The aim of the study was to evaluate the correlation between hiatal hernia and gastro-oesophageal reflux and related histological abnormalities in patients without endoscopic oesophagitis. A consecutive series of 78 patients with a history of gastro-oesophageal reflux symptoms and hiatal hernia, as defined by videofluorography combined with a water siphon test, underwent oesophagogastroduodenoscopy and multiple biopsies. Hiatal hernia was confirmed endoscopically in 99% of cases. The water siphon test was positive for reflux in 72% of cases. At endoscopy 42% of patients had oesophagitis and/or Barrett's oesophagus and 58% had no lesions. In the group without endoscopic lesions, at histology oesophagitis-related alterations were found in 98% and intestinal metaplasia in 27%. In conclusion, this study shows that symptomatic gastro-oesophageal reflux patients with radiologically defined hiatal hernia should undergo endoscopy with multiple biopsies above the squamocolumnar junction, even when endoscopy is normal. This is in order to detect histological gastro-oesophageal-reflux-related alterations, above all, when a positive water siphon test is also present, owing to its known correlation with intestinal metaplasia.

Background: The role of Barrett esophagus in carcinogenesis is widely accepted, but the significance of esophageal columnar mucosa without histological intestinal metaplasia, known as columnar-lined esophagus, is debated.<br /> Material/Methods: We studied 128 patients free of Helicobacter pylori with reflux-related symptoms and columnar mucosa in the esophagus at endoscopy, 106 patients with Barrett esophagus (referred to as the Barrett group) and 22 patients without intestinal metaplasia (columnar group). Samples from 20 subjects free of H. pylori were used as controls. Immunostaining for keratin 7 (KRT7), keratin 20 (KRT20), caudal type homeobox 2 (CDX2), mucin 2, oligomeric mucus/gel-forming (MUC2), and tumor protein p53 (TP53) was assessed.<br /> Results: Samples taken 1 cm above the gastroesophageal junction showed KRT7 staining in all cases in the Barrett and columnar groups and none in the control group. Immunostaining for TP53 was absent in the control group, and more frequent in the columnar group (7, 31.8%) compared with the Barrett group (14, 13.2%, P=0.033). In the columnar group, low grade dysplasia and TP53 expression was seen in 7 of 22 biopsy specimens (31.8%) at baseline and in 4 additional specimens after 2 years, for a total of 11 specimens (50.0%).<br /> Conclusions: The expression of KRT7 might help to explain the pathological, reflux-related nature of columnar-lined esophagus, as aberrant expression in a very early stage of the multistep Barrett esophagus progression. Expression of KRT7 may occur in basal glandular cells as a result of their multipotentiality and susceptibility to immunophenotype changes induced by reflux.<br />

Although a possible link between gastro-oesophageal reflux disease (GORD) and obstructive sleeping apnoea has already been reported in the literature, there has never been any suggestion of an association with epilepsy, and epileptic attacks have not so far been included among gastro-oesophageal reflux disease symptoms. We report the case of a patient with gastro-oesophageal reflux disease associated with a sliding hiatus hernia, a short oesophagus and oesophagitis, who for the last ten years had not only presented the typical symptoms of gastrooesophageal reflux, but also symptoms of obstructive sleep apnoea and epileptic-like attacks occurring occasionally and only during sleep. Partial posterior fundoplication was performed and considerably reduced the reflux symptoms, and in addition brought about a drastic decrease in the number of epileptic-like attacks. Our case suggests that epileptic-like episodes in patients with obstructive sleeping apnoea may well be linked to the simultaneous presence of GORD associated with hiatus hernia, and surgical treatment of GORD may bring about an improvement of the neurological problems.

The aim of this retrospective study was to evaluate the use of digital videofluorography in the preoperative and postoperative management of esophageal achalasia surgical treatment. From 1990 to 2004, 25 patients with achalasia, diagnosed by digital videofluorography and confirmed by motility studies and endoscopy, underwent surgery. All patients underwent digital videofluorography at 1, 6 and 12 months in order to evaluate the completeness of the myotomy and the efficacy of the antireflux procedures. At postoperative videofluorography esophageal transit time was decreased in all patients (100%); esophageal motor activity was unchanged in 23 (92%), and modified in two patients (8%) with onset of peristaltic-like motor activity; 8 patients (35%) presented decreased preoperative dilatation; all patients had a WST negative for post-myotomy reflux. On the basis of our experience and the advantages of the procedure we suggest videofluorography as a first-approach diagnostic examination useful for surgical indications and postoperative follow-up in achalasic patients.

The aim of the study was to report our experience with the use of radiology in functional disorders of the cricopharyngeal muscle and their surgical therapy using digital cineradiology. Five-hundred and seventy dysphagic patients underwent dynamic study of the oral and pharyngeal phases of swallowing (Videofluoroscopic Swallowing Study, VFSS). A motor disorder of the cricopharyngeal muscle was diagnosed by videofluorography in 19 patients: the disorder was mild in 8, moderate in 7 and severe in 4. Two of these underwent cricopharyngeal myotomy, with an improvement in their dysphagia and swallowing mechanisms. VFSS provides a morphological and functional view of the aero-digestive tracts: this is essential in the diagnosis of cricopharyngeal dysfunction and is capable of revealing the related laryngeal penetration and tracheal aspiration. VFSS must always include an oesophageal phase study because of the known clinical and physico-pathological correlations between the gastro-oesophageal junction and the upper oesophageal sphincter. On the basis of our experience we believe that VFSS could be used as a primary investigation, followed by motility studies, and that it may be a useful complementary procedure both in the diagnosis of pharyngo-oesophageal junction motor disorders and with a view to surgical indications.

Intra- and postoperative bleeding represents an extremely serious and frequent complication of hepatic surgery. In this study, we evaluated the effectiveness of a radiofrequency (RF) device using heat to cause coagulative necrosis of the hepatic parenchyma to control hemostasis in minor hepatic resection. Between December 2005 and November 2007, a study was conducted of 21 patients undergoing 22 hepatic resections with the RF-assisted technique. Sixteen of these were affected by hepatocellular carcinoma and five had liver metastases from colorectal cancer. Intraoperative blood loss, the need for blood transfusion, the complication rates, operating times, and the duration of postoperative hospitalization were evaluated. Four segmentectomies and 18 tumor-ectomies were performed. The average blood loss was of 15.7 mL (range, 0-40 mL); the average operating time was 25.7 minutes (range, 12-43 minutes); the mean postoperative hospital stay was 8.2 days (range, 3-49 days) with a median of 6.0 days. The authors concluded that the RF-assisted technique can be a useful method not only for reducing blood loss and avoiding blood transfusions, but also for reducing operating time and postoperative hospitalization for minor liver resections.

ABSTRACT: INTRODUCTION: A retained surgical sponge in the abdomen is uncommon although it is likely that this finding is underreported in the medical literature. The intravisceral migration of retained surgical gauze is even rarer, as demonstrated by the very few cases reported. CASE PRESENTATION: Three years after undergoing anterior resection of the rectum, a 75-year-old man presented with symptoms of small bowel obstruction. Plain abdominal radiography and CT showed a radio-opaque marker; a foreign body was suspected, probably a piece of retained surgical gauze. An ileotomy of about 5 cm. was performed to confirm this diagnosis and remove the gauze. CONCLUSION: Although rare, retained gauze in the abdomen is a complication of surgery. The authors consider that this event may be more frequent than it appears from reports in the literature, probably because of its medico-legal implications. If all such cases were reported, it would be possible to estimate their exact number, classify the occurrence as a possible surgical complication and thus modify its medico-forensic consequences.

24-hour oesophageal pH monitoring with a dual pH probe is considered to be the most sensitive test for diagnosing GORD-related otolaryngological manifestations. In this study we evaluate an initial diagnostic approach with digital videofluorography associated to the water siphon test and primary "ex juvantibus" therapy with proton pump inhibitors for patients with supra-oesophageal symptoms of GORD. The results of Nissen fundoplication surgical treatment are also assessed in some of these patients. Two hundred and thirty patients with suspected GORD-related supra-oesophageal symptoms were referred for videofluorography and the water siphon test. When hiatal hernia and/or reflux were found, patients were referred for medical therapy with proton pump inhibitors. Five patients, who had had a good or excellent response to the medical therapy, but had a recurrence underwent laparoscopic Nissen fundoplication and videofluorography 6 months after surgery. Within 6 months, more than 80% of patients had an excellent or good response to medical therapy. In patients undergoing laparoscopic Nissen fundoplication, hoarseness and chronic cough disappeared within 3 months and videofluorography showed good morphofunctional results of the surgery. In patients with GORD-related supra-oesophageal manifestations, videofluorography plus the water siphon test is useful initial investigation, and laparoscopic Nissen fundoplication can be a valid alternative therapeutic option.

BACKGROUND: Pure signet-ring cell colorectal carcinoma (SRCC) is an infrequent and highly malignant histological variant of colorectal cancer (CRC), while it is present as a histological component in colorectal carcinomas more frequently. MATERIALS AND METHODS: The aim of this work was to widen the knowledge of the biological factors involved in the pathogenesis and aggressiveness of SRCC by the identification and evaluation of possible molecular abnormalities. By means of immunohistochemistry the expression of the proteolytic degradation enzyme matrix metalloprotease (MMP)-1, that is a collagenase specifically degrading collagens I, II, III and of the adhesion proteins E-cadherin, beta-catenin and fibronectin which are usually involved in the carcinogenesis of conventional colorectal tumours was investigated. RESULTS: SRCCs showed a significantly greater MMP-1 expression compared to the ordinary intestinal colorectal cancer (ICRC) and a significantly reduced E-cadherin, beta-catenin and fibronectin expression. CONCLUSION: The biological aggressiveness and strong metastatic behaviour of SRCC could be due to high MMP-1 and low expression of the adhesion molecules.

PURPOSE: In breast cancer staging, the need for intraoperative sentinel lymph node (SLN) evaluation has still not been adequately established. This study investigates the impact of intraoperative frozen section (FS) evaluation of SLN to avoid subsequent axillary lymph node dissection (ALND) in patients with positive SLN. METHODS: A retrospective review of 364 breast cancer patients undergoing SLN biopsy with intraoperative FS evaluation of SLN was performed. RESULTS: Sensitivity and accuracy of FS examination of SLN were 76.4% and 94.2%, respectively. The sensitivity was significantly higher in larger tumors (p < 0.01). No significant correlation was found between FS and histologic type. A second intervention was avoided in 83.9% of the patients with positive SLN. CONCLUSIONS: Intraoperative FS examination of the SLN is a useful predictor of axillary lymph node status in breast cancer patients. The majority of SLN-positive patients allows for immediate ALND in a one-stage surgical procedure.

HYPOTHESIS: The results of surgical treatment of patients with long-segment Barrett esophagus (BE) have been extensively reported. However, few publications refer to the results of surgery 5 years after the fact among patients with short-segment BE. This study aimed to determine the late results of 3 surgical procedures in patients with short-segment BE by subjective and objective measurements. DESIGN: Prospective, nonrandomized study starting on March 1, 1987, and ending on December 31, 2005. SETTING: A prospective, descriptive study of a group of patients. PATIENTS: A total of 125 patients with short-segment BE underwent 3 operations in different periods: duodenal switch plus highly selective vagotomy and antireflux technique in 31 patients, vagotomy plus partial gastrectomy and Roux-en-Y loop with antireflux surgery in 58 patients, and laparoscopic Nissen fundoplication in 36 patients. MAIN OUTCOME MEASURES: Late subjective and objective outcomes of the 3 different surgical procedures. RESULTS: No operative mortality and only 2 postoperative complications (1.6%) occurred. The regression from intestinal metaplasia to cardiac or oxyntocardiac mucosa occurred in 60.8% to 65.4% of the patients, at a mean time of 39 to 56 months after surgery. Visick grading showed Visick grade I or II in 86.3% to 100.0% of the patients. No progression to low- or high-grade dysplasia or adenocarcinoma occurred. CONCLUSIONS: On the basis of these results, laparoscopic Nissen fundoplication seems to be the surgical option for patients with short-segment BE because it is less invasive, has fewer side effects, and produces good results in the long-term follow-up.

When biopsies obtained from short tongues of columnar epithelium in the distal esophagus show only corpus or cardia-corpus transitional mucosa, it remains uncertain whether we are dealing with columnar epithelium metaplasia or a sampling error. In 50 patients with gastro-esophageal reflux disease receiving proton pump inhibitor (PPI) with such tongues of columnar epithelium, we noted that under this treatment, PPI-typical hypertrophy of the parietal cells in the corpus can be found, but not in the corpus or cardia/corpus transitional mucosa in biopsy material obtained from tongues of columnar epithelium in the distal esophagus. These observations may by an indication that in short segments of columnar epithelium corpus, mucosa with no PPI-induced hyperplasia of the parietal cells may be interpreted as metaplastic mucosa.

OBJECT: The aim of this study is to valuate the opportunity to associate both laparoscopic Nissen-Rossetti fundoplication and cholecystectomy in patients with gallbladder cholelithiasis and gastro-oesophageal acid reflux (endoscopically and pHmetrically assessed), considerating that the gallbladder removal makes duodenal-gastric reflux worse. PATIENTS AND METHODS: From 2005 until 2007 we associated laparoscopic Nissen-Rossetti fundoplication and cholecystectomy in 10 patiens, who presented surgical indications for gallbladder cholelithiasis and gastro-oesophageal reflux. Clinical data, surgical procedures and post-operative complications were compared to our esperiency on the singular procedure (laparoscopic Nissen-Rossetti fundoplication and cholecystectomy). Results were valuated at 3, 6 and 12 months after surgical interventions by clinical and instrumental follow up (24-pH-metry and oesophagus-gastro-duodenoscopy). RESULTS: The analysis of instrumental data of these associated procedures doesn't present significative differences between the singular surgical approach. In all the patients treated by combined procedure, the follow-up shows a normal pHmetric exam, a good control on the acid reflux by fundosplication, absence of distal oesophagitis and gastric reflux symptoms. CONCLUSIONS: The association of laparoscopic Nissen-Rossetti fundoplication and laparoscopic cholecystectomy is indicated in patients who present both pathologies and needs to be considerating in relations to the good results and the low postoperatoric morbidity.

BACKGROUND AND STUDY AIMS: In patients with presumed Barrett esophagus we evaluated clinical risk factors that could predict the presence of intestinal metaplasia and dysplasia in biopsies of columnar-lined esophagus (CLE), independently of histological results. PATIENTS AND METHODS: In 908 patients with CLE of length >/= 2 cm, data on age, sex, reflux symptoms, tobacco and alcohol use, medication use, and upper gastrointestinal endoscopy findings were prospectively collected. Multivariate logistic regression analysis was performed, and a model for predicting the histological results was developed. RESULTS: In 127/908 patients, biopsies of CLE did not contain intestinal metaplasia. Of the 781 patients with intestinal metaplasia, 663 patients (85 %) had no dysplasia, and 118 (15 %) had low grade dysplasia (LGD). The most important predictors for the presence of intestinal metaplasia were length of CLE, size of hiatal hernia, and male sex, while among those with intestinal metaplasia, age and male sex were most important for the presence of LGD. Multivariate combinations of these predictors yielded reliable models, which were able to discriminate intestinal metaplasia well from no intestinal metaplasia (area under receiver operating characteristic [ROC] curve 0.82), but only reasonably discriminated LGD from no dysplasia (area under ROC 0.65). CONCLUSIONS: A simple model based on clinical findings can be used to predict the presence of intestinal metaplasia in biopsies from CLE. In contrast, predicting the presence of LGD versus no dysplasia in intestinal metaplasia is more difficult. Predictions from these models may aid decision making on whether a patient with CLE should have surveillance, in view of the known sampling error at endoscopy and interobserver variability at histology.

OBJECTIVES: Barrett oesophagus is replacement of squamous epithelium to specialised intestinal metaplasia. It is associated with an increased risk for adenocarcinoma which develops through dysplasia. The aim of this retrospective study was to determine the relative age of occurrence and incidence of dysplasia in this part of our country. METHODS: Between January 1999 and June 2002 we diagnosed 13 cases of Barrett oesophagus. Sections were stained with routine H and E and special stain alcian blue (AB)--PAS at pH 2.5. RESULTS: Out of 55 patients with symptoms of gastro-oesophageal reflux disease, 13 cases were diagnosed as Barrett oesophagus. There were 8 males and 5 females. Majority of the patients (77%) were between 20-40 years of age. At endoscopy, in 84.6% patients, lesions were in the form of islands of red mucosa. On histology examination, in 6 cases, squamous epithelium was replaced by intestinal epithelium containing goblet cells and in 7 cases it was replaced by gastric epithelium. Associated dysplasia was not seen in any of the case, while one case showed associated adenocarcinoma. CONCLUSION: Barrett oesophagus is seen in a younger population amongst Indians. A male predominance is noted, but is not as high as reported in Western literature. There is a paucity of patients with pure dysplasia in Barrett metaplasia. Despite the fact that there are a number of patients presenting with Barrett esophagus and carcinoma, very few patients present with dysplasia, indicating that Barrett oesophagus is a silent disease presenting later as a carcinoma.

OBJECTIVE: The aim of this study is to compare the effect of medical and surgical treatment on the history of patients with Barrett esophagus (BE) and histologic evidence of low-grade dysplasia (LGD). SUMMARY BACKGROUND DATA: BE is a complication of severe gastroesophageal reflux. It is considered a major risk factor for esophageal adenocarcinoma, which may develop through stages from nondysplastic metaplasia to dysplasia (LGD and high-grade dysplasia). Presently, there are no recommended therapeutic guidelines for patients with LGD. METHODS: Between 1998 through 2003, 6592 patients underwent upper endoscopy; 327 of 6592 (5%) patients had BE, and 35 of 327 (10.7%) had LGD. Nineteen patients with LGD were treated with high-dose proton pump inhibitors, and 16 patients underwent laparoscopic Nissen fundoplication. Endoscopic and histologic follow-up was available in all patients after 18 months. We used multiple logistic regression to examine the effect of the 2 treatments on regression of LGD. RESULTS: LGD was predominant in men (male-to-female ratio: 1.7:1). Mean age was 58 +/- 13.5 years. Sixty percent of patients had no endoscopic evidence of esophagitis. A regression from LGD to BE was observed in 12 of 19 (63.2%) patients in the medical group and in 15 of 16 (93.8%) patients in the surgical group (statistically significant difference). Differences between the 2 groups were statistically significant (P = 0.03). CONCLUSION: The results of our study suggest that surgical treatment may be more effective than medical therapy to modify the natural history of LGD in patients with BE, perhaps because it not only controls acid but also biliopancreatic reflux into the esophagus.

An important limitation of antireflux surgery is a 5%-10% failure rate. We investigated the correlation between various diaphragm stressors and failure of antireflux surgery. Forty-one study cases who underwent a reoperative antireflux operation from 1997 to 2001 and 50 control patients who had undergone a successful laparoscopic Nissen fundoplication during the same period without clinical or symptomatic evidence of failure were randomly selected for comparison. A retrospective analysis was conducted utilizing a standardized diaphragm stressor questionnaire, addressing the period between the primary and secondary operation. Stressors considered in the study included height, body mass index (BMI), postoperative gagging, vomiting, weight lifting (greater than 100 pounds), coughing, hiccuping, motion sickness, retching, belching, antidepressant use, smoking, preoperative grade of esophagitis, size of hiatal hernia, lower esophageal sphincter pressure, esophageal body pressures, and preoperative response to proton pump inhibitors. Of the potential stressors investigated, the following were significantly associated with surgical failure after adjusting for other variables through multivariate analysis: gagging (P = 0.005), belching (P = 0.02), and hernia size greater than 3 cm (P = 0.04; Table 1). Other potential risk factors show trends as obvious in Fig. 2. Vomiting was significant (P = 0.01) in the earlier models but lost significance when logistic regression was applied. Patients with postoperative gagging and an intraoperative hiatal hernia (greater than 3 cm) have a poorer outcome, whereas patients with postoperative belching have a better long-term outcome.

BACKGROUND: The effectiveness of laparoscopic Nissen fundoplication for the regression of Barrett's esophagus in gastroesophageal reflux disease remains controversial. The aim of this study, therefore, was to review endoscopic findings and clinical changes after laparoscopic Nissen fundoplication for gastroesophageal reflux disease, particularly for patients with Barrett's esophagus. METHODS: From September 1995 through June 2004, 127 patients with gastroesophageal reflux disease underwent laparoscopic Nissen fundoplication. All the patients had clinical and endoscopic follow-up evaluation. We further analyzed the course of 37 consecutive patients with Barrett's esophagus (29% of all laparoscopic fundoplications performed in our institution) using endoscopic surveillance with appropriate biopsies and histologic evaluation. The median follow-up period for all the patients after fundoplication was 34 months (range, 3-108 months). The median follow-up period for the patients with Barrett's esophagus was 19 months (range, 3-76 months). RESULTS: During the 9-year period, 70 women (55 %) and 57 (45%) men were treated with laparoscopic Nissen fundoplication. The median age of these patients was 42 years (range, 7-81 years). The clinical results were considered excellent for 67 patients (53%), good for 51 patients (40%), fair for 7 patients (6%), and poor for 2 patients (1%). Endoscopic surveillance showed regression of the macroscopic columnar segment in 23 patients with Barrett's esophagus (62%). Regression at a histopathologic level occurred for 15 patients (40%). The histopathology remained unchanged for 14 patients with Barrett's esophagus (38%). CONCLUSION: Laparoscopic Nissen fundoplication effectively controls intestinal metaplasia and clinical symptoms in the majority of patients with Barrett's esophagus.