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  • 1.
    Borch, Kurt
    et al.
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Östergötlands Läns Landsting, MKC-2, GE: Gastrokir.
    Jönsson, Björn
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Kärlkirurgi. Östergötlands Läns Landsting, Hjärtcentrum, Thorax-kärlkliniken.
    Tarpila, Erkki
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för biomedicin och kirurgi, Hand och plastikkirurgi. Östergötlands Läns Landsting, Rekonstruktionscentrum, Hand- och plastikkirurgiska kliniken US.
    Franzén, Thomas
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Östergötlands Läns Landsting, MKC-2, GE: Gastrokir.
    Berglund, J
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för medicin och vård, Kärlkirurgi. Östergötlands Läns Landsting, Hjärtcentrum, Thorax-kärlkliniken.
    Kullman, Eric
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Östergötlands Läns Landsting, MKC-2, GE: Gastrokir.
    Franzén, L
    Changing pattern of histological type, location, stage and outcome of surgical treatment of gastric carcinoma2000Ingår i: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 87, nr 5, s. 618-626Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: There are indications that some features of gastric carcinoma are changing, with a possible impact on prognosis. The aim of this study was to examine any changes in type, location, stage, resection rate, postoperative mortality rate or prognosis for patients with gastric carcinoma in a well defined population. Methods: During 1974-1991, 1161 new cases of gastric adenocarcinoma were diagnosed in Ostergotland County, Sweden. Tumour location, Lauren histological type, tumour node metastasis (TNM) stage, radicality of tumour resection and postoperative complications were recorded after histological re-evaluation of tissue specimens and examination of all patient records. Dates of death were obtained from the Swedish Central Bureau of Statistics. Time trends were studied by comparing the intervals 1974-1982 (period 1) and 1983-1991 (period 2). Results: The proportion of diffuse type of adenocarcinoma increased (from 27 to 35 per cent), while that of mixed type decreased (from 16 to 9 per cent) and that of intestinal type was unchanged. The proportion of tumours located in the proximal two-thirds of the stomach increased (from 32 to 42 per cent) and the proportion of patients with tumours in TNM stage IV decreased (from 32 to 25 per cent). Overall tumour resection rates were unchanged, although the proportion of radical total gastrectomies increased (from 36 to 50 per cent). Excluding tumours of the cardia or gastric remnant after previous ulcer surgery, the 5-year relative survival rate after radical resection increased from 25 to 36 per cent and the postoperative mortality rate decreased for both radical (from 11 to 4 per cent) and palliative (from 18 to 6 per cent) resection. Conclusion: The patterns of tumour histology, location and stage of gastric carcinoma have changed in the authors' region. These changes were paralleled by a significant improvement in survival and postoperative mortality rates.

  • 2.
    Franzen, Thomas
    et al.
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för biomedicin och kirurgi, Avdelningen för kirurgi. Östergötlands Läns Landsting, Kirurgi- och onkologicentrum, Kirurgiska kliniken i Östergötland med verksamhet i Linköping, Norrköping och Motala.
    Anderberg, Bo
    Wirén, Michael
    Johansson, Karl-Erik
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för biomedicin och kirurgi, Avdelningen för kirurgi. Östergötlands Läns Landsting, Kirurgi- och onkologicentrum, Kirurgiska kliniken i Östergötland med verksamhet i Linköping, Norrköping och Motala.
    Long-term outcome is worse after laparoscopic than after conventional Nissen fundoplication2005Ingår i: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 40, nr 11, s. 1261-1268Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective. No long-term studies of laparoscopic and open fundoplication were available in 1994. The aim of this study was to compare reflux control and side effects after laparoscopic and open fundoplication. Material and methods. Adult patients with uncomplicated gastro-oesophageal reflux disease were included in this prospective randomized clinical trial between laparoscopic and open 360° fundoplication. Patients with uncomplicated gastro-oesophageal reflux disease were included with the exception of those with weak peristalsis or suspected short oesophagus. Two senior surgeons, well trained in laparoscopic antireflux surgery, performed the 45 laparoscopic operations. Forty-eight patients underwent open surgery performed or supervised by two other senior surgeons, also well trained in gastro-oesophageal surgery. One of the latter recruited all the patients. Manometry and 24-h oesophageal pH monitoring were performed before operation and 6 months postoperatively. Manometry also included a short-term reflux test, an acid clearing test and an acid perfusion test. Symptom evaluation was performed before surgery, 6 moths after and at long-term follow-up (33-79 months postoperatively) by the same surgeon. Long-term follow-up also included endoscopy. Results. Six months after laparoscopy 4 patients had disabling dysphagia. None of the patient had disabling dysphagia after laparotomy. Four patients had mild heartburn 6 months after laparoscopy and 2 patients after laparotomy. Between 6 months' follow-up and long-term follow-up, 6 patients were reoperated on in the laparoscopy group and 2 patients in the laparotomy group. Three patients operated on with laparotomy had died of intercurrent diseases. After laparoscopy, at long-term follow-up, 62% of patients (28/45) were satisfied compared with 91% (41/45) after laparotomy. The difference was significant (p < 0.01). Conclusions. Early postoperative reflux control was similar for laparoscopic and conventional fundoplication. At long-term follow-up significantly more patients were satisfied after laparotomy than after laparoscopy. © 2005 Taylor & Francis.

  • 3.
    Franzen, Thomas
    et al.
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Johansson, Karl-Erik
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Prospective study of symptoms and gastro-oesophageal reflux 10 years after posterior partial fundoplication - reply2000Ingår i: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 87, nr 1, s. 122-122s. 122-Artikel i tidskrift (Övrigt vetenskapligt)
    Abstract [en]

    No abstract is available for this article.

  • 4.
    Franzen, Thomas
    et al.
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för kliniska vetenskaper. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Centrum för kirurgi, ortopedi och cancervård, Kirurgiska kliniken ViN.
    Tibbling, Lita
    Östergötlands Läns Landsting, Centrum för kirurgi, ortopedi och cancervård, Kirurgiska kliniken ViN.
    Is the severity of gastroesophageal reflux dependent on hiatus hernia size?2014Ingår i: World Journal of Gastroenterology, ISSN 1007-9327, E-ISSN 2219-2840, Vol. 20, nr 6, s. 1582-1584Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    AIM:

    To determine if the severity of gastroesophageal reflux disease is dependent on the size of a hiatus hernia.

    METHODS:

    Seventy-five patients with either a small (n = 25), medium (n = 25) or large (n = 25) hiatus hernia (assessed by high resolution esophageal manometry) were investigated using 24-h esophageal monitoring and a self-assessed symptom questionnaire. The questionnaire comprised the following items, each graded from 0 to 3 according to severity: heartburn; pharyngeal burning sensation; acid regurgitation; and chest pain.

    RESULTS:

    The percentage total reflux time was significantly longer in the group with hernia of 5 cm or more compared with the group with a hernia of < 3 cm (P < 0.002), and the group with a hernia of 3 to < 5 cm (P < 0.04). Pharyngeal burning sensation, heartburn and acid regurgitation were more common with large hernias than small hernias, but the frequency of chest pain was similar in all three hernia groups.

    CONCLUSION:

    Patients with a large hiatus hernia are more prone to have pathological gastroesophageal reflux and to have more acid symptoms than patients with a small hiatus hernia. However, it is unlikely that patients with an absence of acid symptoms will have pathological reflux regardless of hernia size.

  • 5.
    Franzén, Thomas
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Success and failure of conventional and laparoscopic fundoplication in gastro-oesophageal reflux disease2003Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
    Abstract [en]

    The outcome of antireflux surgery in a single institution during two decades is presented.

    101 consecutive patients operated with open partial2 70° fundoplication and crural repair during 1982-1989 were prospectively analysed. All stages ofpreoperative oesophagitis were represented. Reflux competence, symptomatology, and postoperative side-effects were evaluated six months and ten years postoperatively. Recurrence (8%) was more common in patients who had severe oesophagitis before operation. The operative method is effective for long-term reflux control, it does not cause dysphagia, and it has few side-effect. Some months prior to the introduction oflaparoscopic fundoplication our unit had changed from partial to total fundoplication as a standard operation for gastro-oesophageal reflux disease (GORD). It was then convenient to perform the total Nissen fundoplication laparoscopically. All 50 patients operated with laparoscopic technique during a 30-months period 1992-1994 were prospectively compared with 21 patients operated with open technique. Nine patients were converted and then analysed in the open group. We tried to select patients with uncomplicated disease for laparoscopy but 7 patients in this group had severe disease diagnosed at preoperative endoscopy or/and at operation. In the open group 9 patients had severe disease. The patients were investigated six months, two years, and five years postoperatively. Early postoperative manometry was prognostic for recurrence. At long term follow-up the reflux control was similar, 10% of the patients operated with laparoscopy had recurrence and 8% of the patients operated with open technique.

    Summer 1994 to spring 1998 we included 93 patients with uncomplicated GORD in a randomised clinical trial between laparoscopic and open 360° floppy Nissen fundoplication with crural repair. 45 patients were operated on laparoscopically and 48 patients underwent laparotomy. Only one patient was converted and then analysed in the laparotomy group. The patients were investigated before operation, half a year after and at long-term follow-up (33-79 months postoperatively). Long-term follow up also included endoscopy. Operation time was significantly longer for laparoscopy compared to laparotomy, 155.6 (±36.5) minutes and 104.3 (±30.7) minutes respectively (p<0.05). Laparoscopy patients had significantly shorter hospital stay, 3.6 (±1.9) days, compared to 5.8 (±1. 7) days for laparotomy patients. Sick leaves were 20.7 (±9.9) days for laparoscopy patients and 28.3 (14.7) for laparotomy patients. The difference was significant (p<0.05). Early postoperative reflux control was similar for laparoscopic and conventional fundoplication. Early side-effects were more frequent after laparoscopy. Significantly less laparoscopy patients were satisfied at long-term follow-up; only 62% of the laparoscopy patients were satisfied compared to 91% of the laparotomy patients.

    We have investigated the mechanisms and anatomical failures in twenty-one patients reoperated after laparoscopic total fundoplication. Recurrent heartburn occurs when wrong part of the stomach is used for the fundoplication. Dysphagia after failed laparoscopic total fundoplication is caused by hiatal fibrosis or other mechanical causes rather than a normal and tight fundoplication.

    Also the reproducibility of an important diagnostic tool for GORD, the 24-hour pH monitoring, was evaluated. Twenty-two adult patients admitted to The Oesophageal Laboratory for 24-hour pH monitoring were investigated twice, six weeks apart, under identical conditions. The test was strictly standardised with the use of an antimony pH- probe and the patients hospitalised during 24 hours. We found that a normal 24-hour pH test should be assessed with caution because the biological variability of gastro-oesophageal reflux is not negligible from time to time.

    Delarbeten
    1. Prospective study of symptoms and gastro-oesophageal reflux 10 years after posterior partial fundoplication
    Öppna denna publikation i ny flik eller fönster >>Prospective study of symptoms and gastro-oesophageal reflux 10 years after posterior partial fundoplication
    1999 (Engelska)Ingår i: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 86, nr 7, s. 956-960Artikel i tidskrift (Refereegranskat) Published
    Abstract [en]

    Background:

    This was a prospective study of symptoms, and short-term and long-term reflux competence after partial fundoplication.

    Methods:

    Some 101 patients were operated consecutively with posterior partial (270°) fundoplication. Indications for surgery were reflux disease without erosive oesophagitis in 25 patients, moderate oesophagitis in 43, severe oesophagitis in 25 and paraoesophageal hernia in eight. Symptom score, manometry and pH tests were performed before operation, 6 months after operation and after 6–14 years.

    Results:

    All patients (n = 101) were free from heartburn and regurgitation at early follow-up. There was evidence of clinical recurrence at late follow-up (n = 87) in two of 22 patients without oesophagitis before operation, two of 39 with moderate oesophagitis before operation and three of 19 patients with severe oesophagitis before operation; 92 per cent had good reflux control at late follow-up.

    Conclusion

    Posterior partial fundoplication shows excellent reflux control at early follow-up. Ten years later fewer than 10 per cent of patients have recurrence, which is more common in patients who had severe oesophagitis before operation.

    Nationell ämneskategori
    Medicin och hälsovetenskap
    Identifikatorer
    urn:nbn:se:liu:diva-25023 (URN)10.1046/j.1365-2168.1999.01183.x (DOI)9444 (Lokalt ID)9444 (Arkivnummer)9444 (OAI)
    Tillgänglig från: 2009-10-07 Skapad: 2009-10-07 Senast uppdaterad: 2017-12-13Bibliografiskt granskad
    2. Prospective evaluation of laparoscopic and open 360o fundoplication in mild and severe gastro-oesophageal reflux disease
    Öppna denna publikation i ny flik eller fönster >>Prospective evaluation of laparoscopic and open 360o fundoplication in mild and severe gastro-oesophageal reflux disease
    2002 (Engelska)Ingår i: European Journal of Surgery, ISSN 1102-4151, E-ISSN 1741-9271, Vol. 168, nr 10, s. 539-545Artikel i tidskrift (Refereegranskat) Published
    Abstract [en]

    OBJECTIVE:

    To investigate the relationship between five-year control of reflux and early postoperative oesophageal function after total fundoplication done either laparoscopically or through a laparotomy in severe and mild reflux disease.

    DESIGN:

    Prospective open study.

    SETTING:

    University hospital, Sweden.

    PATIENTS:

    In the group with severe disease 9 patients had a laparotomy and 7 laparoscopy. The corresponding figures for the group with mild disease were 21 and 34 respectively.

    RESULTS:

    The increase in lower oesophageal sphincter pressure 6 months after operation in patients with recurrent disease was significantly less than that for patients with good reflux control (p < 0.01). In patients who had laparotomy, including 30% (9/30) with severe reflux disease, good long-term reflux control was found in 93% (27/29). In patients operated on laparoscopically including 17% (7/41) with severe reflux disease good long-term reflux control was found in 90% (35/39).

    CONCLUSION:

    The mechanism of recurrence differed between patients with severe disease who had a laparotomy and patients with mild disease operated on laparoscopically. Early postoperative manometry was prognostic for recurrence. Long-term reflux control seems to be similar after laparotomy and laparoscopy. Further randomised studies are needed.

    Nationell ämneskategori
    Medicin och hälsovetenskap
    Identifikatorer
    urn:nbn:se:liu:diva-24845 (URN)12666693 (PubMedID)9243 (Lokalt ID)9243 (Arkivnummer)9243 (OAI)
    Tillgänglig från: 2009-10-07 Skapad: 2009-10-07 Senast uppdaterad: 2017-12-13Bibliografiskt granskad
    3. Laparoscopic or conventional fundoplication for long-term management of gastroesophageal reflux disease?
    Öppna denna publikation i ny flik eller fönster >>Laparoscopic or conventional fundoplication for long-term management of gastroesophageal reflux disease?
    (Engelska)Manuskript (preprint) (Övrigt vetenskapligt)
    Abstract [en]

    Background: The study started in 1994 after over 50 laparoscopic 360o fundoplications had been performed by the surgeons involved. Complete mobilization of the fundus with posterior crural repair was used where a short floppy total fundoplication was constructed using three non-absorbable sutures, two of them including the esophageal wall. Initial experience in the first 50 consecutive patients operated laparoscopically in this center demonstrated 90% good reflux control.

    Methods: Adult patients with uncomplicated reflux disease during the years 1994-1998 were included in this prospective ranomized clincal trial between laparoscopic and open total fundoplication. Patients with long segment Barrett's esophagus, strictures, unhealed severe esophagitis or paraesophageal hernia were excluded, as were patients with previous esophagus or stomach operations, those with weak peristalsis or suspected short esophagus. Two senior surgeons well trained in laparoscopic antireflux surgery performed the 45 laparoscopic operations. Forty-eight patients underwent open surgery performed and supervised by two other senior surgeons well trained in gastroesophageal surgery. One of the latter recruited all patients. Manometry and 24-h esophageal pH monitoring were performed before operation and half a year postoperatively. Manometry also included a short-term reflux test, an acid clearing test and an acid perfusion test. Symptom evaluation (modified DeMeester score) was performed before operation, half a year after and at long-term follow-up (33-79 months postoperatively). Long-term follow-up also included endoscopy.

    Results: Half a year after laparoscopy four patients had disabling dysphagia. No patient had disabling dysphagia after laparotomy. Four patients had mild heartburn six mouths after laparoscopy and two patients after laparotomy. Between six months follow-up and long-term follow up six patients were reoperated in the laparoscopy group and two patients in the laparotomy group. Three patients operated with laparotomy had died in intercurrent diseases. After laparoscopy, at long-term follow-up, 62% (28/45) were satisfied compared to 91% ( 41145) after laparotomy. The difference was significant (p<0.01).

    Conclusions: Early postoperative reflux control was similar for laparoscopic and conventional fundoplication. At long-term follow-up significantly more patients were satisfied after laparotomy than after laparoscopy.

    Nationell ämneskategori
    Medicin och hälsovetenskap
    Identifikatorer
    urn:nbn:se:liu:diva-84500 (URN)
    Tillgänglig från: 2012-10-10 Skapad: 2012-10-10 Senast uppdaterad: 2012-10-10Bibliografiskt granskad
    4. Symptoms and reflux competence in relation to anatomical findings at reoperation after laparoscopic total fundoplication
    Öppna denna publikation i ny flik eller fönster >>Symptoms and reflux competence in relation to anatomical findings at reoperation after laparoscopic total fundoplication
    2002 (Engelska)Ingår i: European Journal of Surgery, ISSN 1102-4151, E-ISSN 1741-9271, Vol. 168, nr 12, s. 701-706Artikel i tidskrift (Refereegranskat) Published
    Abstract [en]

    OBJECTIVE:

    To investigate the mechanisms and anatomical failures after total laparoscopic fundoplication using the symptoms and findings at reoperation.

    DESIGN:

    Prospective open study.

    SETTING:

    University hospital, Sweden.

    PATIENTS:

    Twenty-one patients who were reoperated on a median of 33 (0.5-102) months after laparoscopic fundoplication.

    INTERVENTIONS:

    The patients were divided into three groups according to the mode of presentation. The first group presented with dysphagia and no gastro-oesophageal reflux (GOR) (n = 6). The second group (n = 11) had recurrent GOR and the third group (n = 4) complained of a sense of excessive fullness.

    RESULTS:

    In the dysphagia group the reason for it in 4 patients was severe fibrosis in the hiatal region including the right part of the fundoplication. One patient had correctly located fundoplication but it was too tight. In the last patient the part of the stomach used was too low down. All patients in the GOR group had a slippage and rupture of the fundoplication. Ten patients also had a recurrent hernia. In 6/11 patients the fundal mobilisation was incomplete. In the last group (excessive fullness) one patient had a postoperative leak from the fundal part, one patient a para-oesophageal hernia, and one patient an intact but herniated repair. One further patient had an intact abdominal oesophagus and crural repair, but a large portion of the stomach had herniated through the left part of the fundoplication and acted as a volvulus.

    CONCLUSIONS:

    Dysphagia was caused by hiatal fibrosis or other technical failures rather than a normal tight fundoplication. Using the wrong part of the stomach causes recurrent heartburn. The laparoscopic suturing technique must be improved.

    Nationell ämneskategori
    Medicin och hälsovetenskap
    Identifikatorer
    urn:nbn:se:liu:diva-25025 (URN)15362579 (PubMedID)9446 (Lokalt ID)9446 (Arkivnummer)9446 (OAI)
    Tillgänglig från: 2009-10-07 Skapad: 2009-10-07 Senast uppdaterad: 2017-12-13Bibliografiskt granskad
    5. Reliability of 24-hour oesophageal pH monitoring under standardized conditions
    Öppna denna publikation i ny flik eller fönster >>Reliability of 24-hour oesophageal pH monitoring under standardized conditions
    2002 (Engelska)Ingår i: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 37, nr 1, s. 6-8Artikel i tidskrift (Refereegranskat) Published
    Abstract [en]

    BACKGROUND:

    Twenty-four-hour pH monitoring is an investigation technique that can give both false-positive and false-negative results, depending on patient factors such as diet and different activities. The aim was to study the reproducibility of 24-h oesophageal pH monitoring under as standardized conditions as possible in patients with symptoms of gastro-oesophageal reflux disease.

    METHODS:

    Antimony pH electrodes were used in 22 adult patients who were investigated twice, 6 weeks apart, under identical conditions. They were hospitalized and were served a standardized diet which had been tested to contain no lower than pH 5.0. Neither coffee nor smoking was allowed. The patients had to refrain from proton-pump inhibitors for 10 days and H2 blockers for 2 days prior to the investigation. The paired t test was used.

    RESULTS:

    There was no significant difference in total reflux time, upright or supine reflux time, or longest reflux periods between the two test occasions. However, there were discordant results in six patients who had normal total reflux time on one test occasion but pathological results on the other.

    CONCLUSION:

    Since the biological variability of gastro-oesophageal reflux is not negligible from time to time, a normal 24-h oesophageal pH test should be assessed with caution.

    Nationell ämneskategori
    Medicin och hälsovetenskap
    Identifikatorer
    urn:nbn:se:liu:diva-25024 (URN)10.1080/003655202753387275 (DOI)11843037 (PubMedID)9445 (Lokalt ID)9445 (Arkivnummer)9445 (OAI)
    Tillgänglig från: 2009-10-07 Skapad: 2009-10-07 Senast uppdaterad: 2017-12-13Bibliografiskt granskad
  • 6.
    Franzén, Thomas
    et al.
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Anderberg, Bo
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Tibbling Grahn, Lita
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Johansson, Karl-Erik
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Prospective evaluation of laparoscopic and open 360o fundoplication in mild and severe gastro-oesophageal reflux disease2002Ingår i: European Journal of Surgery, ISSN 1102-4151, E-ISSN 1741-9271, Vol. 168, nr 10, s. 539-545Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE:

    To investigate the relationship between five-year control of reflux and early postoperative oesophageal function after total fundoplication done either laparoscopically or through a laparotomy in severe and mild reflux disease.

    DESIGN:

    Prospective open study.

    SETTING:

    University hospital, Sweden.

    PATIENTS:

    In the group with severe disease 9 patients had a laparotomy and 7 laparoscopy. The corresponding figures for the group with mild disease were 21 and 34 respectively.

    RESULTS:

    The increase in lower oesophageal sphincter pressure 6 months after operation in patients with recurrent disease was significantly less than that for patients with good reflux control (p < 0.01). In patients who had laparotomy, including 30% (9/30) with severe reflux disease, good long-term reflux control was found in 93% (27/29). In patients operated on laparoscopically including 17% (7/41) with severe reflux disease good long-term reflux control was found in 90% (35/39).

    CONCLUSION:

    The mechanism of recurrence differed between patients with severe disease who had a laparotomy and patients with mild disease operated on laparoscopically. Early postoperative manometry was prognostic for recurrence. Long-term reflux control seems to be similar after laparotomy and laparoscopy. Further randomised studies are needed.

  • 7.
    Franzén, Thomas
    et al.
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Anderberg, Bo
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Wirén, Michael
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Johansson, Karl-Erik
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Laparoscopic or conventional fundoplication for long-term management of gastroesophageal reflux disease?Manuskript (preprint) (Övrigt vetenskapligt)
    Abstract [en]

    Background: The study started in 1994 after over 50 laparoscopic 360o fundoplications had been performed by the surgeons involved. Complete mobilization of the fundus with posterior crural repair was used where a short floppy total fundoplication was constructed using three non-absorbable sutures, two of them including the esophageal wall. Initial experience in the first 50 consecutive patients operated laparoscopically in this center demonstrated 90% good reflux control.

    Methods: Adult patients with uncomplicated reflux disease during the years 1994-1998 were included in this prospective ranomized clincal trial between laparoscopic and open total fundoplication. Patients with long segment Barrett's esophagus, strictures, unhealed severe esophagitis or paraesophageal hernia were excluded, as were patients with previous esophagus or stomach operations, those with weak peristalsis or suspected short esophagus. Two senior surgeons well trained in laparoscopic antireflux surgery performed the 45 laparoscopic operations. Forty-eight patients underwent open surgery performed and supervised by two other senior surgeons well trained in gastroesophageal surgery. One of the latter recruited all patients. Manometry and 24-h esophageal pH monitoring were performed before operation and half a year postoperatively. Manometry also included a short-term reflux test, an acid clearing test and an acid perfusion test. Symptom evaluation (modified DeMeester score) was performed before operation, half a year after and at long-term follow-up (33-79 months postoperatively). Long-term follow-up also included endoscopy.

    Results: Half a year after laparoscopy four patients had disabling dysphagia. No patient had disabling dysphagia after laparotomy. Four patients had mild heartburn six mouths after laparoscopy and two patients after laparotomy. Between six months follow-up and long-term follow up six patients were reoperated in the laparoscopy group and two patients in the laparotomy group. Three patients operated with laparotomy had died in intercurrent diseases. After laparoscopy, at long-term follow-up, 62% (28/45) were satisfied compared to 91% ( 41145) after laparotomy. The difference was significant (p<0.01).

    Conclusions: Early postoperative reflux control was similar for laparoscopic and conventional fundoplication. At long-term follow-up significantly more patients were satisfied after laparotomy than after laparoscopy.

  • 8.
    Franzén, Thomas
    et al.
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Boström, J.
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Tibbling Grahn, Lita
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Johansson, Karl-Erik
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Prospective study of symptoms and gastro-oesophageal reflux 10 years after posterior partial fundoplication1999Ingår i: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 86, nr 7, s. 956-960Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background:

    This was a prospective study of symptoms, and short-term and long-term reflux competence after partial fundoplication.

    Methods:

    Some 101 patients were operated consecutively with posterior partial (270°) fundoplication. Indications for surgery were reflux disease without erosive oesophagitis in 25 patients, moderate oesophagitis in 43, severe oesophagitis in 25 and paraoesophageal hernia in eight. Symptom score, manometry and pH tests were performed before operation, 6 months after operation and after 6–14 years.

    Results:

    All patients (n = 101) were free from heartburn and regurgitation at early follow-up. There was evidence of clinical recurrence at late follow-up (n = 87) in two of 22 patients without oesophagitis before operation, two of 39 with moderate oesophagitis before operation and three of 19 patients with severe oesophagitis before operation; 92 per cent had good reflux control at late follow-up.

    Conclusion

    Posterior partial fundoplication shows excellent reflux control at early follow-up. Ten years later fewer than 10 per cent of patients have recurrence, which is more common in patients who had severe oesophagitis before operation.

  • 9.
    Franzén, Thomas
    et al.
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Johansson, Karl-Erik
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Symptoms and reflux competence in relation to anatomical findings at reoperation after laparoscopic total fundoplication2002Ingår i: European Journal of Surgery, ISSN 1102-4151, E-ISSN 1741-9271, Vol. 168, nr 12, s. 701-706Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE:

    To investigate the mechanisms and anatomical failures after total laparoscopic fundoplication using the symptoms and findings at reoperation.

    DESIGN:

    Prospective open study.

    SETTING:

    University hospital, Sweden.

    PATIENTS:

    Twenty-one patients who were reoperated on a median of 33 (0.5-102) months after laparoscopic fundoplication.

    INTERVENTIONS:

    The patients were divided into three groups according to the mode of presentation. The first group presented with dysphagia and no gastro-oesophageal reflux (GOR) (n = 6). The second group (n = 11) had recurrent GOR and the third group (n = 4) complained of a sense of excessive fullness.

    RESULTS:

    In the dysphagia group the reason for it in 4 patients was severe fibrosis in the hiatal region including the right part of the fundoplication. One patient had correctly located fundoplication but it was too tight. In the last patient the part of the stomach used was too low down. All patients in the GOR group had a slippage and rupture of the fundoplication. Ten patients also had a recurrent hernia. In 6/11 patients the fundal mobilisation was incomplete. In the last group (excessive fullness) one patient had a postoperative leak from the fundal part, one patient a para-oesophageal hernia, and one patient an intact but herniated repair. One further patient had an intact abdominal oesophagus and crural repair, but a large portion of the stomach had herniated through the left part of the fundoplication and acted as a volvulus.

    CONCLUSIONS:

    Dysphagia was caused by hiatal fibrosis or other technical failures rather than a normal tight fundoplication. Using the wrong part of the stomach causes recurrent heartburn. The laparoscopic suturing technique must be improved.

  • 10.
    Franzén, Thomas
    et al.
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Tibbling Grahn, Lita
    Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Reliability of 24-hour oesophageal pH monitoring under standardized conditions2002Ingår i: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 37, nr 1, s. 6-8Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND:

    Twenty-four-hour pH monitoring is an investigation technique that can give both false-positive and false-negative results, depending on patient factors such as diet and different activities. The aim was to study the reproducibility of 24-h oesophageal pH monitoring under as standardized conditions as possible in patients with symptoms of gastro-oesophageal reflux disease.

    METHODS:

    Antimony pH electrodes were used in 22 adult patients who were investigated twice, 6 weeks apart, under identical conditions. They were hospitalized and were served a standardized diet which had been tested to contain no lower than pH 5.0. Neither coffee nor smoking was allowed. The patients had to refrain from proton-pump inhibitors for 10 days and H2 blockers for 2 days prior to the investigation. The paired t test was used.

    RESULTS:

    There was no significant difference in total reflux time, upright or supine reflux time, or longest reflux periods between the two test occasions. However, there were discordant results in six patients who had normal total reflux time on one test occasion but pathological results on the other.

    CONCLUSION:

    Since the biological variability of gastro-oesophageal reflux is not negligible from time to time, a normal 24-h oesophageal pH test should be assessed with caution.

  • 11.
    Hagg, Mary
    et al.
    Hudiksvall Hospital, Sweden; Uppsala University, Sweden.
    Tibbling, Lita
    Linköpings universitet, Institutionen för klinisk och experimentell medicin. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Centrum för kirurgi, ortopedi och cancervård, Kirurgiska kliniken US.
    Franzen, Thomas
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för kliniska vetenskaper. Linköpings universitet, Hälsouniversitetet. Region Östergötland, Centrum för kirurgi, ortopedi och cancervård, Kirurgiska kliniken ViN.
    Esophageal dysphagia and reflux symptoms before and after oral IQoro(R) training2015Ingår i: World Journal of Gastroenterology, ISSN 1007-9327, E-ISSN 2219-2840, Vol. 21, nr 24, s. 7558-7562Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    AIM: To examine whether muscle training with an oral IQoro(R) screen (IQS) improves esophageal dysphagia and reflux symptoms. METHODS: A total of 43 adult patients (21 women and 22 men) were consecutively referred to a swallowing center for the treatment and investigation of long-lasting nonstenotic esophageal dysphagia. Hiatal hernia was confirmed by radiologic examination in 21 patients before enrollment in the study (group A; median age 52 years, range: 19-85 years). No hiatal hernia was detected by radiologic examination in the remaining 22 patients (group B; median age 57 years, range: 22-85 years). Before and after training with an oral IQS for 6-8 mo, the patients were evaluated using a symptom questionnaire (esophageal dysphagia and acid chest symptoms; score 0-3), visual analogue scale (ability to swallow food: score 0-100), lip force test (greater than= 15 N), velopharyngeal closure test (greater than= 10 s), orofacial motor tests, and an oral sensory test. Another twelve patients (median age 53 years, range: 22-68 years) with hiatal hernia were evaluated using oral IQS traction maneuvers with pressure recordings of the upper esophageal sphincter and hiatus canal as assessed by high-resolution manometry. RESULTS: Esophageal dysphagia was present in all 43 patients at entry, and 98% of patients showed improvement after IQS training [mean score (range): 2.5 (1-3) vs 0.9 (0-2), P less than 0.001]. Symptoms of reflux were reported before training in 86% of the patients who showed improvement at follow-up [1.7 (0-3) vs 0.5 (0-2), P less than 0.001). The visual analogue scale scores were classified as pathologic in all 43 patients, and 100% showed improvement after IQS training [71 (30-100) vs 22 (0-50), P less than 0.001]. No significant difference in symptom frequency was found between groups A and B before or after IQS training. The lip force test [31 N (12-80 N) vs 54 N (27-116), P less than 0.001] and velopharyngeal closure test values [28 s (5-74 s) vs 34 s (13-80 s), P less than 0.001] were significantly higher after IQS training. The oral IQS traction results showed an increase in mean pressure in the diaphragmatic hiatus region from 0 mmHg at rest (range: 0-0 mmHG) to 65 mmHg (range: 20-100 mmHg). CONCLUSION: Oral IQS training can relieve/improve esophageal dysphagia and reflux symptoms in adults, likely due to improved hiatal competence.

  • 12.
    Hägg, Mary
    et al.
    Hudiksvall Hospital, Sweden; Uppsala University, Sweden.
    Tibbling, Lita
    Linköpings universitet, Institutionen för klinisk och experimentell medicin. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Centrum för kirurgi, ortopedi och cancervård, Kirurgiska kliniken US.
    Franzen, Thomas
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för kliniska vetenskaper. Linköpings universitet, Hälsouniversitetet. Region Östergötland, Centrum för kirurgi, ortopedi och cancervård, Kirurgiska kliniken ViN.
    Effect of IQoro(R) training in hiatal hernia patients with misdirected swallowing and esophageal retention symptoms2015Ingår i: Acta Oto-Laryngologica, ISSN 0001-6489, E-ISSN 1651-2251, Vol. 135, nr 7, s. 635-639Artikel, forskningsöversikt (Refereegranskat)
    Abstract [en]

    Conclusion: Misdirected swallowing can be triggered by esophageal retention and hiatal incompetence. The results show that oral IQoro(R) screen (IQS) training improves misdirected swallowing, hoarseness, cough, esophageal retention, and globus symptoms in patients with hiatal hernia. Objectives: The present study investigated whether muscle training with an IQS influences symptoms of misdirected swallowing and esophageal retention in patients with hiatal hernia. Methods: A total of 28 adult patients with hiatal hernia suffering from misdirected swallowing and esophageal retention symptoms for more than 1 year before entry to the study were evaluated before and after training with an IQS. The patients had to fill out a questionnaire regarding symptoms of misdirected swallowing, hoarseness, cough, esophageal retention, and suprasternal globus, which were scored from 0-3, and a VAS on the ability to swallow food. The effect of IQS traction on diaphragmatic hiatus (DH) pressure was recorded in 12 patients with hiatal hernia using high resolution manometry (HRM). Results: Upon entry into the study, misdirected swallowing, globus sensation, and esophageal retention symptoms were present in all 28 patients, hoarseness in 79%, and cough in 86%. Significant improvement was found for all symptoms after oral IQS training (p less than 0.001). Traction with an IQS resulted in a 65 mmHg increase in the mean HRM pressure of the DH.

  • 13.
    Kechagias, Stergios
    et al.
    Linköpings universitet, Institutionen för molekylär och klinisk medicin, Gastroenterologi och hepatologi. Linköpings universitet, Institutionen för medicin och hälsa, Rättskemi. Linköpings universitet, Hälsouniversitetet.
    Jönsson, K. Å.
    Östergötlands Läns Landsting, Närsjukvården i centrala Östergötland, Akutkliniken. Linköpings universitet, Hälsouniversitetet.
    Franzén, Thomas
    Linköpings universitet, Institutionen för medicin och vård, Klinisk farmakologi. Linköpings universitet, Hälsouniversitetet.
    Andersson, L.
    Jones, A. Wayne
    Linköpings universitet, Institutionen för medicin och hälsa, Rättskemi.
    Reliability of breath-alcohol analysis in individuals with gastroesophageal reflux disease1999Ingår i: Journal of Forensic Sciences, ISSN 0022-1198, E-ISSN 1556-4029, Vol. 44, nr 4, s. 814-818Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Gastroesophageal reflux disease (GERD) is widespread in the population among all age groups and in both sexes. The reliability of breath alcohol analysis in subjects suffering from GERD is unknown. We investigated the relationship between breath-alcohol concentration (BrAC) and blood-alcohol concentration (BAC) in 5 male and 5 female subjects all suffering from severe gastroesophageal reflux disease and scheduled for antireflux surgery. Each subject served in two experiments in random order about 1-2 weeks apart. Both times they drank the same dose of ethanol (~0.3 g/kg) as either beer, white wine, or vodka mixed with orange juice before venous blood and end-expired breath samples were obtained at 5-10 min intervals for 4 h. Ah attempt was made to provoke gastroesophageal reflux in one of the drinking experiments by applying an abdominal compression belt, Blood-ethanol concentration was determined by headspace gas chromatography and breath-ethanol was measured with an electrochemical instrument (Alcolmeter SD-400) of a quantitative infrared analyzer (Data-Master). During the absorption of alcohol, which occurred during the first 90 min after the start of drinking, BrAC (mg/210 L) tended to be the same of higher than venous BAC (mg/dL). In the post-peak phase, the BAC al ways exceeded BrAC. Four of the 10 subjects definitely experienced gastric reflux during the study although this did not result in widely deviant BrAC readings compared with BAC when sampling occurred at 5- min intervals. We conclude that the risk of alcohol erupting from the stomach into the mouth owing to gastric reflux and falsely increasing the result of an evidential breath-alcohol test is highly improbable.

  • 14.
    Strand, A. Horna
    et al.
    Karolinska University Hospital, Sweden .
    Franzen, Thomas
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för kliniska vetenskaper. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Centrum för kirurgi, ortopedi och cancervård, Kirurgiska kliniken ViN.
    Influence of Life Style Factors on Barretts Oesophagus2014Ingår i: Gastroenterology Research and Practice, ISSN 1687-6121, E-ISSN 1687-630X, Vol. 2014, nr 408470Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background. Since the incidence of adenocarcinoma of the oesophagus is rising, the prognosis is poor, and surveillance programs are expensive and mostly cost ineffective, there is a need to increase the knowledge of risk factors in Barretts oesophagus and oesophageal cancer in order to be able to give attention to medical prevention and/or surveillance programs. Aim. To study if there is a correlation between the development of Barretts oesophagus and GOR (gastro oesophageal reflux), family history of GOR, and life style factors, such as alcohol, smoking habits, and mental stress. Methods. Fifty-five consecutively selected patients with Barretts oesophagus (BO) examined at Linkoping University Hospitals Oesophageal Laboratory were matched by sex, age, and duration of reflux symptoms with 55 GOR patients without Barretts oesophagus at the Oesophageal Laboratory. The medical charts in respective groups were examined for comparison of life style factors, mental stress, medication, duration of gastroesophageal acid reflux at 24 hr-pH-metry, and incidence of antireflux surgery and of adenocarcinoma of the oesophagus (ACO). Also, potential gender differences and diagnosis of ACO were studied. Results. Mean percentage reflux time on 24 hr-pH-metry was higher for the Barretts oesophagus group, 18% for women and 17% for men compared to 4% for women and 4% for men in the control group (P less than 0.05). Family history of GOR was more frequent in Barretts oesophagus patients (62%) than in the control group (35%) (P less than 0.05). Male patients with Barretts oesophagus had medical therapy for their GOR symptoms to a higher extent (38%) than male controls (65%) (P less than 0.05). No difference was found in the number of tobacco users or former tobacco users between Barretts oesophagus patients and controls. Barretts oesophagus patients had the same level of alcohol consumption and the same average BMI as the control subjects. Female patients with Barretts oesophagus rated themselves as more mentally stressed (67%) than the female controls (38%) (P less than 0.05). In the five-year medical chart follow-up, five of 55 patients developed adenocarcinoma among the Barretts oesophagus patients, none in the control group. Conclusions. Long reflux time and family clustering of GOR seem to influence the development of Barretts oesophagus. Smoking habits, alcohol consumption and BMI do not seem to have any impact on the development of Barretts oesophagus.

  • 15.
    Tibbling Grahn, Lita
    et al.
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Östergötlands Läns Landsting, Kirurgi- och onkologicentrum, Kirurgiska kliniken i Östergötland med verksamhet i Linköping, Norrköping och Motala.
    Blackadder, L
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Östergötlands Läns Landsting, Kirurgi- och onkologicentrum, Kirurgiska kliniken i Östergötland med verksamhet i Linköping, Norrköping och Motala.
    Franzén, Thomas
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Östergötlands Läns Landsting, Kirurgi- och onkologicentrum, Kirurgiska kliniken i Östergötland med verksamhet i Linköping, Norrköping och Motala.
    Kullman, Eric
    Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Östergötlands Läns Landsting, Kirurgi- och onkologicentrum, Kirurgiska kliniken i Östergötland med verksamhet i Linköping, Norrköping och Motala.
    Gastric bile monitoring: An in vivo and in vitro study of bilitec reliability2002Ingår i: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 37, nr 11, s. 1334-1337Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: It has been claimed that the combination of bile and hydrochloride acid (HCl) has a noxious effect on intestinal mucosa. The aim was to study the reliability of the Bilitec 2001 method in monitoring the presence of bile in repeated tests and at different pH and water dilutions. Methods: 24-h esophageal pH and gastric Bilitec monitoring were performed twice with an interval of 6 weeks in 23 patients with symptomatic gastroesophageal reflux (GER). In vitro tests of pH and Bilitec recordings were performed with different mixtures of bile, HCl and water. Results: Gastric bile was present in 37% of the recording time, 28% during day time and 47% during nights. No significant difference was found between the two test occasions. The maximum bile concentration in the stomach was significantly lower in patients with severe pathological GER than in those with normal GER. When concentrated bile was diluted with the same volume of HCl, the pH level fell below 4. The maximum absorption limit with Bilitec in concentrated bile was gradually reduced with decreasing pH. The Bilitec technique recorded the presence of bile even at a pH of 1.4, but not if the bile was diluted with water at a ratio of 1:100 or more. Conclusions: Bilitec gastric recordings show the same clinical result when repeated under standardized conditions. The Bilitec technique is not reliable for monitoring the amount and concentration of bile in the stomach. Bile reflux cannot be monitored with the pH recording technique.

  • 16.
    Tibbling, Lita
    et al.
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Gezelius, Per
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Kirurgi. Linköpings universitet, Hälsouniversitetet.
    Franzen, Thomas
    Linköpings universitet, Institutionen för klinisk och experimentell medicin, Kirurgi. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Centrum för kirurgi, ortopedi och cancervård, Kirurgiska kliniken i Östergötland.
    Factors influencing lower esophageal sphincter relaxation after deglutition2011Ingår i: World Journal of Gastroenterology, ISSN 1007-9327, E-ISSN 2219-2840, Vol. 17, nr 23, s. 2844-2847Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    AIM: To study the relationship between upper esophageal sphincter (UES) relaxation, peristaltic pressure and lower esophageal sphincter (LES) relaxation following deglutition in non-dysphagic subjects. METHODS: Ten non-dysphagic adult subjects had a high-resolution manometry probe passed transnasally and positioned to cover the UES, the esophageal body and the LES. Ten water swallows in each subject were analyzed for time lag between UES relaxation and LES relaxation, LES pressure at time of UES relaxation, duration of LES relaxation, the distance between the transition level (TL) and the LES, time in seconds that the peristaltic wave was before (negative value) or after the TL when the LES became relaxed, and the maximal peristaltic pressure in the body of the esophagus. RESULTS:Relaxation of the LES occurred on average 3.5 s after the bolus had passed the UES and in most cases when the peristaltic wave front had reached the TL. The LES remained relaxed until the peristaltic wave faded away above the LES. CONCLUSION: LES relaxation seemed to be caused by the peristaltic wave pushing the bolus from behind against the LES gate.

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