Anahita Jalilvand

Diagnostic Evaluation of Achalasia: From the Whalebone to the Chicago Classification

From the earliest description of dysphagia relieved by dilatation with a whalebone in 1674 we have witnessed the evolution of esophageal function testing from the conventional manometry to the high-resolution manometry (HRM) and esophageal topography pressure plotting that have led to the revised Chicago classification for esophageal motility disorders in 2014. The goals of this paper are, therefore, (1) to highlight the historical milestones that have led to the diagnostic definition of achalasia, as we know it today; (2) to describe the evaluation process of patients with suspected achalasia; (3) to describe the diagnostic value of the HRM and the usefulness of the Chicago classification in predicting treatment outcomes. The value of Chicago classification is linked to the ability of the clinician to perform a thorough clinical evaluation to identify and correlate specific clinical phenotypes to specific manometric subtypes and predict treatment outcomes. Chicago classification, however, cannot predict which treatment, pneumatic dilatation, or Heller myotomy, should be selected for those with a specific subtype of achalasia.

Achalasia and epiphrenic diverticulum.

Epiphrenic diverticula are a rare disease almost always associated with an underlying motility disorder of the esophagus, such as achalasia. Treatment of any underlying motility disorder must be included in the management of epiphrenic diverticula to prevent postoperative complications and recurrences. Therefore, the goal of this paper is to describe the pathophysiology, clinical presentation, and proper methods of diagnosis and treatment of patients with epiphrenic diverticula. In addition, we aim to provide an overview of the surgical management and discuss the indications for surgery and choice of surgical approach. In general, surgical intervention is favored for symptomatic patients and the optimal surgical approach depends on the size and location of the diverticulum. Surgery is not without seemingly high rates of morbidity when a myotomy is not performed together with the diverticulectomy, even in those with normal manometry. The risk of carcinoma is exceedingly rare and it is usually discovered at later stages; therefore, no surveillance programs have been established in asymptomatic patients with unresected diverticula.

Adipocyte DIO2 Expression Increases in Human Obesity but Is Not Related to Systemic Insulin Sensitivity

Deiodinase type II (D2), encoded by DIO2, catalyzes the conversion of T4 to bioactive T3. T3 not only stimulates adaptive thermogenesis but also affects adipose tissue (AT) lipid accumulation, mitochondrial function, inflammation, and potentially systemic metabolism. Although better defined in brown AT, the precise role of DIO2 expression in white AT remains largely unknown, with data derived only from whole fat. Therefore, the purpose of this study was to determine whether subcutaneous (SAT) and visceral (VAT) adipocyte-specific gene expression of DIO2 differs between obese and lean patients and whether these differences relate to alterations in mitochondrial function, fatty acid flux, inflammatory cytokines/adipokines, and ultimately insulin sensitivity. Accordingly, adipocytes of 73 obese and 21 lean subjects were isolated and subjected to gene expression analyses. Our results demonstrate that obese compared to lean human individuals have increased adipocyte-specific DIO2 expression in both SAT and VAT. Although higher DIO2 was strongly related to reduced fatty acid synthesis/oxidation and mitochondrial function, we found no relationship to proinflammatory cytokines or insulin resistance and no difference based on diabetic status. Our results suggest that adipocyte-derived DIO2 may play a role in weight maintenance but is likely not a major contributor to obesity-related insulin resistance.

Efficacy and safety of a single staged endoscopic approach to Barrett’s esophagus and early esophageal adenocarcinoma

Over the past decade, endoscopic eradication therapy (EET) has replaced esophagectomy as the preferred treatment approach for patients with high-grade dysplasia (HGD) and low-risk, early stage esophageal cancer, largely owing to the significant morbidity and mortality associated with this procedure.

Laparoscopic Treatment of Epiphrenic Diverticula

The laparoscopic repair of epiphrenic diverticulum is today considered the standard surgical approach that has replaced the traditional repair through a left thoracotomy. The laparoscopic approach has in fact several advantages over a left thoracotomy or thoracoscopy: it allows a cardiomyotomy extending far onto the stomach, contralateral to the diverticular staple line; it allows a partial fundoplication that prevents gastroesophageal reflux and covers the cardiomyotomy; and it avoids the discomfort of a chest tube postoperatively. This chapter illustrates the preoperative work-up and choice of surgical technique.