Joshua A. Boys

Can ultrasound common bile duct diameter predict common bile duct stones in the setting of acute cholecystitis

BACKGROUND Our aim is assessment of ultrasound (US) common bile duct (CBD) diameter to predict the presence of CBD stones in acute cholecystitis (AC). METHODS A retrospective review from 2007 to 2011 with codes for ultrasound, magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography, and AC was conducted. RESULTS The incidence of CBD stones was 1.8%. Two hundred forty eight individuals had US+MRCP+ERCP+AC, of which 48 had CBD stones and 200 did not have CBD stones. US CBD diameter range was 3.6 to 19 mm. Ninety percent of MRCPs were negative, and it delayed care by 2.9 days. Mean CBD diameter was narrower in those negative for CBD stones (5.8 vs 7.08; P = .0043). Groups based on diameter ranges <6, 6 to 9.9, and ≥10 mm demonstrated 14%, 14%, and 39% CBD stones, respectively. CONCLUSIONS US CBD diameter is not sufficient to identify patients at significant risk for CBD stones. MRCP delayed care by 2.9 days. Intraoperative cholangiography may be more effective, based on the low risk of CBD stones in AC.

Peroral Endoscopic Myotomy for Achalasia in a Thoracic Surgical Practice

BACKGROUND Peroral endoscopic myotomy (POEM) is a new option in the treatment of achalasia. It has typically been performed by general surgeons and gastroenterologists familiar with advanced endoscopic procedures. Our objective was to assess the initial experience and outcomes with POEM by a thoracic surgeon. METHODS A retrospective chart review was performed of all patients who underwent POEM from October 2012 until December 2014. Pre- and post-POEM evaluation included upper endoscopy, high-resolution manometry, and a timed barium swallow. RESULTS There were 35 patients (18 men and 17 women), with a median age of 53 years. Based on high-resolution manometry, there were 8 patients (23%) with type I, 21 (60%) with type II, and 5 (14%) with type III achalasia, and 1 patient had hypertensive lower esophageal sphincter. Prior therapy had been performed in 18 patients (51%). The POEM procedure was completed in all but 1 patient. On follow-up, dysphagia was improved in all patients. The Eckardt score was significantly reduced from 7 before POEM to 0 after POEM (p < 0.0001), and improved similarly for all manometric types of achalasia. Post-POEM upper endoscopy showed esophagitis in 55% of patients, but this condition resolved in all with acid suppression. Timed barium swallow showed a reduction of esophageal retention at 5 minutes from 63% before POEM to 5% after POEM. Ten patients had follow-up at 12 months or greater after POEM and the improvements persisted. CONCLUSIONS Peroral endoscopic myotomy is a safe and effective therapy for achalasia. It provides reliable and persistent palliation of dysphagia and objective improvement in esophageal emptying. Esophagitis is common but resolves with acid suppression therapy. Thoracic surgeons with an interest in esophageal diseases and experience with endoscopy are encouraged to adopt the procedure.

Strongyloidiasis Hyperinfection in a Patient with a History of Systemic Lupus Erythematosus

Strongyloidiasis is a parasitic disease caused by Strongyloides stercoralis, a nematode predominately endemic to tropical and subtropical regions, such as Southeast Asia. Autoinfection enables the organism to infect the host for extended periods. Symptoms, when present, are non-specific and may initially lead to misdiagnosis, particularly if the patient has additional co-morbid conditions. Immunosuppressive states place patients at risk for the Strongyloides hyperinfection syndrome (SHS), whereby the organism rapidly proliferates and disseminates within the host. Left untreated, SHS is commonly fatal. Unfortunately, the non-specific presentation of strongyloidiasis and the hyperinfection syndrome may lead to delays in diagnosis and treatment. We describe an unusual case of SHS in a 30-year-old man with a long-standing history of systemic lupus erythematosus who underwent a partial colectomy. The diagnosis was rendered on identification of numerous organisms during histologic examination of the colectomy specimen.

Collis Gastroplasty for a Foreshortened Esophagus

Abstract Over 50 years after Dr. John Leigh Collis described his procedure for lengthening the esophagus there is still controversy about the existence and prevalence of a foreshortened esophagus. Further, the laparoscopic management of a short esophagus is challenging, and as a result there is a tendency by many surgeons to ignore esophageal length and proceed with a standard repair. Importantly, tension is the enemy of any hernia repair, and long-term successful outcomes with hiatal hernia repairs, as for all other abdominal hernias, require addressing tension when encountered. This chapter will address the role for, techniques to perform, and outcomes with a Collis gastroplasty for the foreshortened esophagus.

A History of Thoracic Aortic Surgery

Ancient historical texts describe the presence of aortic pathology conditions, although the surgical treatment of thoracic aortic disease remained insurmountable until the 19th century. Surgical treatment of thoracic aortic disease then progressed along with advances in surgical technique, conduit production, cardiopulmonary bypass, and endovascular technology. Despite radical advances in aortic surgery, principles established by surgical pioneers of the 19th century hold firm to this day.

Identification and Management of a “Short Esophagus” and a Complex Hiatus

Normally, several centimeters of the distal esophagus and the gastroesophageal junction (GEJ) lie below the hiatus within the abdomen. When the GEJ, the fundus of the stomach, or both migrate into the chest above the hiatus, a hiatal hernia is present. Intrinsic to the repair of a hiatal hernia is the need to bring the GEJ, stomach, and distal esophagus back into the abdomen. In some patients, the esophagus has shortened related to chronic reflux injury or a large hiatal hernia, and in these patients, a Collis gastroplasty can be useful to reduce tension on the repair and hopefully prevent a recurrent hernia. The original Collis gastroplasty was a transthoracic procedure, but techniques have been developed to allow a Collis gastroplasty to be done as part of a laparoscopic operation with good outcomes.

Tu1773 Quality of Life and Alimentary Satisfaction After Gastrectomy Versus Esophagectomy

Introduction: Tumors at the gastroesophageal junction can be treated by gastrectomy or esophagectomy. Oncologic outcomes are reported to be similar, therefore the aim of this study was to evaluate quality of life (QOL) and alimentary satisfaction after gastrectomy versus esophagectomy. Methods: A retrospective chart review was performed of patients that had gastrectomy with Roux-en-Y esophagojejunostomy or esophagectomy with gastric pull-up from 2000-2014. Symptoms, alimentary satisfaction and QOL were assessed by telephone interview and questionnaires (RAND 36-item Short Form Health Survey [SF-36], Gastrointestinal Quality of Life Index [GIQLI], and the Alimentary Satisfaction [AS] Score). In each questionnaire higher scores denote better satisfaction. Follow-up was divided into early (≤ 2years), medium (>2-5 years) and long (>5 years). Patients that could not be contacted or who refused to participate were excluded. Results: There were 20 patients in each group (table). There were no significant differences between groups for age, gender, initial BMI, or BMI at follow-up. All but 3 patients lost weight after gastrectomy and all lost weight after esophagectomy. The median weight loss after gastrectomy was 14 and after esophagectomy was 11.6 pounds. The mean number of meals a day (3) was similar between groups. There were no significant differences in symptoms but more patients used proton pump inhibitors after esophagectomy. Overall, QOL by SF-36 was similar between groups in all but the category role limitation due to physical health which was higher after esophagectomy. However, at early follow-up QOL was better after esophagectomy (Figure). There was no significant difference in the overall scores for GIQLI (97 after gastrectomy versus 101 after esophagectomy, p=0.685) and AS (7.5 in each group, p=0.926), but GIQLI scores were significantly higher at early follow-up after esophagectomy (78.7 for gastrectomy versus 105.6 for esophagectomy, p=0.014). The SF-36 scores were similar between males and females after gastrectomy, but after esophagectomy scores in the categories for general health and physical function were significantly better in females (71.7 and 88.3 for females respectively versus 48.9 and 63.2 for males, p=0.043 and p=0.008). Comparing GIQOL and AS scores by gender, females tended to have higher scores for both questionnaires after a gastrectomy (100 and 8 for females respectively versus 95.4 and 7.2 for males) and an esophagectomy (116 and 9.1 for females versus 94 and 6.8 for males). Conclusions: Overall QOL and alimentary satisfaction were similar after gastrectomy and esophagectomy, but in the first two years the scores for both SF-36 and the GIQLI questionnaires were better after an esophagectomy. Satisfaction was similar by gender, but females tended to score higher than males after both procedures. Demographic and clinical data.