Anatomical classification of the shape and topography of the stomach

The aim of the study was to present the classification of anatomical variations of the stomach, based on the radiological and historical data. In years 2006–2010, 2,034 examinations of the upper digestive tract were performed. Normal stomach anatomy or different variations of the organ shape and/or topography without any organic radiologically detectable gastric lesions were revealed in 568 and 821 cases, respectively. Five primary groups were established: abnormal position along longitudinal (I) and horizontal axis (II), as well as abnormal shape (III) and stomach connections (IV) or mixed forms (V). The first group contains abnormalities most commonly observed among examined patients such as stomach rotation and translocation to the chest cavity, including sliding, paraesophageal, mixed-form and upside-down hiatal diaphragmatic hernias, as well as short esophagus, and the other diaphragmatic hernias, that were not found in the evaluated population. The second group includes the stomach cascade. The third and fourth groups comprise developmental variations and organ malformations that were not observed in evaluated patients. The last group (V) encloses mixed forms that connect two or more previous variations

Association of gastroesophageal reflux and O2 desaturation: A novel study of simultaneous 24-h MII-pH and continuous pulse oximetry

Background: Proof of the relationship between gastroesophageal reflux disease (GERD) and respiratory symptoms remains a challenge. Our aim was to determine the association between reflux events and O2 desaturation in GERD patients with primary respiratory symptoms (RS) compared to those with primary esophageal symptoms (ES) using ambulatory monitoring systems. Methods: One thousand eight hundred fifty-one reflux episodes were detected by multichannel intraluminal impedance (MII)-pH testing in 30 patients with symptoms of GERD (20 RS, ten ES.) All patients underwent simultaneous 24-h MII-pH and continuous O2 saturation monitoring via pulse oximetry. Reflux-associated desaturation events were determined by correlating synchronized 24-h esophageal pH and/or impedance and O2 desaturation. Results: One thousand one hundred seventeen reflux events occurred in patients with RS and 734 in those with ES. Nearly 60% of these 1,851 reflux events were associated with O2 desaturation. Markedly more events were associated with O2 desaturation in patients with RS (74.5%, 832/1,117) than in patients with ES (30.4%, 223/734, p 08< 080.0001). The difference in reflux desaturation association was more profound with proximal reflux-80.3% with RS vs. 29.4% with ES (p 08< 080.0001). Conclusions: A remarkably high prevalence of O2 desaturation associated with gastroesophageal reflux was noted in patients with RS. Given further study, simultaneous combined esophageal reflux and O2 saturation monitoring may prove a useful diagnostic tool in this difficult group of patients. \ua9 2009 The Society for Surgery of the Alimentary Tract

A New Era in Esophageal Diagnostics: The Image-Based Paradigm of High-Resolution Manometry

Background: The development of high-resolution (HRM) catheters and software displays of manometric recordings in color-coded pressure plots has changed the diagnostic assessment of esophageal disease. HRM may offer advantages over conventional methods, including improved identification of motility disorders, hiatal hernia, and outflow obstruction, and ease interpretation. Study Design: HRM studies were obtained in 50 healthy volunteers and 106 patients. HRM was performed using a 36-channel catheter, with sensors spaced at 1-cm intervals. Manometric findings were classified into abnormalities of the gastroesophageal barrier and those of the esophageal body and validated by comparison with endoscopic and radiographic diagnostic methods. Results: The mean time for HRM was significantly lower than that for a conventional method (8.1versus 24.4 minutes; p < 0.0001). A structurally defective lower esophageal sphincter (LES) was present in 53 (57.3%) patients, a hypertensive LES in 6 (7.8%), and impaired LES relaxation in 17 patients (16.7%). Validating the LES findings, 86.3% (44 of 51) of patients with a defective sphincter by HRM had radiographic or endoscopic evidence of a hiatal hernia, and 80% (41 of 51) had a positive pH study, endoscopic erosive esophagitis, or Barrett's esophagus. Evidence of a hiatal hernia by HRM was seen in 33 (56%) patients; a hiatal hernia was seen in 91% (30 of 33) of these on endoscopy and 81% (17 of 21) on barium swallow. Fifty-eight patients (54.7%) had an abnormal body motility. Conclusions: HRM studies are shorter than those using conventional methods. Interpretation is image based, and correlation with objective endoscopic and physiologic findings confirms the accuracy of interpretation. The introduction of HRM is a significant advance in the outpatient evaluation of esophageal function. \ua9 2009 American College of Surgeons

Esophageal stenting for malignant and benign disease: 133 cases on a thoracic surgical service

Background: Esophageal stenting is increasingly being utilized to treat a variety of benign and malignant esophageal conditions. The aim of our study was to review our experience with self-expanding metal, plastic, and hybrid stents in the treatment of esophageal disease on a thoracic surgical service. Methods: The study population consisted of 126 patients undergoing placement of 133 stents at a single institution from 2000 to 2008. Data were reviewed retrospectively for patient characteristics, indications, complications, reinterventions, and efficacy. Results: Most stents were placed for palliation of dysphagia due to advanced esophageal cancer (90 of 133; 68%) or extrinsic compression from lung cancer (13 of 133; 9.8%). A total of 123 self-expanding metal stents (SEMS), 7 self-expanding plastic stents (SEPS), and 3 hybrid stents were placed. Of the SEMS, 57 were uncovered and 66 were covered. Malignant obstruction was typically palliated with SEMS, while covered stents were chosen for perforations or anastomotic leaks. The median length of stay was 1 day. Complications occurred in 38.3% of stent placements, with a single perioperative mortality resulting from massive hemorrhage on postoperative day 4. Most complications resulted from stent impaction (12.8%), migration (9.7%), or tumor ingrowth (5.3%). Tumor ingrowth was uncommon with uncovered stents (2 of 57; 3.5%). Stent migration was common with SEPS (4 of 7; 57%), or hybrid stents (2 of 3; 67%). Survival was short in patients with underlying malignancy (median 104 days for esophageal cancer and 48 days for lung cancer), with 20% of patients surviving less than 1 month. Conclusions: Esophageal stent placement is safe and reliable. The goals of therapy are typically met with a single intervention. The majority of patients require no further interventions, though life expectancy often is short and patient selection may be difficult. Most complications are due to stent obstruction, though stent migration is an issue particularly with SEPS and hybrid stents. Esophageal surgeons should be adept at stent placement. \ua9 2011 The Society of Thoracic Surgeons

Association of Kyphosis and Spinal Skeletal Abnormalities with Intrathoracic Stomach: A Link Toward Understanding its Pathogenesis

Background: Modern-day concepts about the pathogenesis of an intrathoracic stomach include crural diaphragm muscular deterioration, loss of phrenoesophageal ligament integrity, and presence of abdominothoracic pressure gradients. The role of spinal abnormalities has received little attention. Based on clinical observation, we hypothesized that kyphosis and other spinal diseases are components of the pathophysiology of an intrathoracic stomach. Study Design: The study population consisted of 98 patients (men, n = 22; women, n = 76; mean age 69.4 years) undergoing operations for type III or IV hiatal hernia with an intrathoracic stomach. Twenty-four age- and gender-matched control patients without hiatal hernia undergoing pulmonary or pleural procedures were used for comparison. Chest radiographs were assessed for spinal abnormalities, including degree of kyphosis, measured from superior T4 to inferior T12 (modified Cobb method), spinal fractures, osteoporosis, and scoliosis. Statistical analyses included two-sample t-test and Fisher's exact test. Results: Patients with intrathoracic stomach had a greater degree of kyphosis than control patients (Cobb angle, 50.2 degrees versus 39.7 degrees; p < 0.001). This difference was most pronounced in women (Cobb angle, 51.7 degrees versus 40.4 degrees; p < 0.001), although the difference in men was not significant (Cobb angle, 45.0 degrees versus 38.1 degrees; p = 0.25). Patients with an intrathoracic stomach had significantly more vertebral fractures (37 of 98 [38%] versus 3 of 24 [13%]; p < 0.05). There was no difference in prevalence of degenerative changes (51 of 98 [52%], versus 13 of 24 [54%]), osteopenia (30 of 98 [31%] versus 6 of 24 [25%]), and scoliosis (27 of 98 [28%] versus 6 of 24 [25%]). Conclusion: Patients with an intrathoracic stomach have a higher degree of kyphosis and more vertebral fractures than age- and gender-matched controls. These data suggest that change in spinal curvature can be important in the pathogenesis of the intrathoracic stomach, a growing problem of our aging population. © 2009 American College of Surgeons

Surgical resection for locoregional esophageal cancer is underutilized in the United States

Background Although esophagectomy provides the highest probability of cure in patients with esophageal cancer, many candidates are never referred for surgery. We hypothesized that esophagectomy for esophageal cancer is underused, and we assessed the prevalence of resection in national, state, and local cancer data registries. Study Design Clinical stage, surgical and nonsurgical treatments, age, and race of patients with cancer of the esophagus were identified from the Surveillance, Epidemiology and End Results (SEER) registry (1988 to 2004), the Healthcare Association of NY State registry (HANYS 2007), and a single referral center (2000 to 2007). SEER identified a total of 25,306 patients with esophageal cancer (average age 65.0 years, male-to-female ratio 3:1). HANYS identified 1,012 cases of esophageal cancer (average age 67 years, M:F ratio 3:1); stage was not available from NY State registry data. A single referral center identified 385 patients (48 per year; average age 67 years, M:F 3:1). For SEER data, logistic regression was used to examine determinants of esophageal resection; variables tested included age, race, and gender. Results Surgical exploration was performed in 29% of the total and only 44.2% of potentially resectable patients. Esophageal resection was performed in 44% of estimated cancer patients in NY State. By comparison, 64% of patients at a specialized referral center underwent surgical exploration, 96% of whom had resection. SEER resection rates for esophageal cancer did not change between 1988 and 2004. Males were more likely to receive operative treatment. Nonwhites were less likely to undergo surgery than whites (odds ratio 0.45, p < 0.001). Conclusions Surgical therapy for locoregional esophageal cancer is likely underused. Racial variations in esophagectomy are significant. Referral to specialized centers may result in an increase in patients considered for surgical therapy. \ua9 2010 American College of Surgeons