Davide Bona

Laparoscopic sphincter augmentation device eliminates reflux symptoms and normalizes esophageal acid exposure: one- and 2-year results of a feasibility trial.

Objectives:One- and 2-year evaluation of a feasibility trial (clinicaltrials.gov registration numbers NCT01057992, NCT01058070, and 01058564) to assess the safety and efficacy of a laparoscopically implanted sphincter augmentation device for the treatment of gastroesophageal reflux disease (GERD). Methods:A sphincter augmentation device (LINX Reflux Management System; Torax Medical, Shoreview, MN), designed to prevent reflux due to abnormal opening of the lower esophageal sphincter (LES), was laparoscopically implanted at the gastroesophageal junction in 44 patients. At baseline, all patients had abnormal esophageal acid exposure on 24-hour pH monitoring and improved, but persistent, typical GERD symptoms while on acid suppression therapy with proton pump inhibitors (PPIs). The device comprises a miniature string of interlinked titanium beads, with magnetic cores, placed around the gastroesophageal junction. The magnetic bond between adjacent beads augments sphincter competence. The beads temporarily separate to accommodate a swallowed bolus, allow belching or vomiting, and reapproximate to augment the LES in the closed position. Patients were evaluated after surgery by GERD Health-Related Quality of Life symptom score, PPI usage, endoscopy, esophageal manometry, and 24-hour esophageal pH monitoring. Results:The total mean GERD Health-Related Quality of Life symptom scores improved from a mean baseline value of 25.7 to 3.8 and 2.4 at 1- and 2-year follow-up, representing an 85% and 90% reduction, respectively (P < 0.0001). Complete cessation of PPI use was reported by 90% of patients at 1 year and by 86% of patients at 2 years. Early dysphagia occurred in 43% of the patients and self-resolved by 90 days. One device was laparoscopically explanted for persistent dysphagia without disruption of the anatomy or function of the cardia. There were no device migrations, erosions, or induced mucosal injuries. At 1 and 2 years, 77% and 90% of patients had a normal esophageal acid exposure. The mean percentage time pH was less than 4 decreased from a baseline of 11.9% to 3.1% (P < 0.0001) at 1 year and to 2.4% (P < 0.0001) at 2 years. Patient satisfaction was 87% at 1 year and 86% at 2 years. Conclusions:The new laparoscopically implanted sphincter augmentation device eliminates GERD symptoms without creating undue side effects and is effective at 1 and 2 years of follow-up.

Outcome of esophageal adenocarcinoma detected during endoscopic biopsy surveillance for Barrett's esophagus

Background: In an attempt to reduce mortality from esophageal adenocarcinoma, it has been recommended to enroll patients with Barrett’s esophagus in endoscopic surveillance programs in order to detect malignant degeneration at an early and possibly curable stage. The aim of this study was to assess the impact of endoscopic biopsy surveillance on outcome of Barrett’s adenocarcinoma. Methods: Between November 1992 and June 2000, 312 patients with histologically proven esophageal adenocarcinoma were referred to our department. Ninety-seven of these patients had Barrett’s adenocarcinoma. In 12 (12.2%) patients, cancer was discovered during endoscopic surveillance for Barrett’s metaplasia. Results: The prevalence of gastroesophageal reflux disease in the Barrett’s group was 38.8% versus 8% (p < 0.01) in non-Barrett’s patients. In the surveyed group, there were 9 (75%) early stage tumors (Tis-1/N0) versus 9 (10.6%, p < 0.01) in the nonsurveyed patients. Three of 5 surveyed patients operated on for high-grade dysplasia proved to have invasive carcinoma in the esophagectomy specimen. All surveyed patients were alive at a median follow-up of 48 months; the median survival in the nonsurveyed group was 24 ± 3 months (p < 0.01). Conclusion: Endoscopic surveillance of Barrett’s esophagus provides early detection of malignant degeneration and a better long-term survival than in nonsurveyed patients.

One hundred consecutive patients treated with magnetic sphincter augmentation for gastroesophageal reflux disease: 6 years of clinical experience from a single center

BACKGROUND This study was undertaken to evaluate our clinical experience during a 6-year period with an implantable device that augments the lower esophageal sphincter for gastroesophageal reflux disease (GERD). The device uses magnetic sphincter augmentation (MSA) to strengthen the antireflux barrier. STUDY DESIGN In a single-center, prospective case series, 100 consecutive patients underwent laparoscopic MSA for GERD between March 2007 and February 2012. Clinical outcomes for each patient were tracked post implantation and compared with presurgical data for esophageal pH measurements, symptom scores, and proton pump inhibitor (PPI) use. RESULTS Median implant duration was 3 years (range 378 days to 6 years). Median total acid exposure time was reduced from 8.0% before implant to 3.2% post implant (p < 0.001). The median GERD Health Related Quality of Life score at baseline was 16 on PPIs and 24 off PPIs and improved to a score of 2 (p < 0.001). Freedom from daily dependence on PPIs was achieved in 85% of patients. There have been no long-term complications, such as device migrations or erosions. Three patients had the device laparoscopically removed for persistent GERD, odynophagia, or dysphagia, with subsequent resolution of symptoms. CONCLUSIONS Magnetic sphincter augmentation for GERD in clinical practice provides safe and long-term reduction of esophageal acid exposure, substantial symptom improvement, and elimination of daily PPI use. For candidates of antireflux surgery who have been carefully evaluated before surgery to confirm indication for MSA, MSA has become a standard treatment at our institution because control of reflux symptoms and pH normalization can be achieved with minimal side effects and preservation of gastric anatomy.

Esophagectomy via Laparoscopy and Transmediastinal Endodissection

An original technique for minimally invasive transmediastinal esophagectomy is described. A combined laparoscopic and video-mediastinoscopic approach was attempted in a series of patients with high-grade dysplasia or carcinoma of the esophagus. Laparoscopy allowed mobilization of the stomach and dissection of the distal esophagus at least up to the level of the inferior pulmonary veins. Through a left cervicotomy, endodissection of the upper thoracic esophagus was accomplished with an operating video-mediastinoscope. After complete upward and downward mobilization from the mediastinal bed, the specimen was retrieved through the cervical incision and the stomach was guided laparoscopically into the posterior mediastinum. Compared to the laparoscopic total esophagectomy, this approach provides a more controlled and safer dissection of the upper mediastinum.

Thoracoscopic Management of Chylothorax Complicating Esophagectomy

BACKGROUND Chylothorax is a relatively uncommon complication of esophageal surgery that may lead to severe respiratory, nutritional, and immunologic deficiencies. PATIENTS AND METHODS Between 1992 and 2000, 3 of 316 patients (0.9%) undergoing transthoracic esophagectomy for carcinoma developed postoperative chylothorax. Two of them had previously been treated with neoadjuvant chemoradiation, and one had been submitted to esophagogastric resection through a left thoracotomy. After a 2-week trial of total parenteral nutrition and drainage, two patients underwent thoracic duct ligation via thoracotomy. In the last patient, the operation was completed by thoracoscopy. The azygos vein and the periaortic tissue above the diaphragm were encircled en bloc by a right-angled clamp, and a roticulating endostapler was applied. RESULTS Reoperation was successful in all patients. The postoperative hospital stay was 4 days. CONCLUSION Thoracoscopy is a safe and effective procedure for the treatment of chylothorax complicating esophagectomy. Given the minimal trauma to the patient, early thoracoscopic reoperation can be advocated in patients with high-output chyle loss in order to reduce the hospital stay.

Management of Boerhaave's syndrome with an over-the-scope clip.

Boerhaaves syndrome is a spontaneous barotraumatic disruption of the distal oesophagus secondary to an abrupt increase in intraoesophageal pressure during vomiting. Management ranges from a conservative approach to an oesophagectomy. The over-the-scope-clip (OTSC, Ovesco Endoscopy GmbH, Tuebingen, Germany) system is a newly designed clipping method for tissue mechanical compression in the gastrointestinal tract. We report the case of a patient referred with a delayed diagnosis of Boerhaaves syndrome and successfully treated by OTSC application followed by lung decortication.

Pseudoachalasia occurring after laparoscopic Nissen fundoplication and crural mesh repair

BackgroundBenign esophageal pseudoachalasia is a rare condition.DiscussionWe report the case of a 70-year-old man who complained of severe dysphagia after laparoscopic Nissen fundoplication and crural mesh repair performed for long-standing gastroesophageal reflux disease. Severe dysphagia and nocturnal aspiration developed soon after the operation. A marked dilatation of the esophageal body and a manometric pattern resembling achalasia was documented.ResultsEndoscopic balloon dilatation was ineffective. Five months after the initial operation, the patient underwent revisional laparoscopic surgery that consisted of Nissen’s wrap takedown, enlargement of the hiatus with partial resection of the mesh, Heller myotomy, and Dor fundoplication. After a 2-year follow-up, the patient is doing well and is free of symptoms.

Giant leiomyoma of the gastroesophageal junction: technique and results of endoscopic full-thickness resection.

Four consecutive patients with a giant leiomyoma originating from the posterior aspect of the gastroesophageal junction were treated with full-thickness endoscopic retroflex dissection. A complete removal of the lesion was obtained in all cases. No complications were observed except for some degree of air filtration causing symptomatic pneumoperitoneum in one patient. Retroflex endoscopic full-thickness resection of giant leiomyoma at the gastroesophageal junction is feasible and safe.

Stent-in-stent, a safe and effective technique to remove fully embedded esophageal metal stents: case series and literature review

Background: Endoscopic stenting is a widely used method for managing esophageal anastomotic leaks and perforations. Self-expanding metal stents (SEMSs) have proved effective in sealing these defects, with a lower rate of displacement than that of self-expanding plastic stents (SEPSs) as a result of tissue proliferation and granulation tissue ingrowth at the uncovered portion of the stent, which anchor the prosthesis to the esophageal wall. Removal of a fully embedded stent is challenging because of the risk of bleeding and tears. Materials and methods: Temporary placement of a new stent within the first stent (stent-in-stent technique) may facilitate the mobilization and safe removal of both stents by inducing pressure ischemia of the granulation tissue. We report our own experience with the stent-in-stent technique in five consecutive patients in whom a partially covered Ultraflex stent had previously been implanted and compare our results with those in the current literature. Results: The first SEMSs remained in place for a median of 40 days (range 18 – 68) without displacement. Placement of the new stent was technically successful in all patients. All stents were left in place for a median of 9 days. The overall stent-in-stent success rate was 100 % for the removal of embedded stents. No serious adverse events related to the procedure occurred. Conclusion: The procedure was safe, well tolerated, and effective. The use of a partially covered Ultraflex stent of the same size as the old stent for a limited time (≤ 6 days) was consistently successful.

Proposal of a Punch Biopsy Protocol as a Pre-requisite for the Establishment of a Tissue Bank from Resected Esophageal Tumors

With the development of tissue banking, a need for homogeneous methods of collection, processing, and storage of tissue has emerged. We describe the implementation of a biological bank in a high-volume, tertiary care University referral center for esophageal cancer surgery. We also propose an original punch biopsy technique of the surgical specimen. The method proved to be simple, reproducible, and not expensive. Unified standards for specimen collection are necessary to improve results of specimen-based diagnostic testing and research in surgical oncology.