Renato Salvador

Outcomes of Treatment for Achalasia Depend on Manometric Subtype

BACKGROUND & AIMS Patients with achalasia are treated with either pneumatic dilation (PD) or laparoscopic Heller myotomy (LHM), which have comparable rates of success. We evaluated whether manometric subtype was associated with response to treatment in a large population of patients treated with either PD or LHM (the European achalasia trial). METHODS Esophageal pretreatment manometry data were collected from 176 patients who participated in the European achalasia trial. Symptoms (weight loss, dysphagia, retrosternal pain, and regurgitation) were assessed using the Eckardt score; treatment was considered successful if the Eckardt score was 3 or less. Manometric tracings were classified according to the 3 Chicago subtypes. RESULTS Forty-four patients had achalasia type I (25%), 114 patients had achalasia type II (65%), and 18 patients had achalasia type III (10%). After a minimum follow-up period of 2 years, success rates were significantly higher among patients with type II achalasia (96%) than type I achalasia (81%; P < .01, log-rank test) or type III achalasia (66%; P < .001, log-rank test). The success rate of PD was significantly higher than that of LHM for patients with type II achalasia (100% vs 93%; P < .05), but LHM had a higher success rate than PD for patients with type III achalasia (86% vs 40%; P = .12, difference was not statistically significant because of the small number of patients). For type I achalasia, LHM and PD had similar rates of success (81% vs 85%; P = .84). CONCLUSIONS A higher percentage of patients with type II achalasia (based on manometric tracings) are treated successfully with PD or LHM than patients with types I and III achalasia. Success rates in type II are high for both treatment groups but significantly higher in the PD group. Patients with type III can probably best be treated by LHM. Trialregister.nl number NTR37; ISRCTN56304564.

Long-term outcome of laparoscopic Heller-Dor surgery for esophageal achalasia: possible detrimental role of previous endoscopic treatment.

Laparoscopic Heller myotomy has recently emerged as the treatment of choice for esophageal achalasia. Previous unsuccessful treatments (pneumatic dilations or botulinum toxin [BT] injections) can make surgery more difficult, causing a higher risk of mucosal perforation and jeopardizing the outcome. The study goal was to evaluate the effects of prior endoscopic treatments on laparoscopic Heller myotomy. Between January 1992 and February 2005, 248 patients (130 males and 118 females; median age, 43 years) underwent a laparoscopic Heller-Dor operation for achalasia: 203 underwent primary surgery (group A), 19 had been previously treated with pneumatic dilations (group B), and 26 had BT injections (alone [22] or with dilations [4] (group C). Median duration of the operation and rate of intraoperative mucosal lesions were not different in the three groups. Median follow-up was 41 months. The 5-year actuarial of control of dysphagia was similar in groups A (86%) and B (94%), whereas only 75% of group C patients were symptom free at 5 years (P 5 =.02). On logistic regression analysis, prior treatment with two BT injections or BT combined with dilation was associated with poor outcome of surgery. Further, dilations for surgical failure patients were effective in 80% of group A but in only 33% of group B or C patients. Heller-Dor surgery is safe and effective as a primary or a second-line treatment (after pneumatic dilations or BT injections) for achalasia. However, long-term results seem less satisfactory in patients previously treated with BT.

Minimally invasive enucleation of esophageal leiomyoma

BackgroundLeiomyoma accounts for 70% of all benign tumors of the esophagus. Open enucleation via thoracotomy has long been the standard procedure, but thoracoscopic and laparoscopic approaches have recently emerged as interesting alternatives. To date, only case reports or very small series of such techniques have been reported. The authors report their experience over the past decade.MethodsBetween January 1999 and August 2005, 11 patients (6 men and 5 women; median age, 44 years) underwent surgery after presenting with dysphagia, chest pain, or heartburn. The surgical approaches included right video-assisted thoracoscopy (n = 7) for tumors of the middle lower third of the esophagus and laparoscopy (n = 4) for tumors within 4 to 5 cm of the lower esophageal sphincter or located at the gastroesophageal junction (GEJ). Intraoperative endoscopy with air insufflation during enucleation was used to confirm mucosal integrity and safeguard against esophageal perforation. Reapproximation of the muscle layers was performed after tumor enucleation to prevent the development of a pseudodiverticulum. A Nissen or Toupet fundoplication was added for patients undergoing laparoscopic enucleation of the leiomyoma.ResultsThe median operative time was 150 min. All tumors were benign leiomyomas (median size, 4.5 cm). One leiomyoma located at the gastroesophageal junction required intraoperative mucosal repair with three stitches for an esophageal perforation (preoperative biopsies had been taken). There were no major morbidities, including deaths or postoperative leaks. The median postoperative hospital stay was 6 days. All the patients were free of dysphagia during a median follow-up period of 27 months. One patient had a small (<2 cm) asymptomatic pseudodiverticulum at the 6-month follow-up endoscopy.ConclusionsVideo-assisted enucleation of esophageal leiomyoma can be performed effectively and safely with no mortality and low morbidity. Thoracoscopic and laparoscopic techniques for the removal of esophageal leiomyomas may be recommended as the treatment of choice in centers experienced with minimally invasive surgery.

Esophagogastric junction morphology is associated with a positive impedance-pH monitoring in patients with GERD

High‐resolution manometry (HRM) provides information on esophagogastric junction (EGJ) morphology, distinguishing three different subtypes. Data on the correlation between EGJ subtypes and impedance‐pH detected reflux patterns are lacking. We aimed to correlate the EGJ subtypes with impedance‐pH findings in patients with reflux symptoms.

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.

The GerdQ questionnaire and high resolution manometry support the hypothesis that proton pump inhibitor-responsive oesophageal eosinophilia is a GERD-related phenomenon.

Little is known about the relationship between proton pump inhibitor‐responsive oesophageal eosinophilia (PPI‐REE), eosinophilic esophagitis (EoE) and gastro‐oesophageal reflux disease (GERD).

A new endoscopic technique for suspension of esophageal prosthesis for refractory caustic esophageal strictures.

There is no clear consensus concerning the best endoscopic treatment of benign refractory esophageal strictures due to caustic ingestion. Different procedures are currently used: frequent multiple dilations, retrievable self-expanding stent, nasogastric intubation and surgery. We describe a new technique to fix a suspended esophageal silicone prosthesis to the neck in benign esophageal strictures; this permits us to avoid the frequent risk of migration of the expandable metallic or plastic stents. Under general anesthesia a rigid esophagoscope was placed in the patients hypopharynx. Using transillumination from the optical device, the patients neck was pierced with a needle. A n.0 monofilament surgical wire was pushed into the needle, grasped by a standard foreign body forceps through the esophagoscope and pulled out of the mouth (as in percutaneous endoscopic gastrostomy procedure). After tying the proximal end of the silicone prosthesis with the wire, it was placed through the strictures under endoscopic view. This procedure was successfully utilized in four patients suffering from benign refractory esophageal strictures due to caustic ingestion. The prosthesis and its suspension from the neck were well-tolerated until removal (mean duration 4 months). A postoperative transitory myositis was diagnosed in only one patient. One of the most frequent complications of esophageal prostheses in refractory esophageal strictures due to caustic ingestion is distal migration. Different solutions were proposed. For example the suspension of a wire coming from the nose and then fixed behind the ear. This solution is not considered optimal because of patient complaints and moreover the aesthetic aspect is compromised. The procedure we utilized in four patients utilized the setting of a silicone tube hanging from the neck in a way similar to that of endoscopic pharyngostomy. This solution is a valid alternative both for quality of life and for functional results.

Mo1884 Inter-Rater and Inter-Device Agreement for the Diagnosis of Primary Esophageal Motility Disorders Based on Chicago Classification Between Solid-State and Water-Perfused HRM System -A Prospective, Randomized, Double Blind, Crossover Study

Background:High ResolutionManometry (HRM) is a new technique for intraluminal esophageal pressure measurement that employs an increased number of pressure sensors spaced closely together. Two systems have now become widely available: the 36 solid-state (SS) pressure transducers system, used to create the new Chicago Classification (CC) for Primary Esophageal Motility Disorders, and the recently introduced 24-channel water perfused (WP) system. Comparative data in terms of inter-device pressure parameters variability and diagnostic accuracy are lacking. Aim: To assess and compare normal values for pressure measurements between the 36-SS and the 24-WP HRM systems. Moreover, diagnostic inter-rater and inter-device agreement in a group of patients with esophageal symptoms were assessed. Methods: In this prospective, randomized, double blind, crossover study, 20 healthy volunteers [HVs; 11M/9F; median age 29 (IQR 26-33)] and 20 patients [11M/9F; 48 (43-55)] with esophageal symptoms (i.e. reflux symptoms, chest-pain or dysphagia) underwent HRM with both 36-SS (Given Imaging, Los Angeles, CA) and 24-WP (EB Neuro, Firenze, Italy) systems, in random order. Normal values from HVs were obtained and compared using non-parametric statistical analysis. Two expert reviewers (RS, ES) performed a blindfolded analysis of the patients tracings. Diagnoses based on CC in patients with esophageal symptoms were formulated. Inter-rater and inter-device agreement for each reviewer were evaluated by means of Cohens k value. Results: As shown in the Figure, there were significant differences between the 2 HRM systems, mainly regarding the measurements of Lower Esophageal Sphincter (LES) and Upper Esophageal Sphincter (UES) basal pressure (p<0.01 and p=0.02, respectively), wave amplitude at 3 cm above the LES (p<0.01) and wave duration at 3, 7 and 11 cm above the LES (p<0.01, p<0.01 and p=0.01, respectively). Almost, all CC parameters were significantly different between the two HRM systems: Integrated Relaxation Pressure (IRP) (p=0.01), Distal Contractile Integral (DCI) (p=0.02) and Distal Latency (DL) (p<0.01). Diagnostic inter-rater agreement was higher for SS system (k=1) than for WP system (k=0,68). Diagnostic inter-device agreement was moderate for both reviewers (k[RS]= 0.5; k[ES]=0.4).Conclusions:Compared to the SS system, theWP technique underestimated almost all pressure measurements, including the CC parameters. This is likely due to the increased compliance of the WP system at low water perfusion rates, leading to poor interrater diagnosis reproducibility and inter-device agreement. By contrast, the SS system appears high reproducible in terms of inter-rater agreement. Thus, caution about the interpretation and application of CC in all HRM systems is recommended.

Economic evaluation of the randomized European Achalasia trial comparing pneumodilation with Laparoscopic Heller myotomy

A recent multicenter randomized trial in achalasia patients has shown that pneumatic dilation resulted in equivalent relief of symptoms compared to laparoscopic Heller myotomy. Additionally, the cost of each treatment should be also taken in consideration. Therefore, the aim of the present study was to perform an economic analysis of the European achalasia trial.