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Concept: Achalasia

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The motility change after per-oral endoscopic myotomy (POEM) in achalasia is currently focused on lower esophageal sphincter (LES). This study aims to investigate the correlation of motility response between distal and proximal esophagus after POEM.

Concepts: Digestive system, Stomach, Gastroesophageal reflux disease, Esophagus, Cardia, Achalasia, Esophageal cancer, Esophageal arteries

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This is a description of transhiatal laparoscopic approach for mid-esophageal diverticulum. Traditionally mid-esophageal diverticula are approached by thoracotomy or thoracoscopy, with the laparoscopic technique being reserved for epiphrenic diverticula. A 78-year-old Caucasian female with a secondary dilatative ischemic cardiomyopathy presented with dysphagia, tenderness in the epigastrium and a considerable weight loss. A large mid-esophageal diverticulum was found on barium swallow and confirmed by CT scan. Underlying achalasia was recorded on manometry. The patient underwent diverticulectomy via transhiatal approach, followed by Heller myotomy and Dor fundoplication. Throughout the procedure auxiliary, esophagoscopic image was provided by interventional gastroenterologist due to a very narrow operating field and lack of orientation points. Based on our experience with this case, we propose transhiatal approach as a feasible alternative to thoracoscopy, in particular with patients who suffer from cardiac or pulmonary co-morbidities which make traditional techniques of high risk.

Concepts: Surgery, Gastroenterology, Nissen fundoplication, Achalasia, Swallowing, Heller myotomy, Barium swallow, Zenker's diverticulum

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Also available: Consumer Reports Patient Resource on High-Value Care for GERD BACKGROUND: Upper endoscopy is commonly used in the diagnosis and management of gastroesophageal reflux disease (GERD). Evidence demonstrates that it is indicated only in certain situations, and inappropriate use generates unnecessary costs and exposes patients to harms without improving outcomes. METHODS: The Clinical Guidelines Committee of the American College of Physicians reviewed evidence regarding the indications for, and yield of, upper endoscopy in the setting of GERD, and to highlight how clinicians can increase the delivery of high-value health care. BEST PRACTICE ADVICE 1: Upper endoscopy is indicated in men and women with heartburn and alarm symptoms (dysphagia, bleeding, anemia, weight loss, and recurrent vomiting). BEST PRACTICE ADVICE 2: Upper endoscopy is indicated in men and women with:      Typical GERD symptoms that persist despite a therapeutic trial of 4 to 8 weeks of twice-daily proton-pump inhibitor therapy.      Severe erosive esophagitis after a 2-month course of proton-pump inhibitor therapy to assess healing and rule out Barrett esophagus. Recurrent endoscopy after this follow-up examination is not indicated in the absence of Barrett esophagus.      History of esophageal stricture who have recurrent symptoms of dysphagia. BEST PRACTICE ADVICE 3: Upper endoscopy may be indicated:      In men older than 50 years with chronic GERD symptoms (symptoms for more than 5 years) and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated body mass index, tobacco use, and intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and Barrett esophagus.      For surveillance evaluation in men and women with a history of Barrett esophagus. In men and women with Barrett esophagus and no dysplasia, surveillance examinations should occur at intervals no more frequently than 3 to 5 years. More frequent intervals are indicated in patients with Barrett esophagus and dysplasia.

Concepts: Obesity, Gastroenterology, Gastroesophageal reflux disease, Esophagogastroduodenoscopy, Achalasia, Esophageal cancer, Barrett's esophagus, Esophageal stricture

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We aimed to identify the presence and length of esophagectomy proficiency gain curves in terms of short- and long-term mortality for esophageal cancer.

Concepts: Obesity, Squamous cell carcinoma, Helicobacter pylori, Achalasia, Esophageal cancer, Esophagectomy, Nitrosamine

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The term Cricopharyngeal Bar (CPB) describes a posterior indentation at the pharyngoesophageal junction which becomes apparent during a Video Fluoroscopic Swallowing Exam (VFSE, modified barium swallow). The effect CPBs might have on swallowing is still under debate. This paper intends to review appearance, effects and the associated therapy of CPBs.For this systematic review a selective literature research in PubMed has been carried out.CPBs are usually diagnosed during VFSE. As VFSEs are mostly carried out in dysphagic patients, CBPs were also associated with dysphagia. Even though, CPBs are often related to dysphagia, they do also appear in patients without dysphagia. Therefore, the appearance of a CBP does not automatically represent the cause of dysphagic symptoms. Its impact on swallowing might, however, depend on the dimension of the protrusion as well as the weakening and dysfunction of the inferior pharyngeal constrictor muscle.CBPs often present as an incidental finding during a modified barium swallow. A relation to dysphagia can only be assumed for severe CPBs. Therapy options include cricopharyngeal myotomy or esophago-gastro endoscopy using either bougies or balloons.

Concepts: Effect, Medical imaging, Radiology, Achalasia, Dysphagia, Swallowing, Barium swallow, Swallow

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PURPOSE: Nonspecific esophageal motility disorder (NEMD) is a vague category that includes patients with poorly defined contraction abnormalities observed during esophageal manometry. This study investigated the therapeutic effects of the video-assisted thoracoscopic surgery (VATS) approach using long myotomy and fundopexy for NEMD. METHODS: The VATS approach using myotomy and fundopexy was performed for 4 patients of NEMD between 2005 and 2008. A total of 4 patients with NEMD that underwent treatment at our institution were analyzed retrospectively. RESULTS: The patients included 2 males and 2 females with a median age of 48 years (range 21-74 years). The median duration of NEMD symptoms was 58 months (range 4-108 months). Dysphagia was a primary symptom in all patients. Chest pain was a primary symptom in 3 of 4 patients (75 %). Treatment with medication was attempted before the operation. The median operative time was 344.5 min (range 210-476 min). The median time before starting oral feeding was 2.5 days (range 2-22 days). All patients achieved a significant improvement of their previous condition. CONCLUSIONS: The VATS approach using myotomy and fundopexy for NEMD is a good treatment in cases resistant to medication and balloon dilation.

Concepts: Surgery, Gastroesophageal reflux disease, Achalasia, VATS lobectomy, Video-assisted thoracoscopic surgery, Nutcracker esophagus, Esophageal motility study, Esophageal motility disorder

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INTRODUCTION: The standard of care for achalasia is laparoscopic Heller’s cardiomyotomy. This procedure achieves satisfactory and long-standing results in over 85 % of patients. However, in 10-15 % of patients, esophageal function will progressively deteriorate, and up to 5 % will develop end-stage achalasia. Options in these difficult patients are limited, and include redo cardiomyotomy, repeat dilatation, and in severe cases, esophagectomy. METHODS: In this report, we describe an alternate approach, a cardioplasty, which was originally described by Heyrovsky in 1913. RESULTS: The development of an angulated stapling device now makes this operation feasible by a laparoscopic approach. CONCLUSION: This report highlights our technique for laparoscopic cardioplasty in patients with end-stage achalasia.

Concepts: Surgery, Staple, Achalasia, Esophageal cancer, Esophagectomy, Heller myotomy

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Pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) can be definitive therapies for achalasia; recent data suggest comparable efficacy. However, risk must also be considered. We reviewed the major complication rate of PD and LHM in a high-volume center and reviewed the corresponding literature.

Concepts: Surgery, Review, Major, Achalasia, Heller myotomy, Esophageal dilatation

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Background/Aims: Pneumatic balloon dilation and surgical myotomy are the most effective treatments for achalasia. While there is controversy which method is best, the aim of the current study was to identify predictors of symptom recurrence after endoscopic or surgical therapy. Methodology: Patients undergoing pneumatic balloon dilatation (30mm) or laparoscopic Heller myotomy with Dor fundoplication were included in the study. Analyzed parameters include total symptom score (sum of 0-5 point intensity for dysphagia, regurgitation and chest pain), width and height of esophageal column at 2 and 5 minutes after oral barium ingestion, lower esophageal sphincter (LES) length, resting (LESP) and residual pressure (LESRP) before and 3 months after intervention. Patients with symptoms score <3 at the 3-month follow-up visit were considered asymptomatic. Results: Twenty-one patients underwent pneumatic dilation (14) or laparoscopic myotomy (7). Total symptom score improved (p<0.01) from pre- (7.2±2.7) to post-intervention (1.7±2.6). Eleven (85.8%) patients in the endoscopic group vs. 7 (100%) patients in the surgical group were symptom-free 3 months after intervention. Therapies improved LESP (24.4±8.2mmHg pre- vs. 15.4±10.3mmHg post-therapy; p=0.003) and mean LESRP (7.9±4.3mmHg pre- vs. 5.3±6.7mmHg post-therapy; p=0.03). Univariate linear regression analysis identified barium contrast column width >5cm at 2 minutes (p=0.04), LES length <2cm (p=0.003) and LESRP >10mmHg (p=0.02) as predictors for persistent symptoms. Conclusions: While >85% of achalasia patients responded well to 30mm pneumatic balloon dilation, patients with elevated LES pressure, short LES and wide esophagus should be considered as primary surgical candidates.

Concepts: Regression analysis, Linear regression, Surgery, Gastroesophageal reflux disease, Esophagus, Cardia, Achalasia, Heller myotomy

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BACKGROUND: The aim of the present study was to clarify the efficacy of peroral endoscopic myotomy (POEM) for esophageal achalasia. PATIENTS AND METHODS: Twenty-eight esophageal achalasia patients who underwent POEM in our institution between August 2010 and October 2012 were enrolled. Under general anesthesia with tracheal intubation, initial incision was made on the anterior wall of the esophagus after submucosal injection. Submucosal tunnel was created and extended below the lower esophageal sphincter (LES) onto the gastric cardia. Subsequently, myotomy was done using triangle tip knife. After confirmation of smooth passage of scope through the esophagogastric junction, the entry was closed. Esophagogram and manometry study was done before and after the procedure. Also, subjective symptom score and Eckardt score were assessed before and 3 months after POEM. RESULTS: POEM was successfully done in all cases without any severe complications such as perforation and mediastinitis.Mean procedure time was 99.1 min (range 61-160) and mean myotomy length was 14.4 cm (range 10-18). Significant improvement was achieved in both esophagogram and endoscopic findings. Mean LES pressure was 71.2 mmHg (35.8-119.0) and 21.0 mmHg (6.7-41.0) before and after the procedure (P < 0.05), respectively. Mean Eckardt score was 6.7 (3-12, median 7) and 0.7 (0-3, median 1) before and 3 months after POEM, respectively (P < 0.05). Symptomatic gastroesophageal reflux disease that was easily controlled by the usual dose of proton pump inhibitor was seen in six cases (21.4%) after the procedure. CONCLUSION: POEM could be a curative standard treatment of choice for esophageal achalasia.

Concepts: Gastroenterology, Stomach, Gastroesophageal reflux disease, Esophagus, Cardia, Achalasia, Esophageal cancer, Dysphagia