Faculty Bibliography

This study determines the relationship among esophageal dysmotility, esophageal acid exposure, and esophageal mucosal injury in patients with gastroesophageal reflux disease (GERD). A total of 827 patients with GERD (confirmed by ambulatory pH monitoring) were divided into three groups based on the degree of mucosal injury: group A, no esophagitis, 493 patients; group B, esophagitis grades I to III, 273 patients; and group C, Barrett's esophagus, 61 patients. As mucosal damage progressed from no esophagitis to Barrett's esophagus, there was a significant decrease in lower esophageal sphincter pressure and amplitude of peristalsis in the distal esophagus, with a subsequent increase in the number of reflux episodes in 24 hours, the number of reflux episodes longer than 5 minutes, and the reflux score. These data suggest that in patients with GERD, worsening of esophageal mucosal injury may determine progressive deterioration of esophageal motor function with impairment of acid clearance and increase of esophageal acid exposure. These findings suggest that Barrett's esophagus is an end-stage form of gastroesophageal reflux, and that if surgical therapy is performed early in the course of the disease, this cascade of events might be blocked.

The cause of idiopathic pulmonary fibrosis (IPF) is unknown. The pathology suggests that IPF results from serial lung injury. It has been suggested that gastroesophageal reflux disease (GERD) may relate to the cause or the progression of the disease. The aims of this study were to determine the prevalence of GERD, the clinical presentation of GERD, and the manometric and reflux profiles in patients with end-stage IPF. Between July 2003 and October 2004, 18 patients with IPF on the lung transplant waiting list were referred for evaluation to the Swallowing Center of the University of California San Francisco. On the basis of the results of the pH monitoring test (5 and 20 cm above the lower esophageal sphincter), the patients were divided into two groups: group A, 12 patients (66%), GERD+; group B, 6 patients (34%), GERD-. The incidence of heartburn and regurgitation was similar between GERD+ and GERD- patients; reflux was clinically silent in one third of GERD+ patients. Reflux was associated with a hypotensive lower esophageal sphincter and abnormal esophageal peristalsis, and it was present in the upright and supine position. The reflux often extended into the proximal esophagus. These results show the following: (1) Two thirds of patients with IPF had GERD; (2) symptoms could not distinguish between those with and without GERD; (3) reflux occurred in the presence of a hypotensive lower esophageal sphincter and abnormal esophageal peristalsis; and (4) reflux occurred in the upright and supine positions, and often extended into the proximal esophagus. We conclude that patients with IPF should be screened for GERD, and if GERD is present, a fundoplication should be performed before or shortly after lung transplantation.

Patients undergoing endovascular abdominal aortic aneurysm (AAA) repair have lower perioperative morbidity and leave the hospital earlier than patients undergoing open repair. However, potential complications require continuous surveillance of endografts and there are few data regarding their long-term fate. If an open operation were well tolerated, this might be a preferable alternative. The purpose of this study was to identify patients with lower morbidity and shorter hospital stay following open AAA repair and to analyze factors that might point to open repair as the preferred approach. We performed a retrospective review of all patients who underwent AAA repair between 1995 and 2000 at our institution. All patients with ruptured aneurysms and those that required renal, celiac, or superior mesenteric reconstructions during the AAA repair were excluded. Patient demographics, preoperative comorbid conditions, intraoperative data, and postoperative complications were analyzed in detail. A total of 115 patients fulfilled the inclusion criteria. There was only one perioperative death (0.9%). The mean hospital stay was 8.1 days. A history of chronic obstructive pulmonary disease (COPD) and longer operative time were independent factors associated with prolonged hospital stay. Forty-one patients (35.6%) left the hospital in 5 or less days. Compared to the group with hospital stay >5 days, these patients had a lower incidence of COPD (7.3% vs. 25.7%, p < 0.05) and smaller-size AAAs (5.6 vs. 6.4 cm, p < 0.0001), and were more often operated on via a retroperitoneal approach (61% vs. 40.5%, p < 0.05). Their time in the operating room was less (3.5 vs. 4.5 hr, p < 0.0001), and they had less estimated blood loss (750 vs. 1500 cc, p < 0.001) and fewer transfusions (0.95 vs. 2.45 units, p < 0.0001). Patients without COPD and smaller AAAs that can be repaired via a retroperitoneal approach have a lower incidence of perioperative complications and a shorter hospital stay following open AAA repair. Until long-term results for endografts are available, our data suggest that these patients are well served with an open repair.