Francesco Palazzo

Clinical, Radiological, and Manometric Profile in 145 Patients with Untreated Achalasia

BackgroundEsophageal achalasia is characterized by the absence of esophageal peristalsis and by a dysfunctional lower esophageal sphincter (LES). Descriptions of clinical, radiological, and manometric findings in patients with achalasia usually have been based on small numbers of patients. This study was designed to determine in patients with untreated achalasia: (1) clinical presentation; (2) how often a diagnosis of gastroesophageal reflux disease (GERD) was erroneously made based on the presence of heartburn; (3) manometric profile; (4) relationship between chest pain and the manometric finding of vigorous achalasia.MethodsBetween 1990 and 2004, a diagnosis of esophageal achalasia was established in 145 patients. None of them had been previously treated (no previous endoscopic or surgical treatment). We evaluated the demographic and clinical characteristics, as well as the results of the endoscopy, barium swallow, esophageal manometry, and ambulatory pH monitoring. We also compared the clinical and the manometric profile of patients with classic and patients with vigorous achalasia.ResultsMost patients with untreated achalasia had dysphagia (94%). Regurgitation was present in 76% and heartburn in 52%. Chest pain (41%) and weight loss (35%) were less common. Acid-suppressing medications had been prescribed to 65 patients (45%) who complained of heartburn on the assumption that GERD was present. The LES was hypertensive in 43% of patients only. There was no significant difference in the prevalence, severity, and duration of chest pain in patients with classic and with vigorous achalasia.ConclusionsThese results show that in patients with untreated achalasia: (1) dysphagia was the most frequent complaint, but regurgitation and heartburn were frequently present; (2) a diagnosis of GERD based on the presence of heartburn was highly unreliable; (3) the LES was hypertensive in less than half of patients; and (4) the prevalence, severity, and duration of chest pain did not correlate with the manometric finding of vigorous achalasia.

Gastroesophageal Reflux Disease and Connective Tissue Disorders: Pathophysiology and Implications for Treatment

IntroductionIt has been postulated that in patients with connective tissue disorders (CTD) and gastroesophageal reflux disease (GERD), esophageal function is generally deteriorated, often with complete absence of peristalsis. This belief has led to the common recommendation of avoiding antireflux surgery for fear of creating or worsening dysphagia.MethodsWe hypothesized that in most patients with CTD and GERD: (a) esophageal function is often preserved; (b) peristalsis is more frequently absent when end-stage lung disease (ESLD) is also present; (c) a tailored surgical approach (partial or total fundoplication) based on the findings of esophageal manometry allows control of reflux symptoms without a high incidence of postoperative dysphagia. Forty-eight patients with CTD were evaluated by esophageal manometry and 24-hour pH monitoring (EFT). Twenty patients (group A) had EFT because of foregut symptoms, and 28 patients with ESLD (group B) had EFT as part of the lung transplant evaluation. Two hundred and eighty-six consecutive patients with GERD by pH monitoring served as a control group (group C). A laparoscopic fundoplication was performed in two group A patients (total), eight group B patients (three patients total, five patients partial) and in all group C patients (total).ResultsEsophageal peristalsis was preserved in all patients with CTD and GERD. In contrast, peristalsis was absent in about half of patients when ESLD was also present. A tailored surgical approach resulted in control of reflux symptoms in all patients. One patient only developed postoperative dysphagia, which resolved with two Savary dilatations.ConclusionThese data show that esophageal motor function is preserved in most patients with CTD, so that they should be offered antireflux surgery early in the course of their disease to prevent esophageal and respiratory complications. In patients with ESLD in whom peristalsis is absent, a partial rather than a total fundoplication should be performed, as it allows control of reflux symptoms while avoiding postoperative dysphagia.

Minimally Invasive Esophagectomy Provides Significant Survival Advantage Compared with Open or Hybrid Esophagectomy for Patients with Cancers of the Esophagus and Gastroesophageal Junction

BACKGROUND Minimally invasive esophagectomy (MIE) is increasingly being used to treat patients with cancer of the esophagus and gastroesophageal junction. We previously reported that oncologic efficacy may be improved with MIE compared with open or hybrid esophagectomy (OHE). We compared survival of patients undergoing MIE and OHE. STUDY DESIGN Our contemporary series of patients who underwent MIE (2008 to 2013) was compared with a cohort undergoing OHE (3-hole [n = 39], Ivor Lewis [n = 16], hybrid [n = 13], 2000 to 2013). Summary statistics were calculated by operation type; Kaplan-Meier methods were used to compare survival. Cox regression was used to assess the impact of operation type (MIE vs OHE) on mortality, adjusting for age, sex, total lymph nodes, lymph node ratio (LNR), neoadjuvant chemoradiotherapy (CRT), and stage. RESULTS The MIE (n = 104) and OHE (n = 68) groups were similar with respect to age and sex. The MIE group tended to have higher BMI, earlier stage disease, and was less likely to receive CRT. The MIE group experienced lower operative mortality (3.9% vs 8.8%, p = 0.35) and significantly fewer major complications. Five-year survival between groups was significantly different (MIE, 64%, OHE, 35%, p < 0.001). Multivariate analysis demonstrated that patients undergoing OHE had a significantly worse survival compared with MIE independent of age, LNR, CRT, and pathologic stage (hazard ratio 2.00, p = 0.019). CONCLUSIONS This study supports MIE for EC as a superior procedure with respect to overall survival, perioperative mortality, and severity of postoperative complications. Several biases may have affected these results: earlier stage in the MIE group and disparity in timing of the procedures. These results will need to be confirmed in future prospective studies with longer follow-up.

Defining Benchmarks for Transthoracic Esophagectomy: A Multicenter Analysis of Total Minimally Invasive Esophagectomy in Low Risk Patients

Objective: To define “best possible” outcomes in total minimally invasive transthoracic esophagectomy (ttMIE). Background: TtMIE, performed by experts in patients with low comorbidity, may serve as a benchmark procedure for esophagectomy. Patients and Methods: From a cohort of 1057 ttMIE, performed over a 5-year period in 13 high-volume centers for esophageal surgery, we selected a study group of 334 patients (31.6%) that fulfilled criteria of low comorbidity (American Society of Anesthesiologists score ⩽2, WHO/ECOG score ⩽1, age ⩽65 years, body mass index 19–29 kg/m2). Endpoints included postoperative morbidity measured by the Clavien-Dindo classification and the comprehensive complication index. Benchmark values were defined as the 75th percentile of the median outcome parameters of the participating centers to represent best achievable results. Results: Benchmark patients were predominantly male (82.9%) with a median age of 58 years (53–62). High intrathoracic (Ivor Lewis) and cervical esophagogastrostomy (McKeown) were performed in 188 (56.3%) and 146 (43.7%) patients, respectively. Median (IQR) ICU and hospital stay was 0 (0–2) and 12 (9–18) days, respectively. 56.0% of patients developed at least 1 complication, and 26.9% experienced major morbidity (≥grade III), mostly related to pulmonary complications (25.7%), anastomotic leakage (15.9%), and cardiac events (13.5%). Benchmark values at 30 days after hospital discharge were ⩽55.7% and ⩽30.8% for overall and major complications, ⩽18.0% for readmission, ⩽3.1% for positive resection margins, and ≥23 for lymph node yield. Benchmarks at 30 and 90 days were ⩽1.0% and ⩽4.6% for mortality, and ⩽40.8 and ⩽42.8 for the comprehensive complication index, respectively. Conclusion: This outcome analysis of patients with low comorbidity undergoing ttMIE may serve as a reference to evaluate surgical performance in major esophageal resection.

Minimally Invasive Esophagectomy with Extracorporeal Gastric Conduit Creation—How I Do It

Esophagectomy is associated with significant morbidity and mortality rates. In an attempt to improve these results, many groups have started applying minimally invasive techniques to esophagectomy for benign and malignant disease. A variety of minimally invasive approaches have been developed. At the Thomas Jefferson University, we have offered minimally invasive three-hole esophagectomy with extracorporeal gastric conduit creation since 2008. Herein we report our technique for the abdominal and cervical components of the procedure and briefly discuss the current literature and our short-term perioperative outcomes.

Surgical Apgar score (SAS) predicts perioperative morbidity, mortality, and length of stay in patients undergoing esophagectomy at a high‐volume center

Esophagectomy carries considerable morbidity. Many studies have evaluated factors to predict patients at risk. This study aimed to determine whether the surgical Apgar score (SAS) predicts complications and length of stay (LOS) for patients undergoing esophagectomy.

A Modern Approach to the Surgical Treatment of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common disorder that can cause a variety of typical and atypical symptoms. Although most patients can be rendered asymptomatic with medical treatment, some experience persistent breakthrough symptoms. A long history of GERD is associated with the risk for the development of Barretts esophagus and ultimately esophageal carcinoma. Although often underutilized, minimally invasive antireflux surgery can help manage these patients. However, thorough evaluation and accurate diagnosis of GERD and its underlying pathophysiology are critical in ensuring successful surgical treatment. This review offers a stepwise approach to the diagnostic workup of GERD and how to appropriately tailor available surgical treatments to specific patient subgroups.

Thoracoscopic treatment of barium-induced lung entrapment complicating esophageal perforation.

Patients with suspected esophageal perforations are routinely evaluated with a swallow study using a water-soluble contrast medium followed by thin-barium administration when the first fails to demonstrate a leak. Intrapleural barium instillation has been historically correlated with mild degree of pleural inflammation and a low-grade talclike reactive process. Still, if administered in excessive quantities, it may contribute to complicate the clinical scenario of pleural contamination secondary to the perforated esophagus. We report the case of a patient that presented with a malignant esophageal perforation and developed a trapped lung from extensive pleural contamination with barium sulfate that required video-assisted thoracic drainage and decortication with successful reexpansion of the lung and resolution of the acute symptoms.

Diagnostic and treatment modalities for autoimmune pancreatitis

Since the recognition of autoimmune pancreatitis (AIP) as a clinical entity, many advances have been made in defining clinical, radiologic, histologie, and laboratory parameters to assist in a complete definition of the disease. Despite all these efforts, a preoperative diagnosis still remains a clinical challenge but is of paramount importance, as these cases have been reported to be steroid-responsive; therefore, early treatment may obviate the need for surgical resection. Although the utilization of recently proposed guidelines by the Japanese Pancreas Society and an Italian study group may further assist the clinician and prompt the initiation of steroid treatment, the response to therapy should be observed within 2 to 4 weeks and reflected in progressive resolution of the presenting radiologic and laboratory abnormalities. Should these fail to demonstrate improvement, the diagnosis of AIP should undergo re-evaluation, and consideration for surgical exploration should be made, as the patient may be harboring a malignancy. Surgical resection in the form of pylorus-preserving pancreaticoduodenectomy remains the optimal solution in the attempt to clarify the diagnosis and offer treatment with low complication rates.

Effects of stimulating surface during static upright posture in the elderly

Abstract This study aimed to investigate the influence of three stimulating surfaces based on center of pressure (CoP), anteroposterior sway velocity (VA/P), and medio-lateral sway velocity (VM/L) of 40 elderly subjects. CoP and VM/L showed a significant decrease in all visual conditions only in the stimulating surface whereas VA/P showed a significant decrease only on the same surface with eyes open. Results confirm the importance of multisensory stimulation in postural control in the elderly.