Ciro Andolfi

Importance of Esophageal Manometry and pH Monitoring in the Evaluation of Patients with Refractory Gastroesophageal Reflux Disease: A Multicenter Study.

BACKGROUND Patients who have heartburn are treated with acid-reducing medications on the assumption that gastroesophageal reflux disease (GERD) is causing the symptom. In the absence of a response to therapy, patients are often assumed to have refractory GERD, and they are referred for laparoscopic antireflux surgery (LARS), often without further diagnostic evaluation. HYPOTHESIS We hypothesized that (1) in some patients with refractory GERD, the heartburn is not secondary to reflux, but rather to stasis and fermentation of food in the presence of achalasia and (2) esophageal manometry and pH monitoring are essential to establish proper diagnosis. PATIENTS AND METHODS Five hundred twenty-four patients, whose final diagnosis was achalasia, were referred to two quaternary care centers. Symptomatic evaluation, barium swallow, endoscopy, manometry, and pH monitoring were performed in all patients. RESULTS One hundred fifty-two patients (29%) had been treated with acid-reducing medications for an average of 29.3 months, and were referred for LARS because of lack of response to medical therapy. One patient had already been treated with a Nissen fundoplication. All patients were diagnosed with achalasia and underwent Heller myotomy and partial fundoplication. CONCLUSIONS The results of this study showed that (1) one-third of achalasia patients complained of heartburn and (2) patients with heartburn not responding to medical treatment must be carefully evaluated before referral to surgery. These data confirm the importance of esophageal manometry and pH monitoring in any patient considered for LARS.

POEM vs Laparoscopic Heller Myotomy and Fundoplication: Which Is Now the Gold Standard for Treatment of Achalasia?

Achalasia is a rare idiopathic disease of esophageal motility characterized by a failure of the esophageal gastric junction (EGJ) to relax during swallowing, combined with aperistalsis of the esophageal body. The lower esophageal sphincter (LES) is hypertensive in about 50 % of patients. Dysphagia, regurgitation, retrosternal pain, heartburn, respiratory symptoms, and weight loss are the most common symptoms, and esophageal dilation and tortuosity ultimately develop over time without treatment. Esophageal achalasia is a relatively rare esophageal motility disorder, occurring in approximately one of every 100,000 Americans. The diagnostic criteria for achalasia have recently been changed to reflect findings on high-resolution motility studies, potentiating a greater number of patients to be diagnosed with achalasia rather than other spastic esophageal disorders. The condition was also subtyped by the Chicago Classification, based on the presence of esophageal pressurization (type 2) and spastic esophageal body contractions (type 3), a subtyping which influences the prognosis after endoscopic and surgical therapies, with type 3 (spastic) being the least common and associated with the worst outcome after undergoing current modes of treatment. As there is currently no treatment of the underlying cause of this neuromuscular disorder, therapy is directed at disrupting the muscles at the EGJ to allow esophageal emptying by gravity. Although the sphincter muscle can be disrupted endoscopically using pneumatic balloon dilation, surgical myotomy has been shown to be the most effective and definitive treatment. Approximately 10 years ago, a study of the National Inpatient Sample (NIS), a national hospital admission database, quantified the number of patients in the USA undergoing surgical esophagogastric—or BHeller^—myotomy at just over 2000 patients per year, or about half the number of patients diagnosed with achalasia annually. From the NIS study of the years 1993 to 2005, Heller myotomy by means of minimally invasive surgery was associated with an increase in the annual number of patients undergoing surgical treatment for achalasia. Per oral endoscopicmyotomy (POEM) is the latest innovation in the treatment of achalasia and has disseminated in just over 5year time from a single center in Asia to major medical centers in every continent and every geographic area of the USA. Based on the average annual cases in reports published by centers in the USA (Fig. 1), the POEM procedure is currently reported in just over 200 cases annually. However, the authors surveyed industry representatives for essential POEM equipment to identify unpublished POEM centers (Fig. 2) and estimate its annual incidence at 500 cases in the USA, or approximately 25% of annual surgical procedures for treatment of achalasia. Authors Bowers, Patti, and Soper are considered co-first authors as they shared equally in the preparation of the manuscript. This manuscript is derived from the contents of the debate presented at the 2016 annual meeting of the Society for Surgery of the Alimentary Tract. Dr. Bowers presented the talk, BFrame the Debate^; Dr. Soper presented the talk, BPOEM is now the Gold Standard^; Dr. Patti presented the talk, BLaparoscopic Heller is Still the Gold Standard.^ Dr. Andolfi contributed to literature review and creation of tables.

Achalasia and Respiratory Symptoms: Effect of Laparoscopic Heller Myotomy

BACKGROUND Dysphagia and regurgitation are considered typical symptoms of achalasia. However, there is mounting evidence that some achalasia patients may also experience respiratory symptoms such as cough, wheezing, and hoarseness. AIMS The aims of this study were to determine: (1) what percentage of achalasia patients experience respiratory symptoms and (2) the effect of a laparoscopic Heller myotomy and Dor fundoplication on the typical and respiratory symptoms of achalasia. PATIENTS AND METHODS Between May 2008 and December 2015, 165 patients with achalasia were referred for treatment to the Center for Esophageal Diseases of the University of Chicago. Patients had preoperatively a barium swallow, endoscopy, and esophageal manometry. All patients underwent a Heller myotomy and Dor fundoplication. RESULTS Based on the presence of respiratory symptoms, patients were divided into two groups: group A, 98 patients (59%) without respiratory symptoms and group B, 67 patients (41%) with respiratory symptoms. The preoperative Eckardt score was similar in the two groups (6.5 ± 2.1 versus 6.4 ± 2.0). The mean esophageal diameter was 27.7 ± 10.8 mm in group A and 42.6 ± 20.1 mm in group B (P < .05). The operation consisted of a myotomy that extended for 5 cm on the esophagus and 2.5 cm onto the gastric wall. At a median postoperative follow-up of 17 months, the Eckardt score improved significantly and similarly in the two groups (0.3 ± 0.8 versus 0.3 ± 1.0). Respiratory symptoms improved or resolved in 62 patients (92.5%). CONCLUSIONS The results of this study showed that: (1) respiratory symptoms were present in 41% of patients; (2) patients with respiratory symptoms had a more dilated esophagus; and (3) surgical treatment resolved or improved respiratory symptoms in 92.5% of patients. This study underlines the importance of investigating the presence of respiratory symptoms along with the more common symptoms of achalasia and of early treatment before lung damage occurs.

Paraesophageal Hernia and Reflux Prevention: Is One Fundoplication Better than the Other?

BackgroundThe management of paraesophageal hernia (PEH) is one of the most debated in surgery. Trends regarding indications, approach (open, laparoscopic, thoracoscopic), sac excision, mesh placement, and routine performance of fundoplication have changed over time. Today, most surgeons tend to perform a laparoscopic PEH repair that entails the excision of the sac, liberal use of a mesh to buttress the hiatus, and the addition of an anti-reflux procedure. Nevertheless, very little has been written on which type of fundoplication should be performed in these patients. Therefore, the goal of our study was to provide an evidence-based overview of which type of fundoplication should be performed during a PEH repair and the role of preoperative function tests in the decision-makingMethods We searched the MEDLINE, Cochran, PubMed, Google Scholar, and Embase databases for papers published between 1996 and 2016 pertaining to the surgical treatment of PEH. We hand-searched the bibliographies of included studies and we excluded all reviews and case reports. We selected clinical studies and technical reports. We only considered papers stating rationales for the type of fundoplication performed.ResultsOur search yielded 24 articles: 17 clinical studies and 7 technical reports. In five of the clinical studies, a fundoplication was added only to patients with reflux symptoms. In all clinical studies, the most performed procedure was a total fundoplication (Nissen or Nissen-Rossetti), whereas a partial fundoplication (Toupet more frequently than Dor) or no fundoplication was reserved to those with impaired esophageal motility. All seven technical reports recommended a tailored approach and suggested adding a partial fundoplication (mainly Toupet) when the manometric findings showed esophageal dismotility.Conclusion The argument of whether or not a fundoplication should be added to a PEH repair in patients without evidence of reflux still persists. However, this review highlights that, when a fundoplication is performed, a tailored approach based on preoperative function tests is almost always preferred.

Adverse Outcome and Failure Following Laparoscopic Anti-reflux Surgery for Hiatal Hernia : Is One Fundoplication Better than Other?

The management of hiatal hernia (HH) is one of the most debated in surgery. Trends regarding indications, approach (open, laparoscopic, thoracoscopic), sac excision, mesh placement, and routine performance of fundoplication have changed over time. Today, most surgeons lean to perform a laparoscopic HH repair that entails the excision of the sac, liberal use of a mesh to buttress the hiatus, and the addition of an anti-reflux procedure. The rationale of including an anti-reflux procedure is to treat coexistent reflux or to prevent the onset of “de novo” postoperative reflux [1, 2]. In fact, many studies have shown that in the majority of patients a HH is associated with symptoms—even subtle—of dysphagia, bloating, or gastroesophageal reflux disease (GERD), and that an extensive hiatal dissection could exacerbate GERD postoperatively by impairing the anatomical anti-reflux barrier [3]. Already in 1996, a work by Wo et al. [4] showed that 68% of patients with type III PEH had a history of heartburn. Interestingly, many of these patients (41%) no longer had GERD symptoms at the time the operation, and the authors attributed this finding to the flap valve created by the stomach above the gastro-esophageal junction, suggesting that, in most patients, a type III paraesophageal hernia may be an enlarging sliding hernia. A recent double-blinded randomized controlled trial by Muller-Stich et al. [5] has validated the addition of an anti-reflux procedure by showing that a fundoplication during a PEH repair results in a net improvement in patients’ symptoms with reduced acid exposure and esophagitis. However, very little has been written on which type of fundoplication should be performed in these patients based on the outcome. In general, a total fundoplication is the preferred approach in patients with GERD, as it provides a better control of reflux than a partial fundoplication [6, 7]. Conversely, recent trends have highlighted how in patients with PEH a partial fundoplication could provide—especially in the absence of preoperative manometric data—a satisfactory balance between prevention/control of GERD and prevention of postoperative dysphagia. We have set as the goal of our chapter that to provide an evidence based overview of how the type of fundoplication can affect the outcome of a hiatal hernia repair.

Approach to Esophageal Strictures and Diverticula

Recent data reveal that the incidence of esophageal strictures is decreasing. However, they remain a common problem. Endoscopy is the main tool in evaluating these patients, as it provides a platform for both diagnosis and treatment. Most strictures respond to a combination of endoscopic dilation and medical therapy. Surgery is usually reserved to patients not responding to conservative treatment.

Whose patient is it? The path to multidisciplinary management of achalasia

In the past decade, the introduction of high-resolution manometry and the classification of achalasia into subtypes has made possible to accurately diagnose the disease and predict the response to treatment for its different subtypes. However, even to date, in an era of exponential medical progress and increased insight in disease mechanisms, treatment of patients with achalasia is still rather simplistic and mostly confined to mechanical disruption of the lower esophageal sphincter by different means. In addition, there is partial consensus on what is the best form of available treatments for patients with achalasia. Herein, we provide a comprehensive outlook to a general approach to the patient with suspected achalasia by: 1) defining the modern evaluation process; 2) describing the diagnostic value of high-resolution manometry and the Chicago Classification in predicting treatment outcomes and 3) discussing the available treatment options, considering the patient conditions, alternatives available to both the surgeon and the gastroenterologist, and the burden to the health care system. It is our hope that such discussion will contribute to value-based management of achalasia through promoting a leaner clinical flow of patients at all points of care.

Epidemiology of Obesity and Associated Comorbidities

Obesity currently affects 78.6 million people (33%) in the United States and is expected to increase to over 50% of the population by 2030. This epidemic is fueled by the growing rate of obesity in adolescents. The new science of obesity indicates that there is a tipping point at which genetic resetting occurs and it is reached when adipose tissue dysfunction occurs. It is becoming clear that obesity is less an ongoing personal choice than a fact of biology. With this review, we aim to describe the epidemiology of obesity and the associated comorbidities.

Appraisal and Current Considerations of Robotics in Colon and Rectal Surgery

BACKGROUND Robotic technology aims to obviate some of the limitations of conventional laparoscopic surgery, yet the role of robotics in colorectal surgery is still largely undefined and varies with respect to its application in abdominal versus pelvic surgery. METHODS With this review, we aimed to highlight current developments in colorectal robotic surgery. We systematically searched the following databases: PubMed, EMBASE, and Cochrane Library. We critically reviewed the available literature on the use of robotic technology in colon and rectal surgery. RESULTS Robotic colorectal surgery is oncologically safe and has short-term outcomes comparable to conventional laparoscopy, with potential benefits in rectal surgery. It has a shorter learning curve but increased operative times and costs. It offers potential advantages in the resection of rectal cancer, due to lower conversion rates. There is also a trend toward better outcomes in anastomotic leak rates, circumferential margin positivity, and perseveration of autonomic function. CONCLUSION Laparoscopy remains technically challenging and conversion rates are still high. Therefore, most cases of colorectal surgery are still performed open. Robotic surgery aims to overcome the limits of the laparoscopic technique. This new technology has many advantages in terms of articulating instruments, advanced three-dimensional optics, surgeon ergonomics, and improved accessibility to narrow spaces, such as the pelvis. However, further studies are needed to assess long-term results and benefits.

Evaluation of Gastroesophageal Reflux Disease

IntroductionGastroesophageal reflux disease (GERD) may present with heartburn, regurgitation, dysphagia, chronic cough, laryngitis, or even asthma. The clinical presentation of GERD is therefore varied and poses certain challenges to the physician, especially given the limitations of the diagnostic testing.DiscussionThe evaluation of patients with suspected GERD might be challenging. It is based on the evaluation of clinical features, objective evidence of reflux on diagnostic testing, correlation of symptoms with episodes of reflux, evaluation of anatomical abnormalities, and excluding other causes that might account for the presence of the patient’s symptoms.ConclusionsThe diagnostic evaluation should include multiple tests, in addition to a thorough clinical examination.