Kevin M. Reavis

Wait only to resuscitate: early surgery for acutely presenting paraesophageal hernias yields better outcomes

IntroductionIncarceration and obstruction of an intrathoracic stomach are potentially devastating complications of paraesophageal hernias (PEH). Gastric decompression and resuscitation are important elements of preoperative management of acutely presenting PEH. The optimal time for surgical repair after decompression is unknown. We hypothesized that in obstructed PEH, early surgery may improve outcomes.MethodsFrom the 2005–2010 National Surgical Quality Improvement Project database, we selected PEH repairs with a diagnosis of obstruction. Patients were divided by time to surgery: ≤1xa0day of admission (early) or >1xa0day (interval). Outcomes were mortality and morbidity. Multivariable regression controlled for age and cardiopulmonary comorbidities.ResultsOf 224 patients, 149 (67xa0%) were early and 75 (33xa0%) were interval, with mean 3.6xa0days. Repairs were 89xa0% transabdominal, 9xa0% included fundoplication, and 18xa0% gastrostomy. Early and interval groups experienced similar morbidity 23 versus 31xa0% (pxa0=xa00.2) and mortality 5.4 versus 4xa0% (pxa0=xa00.7). Pulmonary, wound, or VTE complications were equivalent. Sepsis was less (2.7 vs. 13xa0%, pxa0=xa00.002) and length of stay was shorter (5 vs. 11xa0days, pxa0<xa00.001) for early vs. interval patients. On adjusted analysis, the early group had an 80xa0% reduction in sepsis (95xa0% confidence interval (CI), 0.05–0.6, pxa0=xa00.005). Odds of overall or other morbidity or mortality were statistically similar between groups.ConclusionsPatients who required emergency surgery for PEH have disease complicated by strangulation, perforation, bleeding, or sepsis. Emergency surgery for PEH repair is inherently high-risk and preoperative resuscitation and decompression is critical. In our analysis, patients with an obstructed PEH had less postoperative sepsis and fewer days in the hospital if surgery was performed within the first hospital day. However, there was no difference in mortality between early and delayed treatment. Deferring surgery for resuscitation permits optimization, but prolonged delay may worsen patient outcomes.

Endoscopic suturing versus endoscopic clip closure of the mucosotomy during a per-oral endoscopic myotomy (POEM): a case-control study.

AbstractIntroductionnObtaining an adequate mucosal closure is one of the crucial steps in per-oral endoscopic myotomy (POEM). Thus far, there have been no objective data comparing the various available closure techniques. This case-controlled study attempts to compare the application of endoscopic clips versus endoscopic suturing for mucosotomy closure during POEM cases.MethodsA retrospective review of our prospective POEM database was performed. All cases in which endoscopic suturing was used to close the mucosotomy were matched to cases in which standard endoclips were used. Overall complication rate, closure time and mucosal closure costs between the two groups were compared.ResultsBoth techniques offer good clinical results with good mucosal closure and the absence of postoperative leak. Closure time was significantly shorter (pxa0=xa00.044) with endoscopic clips (16xa0±xa012xa0min) when compared to endoscopic suturing (33xa0±xa011xa0min). Overall, the total closure cost analysis showed a trend toward lower cost with clips (1502xa0±xa0849 USD) versus endoscopic suturing (2521xa0±xa0575 USD) without reaching statistical significance (pxa0=xa00.073).ConclusionThe use of endoscopic suturing seems to be a safe method for mucosal closure in POEM cases. Closure time is longer with suturing than conventional closure with clips, and there is a trend toward higher overall cost. Endoscopic suturing is likely most cost-effective for difficult cases where conventional closure methods fail.

Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders

BackgroundPeroral endoscopic myotomy (POEM) is a novel operation for the treatment of achalasia and other esophageal motility disorders. While POEM has shown excellent short-term safety and efficacy, the long-term symptomatic outcomes after the procedure are unknown.MethodsPatients from a single center that underwent POEM for treatment of esophageal motility orders and were greater than 5 years removed from their operation were studied. Patients were contacted to assess current symptoms and encouraged to undergo repeat endoscopyxa0for objective follow-up.ResultsThirty-six patients underwent POEM from October, 2010 to February, 2012 and current symptom scores were obtained from 29 patients at median 65-month follow-up. In the 23 patients with achalasia, Eckardt scores were significantly improved from preoperative baseline (mean current 1.7 vs. preoperative 6.4, pxa0<xa00.001). Nineteen patients (83%) with achalasia had a symptomatic success (Eckardt ≤3) and none required retreatment for symptoms. Eckardt scores were dramatically improved at 6xa0months and maintained at 2xa0years; however, there was a small but significant worsening of symptoms between 2 and 5-years. Of the five patients with EGJ outflow obstruction, all had current Eckardt scores ≤3 but two needed reintervention for persistent or recurrent symptoms, one with a laparoscopic Heller myotomy and another with an endoscopic cricomyotomy and proximal esophageal myotomy extension. At 6-month follow-up, repeat manometry showed decreased EGJ relaxation pressures and esophagram demonstrated improved emptying. 24-h pH monitoring showed abnormal distal esophageal acid exposure in 38% of patients. Fifteen patients underwent endoscopy at 5-years, revealing erosive esophagitis in two (13%), new hiatal hernia in two, and new non-dysplastic Barrett’s esophagus in one. The patient with Barrett’s underwent a subsequent laparoscopic hiatal hernia repair and Toupet fundoplication.ConclusionsPOEM resulted in a successful palliation of symptoms in the majority of patients after 5xa0years, though these results emphasize the importance of long-term follow-up in all patients.

Covered stents in cervical anastomoses following esophagectomy

IntroductionAnastomotic complications after esophagectomy are relatively frequent. The off-label use of self-expanding covered metal stents has been shown to be an effective initial treatment for leaks, but there is a paucity of literature regarding their use in cervical esophagogastric anastomoses. We reviewed our outcomes with anastomotic stenting after esophagectomy with cervical esophagogastric reconstruction.MethodsAll stents placed across cervical anastomoses following esophagectomy from 2004 to 2014 were retrospectively reviewed. Indications for surgery and stent placement were collected. For patients with serial stents, each stent event was evaluated separately and as part of its series. Success was defined as resolution of indicated anastomotic problem for at least 90xa0days. Complications were defined as development of stent-related problems.ResultsTwenty-three patients had a total of 63 stents placed (16xa0% prophylactic, 38xa0% leak, 46xa0% stricture). Sixty percent of patients had successful resolution of their initial anastomotic problem; 67xa0% required more than one stent. Strictures and leaks healed in 27 and 70xa0% of patients, respectively, at a median of 55.5xa0days. Stent-related complications occurred in 78xa0% of patients. Complications (per stent event) included 62xa0% migration, 11xa0% clinically significant tissue overgrowth, 8xa0% minor erosion (ulcers), and 8xa0% major erosion. Stents placed for stricture were more likely to result in complications, especially migration (76.7 vs. 48.5xa0%, pxa0=xa00.02). Preoperative chemoradiation was a significant risk factor for erosion (22.5 vs. 4.3xa0%, pxa0=xa00.05), but not for overall complications. Patients with major erosions had longer stent duration compared to those without (92 vs. 36xa0days, pxa0=xa00.14).DiscussionAlthough stents are effective at controlling post-esophagectomy anastomotic leaks, they are not effective for treating strictures. Stents have high complication rates, but most are minor. Chemoradiation is a risk factor for stent erosion. Caution should be used when stent duration exceeds 2–3xa0months due to the risk of erosion.

Impedance-pH monitoring on medications does not reliably confirm the presence of gastroesophageal reflux disease in patients referred for antireflux surgery

IntroductionThe gold standard for the objective diagnosis of gastroesophageal reflux disease (GERD) is ambulatory-pH monitoring off medications. Increasingly, impedance-pH (MII-pH) monitoring on medications is being used to evaluate refractory symptoms. The aim of this study was to determine whether an MII-pH test on medications can reliably detect the presence of GERD.MethodsPatients referred for persistent reflux symptoms despite pH confirmed adequate acid suppression (DeMeester score ≤14.7) were reviewed retrospectively. All patients who originally had MII-pH testing on medications were re-evaluated with an off medication Bravo-pH study. Acid exposure results (defined by off medication Bravo) were compared to the original on medication MII-pH.ResultsThere were 49 patients who met study criteria (median age 51). Patients had normal acid exposure during their MII-pH test on medications (average DMS 4.35). Impedance was abnormal (normal ≤47) in 25 of the 49 patients (51%). On subsequent Bravo-pH off medications, 37 patients (75.7%) showed increased esophageal acid exposure (average DMS 36.4). Bravo-pH testing was abnormal in 84% of patients with abnormal MII testing and in 67% with normal MII testing. The sensitivity and specificity of an abnormal MII-pH on medications for increased esophageal acid exposure off medications was 56.8 and 66.7%, respectively. The positive predictive value of confirming GERD from an abnormal MII-pH on medications is 84%, while the negative predictive value is 33.3%. A receiver operating characteristic (ROC) curve was generated and the area under the curve was 0.71, indicating that MII-pH on medications is a fair test (0.7–0.8) in diagnosing pathologic GERD.ConclusionCompared to the gold standard, MII-pH on medications does not reliably confirm the presence of GERD. Excellent outcomes with antireflux surgery are dependent on the presence of GERD; thus, patients should not be offered antireflux surgery until GERD is confirmed with pH testing off medications.

Clinical Burden of Laparoscopic Feeding Jejunostomy Tubes

IntroductionFeeding jejunostomies (J tubes) provide enteral nutrition when oral and gastric routes are not options. Despite their prevalence, there is a paucity of literature regarding their efficacy and clinical burden.MethodsAll laparoscopic J tubes placed over a 5-year period were retrospectively reviewed. Clinical burden was measured by number of clinical contact events (tube-related clinic visits, phone calls, ED visits) and morbidity (dislodgement, clogging, tube fracture, infection, other). Tube replacements were also recorded.ResultsOne hundred fifty-one patients were included. Fifty-nine percent had associated malignancy, and 35xa0% were placed for nutritional prophylaxis. Mean time to J tube removal was 146xa0days. J tubes were expected to be temporary in >90xa0% but only 50xa0% had sufficient oral intake for removal. Tubes were removed prematurely due to patient intolerance in 8xa0%. Mortality was 0xa0%. Morbidity was 51xa0% and included clogging (12xa0%), tube fracture (16xa0%), dislodgement (25xa0%), infection (18xa0%) and “other” (leaking, erosion, etc.) in 17xa0%. The median number of adverse events per J tube was 2(0–8). Mean number of clinic phone calls was 2.5(0–22), ED visits 0.5(0–7), and clinic visits 1.4(0–13), with 82xa0% requiring more than one J tube-related clinic visit. Unplanned replacements occurred in 40xa0%.ConclusionWhile necessary for some patients, J tubes are associated with high clinical burden.

Submucosal Tumors of the Esophagus and Gastroesophageal Junction

Abstract Tumors originating in the submucosal space of the esophagus and proximal stomach comprise a heterogeneous group of benign neoplasms, half of which are asymptomatic. Removal is indicated when these tumors generate symptoms, including dysphagia or globus or they present with concerning manifestations, such as ulceration/hemorrhage, large size or increased growth during surveillance. Treatment includes medical, endoscopic, and surgical approaches with organ-sparing return to baseline function in many cases.

Endoscopic resection of giant fibrovascular esophageal polyps

BackgroundGiant fibrovascular esophageal polyps are rare benign intraluminal tumors that originate from the submucosa of the cervical esophagus [Owens et al. (JAMA 103: 838-842, 1994), Totten et al. (JAMA 25:606–622, 1953)]. Due to their indolent course, these tumors tend to reach enormous proportions before patients develop symptoms. Accurately diagnosing these tumors is difficult, as endoscopy may miss 25% of these lesions because these polyps exhibit normal intact esophageal mucosa [Levine et al. (JAMA 166: 781–787, 1996)].MethodsSurgical resection has been the treatment of choice. We present a video that illustrates the feasibility of an endoscopic approach.Technique/caseA 62-year-old man presented to our clinic with a pedunculated esophageal mass. During this time, he developed progressive dysphagia to solid foods. A complete workup confirmed the presence of a giant polyp and endoscopic resection under general anesthesia was planned. Using an endoscopic snare-technique, a 16xa0cmxa0×xa03xa0cm polyp was amputated and retracted out of the oropharynx. Upon repeat endoscopy a second 7xa0cmxa0×xa03xa0cm polyp was discovered originating proximal to the larger polyp. Again, removal of this polyp was attempted using a snare-technique. Following amputation of the polyp, a broad-based component of the polyp remained. Given its proximal location in the esophagus, we were able to use a snare to pull the broad base of the remaining polyp into the oropharynx and remove it at its origin. Postoperative endoscopy and endoscopic ultrasound confirmed that the polyps were completely removed and the muscular resection bed was hemostatic. Clinically, the patient’s symptoms resolved and he encountered no adverse sequela as a result of the operation.ConclusionGiant fibrovascular esophageal polyps are rare benign intraluminal tumors that can lead to obstructive symptoms. Surgical resection is the treatment of choice, and may be possible with an endoscopic approach. An endoscopic snare technique can be used to resect these lesions while minimizing patient morbidity.

Per-oral Endoscopic Pyloromyotomy

Given the initial enthusiasm for per-oral endoscopic myotomy (POEM), surgeons and endoscopists began to search for other applications for the technique. Gastroparesis is a motility disorder of the stomach which is often refractory to medical therapy. Other options for treatment include endoscopic options such as botox injection or transpyloric stenting, gastric electrical stimulation, and surgical therapy such as laparoscopic pyloroplasty. Recently, surgeons have begun to apply POEM inspired techniques to the pylorus in an attempt to perform a transluminal pyloromyotomy. Although early series are small and limited largely to case reports, the early data is encouraging for this nascent procedure.

Role of Endoscopy, Stenting, and Other Nonoperative Interventions in the Management of Bariatric Complications: A US Perspective

Bariatric surgery is becoming safer than ever; however complications still occur and it is not uncommon for non-bariatric general surgeons, emergency physicians, nurse practitioners, and primary care physicians to care for these patients. Historically, complications of bariatric surgery required operative therapy. However, the role of endoscopy is emerging as a more common approach to managing many of these complications nonoperatively including the evaluation of postsurgical anatomy for which decades-old records are not available as well as the acute management of leaks, hemorrhage, ulceration, stricture, erosion, and fistula formation. This chapter outlines how an advanced endoscopic skill set can greatly facilitate the diagnosis and treatment of endolumenally approachable complications following bariatric surgery.