Effect of aging on esophageal motility in patients with and without GERD

Background/Aims: The impact of aging on esophageal motility is not completely understood. This study aims at assessing 1) whether degeneration of esophageal body motility occurs with age and 2) whether this development is influenced by gastroesophageal reflux disease (GERD)

Effect of aging on esophageal motility in patients with and without GERD

Background/Aims: The impact of aging on esophageal motility is not completely understood. This study aims at assessing 1) whether degeneration of esophageal body motility occurs with age and 2) whether this development is influenced by gastroesophageal reflux disease (GERD)

Obesity and Gastroesophageal Reflux: Quantifying the Association Between Body Mass Index, Esophageal Acid Exposure, and Lower Esophageal Sphincter Status in a Large Series of Patients with Reflux Symptoms

Obesity and gastroesophageal reflux disease (GERD) are increasingly important health problems. Previous studies of the relationship between obesity and GERD focus on indirect manifestations of GERD. Little is known about the association between obesity and objectively measured esophageal acid exposure. The aim of this study is to quantify the relationship between body mass index (BMI) and 24-h esophageal pH measurements and the status of the lower esophageal sphincter (LES) in patients with reflux symptoms. Data of 1,659 patients (50% male, mean age 51 ± 14) referred for assessment of GERD symptoms between 1998 and 2008 were analyzed. These subjects underwent 24-h pH monitoring off medication and esophageal manometry. The relationship of BMI to 24-h esophageal pH measurements and LES status was studied using linear regression and multiple regression analysis. The difference of each acid exposure component was also assessed among four BMI subgroups (underweight, normal weight, overweight, and obese) using analysis of variance and covariance. Increasing BMI was positively correlated with increasing esophageal acid exposure (adjusted R 2 = 0.13 for the composite pH score). The prevalence of a defective LES was higher in patients with higher BMI (p < 0.0001). Compared to patients with normal weight, obese patients are more than twice as likely to have a mechanically defective LES [OR = 2.12(1.63–2.75)]. An increase in body mass index is associated with an increase in esophageal acid exposure, whether BMI was examined as a continuous or as a categorical variable; 13% of the variation in esophageal acid exposure may be attributable to variation in BMI

Modular step-up approach to robot-assisted transthoracic esophagectomy-experience of a German high volume center

Background: The use of robotic technology in general surgery is rapidly increasing in Europe. Aim of this study is to evaluate the introduction of new robotic technologies in a center of excellence for upper gastrointestinal surgery. Methods: A standardized teaching protocol of a complete OR team was performed in simulation and animal models at the Center for the Future of Surgery (San Diego CA, USA) and IRCAD (Strasbourg, France) to receive certification as console surgeons. Starting 02/2017 the daVinci Xi and Stryker ICG laparoscopy systems were introduced at our academic center (certified center of excellence for surgery of the upper gastrointestinal tract, n>300 upper gastrointestinal cases/year). After simple training procedures based on our minimally invasive expertise were performed, difficulty was increased based on a modular step up approach to finally perform robotic assisted transthoracic Ivor Lewis esophagectomy. Results: A total of 70 patients (9 females) fulfilled inclusion criteria to our study. Robotic assisted esophagectomy was divided into six modules. Level of difficulty was increased based on our modular step up approach without quality compromises. There were no intraoperative complications and no unplanned conversions to open surgery. Two surgeons were able to sequentially train and perform a completely robotic transthoracic esophagectomy using this modular approach without a substantial learning curve. A total of ten esophagectomies per surgeon were necessary to complete all modules in one case. Conclusions: The standardized training protocol and the University of Cologne modular step up approach allowed safe introduction of the new technology used. All cases were performed safely without operation-associated complications

Botox, dilation, or myotomy? Clinical outcome of interventional and surgical therapies for achalasia

Purpose Achalasia is a rare, but well-defined primary esophageal motor disorder. Classic therapeutic approaches include botulinum toxin injection, balloon dilation, and surgical myotomy of the lower esophageal sphincter. This report summarizes our experience with different treatment modalities for achalasia. Methods Forty-three patients with achalasia treated in our hospital were subdivided according to therapeutic strategy: endoscopic botulinum toxin injection into the lower esophageal sphincter (EBTI; n=7), endoscopic esophageal balloon dilation (EBD; n=16), surgical myotomy after failed esophageal balloon dilation (EBD-HM; n=14), and first-line surgical myotomy (HM; n=6). Therapeutic efficiency was evaluated comparing standardized symptom scores preoperatively and at follow-up. Results There was no mortality and no significant difference between the groups for age, sex, or morbidity. The mean follow-up was at 9, 35, 38, and 17 months. At follow-up, recurrent or persistent symptoms were found in 71.4%, 6.3%, 35.7%, and 16.7% in EBTI, EBD, EBD-HM, and HM, respectively. Considering EBD-HM patients as failures of esophageal dilation, the total rate of recurrent or persistent symptoms after EBD was 50%. Poor symptomatic outcome was correlated to a low esophageal sphincter pressure during pretherapeutic manometry (p=0.03) and to sigmoid-shaped esophageal dilatation (p=0.06). Conclusion Surgical myotomy is the most reliable first-line therapy for achalasia, particularly in patients with a high sphincter pressure and moderate esophageal dilatation. Botox injection has a high failure rate and should be reserved for exceptional cases. Endoscopic dilation provides about 50% of patients with long-term symptomatic relief; in most cases, failure can be successfully treated surgically

Update on Transumbilical Single-Incision Laparoscopic Assisted Appendectomy (TULAA) - Which Children Benefit and What are the Complications?

Background Transumbilical laparoscopic-assisted appendectomy (TULAA) is fast and cost-effective since no endoloops, staplers or wound protection devices are used. We analyzed the effects of TULAA as first approach for perforated (PA) and non-perforated (NPA) appendicitis in children. Patients We performed a retrospective analysis of 181 children for whom TULAA was the first approach for appendicitis between October 2010 and March 2016. Methods Morbidity, additional laparoscopic instrument insertion (AI), conversions to open extraumbilical appendectomy (OC), and complications were evaluated. Results TULAA was initiated in 181 (87.4%) children (113 boys: 68 girls). Median age was 10.3 years (3.3-13.9 years) and BMI 16.8kg/m2 (12.4-30.8). Appendicitis was non-perforated in 157 (86.7%) and perforated in 24 (13.3%) patients. TULAA was finalized in 142 (78.5%) patients, AI were inserted in 20 (11%) and OC were performed in 19 (10.5%) patients. Duration of surgery did not exceed 20min for 12.8%, and 30min for 43.6% of patients with TULAA and NPA. The rate of wound infections did not differ between procedures (TULAA 3/142 (2.1%), AI 0 (0%), OC 1/19 (5.3%), P=1.000). Further postoperative course was uneventful in 179 (98.9%) patients. Conclusion TULAA can be used as first approach for appendicitis in all children with a low rate of complications. Extracorporeal appendix stump closure can be safely achieved in the majority of children without using laparoscopic disposable devices

Ultrasound-guided lymphangiography and interventional embolization of chylous leaks following esophagectomy

Postoperative chylothorax is a serious complication after transthoracic esophagectomy, and is associated with major morbidity due to dehydration and malnutrition. For patients with high-output fistula, re-thoracotomy with ligation of the thoracic duct is the treatment of choice. Radiologic interventional management is an innovative procedure that has the potential to replace surgery in the treatment algorithm

Incidence and management of chylothorax after Ivor Lewis esophagectomy for cancer of the esophagus

Objective: Chylothorax is a major complication after esophagectomy. As recent studies refer to heterogeneous patient cohorts and surgical procedures, this study was conducted to report the incidence and evaluate the optimal management of chylous fistula in patients treated with transthoracic esophagectomy and 2 -field lymphadenectomy for esophageal cancer. Methods: From January 2005 to December 2013, a total of 906 patients underwent transthoracic esophageal resection for esophageal carcinoma at our institution. En bloc esophagectomy was performed with routine supradiaphragmatic ligation of the thoracic duct. The incidence of chylothorax, and associated morbidity and mortality, were analyzed, and subsequent therapeutic management was reviewed. Results: Chylothorax after Ivor Lewis esophagectomy was observed in 17 (1.9%) patients. Fifteen patients required surgical intervention with rethoracotomy and repeat duct ligation. Thoracic duct ligation was successful in all patients. Two patients died within 90 days after primary esophageal resection. The median time between initial tumor resection and rethoracotomy was 13 days. Average daily chest-tube output at time of reoperation was 1900 mL. In 2 patients, pleural effusion did not exceed 1000 mL per day. In these cases, conservative management with additional thoracic drainage and total parenteral nutrition led to complete resolution of chylous fistula. Conclusions: Occurrence of chylothorax after prophylactic thoracic duct ligation during transthoracic esophagectomy for esophageal cancer is rare. In patients with high -output chylous fistula, an early rethoracotomy with repeat ligation of the thoracic duct is safe and helps to shorten recovery time. In cases of low-volume drainage, a conservative approach is feasible

Ultrasound-guided lymphangiography and interventional embolization of chylous leaks following esophagectomy

Objectives: Postoperative chylothorax is a serious complication after transthoracic esophagectomy, and is associated with major morbidity due to dehydration and malnutrition. For patients with high-output fistula, rethoracotomy with ligation of the thoracic duct is the treatment of choice. Radiologic interventional management is an innovative procedure that has the potential to replace surgery in the treatment algorithm. Methods: Four patients with high-output chylous leaks following esophagectomy are presented. Ultrasound-guided lymphangiography with embolization of the thoracic duct and/or disruption of the cisterna chyli was performed to occlude the leakage site. Radiologic interventions and procedure-related outcomes are described in detail. Results: In all four patients, ultrasound-guided lymphangiography of the groin with injection of Lipiodol was able to detect and visualize the leakage site in the lower mediastinum. In three patients, the leak could be successfully occluded by Lipiodol embolization. In one patient, embolization failed and the disruption technique was successfully performed. No procedure-related complications were observed. Conclusions: In case of a postoperative chylothorax, radiologic intervention is feasible and safe. The procedure is indicated for high-output chylous fistulas after esophagectomy, and should be applied early after the diagnosis of this postoperative complication