Saurabh Singhal

Quality of life after esophageal resection

Introduction Esophageal resection is the primary treatment for malignant esophageal disease and the last resort for benign end-stage esophageal disease. There is a paucity of research comparing the long-term quality of life (QoL) following surgery among these two populations. The aim of this study was to examine the patient reported QoL after esophageal resection using questionnaires focusing on general well-being and esophageal-specific symptoms. Methods A prospectively maintained database of post-operatively administered European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) with supplemental esophageal cancer-specific questionnaires (OES-18) was queried after institutional review board approval through Creighton University School of Medicine. Inclusions were made if patients received an esophageal resection for benign or malignant esophageal disease. Emergency procedures, delayed reconstructions, and stage IV disease were excluded. Student’s t-test was used for domains of function, symptoms, QoL, and esophageal-specific complaints to compare the groups with each other and with the general population. Results A total of 39 out of 248 patients with malignant disease and 24 out of 46 with benign disease completed the questionnaire. A mean post-operative follow-up of 53 months with a response rate of 40% was obtained. There was no difference in physical (p=0.81), role (p =0.37), conditional (p=0.73), emotional (p=0.06), or social functions (p=0.42) between the general population and the esophageal resection groups. There was also no significant difference in generalized pain (p=0.86), nausea/vomiting (p=0.27), fatigue (p=0.86), swallowing (p=0.35), or esophageal pain (p=0.12). The malignant cohort had better outcomes than the benign cohort with respect to eating (p=0.04), indigestion (p=0.04), and QoL (p=<0.01). Discussion The underlying disease between these cohorts is drastically different, but postoperative functional status, generalized symptoms, swallowing ability, and esophageal pain were similar. There was no difference in functional status between the general population and the esophageal resection cohorts. Patients with malignant disease reported less problems with eating and a better QoL than their benign counterparts.

Do the Data Support Manometric Subclassifications for Ineffective Esophageal Motility

We read the article by Hiestand et al. entitled, “Manometric Subtypes of Ineffective Esophageal Motility” with great interest. The authors have presented subclassification for the manometric diagnosis of ineffective esophageal motility (IEM) which is defined as≥50% ineffective swallows. Authors have subclassified IEM into more severe IEM-Persistens (IEM-P) and less severe IEM-Alternans (IEM-A) depending on presence of no normal swallows (IEM-P) vs. some normal swallows (IEM-A). Authors showed that there is an increased distal esophageal acid exposure, weaker lower esophageal sphincter (LES), and lesser response to proton pump inhibitors (PPI) as measured by the degree of gastric acid suppression in patients with IEM-P. They go on to state that these are due to the more advanced disease state of dysmotility. We are not sure how degree of acid suppression in the stomach can be physiologically related to esophageal motor activity. The pH study was done on PPI in 85% of included subjects. While authors have used separate criteria to define positive study in such patients, the number of such patients should be mentioned and compared for individual subtypes, as inadequate acid suppression can be related to the pH-study results. Further, the authors are implying that the same pathophysiological causes of decreased motility (IEMP4IEM-A) are also leading to a worsening function of LES resting pressure (LESP)—while they themselves show that there is no difference in motility related issues (e.g. impaired bolus transit: 62% in IEM-A and 58% in IEM-P) or prevalence of connective tissue disorders. Mean LESP was significantly lower in IEM-P vs. IEM-A. The authors should discuss and compare the rate of hiatal hernia among 17/36 IEM-P and 129/195 IEM-A patients with available reflux study rather than the overall groups to see its correlation with reflux. Hiatal hernia and/or weak LES are known to be related to reflux, independent of body motility, and can be major confounding factors in the present study. We believe the conclusion that IEM-P is advanced IEM-A is not adequately supported by the data presented. CONFLICT OF INTEREST