Background: Limited resection of the esophagogastric junction has been applied in the treatment of esophageal cancer and has been proven to be safe and oncologically radical. During the Merendino procedure the continuity of the gastrointestinal tube is created using an jejunal loop oriented isoperistaltic in order to prevent reflux in the remaining esophagus and therefore the recurrence of intestinal metaplasia at the anastomosis. Combined multichannel intraluminal impedance-pH (MII-pH) monitoring identifies acid and non-acid reflux events by flow measurements in the esophagus. The aim of this study was to assess gastroesophageal reflux (acid and non-acid) in patients who underwent Merendino procedure as treatment for esophageal adenocarcinoma.
Methods: Twelve consecutive patients with esophageal adenocarcinoma (3 F;median age 61; range 43-73 years) underwent Merendino procedure between 2002 and 2005 were studied 12 months postoperatively. Ten patients of this prospectively maintained database underwent a Gastrointestinal-Symptom-Rating-Scale (GSRS) assessment, an upper GI-endoscopy, esophageal manometry and combined 24 h MII-pH monitoring. Results are reported as medians and range (min -max)
Results: Twelve month post-operatively upper GI-endoscopy revealed no inflammation, metaplasia or stenosis at the esophagojejunal anastomosis. Esophageal manometry found inefficient motility in 4/10 patients but no cases of esophageal aperistalsis. With regards to reflux symptoms 5/10 patients reported belching but no heartburn or acid regurgitation. A positive symptom index for reflux and belching was found in 3 patients. Although distal esophageal acid exposure was normal with 0.1% (0-3.8%) and 3 (0-11) acid reflux events, the total number of reflux events (liquid and mixed content) was 81.5 (33-184; normal <73); 8/10 patients having an abnormal number of reflux episodes. Furthermore 30.5 (11-62) reflux episodes reached the proximal esophagus.
Conclusions: The Merendino procedure with interposition of an isoperistaltic jejunal loop after distal resection for esophageal cancer reduces acid but not non-acid gastroesophageal reflux. Endoscopic surveillance will help understand the importance of the increased number of non-acid reflux episodes in the genesis of Barrett's mucosa recurrence in these patients.