OBJECTIVES: Data are limited on the effect of age on esophageal function. We evaluated whether aging influences the motor activity of the esophagus. METHODS: Standard esophageal manometry was performed in 79 healthy, nonpaid volunteers of both sexes, 18–73 yr of age. Lower (LES) and upper esophageal sphincter (UES) characteristics and the properties of esophageal peristaltic waves were assessed by age groups: ≤25 yr, 26–35 yr, 36–45 yr, 46–55 yr, 56–65 yr, and >65 yr. RESULTS: Age correlated inversely with LES pressure and length, UES pressure and length, and peristaltic wave amplitude and velocity, and correlated directly with the proportion of simultaneous contractions. Age was inversely correlated with the upper limits of normality (95th percentiles) of LES pressure (r =−0.943, p= 0.005), UES pressure (r =−0.943, p= 0.005), middle and lower peristaltic wave amplitude (r =−0.947, p= 0.004, and r =−0.844, p= 0.035, respectively), upper/middle peristaltic progression speed (r =−0.943, p= 0.005), and the proportion of simultaneous contractions (r = 0.926, p= 0.008), but not with the lower normal limits (5th percentiles) of these variables. Gender did not affect esophageal motility variables. The 95th percentiles of LES pressure differed by 20 mm Hg, those of lower peristaltic amplitude by 82 mm Hg, and those of percent simultaneous contractions by a factor of 2, between the younger and the older age groups. CONCLUSIONS: The results suggest that normal esophageal motility deteriorates with advancing age. Thus, age-related normality limits of esophageal pressures should be considered before establishing the manometric diagnosis of hypercontractile esophageal motility disorders.

BACKGROUND--Oesophageal motor abnormalities have been reported in alcoholism. AIM--To investigate the effects of chronic alcoholism and its withdrawal on oesophageal disease. PATIENTS--23 chronic alcoholic patients (20 men and three women; mean age 43, range 23 to 54). METHODS--Endoscopy, manometry, and 24 hour pH monitoring 7-10 days and six months after ethanol withdrawal. Tests for autonomic and peripheral neuropathy were also performed. Motility and pH tracings were compared with those of age and sex matched control groups: healthy volunteers, nutcracker oesophagus, and gastro-oesophageal reflux disease. RESULTS--14 (61%) alcoholic patients had reflux symptoms, and endoscopy with biopsy showed oesophageal inflammation in 10 patients. One patient had an asymptomatic squamous cell carcinoma. Oesophageal motility studies in the alcoholic patients showed that peristaltic amplitude in the middle third was > 150 mm Hg (95th percentile (P95) of healthy controls) in 13 (57%), the ratio lower/ middle amplitude was < 0.9 in 15 (65%) (> 0.9 in all control groups), and the lower oesophageal sphincter was hypertensive (> 23.4 mm Hg, P95 of healthy controls) in 13 (57%). All three abnormalities were present in five (22%). Abnormal reflux (per cent reflux time > 2.9, P95 of healthy controls) was shown in 12 (52%) alcoholic patients, and was unrelated to peristaltic dysfunction. Subclinical neuropathy in 10 patients did not effect oesophageal abnormalities. Oesophageal motility abnormalities persisted at six months in six patients with ongoing alcoholism, whereas they reverted towards normal in 13 who remained abstinent; reflux, however, was unaffected. CONCLUSIONS--Oesophageal peristaltic dysfunction and reflux are frequent in alcoholism. High amplitude contractions in the middle third of the oesophagus seem to be a marker of excessive alcohol consumption, and tend to improve with abstinence.

There is little information concerning the long term outcome of patients with gastro-oesophageal reflux disease (GORD). Thus 109 patients with reflux symptoms (33 with erosive oesophagitis) with a diagnosis of GORD after clinical evaluation and oesophageal testing were studied. All patients were treated with a stepwise approach: (a) lifestyle changes were suggested aimed at reducing reflux and antacids and the prokinetic agent domperidone were prescribed; (b) H2 blockers were added after two months when symptoms persisted; (c) anti-reflux surgery was indicated when there was no response to (b). Treatment was adjusted to maintain clinical remission during follow up. Long term treatment need was defined as minor when conservative measures sufficed for proper control, and as major if daily H2 blockers or surgery were required. The results showed that one third of the patients each had initial therapeutic need (a), (b), and (c). Of 103 patients available for follow up at three years and 89 at six years, respective therapeutic needs were minor in 52% and 55% and major in 48% and 45%. Eighty per cent of patients in (a), 67% in (b), and 17% in (c) required only conservative measures at six years. A decreasing lower oesophageal sphincter pressure (p < 0.001), radiological reflux (p = 0.028), and erosive oesophagitis (p = 0.031), but not initial clinical scores, were independent predictors of major therapeutic need as shown by multivariate analysis. The long term outcome of GORD is better than previously perceived.

To investigate the influence of reflux esophagitis (RE) on the glandular differentiation of carcinomas of the esophagus induced by 2,6-dimethylnitrosomorpholine (2,6-DMNM), a study was carried out using 4 experimental groups and 2 control groups of 8-week-old Sprague-Dawley rats, each consisting of 20 males and 20 females. An esophagojejunostomy (EJ) with gastric preservation was performed in two groups of animals. Fifteen days thereafter the potent esophagotropic carcinogen 2,6-DMNM was subcutaneously injected, once a week for life, at doses of 1/100 and 1/10 of the 50% lethal dose in each group respectively. The result was a spectrum of carcinomatous tumors mainly developing in the lower half of the esophagus, which were thoroughly investigated by serial sectioning, staining for mucins, and in selected cases by electron microscopy. They were classified as follows: 16 pure squamous cell carcinomas (SCC), 5 SCC with focal mucous or glandular differentiation (FGD), 11 pure adenocarcinomas (ADC), and 12 ADC with areas of squamous cell differentiation (SCD). By contrast, in 2 similar experimental groups in which the previous EJ was not performed, 15 animals showed SCC of the pure type, without evidence of mucous or glandular differentiation. No tumors were observed in the two control groups without carcinogen treatment. Of these, the group that underwent EJ showed reflux esophagitis. In conclusion, the tumors of the esophagus induced by 2,6 DMNM under the influence of EJ are not only pure ADC and pure SCC, as we have previously reported, but also intermediate tumors showing either SCC with focal mucous or glandular differentiation (SCC + FGD) or ADC with areas of squamous cell differentiation (ADC + SCD).(ABSTRACT TRUNCATED AT 250 WORDS)

A total of 160 patients treated by Nissen fundoplication for uncomplicated gastro-oesophageal reflux disease were studied over a 20-year period. Recurrent reflux and side-effects were assessed yearly after surgery. No objective tests for reflux were performed during follow-up if patients were asymptomatic. Perioperative mortality and technique-related morbidity rates were both 2 per cent. At the latest evaluation, 79 per cent of patients were completely relieved of reflux symptoms, 85 per cent had symptoms of Visick grade 1 or 2 and 89 per cent would be willing to undergo surgery again under the same conditions. Actuarial analysis showed that the success rate of fundoplication was 92 per cent at 20 years. Fourteen patients (9 per cent) developed side-effects after fundoplication and had continuing disability. Nissen fundoplication achieves permanent control of reflux symptoms in most patients with few complications and has a high degree of patient satisfaction.

To evaluate esophageal motor function in patients with primary Sjögren's syndrome (PSS) and its relation to the presence of dysphagia, 20 outpatients, who met the four criteria for PSS proposed by Fox et al. were prospectively studied by esophageal manometry after dry or wet swallows. Dysphagia was present in 15 (75%) patients, although the presence or severity of the symptom was not related to any specific motility pattern. Moreover, this study did not show any correlation between dysphagia and degree of inflammatory infiltrate of the labial minor glands, the parotid flow rate, or the presence of autoantibodies. In conclusion, although dysphagia is a common complaint in patients with PSS, esophageal motor studies have failed to show any consistent pattern.

Twenty-four-hour intraesophageal pH monitoring is presently considered the most reliable diagnostic test for gastroesophageal reflux. Prolonged esophageal pH measurements can be obtained in hospitalized patients with a stationary technique and in ambulant outpatients by means of a portable device; however, there have been no studies that have examined whether the two approaches provide a similar diagnostic accuracy. We performed a prospective study to compare stationary and ambulatory pH-metry in the diagnosis of gastroesophageal reflux. Seventy-seven control subjects and 178 patients with proven gastroesophageal reflux disease were randomized to either ambulant or static pH-metry, which was performed with standard pH electrodes, sensors, and recorders. Reflux events (intraesophageal pH < 4.0) analyzed were: number of episodes; total, upright, and supine reflux time; number of episodes lasting >5 min; and duration of the longest episode. A composite score of all reflux events according to DeMeester was also calculated. The limits of normality were defined as the 95th percentiles of the control groups. Both controls and patients assigned to either pH monitoring method were comparable. Of 255 studies attempted, 243 (95%) were completed successfully. The results showed similar median values of reflux events for the two control groups and for the two patients groups. Percent total reflux time provided a good separation between normal and abnormal reflux, with a sensitivity of 0.92 for static pH-metry and 0.68 for the ambulant procedure (respective 95th percentiles, 3.4 and 4.6). The lower sensitivity of ambulatory pH-metry compared to the stationary method could not be attributed to the higher normal limit in the former, circumstantial evidence suggests that dietary restrictions by the patients to minimize symptoms during home monitoring were probably responsible of this relatively high false negative rate. In conclusion, the results confirm the accuracy of stationary pH monitoring in the diagnosis of gastroesophageal reflux and show that the ambulatory procedure is less reliable; its sensitivity could probably be improved by strict dietary standardization.

We report the results of a prospective study designed to evaluate a follow-up program in patients undergoing curative resection for colorectal carcinoma. From January 1984 to December 1989 a total of 328 patients were operated upon for colorectal carcinoma at the Department of Surgery, Hospital Clinic of Barcelona. The protocol included the performance of a physical exam, blood chemistry, CEA assay, chest X ray, endoscopy and US/CT scan, postoperatively after 3 months, every 6 months during the first 2 years and every year thereafter if there were no recurrence findings. Curative operative treatment was possible in 258 patients (78.6%). The actuarial 5-year survival rate was 60 ± 2% with a median survival time of 65.4 ± 9 months. There were four variables with independent prognostic value (p < 0.05): age, Dukes' classification, number of blood units transfused during surgery and Broders' differentiation. Cancer recurrence was detected in 87 patients (36.1%). Recurrence resection rate rose up to 37.9% (33/87) of all recurrences or 13.7% of patients on the follow-up program. Survival rate after recurrence and second curative resection was 45% at 3 years (median = 19.7 months), which compares favorably with a 10% survival at 3 years when resection was not possible (median = 11.5 months); the difference was statistically significant. We think that a follow-up program in patients undergoing curative resection for colorectal carcinoma should be regarded as necessary, since survival after a second resection is significantly improved.

We report on our experience with a modified version of the distal splenorenal shunt (DSRS) initially described by Warren. Since 1976 more than 150 shunts have been done in the department. The first part of this study shows the long-term results of a series of 100 consecutive patients treated electively. The estimated survival at 80 months was around 30%. On the other hand, the median survival rate (68 months) and the five-year survival (52%) of Child's A patients differed significantly from those of Child's B patients (8 months and 15%, respectively). These results suggested that the modified DSRS was an effective and relatively safe procedure for the elective treatment of variceal bleeding and warranted a prospective and randomized trial to compare DSRS and endoscopic sclerotherapy (ES). In the second part of the study, in which ES was compared with DSRS, both modalities showed a similar survival rate, although patients in the DSRS group had a higher incidence of encephalopathy and patients in the ES group were more prone to rebleed. It was concluded that ES was a good alternative to DSRS for the elective treatment of esophageal variceal bleeding. If orthotopic liver transplant is considered the only definitive mode of treatment for the elective management of portal hypertension, the DSRS should be reserved for patients in whom ES has not been totally effective, or varices are located predominantly in the fundus of the stomach.

During the first 18 months of liver transplantation program for adult patients we evaluated 98 potential candidates for this treatment. Forty five patients were refused for transplantation and 53 were accepted. Forty six out of these 53 cases were transplanted. Ten (22%) out of the 46 patients undergoing transplantation had chronic hepatic cholestasis, 31 (67%) chronic hepatic diseases of non biliary origin (3 patients had an associated hepatocarcinoma), and 5 patients (11%) suffered an acute hepatic failure. All transplanted patients with previous chronic hepatic diseases had clinical and biological signs of advanced hepatic failure. There were no operative deaths. During the follow-up period 6 transplanted patients (13%) died. The survival probability among the 46 operated patients was about 84% at 12 months after the transplant. This survival was theoretically higher than that expected to occur without transplantation. The survival probability among the 46 transplanted patients was significantly higher (p = 0.0001) than that recorded in 36 patients with comparable hepatic diseases who were evaluated during the same study period and who were not considered for transplantation due to several reasons. The survival probability at the first year in the later group of 36 patients was 20%.

Intestinal obstruction owing to colonic carcinoma is a relatively frequent cause of acute abdominal pain. The aim of this prospective study is to evaluate the prognostic factors that may influence the final outcome of those patients operated upon for an intestinal obstruction (OG) as opposed to those electively operated upon (EG). From September 1984 to March 1988, a total of 188 patients with colorectal cancer have been included in the study. One hundred thirty-five were EG, while 53 (28.1 percent) were OG. The mean ages were similar in both groups. Sex, morbidity, and mortality rates were equally distributed. Curative resection rate was significantly higher in the EG group (P = 0.029). Tumor staging tended to be significantly more advanced in OG patients (chi-square = 9.054; df = 3; P = 0.026). Multivariate analysis (proportional hazards model) showed that the only independent prognostic factor was tumor staging (P = 0.0000). Obstruction itself disappears as a predictive variable when tumor staging is introduced in the model. We conclude that obstructing colon carcinomas tend to be more locally advanced, that probably being the only reason for a worse long-term prognosis.

Abnormalities in esophageal peristaltic function and acid clearance appear to be responsible for prolonged esophageal acid exposure, a major determinant of the reflux esophagitis and esophageal stricture. We evaluated esophageal motility by manometry in 50 healthy controls and in 35 symptomatic reflux patients before, within 6 months, and 1 year after Nissen fundoplication. Preoperative motility was analyzed in relation to the presence or absence of both nonobstructive dysphagia and erosive esophagitis. We found that (a) preoperative dysphagia was related more to peristaltic dysfunction than to esophagitis; (b) peristaltic wave amplitude and duration were significantly lower than control values in patients with reflux, without correlation to degree of esophagitis or lower esophageal sphincter hypotension; (c) dysphagia ceased in most patients after antireflux surgery at the same time that normal motility was restored independently of lower esophageal sphincter pressure increments. These results suggest that motility disturbances are an important cause of dysphagia in reflux disease, and that reflux is the cause of, rather than the consequence of, peristaltic dysfunction.

Reports on the morbidity and mortality in the surgical treatment of gallstone disease in cirrhotic patients vary markedly depending on the authors. We reviewed our experience over the last 4 years, studying the charts of 36 patients with liver cirrhosis, operated on with the diagnosis of biliary lithiasis. Isolated cholecystectomy was performed in 27 patients and concomitant surgical procedures in 9. Patients were divided according to the Child-Campbell classification: 24 in group A and 12 in group B. Morbidity (33.3%) was related to the degree of liver function impairment: 6 patients in group A (25%), and 6 in group B (50%). Hemorrhage was not a common complication in this series. Only 1 patient died (2.7%) secondary to ascitic fluid infection. We propose a flowchart in the treatment of biliary lithiasis in patients with liver cirrhosis, taking their liver function into account.

Wound healing was studied in 95 jaundiced patients and 123 anicteric patients using skin prolylhydroxylase activity as an index of collagen synthesis. The mean (s.d.) value of skin prolylhydroxylase activity in jaundiced patients was significantly lower than that of controls in the preoperative period (40.1(19.2) versus 369.2(32.2) c.p.m./mg protein, respectively, P less than 0.001). Before operation there was a significant difference between patients with benign or malignant obstruction of the biliary tree (55.0(12.3) versus 25.2(10.4) c.p.m./mg protein, respectively, P less than 0.05). In patients with benign obstruction skin prolylhydroxylase activity returned to normal values (326.3(53.1) c.p.m./mg protein, P less than 0.001 versus preoperative values), while in patients with malignant lesions skin prolylhydroxylase activity increased significantly with respect to the preoperative period (25.2(10.4) versus 82.9(14.3) c.p.m./mg protein, P less than 0.01) but was still below normal values. Abdominal wound dehiscence was more common in jaundiced patients (six of 95) than in the anicteric group (two of 123). This complication appeared to be associated with a low skin prolylhydroxylase activity.

To study the influence of reflux esophagitis on the carcinogenic response of 2,6-dimethylnitrosomorpholine (2,6-DMNM), an experiment was designed, composed of 6 groups of 8-week-old Sprague-Dawley rats, each consisting of 20 males and 20 females. Group 1 served as untreated controls. All animals of groups 2, 4, and 6 underwent an esophagojejunostomy with gastric preservation to produce a chronic reflux esophagitis. 2,6-DMNM was injected s.c. once weekly for life at doses of 1/100 and 1/10 of the 50% lethal dose to groups 3 and 4 and groups 5 and 6, respectively. Carcinogen exposure began in groups 4 and 6 15 days after the esophagojejunostomy. Squamous cell carcinomas were observed in the esophagus of 36 animals, mainly in those receiving the higher dose. Exophytic squamous cell carcinomas, a variety rarely seen in humans, were mostly seen in the groups receiving 2,6-DMNM alone, whereas endophytic squamous cell carcinomas, the variety most frequently seen in humans, mainly developed in the groups receiving the combined treatment. In addition adenocarcinomas with abundant mucin production were found in the distal esophagus of 23 animals. They were found exclusively in animals of groups 4 and 6 which underwent esophagojejunostomy plus 2,6-DMNM exposure. No adenocarcinomas were encountered in groups without experimental reflux esophagitis. These findings may contribute to further understanding of the association between reflux esophagitis and the various histological types of esophageal carcinoma in humans.

A generalized state of immunosuppression during surgery has been implicated in the development of septic complications postoperatively. We studied 18 patients operated upon for benign diseases, to examine the influence of surgical trauma on circulating lymphocyte subpopulations in man. Additionally, we evaluated the effect of thymostimulin on these changes, in another group of 10 patients. Our results suggest that the total number of lymphocytes, as well as lymphocyte subpopulations CD3+ and CD4+, fell significantly following surgery. This reduction in cell number is more pronounced on the helper/inducer lymphocytes. The CD4+/CD8+ ratio decreases significantly after operation. For patients with no complications, the immunosuppression in terms of peripheral lymphocyte population, seen in the postoperative period is usually reversible around the seventh day. On the other hand, peripheral blood lymphocyte changes in the postoperative period were less pronounced in patients treated with thymostimulin. Thymostimulin's action is predominantly on T lymphocytes, and within these, on the T helper/-inducer subpopulation. And finally, thymostimulin is capable of maintaining a normal relationship between helper/inducer and suppressor/cytotoxic cells (CD4+/CD8+ ratio) during the postoperative period, suggesting a better immune state.

To investigate esophageal involvement of scleroderma in primary biliary cirrhosis, esophageal manometry was performed in 18 patients (16 females, two males) with primary biliary cirrhosis and in a control group of 18 subjects matched by age and sex. All patients were screened for clinical manifestations of scleroderma and for the presence of Sjögren's syndrome. Four patients had scleroderma (all of them with Sjögren's syndrome), nine had Sjögren's syndrome without scleroderma, and five had neither scleroderma nor Sjögren's syndrome. Three patients with scleroderma had aperistalsis and diminished lower sphincter pressure. Five patients with Sjögren's syndrome without scleroderma also had esophageal manometric disturbances. Furthermore, lower esophageal sphincter pressure (LESP) and distal mean wave pressure (DMWP) were significantly reduced in patients with scleroderma (LESP: 7.5 ± 1.4 mmHg; DMWP: 29.5 ± 5.9 mmHg) and in patients with Sjögren's syndrome without scleroderma (LESP: 14.8 ± 0.8 mmHg; DMWP: 54.3 ± 7.5 mmHg) compared to controls (LESP: 18.0 ± 0.7 mmHg; DMWP: 83.9 ± 5.1 mmHg). By contrast, LESP and DMWP were similar in patients without Sjögren's syndrome (LESP: 17.6 ± 0.9 mmHg; DMWP: 78.2 ± 10.9 mmHg) and controls. These results indicate that esophageal motility dysfunction is often present in patients with primary biliary cirrhosis who have scleroderma, and also in those with Sjögren's syndrome without scleroderma, suggesting that some esophageal motor disturbances could be related to association with Sjögren's syndrome.

The authors present the results of a therapeutic trial of the conservative or surgical management of penetrating abdominal stab wounds (PASW) based on clinical criteria. In a prospective series of 100 patients, 70 were treated non-operatively. Thirty patients were operated upon, twenty-one immediately and nine during the 48 h observation period. In five laparotomies no significant injuries were found. Morbidity was similar in both immediate and delayed laparotomy groups (3/21 versus 1/9). Acute alcoholic intoxication identifies a subgroup of patients that are difficult to evaluate and hence are more likely to be managed by laparotomy (chi 2 = 4.056, P less than 0.05). The authors conclude that selective surgical management of PASW based on clinical criteria is an accurate and safe procedure.