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Division of Pediatric General and Thoracic Surgery, The Montreal Childrens Hospital, McGill University Health Centre, Montreal, Quebec, Canada
Division of Pediatric Pathology, The Montreal Childrens Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Division of Gastroenterology, The Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Division of Pediatric Gastroenterology, The Montreal Childrens Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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a r t i c l e
i n f o
Article history:
Received 14 October 2013
Received in revised form 3 February 2014
Accepted 24 February 2014
Key words:
GERD
Lower esophageal sphincter
Augmentation
Deux
a b s t r a c t
Background: We previously demonstrated feasibility, safety, and a reproducible histologic bulking effect after
injection of dextranomer hyaluronic acid copolymer (DxHA) into the gastroesophageal junction of rabbits. In
the current study, we investigated the potential for DxHA to augment the lower esophageal sphincter (LES) in
a porcine model of gastroesophageal reux disease (GERD).
Methods: Twelve Yucatan miniature pigs underwent LES manometry and 24-hour ambulatory pH monitoring
at baseline, after cardiomyectomy, and 6 weeks after randomization to endoscopic injection of either DxHA or
saline at the LES. After necropsy, the foregut, including injection sites, was histologically examined.
Results: Pigs in both groups had similar weight progression. Cardiomyectomy induced GERD in all animals, as
measured by a rise in the median % of time pH b5 from 0.6 to 11.6 (p = 0.02). Endoscopic injection of DxHA
resulted in a higher median difference in LES length (1.8 cm vs. 0.4 cm, p = 0.03). In comparison with saline
injection, DxHA resulted in 120% increase in LES pressure, and 76% decrease in the mean duration of reux
episodes, but these results were not statistically signicant. Injection of DxHA induced a foreign body reaction
with broblasts and giant cells.
Conclusions: Porcine cardiomyectomy is a reproducible animal GERD model. Injection of DxHA may augment
the LES, offering a potential therapeutic effect in GERD.
2014 Elsevier Inc. All rights reserved.
Corresponding author at: Division of Pediatric General and Thoracic Surgery, The
Montreal Children's Hospital, 2300 Tupper Street; Room C-818, Montreal, Quebec,
Canada, H3H 1P3. Tel.: +1 514 412 4497; fax: +1 514 412 4289.
E-mail address: Sherif.Emil@McGill.ca (S. Emil).
http://dx.doi.org/10.1016/j.jpedsurg.2014.02.088
0022-3468/ 2014 Elsevier Inc. All rights reserved.
1354
other and with a radial orientation of 90. This allowed for the
collection of four data sets for a given site within the esophagus with a
single dynamic measurement. At each level along the esophagus, a
mean pressure was obtained from all four sensors. Using a stationary
pull-back technique, the catheter was manually pulled out at a speed
of 5 mm/min through the LES, with registration of the pressure within
the LES by all four sensors. The lower border of the LES was
determined at the station that demonstrated a consistent rise of
pressure above the gastric baseline pressure, whereas the upper
border of the LES was determined at the station that showed a drop of
pressure to esophageal baseline pressure. Before removing the
catheter, the distance between the upper border of the LES and the
snout was measured for the subsequent insertion of the pH probe.
From the data obtained, which were automatically recorded as
pressure curves via a polygraph on a standard PC using GastroTrac
(version 4.3.0.47, Alpine Biomed ApS, Skovlunde, Denmark), we
measured the total length, abdominal length, and resting pressure of
the LES, as previously described by Zaninotto et al. [29].
1355
1.4. Cardiomyectomy
Prophylactic cefazolin (20 mg/kg) was given intravenously. A14French orogastric tube was inserted. The abdominal cavity was
accessed through an upper midline laparotomy incision from the
xiphoid to the umbilicus. The left lobe of liver and the spleen were
retracted in order to expose the area of the GEJ. The phrenoesophageal
membrane was incised, the anterior peritoneal reection covering the
esophagus was opened, and the anterior and posterior vagal trunks
were identied and preserved. At the GEJ, an anterior longitudinal
myotomy was performed by incising the longitudinal and the circular
muscle bers using a No. 15 blade and a ne Metzenbaum scissors.
The myotomy was extended 3 cm cephalad on the esophagus and
3 cm caudad on the gastric cardia. Once the submucosal plane was
entered, the esophageal muscle layers were gently peeled away 1 cm
on both sides. Both pieces of muscle were then excised creating a
myectomy segment that was 6 cm in length and 2 cm in width
centered at the GEJ (Fig. 2). A very essential part of the myectomy was
to ensure dividing the gastric sling and clasp muscle bers, a step that
required careful dissection and carried the highest risk of mucosal
perforation. Once hemostasis was ensured, the abdomen was closed
in the standard fashion with a monolament suture. The skin was
closed with subcuticular sutures to avoid the presence of any material
externally. OpSite waterproof spray was used as a dressing. The
animal was awakened and extubated. Intramuscular buprenorphine
0.010.1 mg/kg was administered for analgesia. The pigs were
allowed free access to food and water. Postoperatively, cephalexin
(25 mg/kg) was administered orally twice a day for 10 days.
1.5. Endoscopic injections
A 2-week recovery period was allowed after surgery, during which
computer-generated randomization to either DxHA or saline was
performed. Under general anesthesia, a 45 cm custom-made rigid
endoscope (Fiegert-Endotech, Sunrise, FL) was advanced through the
pigs mouth. After the GEJ was identied, a semirigid beveled needle
was advanced through a working channel in the scope. Submucosal
injections of DxHA or saline were performed in three different
quadrants away from the muscle-decient cardiomyectomy site to
avoid injecting outside the esophagus. A volume of 1 ml of DxHA or
saline was injected in each site. A 30-second waiting period was
allowed for the implant to stabilize before withdrawing the needle.
Immediate mucosal bulging indicated successful implantation (Fig. 3).
Six animals had DxHA injections, whereas four animals received
saline injections. After completing the injection session, the animal
was awakened and extubated. Free access to water and food was
allowed immediately after the procedure. During the ensuing
Fig. 3. Endoscopic injection of DxHA at the GEJ. A volcano-like effect results owing to
installation of the polymer in the submucosa and muscularis.
Fig. 2. Appearance of the completed cardiomyectomy. The mucosa is seen to bulge after
the overlying muscle is removed.
1356
reaction with giant cells and collagen deposition (Fig. 6). No brous
tissue reaction was seen in the saline group. In 4 out of 6 DxHA
specimens, acute inammatory cells (microabscess) were identied
close to injection site. No evidence of perforation or periesophageal
inammation was noted. DxHA did not migrate above or below the
site of injection. There was no histologic evidence of esophagitis in
any of the specimens.
3. Discussion
GERD is a very common condition affecting both adults and
children [29]. Current medical and surgical options do not yield
optimal therapeutic results in a signicant proportion of patients. A
search for alternative treatments has continued. Augmenting the LES
with polymer injections has been investigated over the last decade as
a potential anti-GERD strategy [1521]. Some of these polymers were
synthetic, while others were biocompatible. Enteryx is a liquid
agent, composed of ethylene vinyl alcohol and dimethyl sulfoxide that
consolidates after being endoscopically injected at the GEJ. Initial
results in animal studies and adult patients were promising [18,20].
However, serious side effects resulted from improper placement of
this bulking agent. Intraaortic injection of Enteryx caused aortoenteric stula and renal failure from arterial occlusion leading to its
voluntary recall [30]. Another injectable agent, Plexiglas, consists of
a suspension of polymethylmethacrylate microspheres in gelatin
solution. Once injected, it is phagocytized by macrophages and
Table 1
Manometry (median and interquartile ranges) and pH data precardiomyectomy and postcardiomyectomy in 10 pigs.
Preoperative data
Manometry:
LES pressure (mm Hg)
LES total length (cm)
LES abdominal length (cm)
PH measurement:
Number of reuxes
Number of long reuxes
Time of pH b5 (min)
Percentage of time pH b5
Mean duration of reux episodes (min)
Duration of longest reux episode (min)
DeMeester score
Boix-Ochoa score
Postoperative data
Median
25%
75%
Median
25%
75%
1.35
3.68
2
1
2.5
1
3.03
7
2.75
1
2.1
1
0.63
1.75
0.5
1.6
3.5
1.1
0.06
0.08
0.07
10
0
9
0.6
0.29
1
1.1
0.5
1
0
0
0
0
0
0.1
0.5
178
1
39
3
0.5
10
7.3
1
218
4
147
11.6
0.8
28
11.1
1
107
0
24
1.9
0.21
2
8.3
0.5
311
16
350
27.8
1.54
64
25.8
20.7
0.06
0.05
0.02
0.02
NS
0.01
0.03
NS
Fig. 5. Box plots of the LES total length in the (A) DxHA group and (B) Saline group at
baseline, post cardiomyectomy, and 6 weeks post injection. Transverse lines represent
median values.
1357
Table 2
Histology results.
Pigs
Injection
type
DxHA implant
present?
Foreign body
reaction present?
Giant cells
present?
Fibroblasts
present?
Microabscesses
present?
Comment
1
2
3
4
5
6
Saline
Saline
Saline
Saline
DxHA
DxHA
No
No
No
No
Yes
Yes
No
No
No
No
Yes
Yes
No
No
No
No
Yes
Yes
No
No
No
No
Yes
Yes
No
No
No
No
No
Yes
7
8
DxHA
DxHA
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
9
10
DxHA
DxHA
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No inammation noted
No inammation noted
No inammation noted
No inammation noted
DxHA identied outside the muscularis propria
DxHA identied in the muscularis propria.
Presence of abscess with a small amount of DxHA
outside the muscularis propria
DxHA tracks outside the muscularis propria
DxHA identied outside the muscularis propria
Abscess identied in the submucosa
DxHA identied in the muscularis propria
DxHA present within a 4 cm abscess located outside
the muscularis propria and near the myomectomy site
1358
References
Fig. 6. High power slide showing a DxHA microshphere within a giant cell surrounded
by brosis and collagen deposition (yellow). Hematoxylin ploxine saffron stain.
Acknowledgment
We are grateful for the assistance of Emily Kay-Rivest in the
laboratory, as well as for the statistical review provided by Xianming
Tan, Ph.D. of the Biostatistics Core Facility, McGill University Health
Centre Research Institute.
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