Florian Augustin

Endoscopic resection and ablation versus esophagectomy for high-grade dysplasia and intramucosal adenocarcinoma

BACKGROUND Esophagectomy has been the traditional therapy for high-grade dysplasia and intramucosal adenocarcinoma. New endoscopic approaches allow treatment of these lesions with esophageal preservation. The aim of this study was to compare the outcome of endoscopic therapy with esophagectomy for high-grade dysplasia and intramucosal cancer. METHODS A retrospective review was performed of all patients treated for high-grade dysplasia or intramucosal adenocarcinoma from 2001 to April 2010. RESULTS Endoscopic therapy was performed in 40 patients (high-grade dysplasia = 22, intramucosal cancer = 18) and esophagectomy in 61 patients (high-grade dysplasia = 13, intramucosal cancer = 48). Endotherapy consisted of 102 endoscopic resections and 79 mucosal ablations (median 3 interventions per patient). In the endotherapy group, intramucosal cancer was completely resected in all patients. At last assessment, 10 patients have been converted to intestinal metaplasia without dysplasia and 21 to no residual intestinal metaplasia. Five patients have follow-up biopsy procedures pending after recent ablation, and esophagectomy was performed in 3 patients for failed endotherapy. A laparoscopic Nissen fundoplication has been performed in 8 patients after eradication of intestinal metaplasia. Esophagectomy resected the mucosal disease with negative margins in all patients. Compared with esophagectomy, endotherapy was associated with significantly lower morbidity (39% vs 0; P < .0001) and similar survival (94% at 3 years in both groups; median follow-up 34 months after esophagectomy vs 17 months after endotherapy; P = .0026). CONCLUSIONS Endoscopic therapy for high-grade dysplasia or intramucosal cancer has lower morbidity than an esophagectomy and similar survival during short-term follow-up, but required multiple procedures in most patients. Both therapies are appropriate options, but preservation of the esophagus allows the option of a fundoplication for reflux control, perhaps further improving long-term quality of life.

Laparoscopic versus Open Repair of Paraesophageal Hernia: The Second Decade

BACKGROUND A decade ago we reported that laparoscopic repair of paraesophageal hernia (PEH) had an objective recurrence rate of 42% compared with 15% after open repair. Since that report we have modified our laparoscopic technique. The aim of this study was to determine if these modifications have reduced the rate of objective hernia recurrence. STUDY DESIGN We retrospectively identified all patients that had primary repair of a PEH with ≥ 50% of the stomach in the chest from May 1998 to January 2010 with objective follow-up by videoesophagram. The finding of any size of hernia was considered to be recurrence. RESULTS There were 73 laparoscopic and 73 open PEH repairs that met the study criteria. There were no significant differences in gender, body mass index, or prevalence of a comorbid condition between groups. The median follow-up was similar (12 months laparoscopic versus 16 months open; p = 0.11). In the laparoscopic group, 84% of patients had absorbable mesh reinforcement of the crural closure and 40% had a Collis gastroplasty, compared with 32% and 26%, respectively, in the open group. A recurrent hernia was identified in 27 patients (18%), 9 after laparoscopic repair and 18 after open repair (p = 0.09). The median size of a recurrent hernia was 3 cm, and the incidence of recurrence increased yearly in those with serial follow-up with no early peak or late plateau. CONCLUSIONS In our first decade of laparoscopic PEH repair, no mesh crural reinforcement was used, and no patient had a Collis gastroplasty. Evolution in the technique of laparoscopic PEH repair during the subsequent decade has reduced the hernia recurrence rate to that seen with an open approach. Reduced morbidity and shorter hospital stay make laparoscopy the preferred approach, but continued efforts to reduce hernia recurrence are warranted.

Loss of Alkalization in Proximal Esophagus: a New Diagnostic Paradigm for Patients with Laryngopharyngeal Reflux

IntroductionCervical esophageal pH monitoring using a pH threshold of <4 in the diagnosis of laryngopharyngeal reflux (LPR) is disappointing. We hypothesized that failure to maintain adequate alkalization instead of acidification of the cervical esophagus may be a better indicator of cervical esophageal exposure to gastric juice. The aim of this study was to define normal values for the percent time the cervical esophagus is exposed to a pH ≥7 and to use the inability to maintain this as an indicator for diagnosis of LPR.Material and MethodsFifty-nine asymptomatic volunteers had a complete foregut evaluation including pH monitoring of the cervical esophagus. Cervical esophageal exposure to a pH <4 was calculated, and the records were reanalyzed using the threshold pH ≥7. The sensitivity of these two pH thresholds was compared in a group of 51 patients with LPR symptoms that were completely relieved after an antireflux operation.ResultsCompared to normal subjects, patients with LPR were less able to maintain an alkaline pH in the cervical esophagus, as expressed by a lower median percent time pH ≥ 7 (10.4 vs. 38.2, p < 0.0001). In normal subjects, the fifth percentile value for percent time pH ≥ 7 in the cervical esophagus was 19.6%. In 84% of the LPR patients (43/51), the percent time pH ≥ 7 were below the threshold of 19.6%. In contrast, 69% (35/51) had an abnormal test when the pH records were analyzed using the percent time pH < 4. Of the 16 patients with a false negative test using pH < 4, 11 (69%) were identified as having an abnormal study when the threshold of pH ≥ 7 was used.ConclusionNormal subjects should have a pH ≥7 in cervical esophagus for at least 19.6% of the monitored period. Failure to maintain this alkaline environment is a more sensitive indicator in the diagnosis of the LPR and identifies two thirds of the patients with a false negative test using pH <4.

The Impact of Delayed Gastric Emptying on Outcome of Nissen Fundoplication in GERD Patients

Introduction: Initial outcomes suggest Laparo-Endoscopic Single Site (LESS) Heller myotomy with anterior fundoplication provides safe, efficacious, and cosmetically superior outcomes relative to conventional laparoscopy. This study was undertaken to define the learning curve of LESS Heller myotomy with anterior fundoplication. Methods: 100 patients underwent LESS Heller myotomy with anterior fundoplication. Symptom frequency and severity were scored utilizing a Likert scale (0=never/not bothersome to 10=always/very bothersome). Symptom resolution, additional trocar placements, and complications were compared among patient quartiles. Median data are presented. Results: Preoperative frequency/severity scores were: dysphagia=10/8, regurgitation=8/6, heartburn=2/2. Additional trocars were placed in 11 patients (11%), of whom 81% were in the first two quartiles; placement of additional trocars decreased in successive quartiles (p<0.05). Esophagotomy/gastrotomy occurred in 3 patients. Postoperative complications occurred in 9%, none specific to Heller myotomy (Table). No conversions to open operations occurred. Length of stay was 1 day. Postoperative frequency/severity scores were: dysphagia=2/0, regurgitation=0/0, heartburn=0/0; scores were similar and less than before myotomy across all quartiles, p<0.001(Figure). There were no apparent scars, except where an additional trocar was placed. Conclusions: LESS Heller myotomy with anterior fundoplication well palliates symptoms of achalasia with no apparent scar, without inducing reflux. Placement of additional trocars primarily occurred early in the experience. For surgeons proficient with the conventional laparoscopic approach, the learning curve of LESS Heller myotomy with anterior fundoplication is short and safe, as proficiency is quickly attained. 25Patient Quartiles

982 Spontaneous Reflux During Videoesophagram: Its Clinical Significance and Correlation With pH Monitoring

We present the case of a 71-year-old female with a five month history of dysphagia, weight loss and heartburn. Preoperative investigation with barium swallow and upper endoscopy demonstrated a large lower esophageal pulsion divertictulum. A laparoscopic transhiatal resection of the esophageal diverticulum was performed with Heller myotomy and crural repair. Intraoperative endoscopy helps to identify the diverticulum in the mediastinum, to ensure complete resection of the diverticulum, to ensure an adequate esophageal myotomy, and to perform an air leak test. A Heller myotomy is performed to treat the esophageal dysmotility. A fundoplication is not performed due to poor esophageal motility.