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- Flisberg, Per, et al.
(författare)
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Pain relief after esophagectomy: Thoracic epidural analgesia is better than parenteral opioids
- 2001
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Ingår i: Journal of Cardiothoracic and Vascular Anesthesia. - : Elsevier BV. - 1532-8422 .- 1053-0770. ; 15:3, s. 282-287
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To compare postoperative pain relief and pulmonary function in patients after thoracoabdominal esophagectomy treated by continuing perioperative thoracic epidural anesthesia or changing to parenteral opioids. DESIGN: Prospective, randomized study. SETTING: University teaching hospital. PARTICIPANTS: Thirty-three patients undergoing thoracoabdominal esophagectomy. INTERVENTIONS: General anesthesia was combined with thoracic epidural anesthesia during surgery. The patients either continued with thoracic epidural analgesia (n = 18) or were switched to patient-controlled analgesia with intravenous morphine (n = 15) for 5 postoperative days. Pain scores were estimated twice daily, at rest and after mobilization. Peak expiratory flow, forced expiratory volume, and vital capacity were measured the day before surgery, postoperative day 2, and postoperative day 6. Adverse events and complications were recorded. MEASUREMENTS AND MAIN RESULTS: At rest, there were no differences in pain relief between the groups. Pain scores at mobilization showed a significantly lower value in the epidural group (p < 0.027). No intergroup differences were found regarding pulmonary function, which decreased on postoperative day 2, but was improved on postoperative day 6. CONCLUSION: Continuation of intraoperative thoracic epidural anesthesia for 5 postoperative days provides better pain relief at mobilization compared with a switch to patient-controlled analgesia with intravenous morphine. There was no intergroup difference in the impact on measures of pulmonary function.
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- Öberg, Stefan, et al.
(författare)
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Endoscopic surveillance of columnar-lined esophagus - Frequency of intestinal metaplasia detection and impact of antireflux surgery
- 2001
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Ingår i: Annals of Surgery. - 1528-1140. ; 234:5, s. 619-626
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Tidskriftsartikel (refereegranskat)abstract
- Objective To quantify the occurrence of intestinal metaplasia in columnar-lined esophagus (CLE) during endoscopic surveillance and to evaluate the impact of antireflux surgery on the development of intestinal metaplasia. Summary Background Data The malignant potential in segments of CLE is mainly restricted to those containing intestinal metaplasia. Patients with segments of CLE in which no intestinal metaplasia can be detected are rarely enrolled in a surveillance program but may still be at increased risk of developing esophageal adenocarcinoma because intestinal metaplasia may be missed or may develop with time. Methods The occurrence of intestinal metaplasia on biopsy samples was determined on repeated endoscopies in 177 patients enrolled in a surveillance program for CLE. The incidence of intestinal metaplasia in patients with no evidence of intestinal metaplasia on the two first endoscopies was evaluated on the subsequent endoscopies and compared in patients with medically and surgically treated gastroesophageal reflux disease. Results Intestinal metaplasia was found in 53% of the patients (94/ 177) on their first surveillance endoscopy and was more prevalent in long segments of CLE. The prevalence of intestinal metaplasia increased markedly with increasing number of surveillance endoscopies. Intestinal metaplasia tended to be detected early in patients with long segments of CLE; in patients with shorter segments, intestinal metaplasia was also detected late in the course of endoscopic surveillance. Patients with surgically treated reflux disease were 10.3 times less likely to develop intestinal metaplasia compared with a group receiving standard medical therapy. Conclusion Biopsy samples from a single endoscopy, despite an adequate biopsy protocol, are insufficient to rule out the presence of intestinal metaplasia. Patients in whom biopsy specimens from a segment of CLE show no intestinal metaplasia have a significant risk of having undetected intestinal metaplasia or of developing intestinal metaplasia with time. Sampling error is probably the reason for the absence of intestinal metaplasia in segments of CLE longer than 4 cm, whereas development of intestinal metaplasia is common in patients with shorter segments of CLE. Antireflux surgery protects against the development of intestinal metaplasia, possibly by better control of reflux of gastric contents.
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- Öberg, Stefan, et al.
(författare)
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Metaplastic columnar mucosa in the cervical esophagus after esophagectomy.
- 2002
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Ingår i: Annals of Surgery. - 1528-1140. ; 235:3, s. 338-345
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To evaluate the pathogenesis of metaplastic processes within the esophagus using a human model in which the exact duration of reflux was known. SUMMARY BACKGROUND DATA: The pathogenesis of Barrett's esophagus (BE) is incompletely understood. Patients undergoing esophagectomy and gastric tube reconstruction represent a good model for studying the pathophysiology of columnar cell metaplasia of the human esophagus because the cervical esophagus is rarely or never exposed to gastric contents before the surgical procedure. METHODS: Thirty-two patients underwent manometry, simultaneous 24-hour pH and bilirubin monitoring, and endoscopy with biopsy 3 to 10.4 years after esophagectomy. The presence of columnar mucosa in the cervical esophagus was confirmed on histologic examination. The findings on endoscopy and histology were related to clinical data and the results of pH and bilirubin monitoring 1 cm proximal to the esophagogastrostomy. RESULTS: Fifteen (46.9%) of the 32 patients had metaplastic columnar mucosa within their cervical esophagus. Metaplasia was significantly more common in patients with a preoperative diagnosis of BE. The length of metaplastic mucosa correlated significantly with the degree of esophageal acid exposure, but the presence of abnormal bilirubin exposure was unrelated to the presence of metaplasia. The prevalence of metaplasia did not change with increasing time. Intestinal metaplasia was found within the columnar-lined segment in three patients 8.5, 9.5, and 10.4 years after esophagectomy. All patients with intestinal metaplasia had abnormal exposure of both acid and bilirubin, but the presence of combined reflux was not significantly higher in these patients compared with patients with nonintestinalized segments of columnar mucosa. CONCLUSIONS: Esophageal columnar metaplasia is a common complication after gastric pull-up esophagectomy. Metaplasia is more likely to develop in patients with previous BE than other patients. Metaplasia develops in response to squamous epithelial injury in predisposed individuals.
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