Lisa Zanatta

Four hundred laparoscopic myotomies for esophageal achalasia: a single centre experience.

Objective:Laparoscopic myotomy is the currently preferred treatment for achalasia. Our objectives were to assess the long-term outcome of this operation and preoperative factors influencing said outcome. Methods:Demographic and clinical characteristics and data on long-term outcome were prospectively collected on patients undergoing laparoscopic myotomy for achalasia at our institution from 1992 to 2007. Treatment failure was defined as a postoperative symptom score higher than the 10th percentile of the preoperative score (>9). Logistic regression analysis was used to identify independent preoperative factors associated with successful myotomy. Results:Four hundred seven consecutive patients (220 men, 187 women) underwent the laparoscopic Heller-Dor procedure during the study period; 89 (22%) of them had previously had endoscopic treatment(s). The mortality rate was 0; the conversion and morbidity rates were 1.5% and 1.9%, respectively. The operation failed in 10% of patients (39/407) and the 5-year actuarial probability of being asymptomatic was 87%. Most failures (25/39, 64%) occurred within 12 months of the operation and can be considered as technical failures (incomplete myotomy). Pneumatic dilation overcome the dysphagia in 75% of patients whose surgery was unsuccessful. Considering both the primary surgery and this ancillary treatment, the operation was effective in 97% of achalasia patients. The frequency of sigmoid esophagus, lower esophageal sphincter (LES) resting pressures, and chest pain scores differed statistically between patients with and without recurrences. At multivariate analysis, high preoperative LES pressures (>30 mm Hg) was an independent predictor of a good response. The presence of chest pain and of sigmoid esophagus independently predicted the failure of the procedure. Conclusion:Laparoscopic myotomy can durably relieve dysphagia symptoms. High preoperative LES pressures represent the strongest predictor of a positive outcome, probably reflecting a less severely damaged esophageal muscle.

Barrett's esophagus and adenocarcinoma risk: the experience of the North-Eastern Italian Registry (EBRA).

Objective:To establish the incidence and risk factors for progression to high-grade intraepithelial neoplasia (HG-IEN) or Barretts esophageal adenocarcinoma (BAc) in a prospective cohort of patients with esophageal intestinal metaplasia [(BE)]. Background:BE is associated with an increased risk of BAc unless cases are detected early by surveillance. No consistent data are available on the prevalence of BE-related cancer, the ideal surveillance schedule, or the risk factors for cancer. Methods:In 2003, a regional registry of BE patients was created in north-east Italy, establishing the related diagnostic criteria (endoscopic landmarks, biopsy protocol, histological classification) and timing of follow-up (tailored to histology) and recording patient outcomes. Thirteen centers were involved and audited yearly. The probability of progression to HG-IEN/BAc was calculated using the Kaplan-Meier method; the Cox regression model was used to calculate the risk of progression. Results:HG-IEN (10 cases) and EAc (7 cases) detected at the index endoscopy or in the first year of follow-up were considered to be cases of preexisting disease and excluded; 841 patients with at least 2 endoscopies {median, 3 [interquartile range (IQR): 2–4); median follow-up = 44.6 [IQR: 24.7–60.5] months; total 3083 patient-years} formed the study group [male/female = 646/195; median age, 60 (IQR: 51–68) years]. Twenty-two patients progressed to HG-IEN or BAc (incidence: 0.72 per 100 patient-years) after a median of 40.2 (26.9–50.4) months. At multivariate analysis, endoscopic abnormalities, that is, ulceration or nodularity (P = 0.0002; relative risk [RR] = 7.6; 95% confidence interval, 2.63–21.9), LG-IEN (P = 0.02, RR = 3.7; 95% confidence interval, 1.22–11.43), and BE length (P = 0.01; RR = 1.16; 95% confidence interval, 1.03–1.30) were associated with BE progression. Among the LG-IEN patients, the incidence of HG-IEN/EAc was 3.17 patient-years, that is, 6 times higher than in BE patients without LG-IEN. Conclusions:These results suggest that in the absence of intraepithelial neoplastic changes, BE carries a low risk of progression to HG-IEN/BAc, and strict surveillance (or ablative therapy) is advisable in cases with endoscopic abnormalities, LG-IEN or long BE segments.

Long-Term Follow-up of Barrett’s Epithelium: Medical Versus Antireflux Surgical Therapy

BackgroundBarrett’s esophagus (BE) is the most serious complication of GERD. In BE patients, this observational study compares the effects of antireflux surgery versus antisecretory medical therapy.MethodsOverall, 89 BE patients (long BE = 45; short BE = 44) were considered: 45 patients underwent antireflux surgery and 44 underwent medical therapy. At both initial and follow-up endoscopy, symptoms were assessed using a detailed questionnaire; BE phenotypic changes [intestinal metaplasia (IM) presence/type, Cdx2 expression] were assessed by histology (H&E), histochemistry (HID), and immunohistochemistry. Surgical failures were defined as follows: (1) abnormal 24-h pH monitoring results after surgery, (2) endoscopically evident recurrent esophagitis, and (3) recurrent hiatal hernia or slipped fundoplication on endoscopy or barium swallow.ResultsReversion of IM was observed in 12/44 SSBE and 0/45 LSBE patients (p < 0.01). Reversion was more frequently observed after effective antireflux surgery than after medical treatment (p = 0.04). In patients with no further evidence of IM after therapy, Cdx2 expression was also absent (p = 0.02). The extent of IM was reduced, and the IM phenotype improved in SSBE patients after surgery.ConclusionsPatients with short BE (but not those with long BE) may benefit from surgically reducing the esophagus’ exposure to GE reflux; among these patients, successful surgery carries a higher IM reversion rate than medical treatment.

Therapeutic Strategies for Epiphrenic Diverticula: Systematic Review

Most patients with epiphrenic diverticula are asymptomatic. When dysphagia or regurgitation is limited and respiratory complaints are absent, these patients usually can live with the diverticulum left in place. Fewer than one-third of the diverticula produce symptoms severe enough to seek medical attention or to warrant surgery. The purpose of this systematic review was to analyze the therapeutic strategies for epiphrenic diverticula—from a nonsurgical alternative such as endoscopic dilatation for symptomatic patients unfit for surgery, to the traditional approach of surgical resection (left thoracotomy), and finally to the minimally invasive techniques (thoracoscopy, laparoscopy) used more recently. Whatever treatment and approach are used for the patient with epiphrenic diverticula, a tailored protocol always involves detailed study of the esophageal morphology and function.

Flexible endoscopic treatment for Zenker's diverticulum with the SB Knife. Preliminary results from a single-center experience

Flexible endoscopic septum division is becoming a prominent treatment option for Zenkers diverticulum (ZD). Over the years, various techniques have been developed and many cutting tools have been tested with varying results. We report our experience with a recently designed, monopolar, rotating, scissor‐shaped device (SB Knife).

Clinical, endoscopic, histological and radiological characteristics of Italian patients with eosinophilic oesophagitis

BACKGROUND Limited data are available on eosinophilic oesophagitis in Italy. AIM To evaluate typical features of eosinophilic oesophagitis patients in a tertiary centre. METHODS 973 consecutive patients with dysphagia and/or bolus impaction were prospectively enrolled and underwent upper endoscopy for eosinophilic oesophagitis (≥15 eosinophils in at least one high-power field [hpf] and no response to acid suppressants). Demographic and multiple clinical factors were collected. RESULTS 45 patients (80% males, mean age 35±16) with incident eosinophilic oesophagitis (mean eosinophil peak count 57.2±40.6/hpf) were enrolled. 32 patients complained of solids dysphagia (71%), and 29 of bolus impaction (64%). Endoscopy found rings in 20 (44%), furrows in 9 (20%), whitish exudates/plaques in 12 (27%), crêpe paper in 7 (13%) and normal findings in 14 patients (31%). Endoscopic and radiologic stenosis occurred in 20 (44%) and 23 (51%), respectively. Ten patients had proton pump inhibitor-oesophageal eosinophilia (22%). Topic fluticasone was effective in 28 of the remaining cases (62%), while 7 required additional treatments (16%). CONCLUSION Eosinophilic oesophagitis prevalence was 12% in patients with dysphagia and/or bolus impaction, emphasizing the importance of this disease in Italy. Despite different environmental factors and dietary habits, Italian patients with eosinophilic oesophagitis present similar characteristics to those of other Western counties.

Autism and esophageal achalasia in childhood: a possible correlation? Report on three cases.

Chronic gastrointestinal symptoms are commonly reported in autistic patients. Dysphagia is often present, and it is generally related to behavioral eating disorders. The association between autism and esophageal achalasia has not been described in literature yet. We report our experience with three cases of autistic children we recently treated for esophageal achalasia. In the first case (a 14-year-old male), achalasia was diagnosed with barium swallow and esophageal manometry and was successfully treated with three pneumatic endoscopic dilatations (follow-up: 3 years). In the second case (a 12-year-old female), achalasia was diagnosed with barium swallow and esophageal manometry and was treated with Heller myotomy after two unsuccessful pneumatic endoscopic attempts (follow-up: 3 months). In the last case, a 15-year-old male underwent barium swallow and endoscopy that confirmed achalasia. He was treated with Heller myotomy, and he is asymptomatic at a 6-month follow-up. To our knowledge, this is the first report of a possible association between autism and esophageal achalasia. Because of the rarity of both diseases, their association in the same patient is unlikely to be casual even if speculation on their common etiology is impossible at present. This finding needs further confirmation, but it is sufficient, in our opinion, to indicate proper evaluation with barium swallow and/or manometry in any autistic children with eating difficulty.

P.1.24: SCCA-IGM AND CEA-IGM IN BARRETT'S ESOPHAGUS AND ESOPHAGEAL CANCERS

Conclusions: The present study confirms our previous results, regarding the reduction of epithelial proliferation activity of ERD respect to NERD patients. Moreover, our study reinforces the idea that individuals who develop ERD could be genetically characterised by a weaker proliferating epithelial cell capability. On the other hand, patients with more efficient epithelial proliferation capability could have a lower probability of developing macroscopic mucosal lesions when stressed by acid and pepsin.

819 Is Laparoscopic Heller Myotomy Still Indicated in Stage IV Sigmoid Megaesophagus

S A T A b st ra ct s LARS is an effective and durable treatment option for GERD. Success or failure cannot be defined in a single domain. A comprehensive analysis of outcomes requires categorization that includes symptom response, side-effects, patients perception and objective measurement of acid exposure, mucosal integrity, and the need for additional medical or surgical treatment. Only then can patients and physicians better understand the role of LARS and make informed decisions.

M1530 Accidental Mucosal Perforation During Laparoscopic Heller-Dor Myotomy Does Not Affect the Final Outcome of the Operation

as ropeway technique, because the nerves can be seen as ropeways after the completion of the dissection. Another one is new HALS method, named as double gloving method for HALS. With this method, thorough lymph node dissection of the lower mediastinum can be securely performed. RESULTS: Between April 2004 and October 2007, we had performed this procedure for 76 cases of esophageal cancer patient. After introduction of this method, the operation time has become shorter and the complication rate, especially hoarseness has decreased. CONCLUSIONS: These new two techniques, ropeway technique and double gloving method of HALS are feasible for endoscopic esophagectomy with the three-field lymph node dissection and also contribute to safer procedures.