Stephanie G. Worrell

Alimentary satisfaction, gastrointestinal symptoms, and quality of life 10 or more years after esophagectomy with gastric pull-up

OBJECTIVE The aim of this study was to evaluate alimentary satisfaction, gastrointestinal symptoms, and quality of life ≥10 years after esophagectomy with gastric pull-up. METHODS Patients who had undergone esophagectomy with gastric pull-up before 2003 were interviewed regarding their alimentary function and completed the Gastrointestinal Quality of Life and RAND short-form, 36-item, questionnaires. RESULTS We identified 67 long-term survivors after esophagectomy and gastric pull-up. Of these, 40 were located, and all agreed to participate. The median age was 75 years, and the median follow-up period was 12 years (interquartile range, 10-19). Most patients (88%) had no dysphagia, 90% were able to eat ≥3 meals/day, and 93% finished ≥50% of a typical meal. The mean alimentary comfort rating was 9 of 10. Dumping, diarrhea ≥3 times/day, or regurgitation occurred in 33% of patients. Six patients (15%) had aspiration episodes requiring hospitalization. The median weight loss after surgery was 26 lbs, and the current median body mass index was 25 kg/m(2). Only 2 patients were underweight (body mass index, <18.5 kg/m(2)). The median Gastrointestinal Quality of Life score was 2.9 of 4. The RAND scores were at the population mean in 1 category (physical function) and above the normal mean in the remaining 7 categories. CONCLUSIONS Long-term nutritional status, quality of life, and satisfaction with eating were excellent after esophagectomy with gastric pull-up. Gastrointestinal side effects were common, but serious complications such as aspiration were uncommon. Pessimism regarding the long-term ability to enjoy a meal and live with a good quality of life after esophagectomy is unwarranted.

Impact of crural relaxing incisions, Collis gastroplasty, and non-cross-linked human dermal mesh crural reinforcement on early hiatal hernia recurrence rates.

BACKGROUND Hernia recurrence is the leading form of failure after antireflux surgery and may be secondary to unrecognized tension on the crural repair or from a foreshortened esophagus. Mesh reinforcement has proven beneficial for repair of hernias at other sites, but the use of mesh at the hiatus remains controversial. The aim of this study was to evaluate the outcomes of hiatal hernia repair with human dermal mesh reinforcement of the crural closure in combination with tension reduction techniques when necessary. STUDY DESIGN We retrospectively reviewed the records of all patients who had hiatal hernia repair using AlloMax Surgical Graft (Davol), a human dermal biologic mesh. Objective follow-up was with videoesophagram and/or upper endoscopy at 3 months postoperatively and annually. RESULTS There were 82 patients with a median age of 63 years. The majority of operations (85%) were laparoscopic primary repairs of a paraesophageal hernia with a fundoplication. The crura were closed primarily in all patients and reinforced with an AlloMax Surgical Graft. A crural relaxing incision was used in 12% and a Collis gastroplasty in 28% of patients. There was no mesh-related morbidity and no mortality. Median objective follow-up was 5 months, but 15 patients had follow-up at 1 or more years. A recurrent hernia was found in 3 patients (4%). CONCLUSIONS Tension-reducing techniques in combination with human biologic mesh crural reinforcement provide excellent early results with no mesh-related complications. Long-term follow-up will define the role of these techniques and this biologic mesh for hiatal hernia repair.

Rat Reflux Model of Esophageal Cancer and Its Implication in Human Disease.

Objectives: The epidemiologic shift in esophageal cancer from squamous cell carcinoma to esophageal adenocarcinoma coincided with popularization of proton pump inhibitors and has focused attention on gastroesophageal reflux disease as a causative factor in this shift. The aim of this study is to review the literature on the rat reflux model in an effort to elucidate this phenomenon. Methods: An extensive online literature review (PubMed) was carried out to identify all seminal contributions to the study of esophageal adenocarcinoma using the rat reflux model. Results: The rat reflux model is a validated reproducible model for the development of Barretts esophagus and esophageal adenocarcinoma. Esophageal reflux of an admixture of gastric acid and duodenal juice induces Barretts esophagus followed by adenocarcinoma. A high-pH environment created by surgical gastrectomy or proton pump inhibitor therapy in combination with a high-fat diet seems to potentiate the development of Barretts esophagus and adenocarcinoma. Early surgical intervention to prevent reflux reduces the progression toward esophageal adenocarcinoma. Anti-inflammatory, antioxidant, and nitrate-trapping agents reduce the incidence of tumorigenesis. Conclusions: As in the rat so also in humans, reflux of an admixture of gastric acid and duodenal juice in a high-pH environment induces the development of Barretts esophagus followed by esophageal adenocarcinoma. This has led to the hypothesis that to prevent Barretts esophagus and subsequent esophageal adenocarcinoma in humans, the reflux of an admixture of acid and bile must be controlled before the development of Barretts esophagus by methods other than acid-suppression therapy.

The state of surgical treatment of gastroesophageal reflux disease after five decades.

The impetus to identify and counsel patients with progressive disease regarding the need for surgical therapy is critical. This goes largely unheeded by gastroenterologists due to their lack of confidence in the durability of a fundoplication and concern over the side effects of the operation. Consequently, early referral of a patient with symptoms and signs of progressive disease for surgical therapy is resisted. Further, there is widespread concern that not all surgeons are sufficiently experienced in evaluating esophageal patients, many are not knowledgeable enough to select the proper antireflux procedure, and some are not sufficiently trained to properly perform the procedure. 4,5 Over the last 5 decades, 5 principles of the surgical treatment of GERD have emerged and when followed, lead to a successful outcome in nearly all patients. These principles are: documentation of the diagnosis of GERD; determination of the status of the lower esophageal sphincter (LES) and esophageal body; identification of the patient who is a proper candidate for surgical therapy; selection of the proper surgical procedure; and surgeon awareness of the technical nuances of the procedure. Application of these principles requires surgeons to hone their cognitive, diagnostic, clinical, and surgical skills regarding reflux disease. Errors can lead to surgical failure and the need for repetitive reoperations with the inherent risk of vagal injury and ischemic damage to esophageal and gastric tissues. The last 5 decades of experience have taught that a successful therapeutic outcome is unlikely after 3 failed antireflux operations. 6-8 Consequently, it is imperative that the first operation be performed for the right diagnosis, on the right patient, and by a knowledgeable and capable surgeon. The objective of this review is to describe the current state of surgical treatment for GERD, to expand on how new knowledge about disease progression and LES function has improved our ability to select the appropriate patient for surgical therapy, and to offer a more personalized surgical approach to these patients.

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.

Acute Esophageal Necrosis: A Case Series and Long-Term Follow-Up

Acute esophageal necrosis (AEN) is a rare condition characterized by circumferential necrosis of varying lengths in the intrathoracic esophagus. Endoscopically, this process is manifested as a black esophagus. To date, limited case series exist describing AEN, and none report long-term follow-up. Our objective was to report 3 patients with AEN, all diagnosed within 1 year at a tertiary academic medical center, describing early and long-term outcomes of this rare disease. In the absence of perforation, patients can be managed conservatively with serial esophagogastroduodenoscopy (EGD). Long-term strictures may occur that require dilation.

Tu1535 Endoscopic Ultrasound Staging of Stenotic Esophageal Cancers May Be Unnecessary to Determine the Need for Neoadjuvant Therapy

Introduction Endoscopic ultrasound (EUS) is an essential component of preoperative staging for esophageal cancer and is used to determine which patients should proceed to primary surgical resection or receive neoadjuvant therapy prior to surgery. However, when the EUS scope cannot traverse a tumor, the role of pre-dilatation is controversial due to the risk of perforation.

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.

Editorial Comment on “Survival Impact of Total Resected Lymph Nodes in Esophageal Cancer Patients with and without Neoadjuvant Chemoradiation”

Currently, there is no consensus as to the extent of lymphadenectomy for esophageal squamous cell carcinoma (SCC) post neoadjuvant therapy that would best impact survival. The extent of lymphadenectomy for primary esophagectomy has been addressed by multiple studies. One such study by Peyre and colleagues used an international database of over 2000 patients with either adenocarcinoma or SCC who underwent primary esophagectomy. They found overall survival, and survival by tumor stage, was significantly improved in patients who had sampling of at least 23 lymph nodes. In this study, the presence of nodal metastases was an independent predictor of poor survival. A randomized trial by Omloo and colleagues found that extensive lymphadenectomy did not benefit all patients. This trial found that those with more than eight positive lymph nodes had no survival benefit regardless of the extent of lymph node dissection. Nowadays, surgeons rarely see patients who are candidates for primary esophagectomy. Following the results of the CROSS trial in 2012, there has been a dramatic increase in the utilization of neoadjuvant chemotherapy and radiation. The CROSS trial demonstrated a strong survival advantage, particularly in squamous cell esophageal carcinoma, for those with local regionally advanced disease who received neoadjuvant therapy compared with primary esophagectomy. The median number of resected lymph nodes in the CROSS trial was 15 in the neoadjuvant therapy group. There was a 31% rate of positive lymph nodes in those who received neoadjuvant therapy compared with 75% in those who underwent primary surgery. The authors did not look further at the impact of the extent of lymphadenectomy on survival. The current study by Ho and colleagues attempts to clarify the role of lymphadenectomy following esophagectomy for patients with SCC. The study included 3156 patients, 44% of whom received neoadjuvant therapy. The results confirm that neoadjuvant therapy for patients with SCC results in a relatively high pathologic complete response rate of 29.3%. The average number of resected lymph nodes was 22 and 21 for those who did and did not receive neoadjuvant therapy. Although the survival data in this study shows a significantly worse survival for those patients who received neoadjuvant therapy, those patients had significantly higher initial T and N stage. The number of resected nodes by multivariate analysis was an independent predictor of survival in those who received neoadjuvant therapy. In the author’s analysis, the logistic regression model best predicted outcomes with a threshold value of 21 lymph nodes. This finding was not true for those who did not receive neoadjuvant therapy, suggesting that extensive lymphadenectomy may not improve survival for all patients. This is likely due to the fact that 57% of the primary esophagectomy patients were N0 and 30% were N1. Patients with no positive lymph nodes are unlikely to have a survival advantage by taking out more lymph nodes. In contrast, almost 80% of patients who received neoadjuvant therapy had N1 or N2 disease. This indicates that there was a survival advantage to extended lymphadenectomy for those with limited nodal disease. This echoes the findings from previous studies on patients who underwent primary esophagectomy. These results are even more Society of Surgical Oncology 2018

Endoscopic Resection and Ablation for Early-Stage Esophageal Cancer

Endoscopic resection and ablation have become the preferred therapy for most patients with high-grade dysplasia or superficial esophageal cancer. Endoscopic therapy offers esophageal preservation with similar oncologic outcomes and significantly fewer complications compared with the alternative of esopahgectomy. The goal of endotherapy is eradication of all the premalignant intestinal metaplasia to minimize the risk for metachronous cancer development. Once accomplished, careful follow-up is necessary to address recurrent intestinal metaplasia or dysplasia and prevent long-term failure of an endoscopic approach in these patients.