Total duodenal diversion for treatment of reflux esophagitis uncontrolled by repeated antireflux procedures

The operations of Nissen, Hill, and Belsey are adequate in controlling esophaegeal reflux in the majority of patients. In a small percentage however, objective and subjective evidence of esophagitis persists in spite of repeated operations to restore lower esophageal sphincter competency. These failures are then usually treated by operative procedures of great magnitude involving organ interposition. Repeated antireflux operations directed to the gastroesophageal area may in some instances result in impairment of blood supply with an increased risk of both esophageal and gastric fistulae. In the past many observers have felt that reflux esophagitis resulted solely from the effects of acid-pepsin secretions bathing the distal esophagus. Recently experimental and clinical data have indicated the importance of duodenal contents in the etiology and perpetuation of reflux esophagitis. During a recent two year period, 6 patients with persistent reflux esophagitis uncontrolled by repeated antireflux procedures have been seen on our service. These 6 patients, underwent 12 unsuccessful antireflux operations elsewhere. Three of the 6 patients had also been subjected to vagotomy-antrectomy for a coexisting duodenal ulcer. A marked lowering of gastric acidity took place but esophageal reflux and esophagitis persisted. These three patients were treated on our service by takedown of the Billroth I anastomosis, closure of the duodenal stump and diversion of the duodenal contents into a Roux-en-Y limb. Three other patients who had undergone unsuccessful antireflux procedures alone were subjected to antral resection, Roux-en-Y diversion and transthoracid vagotomy. This simplified appraoch to the treatment of persistent esophageal reflux uncontrolled by repeated antireflux procedures has given satisfactory results. The operation should be considered when technical considerations preclude further surgical attempts to perform another effective antireflux operation. Total duodenal diversion should, however, not be considered as the primary operation for the patient suffering from reflux esophagitis. However, in circumstances discussed above this direct approach appears preferable to major resectional procedures.     

Immune status indices during the combined treatment of patients with duodenal peptic ulcer

Indices were studied of the immunological status (cell-mediated, humoral immunity) before and after the multimodality pathogenetic treatment of patients with duodenal ulcer. Noted in the course of the complex treatment were changes in the immunoregulatory index, NK-cells, IgM. The findings obtained suggest that the immune defence may be depressed, with the vascular factor, infection (Helicobacter pylori) having their part in the genesis of duodenal ulcer.     

The prevalence of esophagitis in patients with duodenal ulcer or ulcer-like dyspepsia

OBJECTIVE: It has been reported that 30-72% of patients with duodenal ulcer disease also have esophagitis. However, many of these reports included patients who had severe or complicated ulcer disease, so that the high prevalence may reflect pyloric stenosis or gastric hyper-secretion. The objective of this study was to determine the prevalence of esophagitis in unselected patients with duodenal ulcer disease or ulcer-like dyspepsia. METHOD: A prospective study of endoscopic and histological esophagitis in consecutive patients with either duodenal ulcer disease or with ulcer-like dyspepsia. RESULTS: Of 27 patients with duodenal ulcer disease, 33% had endoscopic esophagitis, 26% had histological esophagitis, and 48% had esophagitis by either criterion. Of 66 patients with ulcer-like dyspepsia, 35% had endoscopic esophagitis, 47% had histological esophagitis, and 62% had esophagitis by either criterion. Esophagitis was independent of patients' Helicobacter pylori status. CONCLUSIONS: Esophagitis is common in patients with duodenal ulcer disease, and the prevalence is similar in patients with ulcer-like dyspepsia. In addition to causing heartburn, esophagitis may also be cause ulcer-like epigastric pain. Concomitant esophagitis may account for the persisting or recurring dyspepsia that has been reported in up to one-third of duodenal ulcer patients after successful eradication of H. pylori.     

The significance of gastric helicobacteriosis in the genesis hemorrhage from duodenal peptic ulcer

Based on a comprehensive analysis of findings from examination and surgical treatment of 196 patients with bleeding pyloroduodenal ulcers, it was found out that patients with concurrent helicobacteriosis of the stomach are prone to more unfavourable course of their illness, which fact is evidenced by a greater loss of blood and higher risk for bleeding recurrences. A classification is proposed by the authors, taking advantage of the data from endoscopic, microscopic and immunoenzymatic techniques, with the purpose of providing an assessment of degree of severity of helicobacteriosis of the stomach.     

The etiological and pathogenetic characteristics of duodenal peptic ulcer in adolescents

Studied by endoscopy were 100 adolescents with diagnosed duodenal ulcer, as were 100 essentially healthy subjects and 90 ones of the same age presenting with primary chronic gastroduodenitis together with 60 adults who had duodenal ulcer. The following items were etiologic risk factors for duodenal ulcer, if combined, in the above adolescent series: Frequent episodes nervous of tension, hereditary predisposition and helicobacteriosis. In juveniles with duodenal ulcer, secretion and motility of the stomach appeared to be subjected to changes to a higher degree than it was in adult subjects with duodenal ulcer, while functions of the psychovegetative and immune systems were found to be less changeable in the former. In adolescents presenting with duodenal ulcer and primary chronic gastroduodenitis, the etiologic risk factors and pathogenetic changes were found out to be identical.     

A trial of the use of Maldroxal in treating patients with duodenal peptic ulcer

A 67 year old man presented with non-invasive thymoma, associated aplastic anemia and important hypogammaglobulinemia; the postoperative course has been characterized, three months later, by thrombocytopenia (kept under control with steroid therapy) and, two years later, by squamous lung cancer, not susceptible of surgical treatment. The patient died five years after operation because of progression of the lung cancer. Anemia improved only partially after operation; there where no effects on hypogammaglobulinemia. Thymoma has been reported in literature in 50% of patients with aplastic anemia, 7-13% of adult patients with hypogammaglobulinemia is affected by thymoma, in 21% of patients that presented with thymoma other tumors have been discovered through clinical history.     

Recent topics in the medical treatment of reflux esophagitis

Reflux esophagitis is one of the most common disorders of the upper gastrointestinal tract. It can lead to obstruction through stricture formation, in more severe form to bleeding through ulceration, and to cancer development through the association of Barrett's esophagus. The vast majority of esophagitis can be managed medically. Medical management is separated into two categories: (1) life style modification and (2) drug therapy. Drug therapy includes antacids, prokinetics, sucralfate, H2 receptor antagonists (H2-RAs) and proton pump inhibitors (PPIs). Among these, antisecretory therapy is the mainstay for the treatment. PPIs are shown to be superior to H2-RAs in healing of esophagitis and symptom relief. Recurrence, particularly of erosive esophagitis, is common without maintenance therapy. PPIs are also consistently superior to H2-RAs in maintenance of esophagitis healing. Interestingly, a recent report has suggested that curing Helicobacter pylori infection may provoke reflux esophagitis, raising the possibility that the gastroesophageal reflux diseases become more common in the future. Therefore, treatment strategy for reflux esophagitis needs to be re-established in terms of the future cost-effectiveness evaluation and quality-of-life assessments.     

The use of pylorus-sparing operations in treating duodenal peptic ulcer complicated by stenosis

Based on an analysis of immediate (388 patients) and long-term (259 patients) results of surgical treatment of ulcer disease of the duodenum complicated by stenosis the authors made a conclusion that selective proximal vagotomy in combination with dissection of the ulcer substrate (the stenosis area) without injuries of the pyloric constrictor is the operation of choice in treatment of ulcerous duodenal stenosis resulting in less lethality (0.52%), in practical exclusion of the development of functional disorders and impaired nutrition of the patients.     

The individualized choice of the method of operation in the planned surgery of gastric and duodenal peptic ulcers

A working classification of gastroduodenal ulcers was developed by the authors on the basis of surgical treatment of 1838 patients with ulcer disease of the stomach and duodenum. When used in combination with the complex examination of the patients it allows to individually choose the operative method. The indications and contraindications for different kinds of surgery are given. Specific features of the postoperative management are described.     

Surgical treatment of duodenal ulcer with chronic duodenal obstruction

Follow-up treatment results of 892 patients with duodenal ulcer (DU) are presented and the choice of surgical policy in its combination with chronic duodenal obstruction (CDO) in 307 (34.4%) patients is substantiated. Depending on peculiarities of DU, the kind and the stage of CDO, organ saving (140) or stomach resection (167) in combination with correction CDO interventions (287) were carried out. The course of the postoperative period was characterised by basic morphofunctional changes and by achievement of completeness of duodenal passage. Intermittent motor-evacuatory disorders were observed in 55 (17.9%) patients. Lethal outcome was in 1 case. Long-term functional results of the operations were studied in 267 patients. Excellent and good results were obtained in 66.3%, favorable-in 32.24% and unfavorable-in 1.44% of patients. The dependence of immediate and remote results of the operations on the effectiveness of the correction of associated CDO was established.     

Esophago-jejuno-gastroplasty in the treatment of peptic stenosis of the esophagus]

Resistance to benzalkonium chloride (BC) among Pseudomonas spp. isolated from poultry carcasses was determined and strategies for elimination of resistant strains evaluated. This investigation showed that resistance was quite common, about 30% of the isolates being able to grow in 200 micrograms ml-1 BC. Pseudomonas fluorescens strains were generally less susceptible than strains of Ps. lundensis and Ps. fragi. An overnight incubation in medium containing 200 micrograms ml-1 BC was sufficient to reduce the susceptibility of two Pseudomonas strains to the lethal effect of BC significantly. Adding EDTA enhanced the lethal effect of BC, but the effect was reduced after growing cells in medium containing BC and EDTA. Growth in medium with a quaternary ammonium compound (QAC) rendered the cells more susceptible to chlorine, phenolics, and alkylaminoacetate. These results indicate that alternating use of QACs with these compounds can be used to avoid build-up of resistant strains. In addition, increased temperatures improved the lethal effect of BC and should be considered when planning disinfection routines.