A Controversy That Has Been Tough to Swallow: Is the Treatment of Achalasia Now Digested?

Esophageal achalasia is a rare neurodegenerative disease of the esophagus and the lower esophageal sphincter that presents within a spectrum of disease severity related to progressive pathological changes, most commonly resulting in dysphagia. The pathophysiology of achalasia is still incompletely understood, but recent evidence suggests that degeneration of the postganglionic inhibitory nerves of the myenteric plexus could be due to an infectious or autoimmune mechanism, and nitric oxide is the neurotransmitter affected. Current treatment of achalasia is directed at palliation of symptoms. Therapies include pharmacological therapy, endoscopic injection of botulinum toxin, endoscopic dilation, and surgery. Until the late 1980s, endoscopic dilation was the first line of therapy. The advent of safe and effective minimally invasive surgical techniques in the early 1990s paved the way for the introduction of laparoscopic myotomy. This review will discuss the most up-to-date information regarding the pathophysiology, diagnosis, and treatment of achalasia, including a historical perspective. The laparoscopic Heller myotomy with partial fundoplication performed at an experienced center is currently the first line of therapy because it offers a low complication rate, the most durable symptom relief, and the lowest incidence of postoperative gastroesophageal reflux

The impact of spontaneous bacterial peritonitis on patient outcomes after liver transplantation using the scientific registry of transplant recipient (SRTR) database

Spontaneous bacterial peritonitis (SBP) is associated with abdominal inflammation and increased morbidity in patients with end-stage liver disease. However, SBP has generally not been associated with worse outcomes after liver transplantation (LT) in single center studies. In this analysis, we analyze the impact of a history of SBP on LT outcomes using the SRTR database. METHODS: All patients, 18 years or older, who received an initial LT alone between March 2002 and December 2016 were included leaving 75,576 patients. 2262 were missing SBP data leaving 73,314. Of these 4665 had SBP and 68,649 did not. The two groups were compared for patient and donor characteristics. Groups were compared for length of stay (LOS) and survival using Kaplan-Meier analyses with log rank test. Multivariate analysis was done using Cox regression analysis. RESULTS: Patients with a history of SBP were more ill than those without. They had a higher MELD at LT (26.1 + 10.0 vs 20.7 + 10.3: P\u3c0.001), a higher creatinine (1.69 + 1.23 vs 1.34 + 1.04: P\u3c0.001) and were more likely to be on dialysis (15% vs 7%: P\u3c0.001). They were more likely to be hospitalized (28% vs 16%: P\u3c0.001) or in the ICU (16% vs 11%: P\u3c0.001). They were more likely to have portal vein thrombosis (13% vs 9%: P\u3c0.001) and less likely to have HCC (11% vs 28%). They had an equal incidence of hepatitis C (44% vs 43%). Patients with SBP had longer LOS in days (17.2 + 19.9 vs 14.8 + 18.9: P\u3c0.001). Patients with SBP had worse patient survival at 3 month (94.4% vs 95.1%: P=0.026), 1 year (87.6% vs 90.0%: P\u3c0.001) and 3 year (80.0% vs 81.8%: P=0.001). SBP was not associated with worse graft survival. On univariate analysis, SBP was associated with increased LOS (HR 1.20: 95% CI 1.16-1.23: P\u3c0.001) and diminished patient survival (HR 1.09: 95% CI 1.03-1.016: P=0.002). However on multivariate analysis, SBP was no longer associated with either patient death or increased LOS. CONCLUSIONS: Patients with a history of SBP prior to transplant are considerably more ill than patients without an SBP history and have worse patient survival and longer length of stay. However, when controlling for other medical comorbidities, SBP alone is not associated with worse patient outcomes

An overview of the US Department of Energy Plant Lifetime Improvement Program

This paper provides a brief summary of the U.S. Department of Energy`s (USDOE`s) cooperative effort with the nuclear industry to develop technology to manage the effects of material degradation in systems, structures and components (SSCs) that impact plant safety or can significantly improve plant performance/economics and to establish and demonstrate the license renewal process. Also included are efforts to reduce decontamination/decommission costs, and reduce the uncertainty in long-term service-life decision making. During 1995, the Plant Lifetime Improvement (PLIM) Program was renamed the Commercial Operating Light Water Reactor (COLWR) Program activities are focused on sustaining the LWR option for domestic electricity generation by supporting operation of existing LWRs as long as they are safe, efficient, and economical. The status of the key projects is discussed in this paper

The impact of tumor necrosis on tumor free survival in patients undergoing liver transplant with hepatocellular carcinoma: an analysis using the UNOS liver recipient explant pathology form.

Background: In previous SRTR analyses, we demonstrated that specific donor factors as well as the donor risk index were associated with tumor free survival in patients undergoing liver transplant (LT) with hepatocellular carcinoma (HCC) In this study, we attempt to identify donor and recipient variables associated with tumor free survival controlling for variables in the UNOS liver recipient explant pathology form Methods: We looked at patients who underwent LT with the HCC exception from April 12, 2012 to Dec 31, 2015 who had explant forms. We excluded patients with cholangiocarcinoma, living donor transplant or death within 3 months. Patients were evaluated for tumor free survival using donor, recipient and explant variables with Kaplan‐Meier (KM) curves with log rank tests. Multivariate modeling was done using competing risks regression analysis. Results: There were 5765 recipients who met inclusion criteria and of these 384 (6.7%) had recurrence. On univarate analysis, variables associated with recurrence that were included in multivariate analysis were tumor outside Milan criteria, vascular invasion, poorly differentiated histology, AFP \u3e 100 at LT, male race, hepatitis C, recipient CMV, longer waiting time and incomplete or no necrosis in patients who underwent locoregional therapy. On multivariate analysis, only tumor outside Milan (HR 2.20: CI 1.98‐2.41: P\u3c0.0oi), vasc invasion (HR 2.33: CI 2.10‐2.56: P\u3c0.001), poorly diff histology (HR 2.46: CI 2.20‐2.73: P\u3c0.001), AFP \u3e100 at LT (HR 2.07: CI 1.81‐2.32: P\u3c0.001) and incomplete (HR 1.37: CI 1.07‐1.68: P=0.042) and no necrosis (HR 1.51: CI 1.13‐1.89: P=0.032) were associated with decreased tumor free survival 5221 patients were treated prior to transplant. 1349 (23%) had complete necrosis, 2681 (46.5%) had incomplete and 816 (14.2%) had no necrosis. Patients with complete necrosis had 1 and 3 year recurrence free survival of 98 5% and 96 8% compared to 94 9% and 88 9% for patients with incomplete necrosis and 96 8 and 91 3% with no necrosis The difference was significant (P\u3c0.001). The difference was even greater for patients with tumor outside Milan Criteria on explant Patients with complete necosis had 1 and 3 year recurrence free survival of 97 0 and 96 5% vs 91 1 and 81 8% for incomplete necrosis and 91 5% and 78.3% for no necrosis (P\u3c0.001). Conclusions: Outside of recipient explant pathology, no donor or recipient factors were identified that associated with tunor free survival. In patients who underwent pre‐LT therapy, incomplete or no necrosis was associated with decreased tumor free survival and the effect was more pronounced for patients with tumor outside Milan ciriteria

The impact of the donor risk index on tumor free survival in patients undergoing liver transplantation with hepatocellular carcinoma.

In this study, we look at the impact of donor quality on tumor free survival in patients undergoing liver transplant (LT) with hepatocellular carcinoma (HCC) using the donor risk index (DRI) and its components. METHODS: We looked at all patients who underwent LT from March, 2002 to June, 2015 listed with the UNOS HCC exception. We excluded living donor recipients (214), multi-organ transplants (259), extrahepatic spread at LT (130) cholangiocarcinoma (79) and those who did not survive three months (585) leaving 16,416 patients. Patients were evaluated for tumor free survival using donor variables including DRI with Kaplan-Meier (KM) curves with log rank tests. Multivariate modeling was done using competing risks regression analysis. Recurrence data was obtained using post-transplant malignancy forms or cause of death data. RESULTS: Of the 16,416 patients transplanted with HCC exception, 2134 or 13.0% experienced HCC recurrence. Patients were divided into tertiles (Groups 1-3) by DRI. Group 1 had 5275 patients with mean DRI of 1.04 + 0.09 (range of 0.77-1.19). Group 2 contained 5610 patients with mean DRI of 1.38 + 0.11 (range of 1.2-1.57) and Group 3 had a mean DRI of 1.88 + 0.26 (range of 1.58-3.62). Three year tumor free survival for the three groups respectively was 89.2%, 88.2% and 87.7% and the difference was significant (P=0.001). On multivariate analysis, DRI remained significant with a HR of 1.21 (CI 1.09-1.34: P=0.003) per 1.0 point of DRI. In a separate multivariate analysis of the DRI components, donor age over 60 years (HR=1.15: CI 1.03-1.27: P=0.022), donor height (HR=0.99 per cm: CI 0.99-0.99: P=0.042) and national and regional sharing (HR=1.14: CI 1.03-1.24: P=0.017) remained significant whereas donor race, CVA as cause of death, cold ishemia time and DCD or split livers were not. CONCLUSIONS: In patients undergoing LT with HCC, decreased donor quality, as determined by the DRI, is associated with decreased tumor free survival. While the difference is significant on KM assessment and multivariate modeling, the numerical difference is small and is less than 2% at three years after LT. Individual variables of the DRI associated with decreased tumor free survival include older donor age, shorter donor height, and national and regional sharing

The impact of the donor risk index on tumor free survival in patients undergoing liver transplantation with hepatocellular carcinoma.

In this study, we look at the impact of donor quality on tumor free survival in patients undergoing liver transplant (LT) with hepatocellular carcinoma (HCC) using the donor risk index (DRI) and its components. METHODS: We looked at all patients who underwent LT from March, 2002 to June, 2015 listed with the UNOS HCC exception. We excluded living donor recipients (214), multi-organ transplants (259), extrahepatic spread at LT (130) cholangiocarcinoma (79) and those who did not survive three months (585) leaving 16,416 patients. Patients were evaluated for tumor free survival using donor variables including DRI with Kaplan-Meier (KM) curves with log rank tests. Multivariate modeling was done using competing risks regression analysis. Recurrence data was obtained using post-transplant malignancy forms or cause of death data. RESULTS: Of the 16,416 patients transplanted with HCC exception, 2134 or 13.0% experienced HCC recurrence. Patients were divided into tertiles (Groups 1-3) by DRI. Group 1 had 5275 patients with mean DRI of 1.04 + 0.09 (range of 0.77-1.19). Group 2 contained 5610 patients with mean DRI of 1.38 + 0.11 (range of 1.2-1.57) and Group 3 had a mean DRI of 1.88 + 0.26 (range of 1.58-3.62). Three year tumor free survival for the three groups respectively was 89.2%, 88.2% and 87.7% and the difference was significant (P=0.001). On multivariate analysis, DRI remained significant with a HR of 1.21 (CI 1.09-1.34: P=0.003) per 1.0 point of DRI. In a separate multivariate analysis of the DRI components, donor age over 60 years (HR=1.15: CI 1.03-1.27: P=0.022), donor height (HR=0.99 per cm: CI 0.99-0.99: P=0.042) and national and regional sharing (HR=1.14: CI 1.03-1.24: P=0.017) remained significant whereas donor race, CVA as cause of death, cold ishemia time and DCD or split livers were not. CONCLUSIONS: In patients undergoing LT with HCC, decreased donor quality, as determined by the DRI, is associated with decreased tumor free survival. While the difference is significant on KM assessment and multivariate modeling, the numerical difference is small and is less than 2% at three years after LT. Individual variables of the DRI associated with decreased tumor free survival include older donor age, shorter donor height, and national and regional sharing