances in normal esophageal function associated with dysphagia, gastroesophageal reflux, and noncardiac chest pain. A thorough knowledge of normal esophageal anatomy and physiology is important to a full understanding of these motility derangements. Through a complicated interaction of neuromuscular and hormonal influences, the voluntary act of swallowing transforms into an automated sequence of peristaltic waves propelling food and liquids into the stomach in concert with coordinated relaxation of the sphincters. Anatomic and physiologic barriers exist within the esophagus protecting against gastroesophageal reflux and aspiration. With improvements in diagnostic tools such as barium contrast radiography, scintigraphy, pH measurements, and esophageal manometrics with provocative testing, motility disorders have become better defined and understood. Primary motility disorders consist of achalasia, diffuse esophageal spasm (DES), "nutcracker esophagus," hypertensive lower esophageal sphincter, and nonspecific esophageal motility dysfunction (NEMD). A host of secondary and miscellaneous motility disorders also affect the esophagus, including scleroderma and other connective tissue diseases, diabetes mellitus, Chagas' disease, chronic idiopathic intestinal pseudo-obstruction, and neuromuscular disorders of striated muscle. Gastroesophageal reflux disease (GERD) may also be promoted by associated motility disturbances. Treatment modalities include surgical myotomy; dilatation; and pharmacologic manipulations, including use of nitrates, calcium-channel blockers, H2-blockers, and psychotropic drugs where appropriate.

Deglutition↗
PubMed1998

Gastric tubes in children with caustic esophageal injury: a 32-year review.

PURPOSE: Caustic injury to the upper aerodigestive system with scarring of the pharynx, hypopharynx, and esophagus is a challenging reconstructive problem. The author has used the gastric tube for this purpose for three decades. METHODS: During the last 32 years (1965 to 1996 inclusive) the author treated 11 patients who required esophageal replacement with a gastric tube conduit, which was anastomosed to the cervical esophagus. At the time of injury, ages ranged from 2 months to 13 years (mean, 3 years) in seven boys and four girls. Time from injury to esophageal replacement was 12 months to 14 years (mean, 5 years). All 11 had multiple dilations before the replacement. Two had injury and scarring of the epiglottis and larynx that required pharyngeal reconstruction and tracheostomy before replacement. Nine patients underwent reconstruction with a gastric tube anastomosed to the cervical esophagus, and the other two had an interposition with an intrathoracic anastomosis. Eight tubes were antiperistaltic and three isoperistaltic. Seven tubes were placed in the retrosternal space, three were transthoracic, and one was subcutaneous. Six tubes were completed in two stages and five in a single stage. RESULTS: Nontube complications were wound infection (n = 2), perforation (n = 2), paralyzed hemidiaphragm (n = 1), and recurrent laryngeal nerve injury requiring tracheostomy (n = 1). Tube complications were anastomotic leak (n = 9), stricture (n = 8), anastomotic resection (n = 3), ulcer (n = 1), and perforation (n = 1). Six required posttube multiple dilations for several years including self-bouginage (n = 2). All learned to swallow and eat initially with minimal aspiration; only one remains on tube feed supplements. Long-term follow-up (3 to 30 years) includes nine eating normally and not requiring dilations (the tracheostomy boy has chronic lung disease), one lost to follow-up after 1 year, and one death from tube hemorrhage 2 months after operation. CONCLUSION: Children with caustic injury to the upper aerodigestive system can undergo gastric tube replacement with good results. The majority of the problems relate to the esophagogastric tube anastomosis.

Adolescent↗
PubMed1994

[Results of surgical therapy in esophagus and cardia carcinoma].

Surgery for carcinoma of the esophagus and cardia represents potentially curative therapy in early stage of tumor. In the advanced stage of tumor palliation is the only remaining therapeutic aim. In a retrospective study covering the period 1984-1992 we analyzed 51 patients who underwent surgery for esophageal or cardia cancer to determine whether palliation by surgery is feasible. We also analyzed morbidity and mortality of peri- and postoperative complications. In 88% we carried out standard esophagectomy consisting of abdomino-thoracic access, gastric interposition with thoracic anastomosis and extramucous pyloromyotomy. In the light of postresection histology, 53% of the operations were potentially curative (UICC stage I and II) [1], 47% palliative (UICC stage III and IV) [1]. Perioperative 30-days mortality was nil, perioperative 30-days morbidity 11% (3 patients developed pneumonia postoperatively, 2 patients with cervical anastomosis developed dehiscence of anastomosis which in both cases healed completely with conservative therapy, while a further patient with cervical anastomosis suffered persistent paralysis of the recurrent nerve. All patients were fully able to feed themselves at the time of discharge. 43% of patients had recurrent dysphagia and 24% underwent endoscopic dilatation. Three-year survival was 26%. From these results it may be concluded that esophageal resection represents either good palliation with low morbidity for the majority of patients with non-resectable carcinoma of the esophagus or potentially curative therapy with low morbidity in early stage of tumor.

Adenocarcinoma↗
PubMed1993

[Influences of acupuncture on gastroduodenal mucosal lesion and electrical changing induced by stress in rats].

Experiments were performed in 57 SD rats. The stress was induced by binding plus revolving (5.5 xg, 170 c/min, 10 min) or cold (0-4 degrees C, 30-60 min). Selected acupuncture points were "Zusanli" and "Weishu". Bipolar Ag-AgCl recording electrodes were respectively implanted on the serous membrane surface of the antrum, duodenum and on the abdominal skin corresponding to above areas. The results were as follows: (1) There are 63.2% individuals in the stress group which showed a large quantity of bleeding points spreading over the gastroduodenal mucosal membrane. The area density of lesion was 15.8-27.7%. Under microscope the signs emerged including mucosal blood vessel dilatation and hyperaemia, gland cell swelling, virlus broken and peeling off and lymph cell accumulating, etc. 84% individuals showed obvious inhibition of gastroduodenal electroactivities including that the amplitude of slow wave was lower, the frequency decreased even the rhythm was disordered, the number of fast wave reduced and the IDMEC III cycle was prolonged. (2) In the group of acupuncture plus stress only 16.7% individuals showed bleeding or hyperaemia, and the lesion area density was only 1.7%. Also the pathohistological changes were obviously decreased. Gastroduodenal electrical changes were hardly seen (27.2%) or the inhibitory state above were significantly reduced (54.5%) when compared with the stress group. There is strong reason to consider that acupuncture could effectively reduce the mucosal lesion and the electrical inhibition of stomach and duodenum induced by stress in rats.

Acupuncture Therapy↗
PubMed1978

Fourteen years of gastric tubes.

Since 1964 gastric tube replacement of the esophagus has been done in 30 infants and children. This report reviews and brings up to date our entire series, which includes follow-up of 15 children over 5 yr, 7 of whom have been followed for more than 10 yr. The two-stage proximally based reversed antiperistaltic gastric tube placed retrosternally is still our procedure of choice, although since our last report in 1973 several other methods (one-stage, transthoracic, subcutaneous) have been used, and the spleen has not been removed in our more recent operations. Whether the esophagogastric tube anastomosis is primary or secondary or is in the chest or neck, leakage is still the most common complication (63%), with all but three closing spontenously. A continuing problem may be an anastomotic stricture (43%) that will require some dilatations. Mild sacculation or tortuosity of the gastric tube has been encountered only once. Despite the above problems, the eventual outcome in the growing child with a gastric tube replacement continues to be a satsifying one. We continue to use the gastric tube operation when replacement of the esophagus is required.

Adolescent↗
PubMed1986

Esophageal replacement in two siblings with epidermolysis bullosa.

Dystrophic epidermolysis bullosa is an inherited disorder of squamous epithelium that results in dystrophic scarring of the skin after minor trauma. Although severe scarring of the skin is the most common and obvious complication of the disease, esophageal scarring with formation of long strictures may also develop. In two affected siblings, such esophageal strictures occurred and progressed in severity to degrees necessitating esophageal replacement. Each received a preoperative period of total parenteral nutrition, which was continued into the postoperative period. In one, an isoperistaltic segment of right colon was placed substernally in a single stage procedure. In the other, a substernal reversed gastric tube was constructed, also in a single stage. This latter procedure was shorter and technically simpler than the colon interposition. The early postoperative courses in both were complicated by cervical anastomotic leaks, which sealed spontaneously during a period of parenteral nutrition and gastrostomy feedings. Both subsequently developed cervical anastomotic strictures. These were successfully managed by dilatations, and both patients are now tolerating a solid diet. Neither patient experienced problems from endotracheal intubation. Epithelial loss occurred in the skin adjacent to the surgical incision but healed quickly with topical silver sulfadiazine therapy. This report confirms previous reports that esophageal replacement is well tolerated by patients with epidermolysis bullosa and suggests that the reversed gastric tube technique, not previously reported used for this disease, may be preferable to colon esophagoplasty.

Adult↗
PubMed2002

Early surgical correction for isolated gastric stricture following acid corrosion injury.

OBJECTIVE: To evaluate the feasibility and long-term results of early gastric surgery for patients with isolated gastric stricture following acid corrosion injury. MATERIALS AND METHODS: Upper gastrointestinal (UGI) series was routinely performed around the 4th week after acid corrosion injury. Patients with gastric stricture and no risk of delayed esophageal stricture underwent early solitary gastric surgery, which was defined when performance of the procedure took place within 2 months of the injury. RESULTS: From June 1988 to June 2000, 35 of 378 patients with acid corrosion injury developed isolated gastric stricture. Twenty-four (68.6%) lesions were located in the antrum, and 11 (31.4%) in the gastric body. Postprandial vomiting presented earlier for the antral stricture group (17.6 +/- 1.1 versus 25.4 +/- 3.4 days after injury; p = 0.005). The UGI series was performed from 16 to 41 days after injury (average 25 days). Of the 35 acid corrosion injury patients in this study, 4 were excluded because of late referrals to our institution or the patient's hesitation which resulted in delayed surgery. The remaining 31 patients underwent gastric surgery 35.7 +/- 3.2 days after ingestion (34.6 +/- 3.6 and 38.1 +/- 3.4 days for cases of antral and gastric body stricture, respectively). Surgical procedures consisted of hemigastrectomy (n = 16), antrectomy (n = 2), gastroenterostomy (n = 2), subtotal gastrectomy (n = 6), and total gastrectomy (n = 5). There were 4 cases of postoperative complications (12.9%) including adhesion ileus (n = 2), wound infection (n = 1), and massive, postoperative UGI bleeding (n = 1). Surgical mortality was zero. All patients tolerated oral intake well after surgery. During the minimum follow-up period of 1 year, 1 patient developed esophagojejunostomy stenosis, which was resolved by dilation, and there was 1 case of dumping syndrome, which was treated by diet control. CONCLUSION: Early surgery correction is feasible and safe if patients with isolated gastric stricture following acid corrosion injury are carefully selected. All patients in our study recovered early, with a low morbidity rate.

Adolescent↗
PubMed1987

Cardiotoxicity during chemotherapy for advanced gastroenteric tumors.

The authors report two cases of patients with advanced gastroenteric carcinoma, which developed different cardiotoxicity patterns after the administration of cytotoxic drugs. The first patient showed a picture of dilatative cardiomyopathy with associated symptoms of angina pectoris and congestive heart failure; the second patient presented a cardiac arrhythmia after several administrations of 5-fluorouracil. The possible mechanisms of these toxic effects, as well as the drug interactions are briefly discussed. Cardiotoxicity of cytotoxic drugs should be considered by oncologists even in patients with no previous history of cardiac disease.

Adult↗
PubMed1975

An evaluation of segmental gastrectomy for gastric ulcer: one to ten year follow-up.

UNLABELLED: Of 61 patients with gastric ulcer subjected to an improved technique of segmental gastrectomy, 26 were available for follow-up study for 1 to 10 years; evaluations were made mainly on the postoperative reduction of gastric acid secretion and motor function of the gastric remnant. RESULTS: (1) x-ray observation revealed the gastric remnant to be larger than usually seen following Billroth I or II gastrectomy, with no dilatation or remarkable deformity; sphincteric function of the pylorus and peristaltic activity of the gastric remnant were satisfactory; (2) gastric emptying was usually complete in 60 to 180 minutes in 73 percent of the patients, similar to control patients; (3) no instance of dumping syndrome was recognized; (4) average rates of postoperative acid reduction were 58.3 percent for maximal acid concentration, 67.1 percent for maximal acid output, and 67.6 percent for peak acid output, indicating the reduction of gastric acid secretion to be fairly satisfactory. In none of the patients available for follow-up was identified a recurrence of ulcer. These follow-up results suggest the use of segmental gastrectomy for gastric ulcer and for other benign lesions in the mid portion of the stomach.

Adult↗
PubMed1989

Endoscopic management of gastric outlet obstruction following surgery for morbid obesity.

Surgery of morbid obesity is associated with significant morbidity, which is considerably increased for reoperative surgery. Over the past two and a half years endoscopic balloon dilation was performed in eight patients for stenosis of gastrojejunostomy following gastric bypass. The technique of dilation, indications, and pitfalls are discussed. The procedure was safe and effective. Patients who had dilation performed successfully avoided surgery entirely in seven of eight cases. Therapy was modified in two other patients based on endoscopy findings. Endoscopy was found to be more reliable and superior to upper gastrointestinal (UGI) series for evaluation of symptoms following gastric bypass procedures. Based on our experience and literature review we propose that endoscopy is the preferred alternative to major reoperative surgery and urge its wider use.

Catheterization↗
PubMed1974

Experimental edema disease of swine (E. coli enterotoxemia). 3. Pathology and pathogenesis.

Experimental colibacillary (Escherichia coli) enterotoxemia as described in this report mimics natural edema disease both clinically and in gross pathology. The histopathology is characterized by accumulations of non-inflammatory edema and by arteriopathy. The smaller arterial and arteriolar changes recorded here are similar to those described in natural edema disease. The vascular changes described in recovered cases of experimental colibacillary enterotoxemia concur with those reported in so-called subacute and chronic edema disease. The arteriolar changes that occur in colibacillary enterotoxemia of swine are comparable to those associated with hypertension. Thin sections of cerebral cortex from four pigs with acute experimental edema disease were examined by electron microscopy in an attempt to demonstrate brain edema. Sections from one pig taken during the convulsive phase of disease revealed dilatation of perivascular glial processes. However, examination of sections taken from three other pigs during an earlier phase of the neurological disturbance revealed no significant lesions. We were unable to ascertain the role of brain edema in the pathogenesis of the nervous system disturbance in these experiments.

Animals↗
PubMed1993

Gastric vascular ectasia in cirrhosis.

Eight cases of upper gastro-intestinal bleeding associated with liver cirrhosis are reported in this paper. Morphological studies revealed gastroduodenal ulceration with severe vascular changes in the mucosa and submucosa layer. Capillary dilatation was seen in the superficial region of the mucosa. Thick-walled and tortuous vessels similar to angiodysplasia were noted in the submucosa. The latter vessels were surrounded by scar-like connective tissue considerably thickening the gastric submucous layer. It is assumed that scar-like thickening of the submucous layer surrounding the tele-angiectatic vessels causes microcirculatory disorders thus giving rise to bleeding ulcers.

Adult↗
PubMed1995

Different responses of arterioles and venules in rat gastric mucosal microcirculation to endothelin-1 and endothelin-3.

Responses of the microvessels in the basal part of the gastric mucosa of anesthetized rats to endothelin (ET)-1 and ET-3 were examined by intravital microscopy. The posterior wall of the stomach, which was incised along the greater curvature, was secured in an observation chamber and superfused with Tyrode's solution, and the microcirculation was observed through a window made by removing a limited area of smooth-muscle layers with the serosa and submucosal tissue. Topical application of the same ranges of ET-1 and ET-3 (0.1-10 microM, 20 microliters) to the window dose-dependently constricted collecting venules and venules downstream. The constriction was inhibited by BQ-123, an ETA receptor antagonist, but the equipotency of ET-1 and ET-3 did not support the presence of the ETA receptor (tentatively called ETR-m). Arterioles were constricted through ETR-m, particularly at higher doses (> 3 microM), but 1 microM ET-1 dilated the arterioles by generating prostaglandin through BQ-123-sensitive ET receptor (tentatively called ETR-e), as shown by the inhibition of dilatation by indomethacin. Furthermore, the dilatation component of the arteriolar smooth-muscle responses to ET-1 and ET-3 was elicited by BQ-123 and was inhibited by NG-monomethyl-L-arginine (L-NMMA), indicating the generation of nitric oxide. This dilating effect of the endothelins was mediated by the ETB receptor.

Animals↗
PubMed1995

[Ureteral obstruction caused by retroperitoneal metastasis of gastric carcinoma].

Nine patients with ureteric obstruction caused by retroperitoneal metastasis of gastric tumor have been observed in our clinic during the last five years. In all cases flank pain and the dilatation of the renal collecting system were the first signs of the disease. Despite the urological and radiological examinations in 3 cases the exact cause of the occlusion could be established only by autopsy. Most of the carcinomas showed the same histological type and were advanced tumors at the time of diagnosis. This kind of aggressive tumor carries a very poor prognosis, palliative nephrostomy has been performed.

Adenocarcinoma↗
PubMed2000

Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis.

BACKGROUND: Although the acute postoperative complications of a cervical esophagogastric anastomosis are less than those with an intrathoracic esophageal anastomosis, the long-term sequelae of a cervical anastomotic leak are not as minor as initially reported. Nearly 50% of cervical anastomotic leaks result in an anastomotic stricture, and the subsequent need for chronic dilatations negates the merits of an operation intended to restore comfortable swallowing. OBJECTIVE: This study was undertaken to determine whether construction of a side-to-side stapled cervical esophagogastric anastomosis after transhiatal esophagectomy could reliably eliminate the majority of anastomotic leaks. METHODS: In 114 consecutive patients undergoing transhiatal esophagectomy, a functional side-to-side cervical esophagogastric anastomosis was constructed with the Auto Suture Endo-GIA II stapler (United States Surgical Corporation, Auto Suture Company Division, Norwalk, Conn) applied directly through the cervical wound. This side-to-side stapled anastomosis has 3 rows of staples. Early postoperative anastomotic morbidity, subsequent need for anastomotic dilatations, and patient satisfaction with swallowing were evaluated. RESULTS: Before the side-to-side stapled anastomosis, the incidence of cervical esophagogastric anastomosis leak in over 1000 patients undergoing transhiatal esophagectomy having a manually sewn anastomosis varied from 10% to 15%. Among the 111 survivors of transhiatal esophagectomy and a side-to-side stapled anastomosis, there were 3 (2.7%) clinically significant anastomotic leaks. This lowered incidence of leaks has contributed to reduction in the average length of stay after an uncomplicated transhiatal esophagectomy to 7 days and has provided more comfortable swallowing, ease of subsequent esophageal dilatations, and greater patient satisfaction. CONCLUSIONS: Construction of the cervical esophagogastric anastomosis with a side-to-side stapled anastomosis greatly reduces the frequency of anastomotic leaks and later strictures. The side-to-side stapled anastomosis is a major technical advance in the progression of refinements of transhiatal esophagectomy and a cervical esophagogastric anastomosis.

Aged↗
PubMed1992

Gastric volvulus complicating myotonic dystrophy.

Myotonic dystrophy is an autosomal inherited disorder of both striated and smooth muscle, and is considered to be a rare cause of gastrointestinal dilatation and abnormal peristalsis. We report on a patient with myotonic dystrophy complicated by gastric volvulus. A 57-year-old female with myotonic dystrophy suddenly developed abdominal pain, nausea and vomiting. X-ray examinations revealed gastric dilatation and pyloroantral obstruction, consistent with acute gastric volvulus. The patient underwent successful emergency gastrectomy. Gastric volvulus is often an unrecognized surgical emergency, but its clinical and radiographic features are so characteristic that accurate diagnosis is possible if the condition is kept in mind. Thus, the clinician should consider the possibility of gastric volvulus when evaluating gastrointestinal complaints in patients with myotonic dystrophy.

Acute Disease↗
PubMed1991

Colon interposition for esophageal disease: histologic finding of colonic mucosa after a follow-up of 5 months to 15 years.

Thirty-six patients, subjected to colon interposition for benign esophageal disease or carcinoma of the esophagus or gastric cardia, were studied by endoscopy for signs of mucosal disease in the interposed colon. Five months to 15 yr (mean 57 months) after the operation, endoscopic finding of the interposed colon was macroscopically normal in 28 patients. Signs of inflammation, including hyperemia or hyperemia and friability, were observed in seven patients. Histologic specimens obtained at endoscopy were examined microscopically, and the findings were compared with those seen in the preoperative graft. In two patients, chronic inflammatory changes were observed in the graft mucosa, consisting of mononuclear cell infiltration of the lamina propria accompanied by crypt dilatation and deformation. In one of these patients, the inflammation was in the proximal third of the graft, and it was also seen at the endoscopy. In the remaining 34 patients, the graft mucosa was microscopically comparable to normal. The alterations were unexpectedly few and mild considering the marked change in the location and function of the colonic segment.

Adult↗
PubMed2006

The effect of esophageal and gastric distension on the crural diaphragm.

BACKGROUND: The mechanism of prevention of gastric reflux into the esophagus is not exactly known. The lower esophagus has a barrier function provided by the lower esophageal sphincter. We investigated the hypothesis that the crural diaphragm shares in the barrier function not only mechanically but also actively through a crural-esophageal-gastric reflex action. METHODS: The study was performed during repair of abdominal ventral and incisional hernias in 20 subjects (11 men, 9 women; age 38.6+/-4.8 years). The electromyographic response of the crural diaphragm to individual balloon distension of esophagus and stomach was recorded by means of a needle electrode inserted into the crural diaphragm and connected to an electromyographic apparatus. The recordings were repeated after separate crural, esophageal, and gastric anesthetization. RESULTS: The crural diaphragm exhibited basal motor unit action potentials, which decreased on esophageal distension (P<0.001) after a mean latency of 17.3+/-2.8 SD ms. The crural diaphragm response to esophageal distension did not occur after the crural diaphragm or esophagus was anesthetized. Gastric distension effected an increase of crural diaphragm electromyographic activity with a mean latency of 18.4+/-4.6 ms; this effect could not be achieved after the crural diaphragm or stomach was anesthetized. CONCLUSIONS: The crural diaphragm has a resting tone that relaxes after esophageal distension and contracts after gastric distension. This sphincter-like action of the crural diaphragm appears to be a reflex and is mediated through the esophagocrural inhibitory and gastrocrural excitatory reflexes. The crural diaphragm seems to share actively in the gastroesophageal competence mechanism.

Action Potentials↗