Altered esophageal motility and gastroesophageal barrier in patients with jejunal interposition after distal esophageal resection for early stage adenocarcinoma.
BACKGROUND
Limited resection of the esophagogastric junction has been proven to be safe and oncologically radical in patients with early esophageal cancer. Reconstruction with interposition of isoperistaltic jejunal loop (Merendino procedure) is supposed to prevent gastroesophageal reflux and therefore the recurrence of intestinal metaplasia at the anastomosis. The aim of this study was to assess the frequency of acid and nonacid refluxes after Merendino procedure using multichannel intraluminal impedance-pH (MII-pH) monitoring.


METHODS
Between 2002 and 2005, 12 patients with esophageal adenocarcinoma underwent limited resection and jejunal interposition. Ten patients agreed to undergo a Gastrointestinal Symptom Rating Scale assessment, upper gastrointestinal (GI) endoscopy, esophageal manometry, and combined 24-h MII-pH monitoring more than 10 months postoperatively.


RESULTS
Postoperatively, 4 (40%) patients reported belching without heartburn or acid regurgitation, 3 of them having a positive symptom index during 24-h MII-pH monitoring. Upper GI endoscopy revealed no inflammation, metaplasia, or stenosis at the esophagojejunal anastomosis. Esophageal manometry showed ineffective esophageal motility in four of ten patients. Combined 24-h MII-pH monitoring revealed normal distal esophageal acid exposure (% time pH < 4: 0.1% [0-1.5]), normal number of acid reflux episodes (3 [0-11]) but a high number of nonacid reflux episodes (82 [33-184]). Overall, eight patients revealed an abnormal number of nonacid reflux episodes.


CONCLUSIONS
The limited resection with jejunal interposition for early esophageal cancer is efficient in controlling acid but not nonacid reflux. While the clinical relevance of nonacid reflux in the recurrence of Barrett's esophagus is currently unknown, endoscopic surveillance should be considered in these patients.
Linke
Georg R
GR
Department of Surgery, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland. gelinke@web.de
Borovicka
Jan
J
Tutuian
Radu
R
Warschkow
Rene
R
Zerz
Andreas
A
Lange
Jochen
J
Zünd
Michael
M
D000230:Adenocarcinoma / Q000601:surgery*; D013505:Digestive System Surgical Procedures / Q000379:methods; D004938:Esophageal Neoplasms / Q000601:surgery*; D005769:Gastrointestinal Motility / Q000502:physiology*; D006801:Humans; D007583:Jejunum / Q000637:transplantation*; D008197:Lymph Node Excision; D008365:Manometry; D019651:Plastic Surgery Procedures