bluuebunny/crossref_metadata_2025 huggingface dataset:
PS01.033: THE ROLE OF EARLY LAPAROSCOPY IN CORROSIVE INJURY OF ESOPHAGUS AND STOMACH
Authors: Chou Yi-Pin
Published: September 2018

Background

Corrosive agents usually induce chemical burn of upper gastro-intestine tract. Most patients could be managed successfully with medical treatment, but damage control surgery (DCS) with esophagectomy and gastrectomy are required when trans-mural necrosis is progressed. Making decision of timing on these radical surgeries is quite difficult in patients without initial peritoneal signs.

Methods

From Feb. 2007 to Oct. 2016, patients with corrosive injury without indication of emergent DCS were included. All these patients were divided into two groups. The Group 1 receives early laparoscopy within 24 hours after accidents. The other patients receive observations and surgical intervention once organs injuries are progressed. All basic demographic data and clinical outcomes were recorded.

Results

Total 65 patients were included. 14 patients receive emergent laparoscopy as Group 1. The other 51 patients receive close observations as Group 2. Two patients in Group 1 convert to DCS and the other patients receive gastrostomy and feeding jejunostomy. 18 patients in Group 2 receive DCS due to progressing peritoneal signs. Rates of esophageal stricture and stomach contracture are higher in Group 2 (8.3% vs. 48.5%, P = 0.014).

Conclusion

Early laparoscopy is a good diagnostic tool in corrosive injury patient without obvious peritoneal signs. This method could early detect trans-mural necrosis. In addition to diagnosis, laparoscopy could also perform gastrostomy for adequate drainage that could prevent esophageal and gastric stricture.

Disclosure

All authors have declared no conflicts of interest.
PS01.037: APPLYING THORACIC ENDOVASCULAR AORTIC REPAIR (TEVAR) AND SURGICAL RESECTION WITH RECONSTRUCTION OF ESOPHAGUS IN MANAGING OF AORTA-ESOPHAGEAL FISTULA
Authors: Chou Yi-Pin , Lin Hsing-Lin
Published: September 2018

Background

Aorta-esophageal fistula (AEF) is very dangerous with high mortality. Treatment is difficult because of hemorrhagic shock in acute stage and infection in sub-acute stage. We develop a method to manage both perforations from aorta and esophagus successfully.

Methods

A 56 male patient had fish bone incarcerated in thoracic esophagus. Two months after this accident, intermittent massive hematemesis occurred. The esophagoscopy displayed active bleeding and AEF was diagnosed by computed tomography angiography (CTA). TEVAR is applied immediately and stopped bleeding successfully. Fever with sepsis and mediastinitis was happened after oral intake. The perforated esophagus was removed by wire-stripper through neck and abdomen incisions and reconstructed with gastric tube via retro-sternal route.

Results

After subtotal esophagectomy with gastric tube reconstruction, the ventilator is weaned and endotracheal tube was removed. No leakage from anastomosis between cervical esophagus and gastric tube. Patient could swallow regular diet smoothly. No further post-operative complication was happened after follow up two years.

Conclusion

TEVAR is the first step in managing AEF in acute stage to prevent hemorrhagic shock. Although esophageal perforation could be managed with esophageal stent, the marginal ulcer with pain and bleeding may cause other side effects. Esophageal stent is also another contra-indication applied in benign disease. Subtotal esophagectomy with wire-stripper and reconstruction with gastric tube could provide definite treatment for this esophageal perforation.

Disclosure

All authors have declared no conflicts of interest.
PS01.039: RECURRENCE PREDICTION EQUATION OF ESOPHAGEAL VARICES
Authors: Iwamoto Takuya , Ishikawa Tsuyoshi , Sakaida Isao
Published: September 2018

Background

Endoscopic treatment is widely performed for esophageal varices, but prediction of post-treatment recurrence is difficult.

Methods

The subjects were 298 patients with cirrhosis who underwent initial endoscopic treatment for esophageal varices from January 1997 to December 2010 and were followed-up at our hospital. The average age was 64.5 years (29–84) and the male/female ratio was 119:89. The causes of cirrhosis were hepatitis C virus (HCV), hepatitis B virus (HBV), alcoholism, non-alcoholic steatohepatitis (NASH), and others in 66, 14, 13, 3 and 4% of the subjects, respectively. Hepatic reserve capacity before treatment was Child-Pugh score 6.9 ± 1.5 points, albumin 3.2 ± 0.6 g/dl, total bilirubin 1.4 ± 0.7 mg/dl, and PT% 71.0 ± 13.8%. Complication of hepatocellular cancer (HCC) was present in 63 subjects (30.4%). Treatment-indicated recurrence was defined as ³F2 and ³RC2. Recurrence occurred in 102 subjects, including 65 who redeveloped varicosity within 1 year. Data were compared between patients with (n = 65) and without (n = 43) early recurrence (within 1 year).

Results

The early recurrence group had a significantly higher Child-Pugh score (7.4 ± 1.8 vs. 6.7 ± 1.3, P < 0.01), total bilirubin (1.6 ± 0.8 vs. 1.2 ± 0.6 mg/dl, P < 0.01), and HCC complication rate (44.6% vs. 23.9%, P < 0.01), and significantly lower albumin (3.0 ± 0.7 vs. 3.3 ± 0.6 g/dl, P < 0.01) and administration rate of antihypertensive drugs (10.8% vs. 41.0%, P < 0.01). In multivariate logistic regression analysis, use of antihypertensive drugs, total bilirubin, HCC, underlying disease (alcoholism), and treatment method (endoscopic injection sclerotherapy [EIS] or endoscopic variceal ligation [EVL]) emerged as factors that affected early recurrence. Based on these findings, we developed the following predictive equation: recurrence time (months) = - 12.5206 (HCC: confirmed = 1, not confirmed = 0) - 3.5029 (total bilirubin) + 6.2169 (antihypertensive drug: used = 1, not used = 0) - 7.2581 (alcoholism: yes = 1, no = 0) - 6.0764 (EVL = 1, EIS = 0) + 35.7165. Based on this formula, we examined the predicted and actual recurrence times in 68 subjects from January 2011 to December 2012 and found a significant positive correlation between these data (R = 0.583, P < 0.01).

Conclusion

An equation was developed for prediction of recurrence of esophageal varices after treatment and was shown to have utility in actual cases.

Disclosure

All authors have declared no conflicts of interest.
PS01.041: REMOVAL OF ESOPHAGEAL HEMANGIOMA USING ENDOSCOPIC SUBMUCOSAL DISSECTION: A CASE REPORT AND REVIEW
Authors: Tani Yukiko , Nakajima Masanobu , Muroi Hiroto , Fujita Junki
Published: September 2018

Background

Esophageal hemangiomas are rare, representing around 3% of all benign esophageal tumors. Esophagectomy or tumor enucleation has been performed to treat esophageal hemangiomas, but recently the use of endoscopic therapy, such as endoscopic mucosal resection or endoscopic injection sclerotherapy, is increasing. We describe removal of a hemangioma using endoscopic submucosal dissection.

Methods

A 59-year-old woman underwent endoscopic examination after an esophageal lesion was found during a general health examination. Endoscopy identified a broad-based, elevated, dark purple lesion located 17 cm distal from the incisor teeth. It measured approximately 25 mm and was rounded and soft.Endoscopic ultrasonography using a 20-MHz catheter probe and the water filling method identified a tumor 25 mm in diameter located in the mucosal and submucosal layers. The border was unclear, but the bottom of the tumor was demarcated from the adjacent normal muscle layer. Compared with the adjacent muscle layer, the tumor was hyperechoic. On the basis of these endoscopic findings, the lesion was diagnosed as a hemangioma. Because the tumor was broad-based and relatively large, we thought that polypectomy or EMR should be avoided to prevent incomplete resection and postoperative hemorrhage from the residual stump. We therefore decided that ESD was the best treatment modality for this lesion.

Results

Approximately 2 mL of the solution was injected into the submucosal layer at intervals, which was repeated until the mucosa became elevated. After lifting the lesion, the mucosa including the tumor was gently cut with the Flush knife using the Endocut mode. The submucosal layer was highly fibrous, so lifting the lesion was somewhat difficult. The histopathological findings showed formation of a vascular lumen with irregular dilatation just below the lamina muscularis mucosa, suggesting a cavernous hemangioma. The patient was discharged 5 days after surgery without complications.

Conclusion

Until quite recently, large or broad-based esophageal hemangiomas had been treated by esophagectomy or sclerotherapy. Esophagectomy is associated with a high mortality rate [19], and endoscopic sclerotherapy may cause hemorrhage upon puncture, side effects due to the infused agents, and other complications. Endoscopic resection is less invasive than sclerotherapy, and further advances in endoscopic treatment and instruments may reduce the risk of several complications. ESD has being established as a safer, less invasive therapy than esophagectomy, it is perhaps the best therapeutic option for treating large or broad-based submucosal esophageal hemangiomas.

Disclosure

All authors have declared no conflicts of interest.
PS01.044: PER-ORAL ENDOSCOPIC PYLOROMYOTOMY (G-POEM) IN THE TREATMENT OF REFRACTORY GASTROPARESIS: MID—TERM SINGLE CENTRE EXPERIENCE
Authors: Husťak Rastislav , Vackova Zuzana , Rabekova Zuzana , Spicak Julius , Martinek Jan
Published: September 2018

Background

Gastroparesis is a chronic, debilitating motility disorder. Effective treatment is challenging especially in patients with severe symptoms. G-POEM is an emerging modality for refractory gastroparesis with promising preliminary results. The aim of this prospective case series was to assess the first single-center experience with G-POEM. Main outcomes were: the clinical efficacy defined by an improvement of GCSI ≥ 40% from baseline; gastric emptying study (GES) and safety.

Methods

Since Nov 2015, a total of 8 patients have undergone G-POEM. The etiology of gastroparesis was post-operative in 5, diabetic in 2 and idiopathic in 1 patient. One patient underwent G-POEM for gastroparesis following a multivisceral transplantation; one underwent G-POEM and POEM as a single procedure for coexisting refractory idiopathic gastroparesis and achalasia. All patients had abnormal GES. F-u visit at 3, 6, 12 and 24M were completed in 7/8 (87.5%), 7/8 (87.5%), 5/8 (62.5%) and 1/8 (12.5%) of patients, respectively. Upper GI endoscopy and GES were performed 3M after G-POEM.

Results

G-POEM was successfully performed in all patients. Mean procedure time was 75 minutes (range 43–106). After G-POEM, in 7 patients mean GCSI decreased from 3.26 ± 0.96 to 0.79 ± 0.76 (at 3M; P = 0.018), 0,72 ± 0.69 (6M; P = 0.018) and 1.24 ± 0.85 (12M; P = 0.028). One women finished the 24M follow maintaining excellent outcome (mean GCSI 0.77). Treatment success was reached in 6/7 (85%) of patient at 3 and 6 months. GES normalized in all patients, mean T1/2 of GES decreased from 108 ± 30 to 62 ± 23min (P = 0.018); mean residual % at 4h decreased from 17 ± 9.2% to 2.0 ± 2.0% (P = 0.018). One patient developed bleeding ulcer 10 days after G-POEM, which was successfully managed endoscopically (clips) and by a parenteral proton pump inhibitor.

Conclusion

We report our first experiences with G-POEM for refractory gastroparesis, demonstrating its feasibility and safety with promising mid-term efficacy. A clinical effectiveness of G-POEM needs to be assessed in a large clinical trial.

Disclosure

All authors have declared no conflicts of interest.
PS01.045: ENDOSCOPIC NEGATIVE INTRACAVITARY PRESSURE (ENDO-NIP) TO MANAGE ESOPHAGEAL LEAK AND MEDIASTINAL ABSCESS COMPLICATED BY STROKE TREATED WITH TPA
Authors: Singh Prabh , Bhangoo Harangad , Meyer Alyssa , Rizvi Zaheer , Buttar Navtej , Wang Kenneth
Published: September 2018

Background

Post-surgical complications such as leaks are the source of considerable morbidity and mortality. Success of conservative interventions is highly variable. Recurrence after surgical repair is also not uncommon. Our aim was to develop novel endoscopic strategies to maximize negative intracavitary pressure to manage leaks in cases where conventional management either failed or were not feasible.

Methods

We have used transluminal locking loop drains with low intermittent suction in the management of non-healing leaks in various areas. An example presented here illustrates this concept where a 68-year-old male patient underwent paraesophageal hernia repair with Nissen fundoplication. Patient presented 3 weeks later with fistula leading to a 13 cm meditational abscess. Patient developed right hemiparesis requiring tissue plasminogen activator (tPA). Post-tPA patient developed hemoptysis and hematemesis requiring emergency intubation. The defect in the esophagus was 6–8 mm. Endoscopic repair with stitching or clipping would have left a large undrained cavity with a potential to expand. Endoscopic repair with transcutaneous drain placement was challenging due to recent tPA and a difficult location. Moreover there was potential to develop esophago- pleural- broncho- cutaneous fistula. Endoscopic vacuum therapy was felt to be a suboptimal choice. Patient was high-risk surgical candidate as it would have required radical surgery in the setting of tPA.Upper endoscopy was performed and the cavity was debrided. No direct communication with bronchopulmonary tree noted. A transnasal guidewire assisted 16 Fr, 60 cm locking loop drain was placed and connected to low intermittent suction that was switched to bulb based suction.

Results

The output from naso-cavity drain decreased nearly 100 cc per day in the first 5 days and the size reduced by 30, 50 and 80% by day 5, 9 and 12 respectively. Near complete elimination of the cavity was observed on day 15. Esophagogram showed complete resolution of the leak and computerized tomography revealed no residual cavity

Conclusion

Developing transluminal endoscopic strategies to maximize negative intracavitary pressure helps expedite the healing of resistant postsurgical leaks. This technique avoids the need for frequent drain changes that remains a challenge for vacuum therapy.

Disclosure

All authors have declared no conflicts of interest.
PS01.046: ENDOSCOPIC THERAPY FOR ESOPHAGEAL VARICES IN THE ELDERLY CAN BE PERFORMED IN SAFETY
Authors: Sasaki Ryo , Iwamoto Takuya , Nishimura Tatsuro , Sakaida Isao
Published: September 2018

Background

In this study, we evaluated the risk of complications and the effects of the treatment of esophageal varices in elderly patients with cirrhosis, by comparing the data of elderly and non-elderly patients.

Methods

We included 284 patients who received endoscopic therapy for esophageal and gastric varices at our hospital between February 2004 and December 2016 in the study.The subjects were divided into two groups.An elderly group comprising patients who were 65 years of or order.A Non-elderly group comprising patients who were under 65 yearsWe compared various parameters such as blood data before and after the endoscopic therapy, as well as the complications associated with the treatment, and then performed statistical analyses on the results.

Results

Of the 284 subjects, 168 patients were elderly group 65 years or older and 116 patients were non-elderly groupaged less than 65 years. Complications were observed in 30 of 168 subjects (17.8%) in the elderly groupwho were aged 65 years or greater and in 25 of 116 subjects (21.6%) under 65 yearsin the non-elderly group, which did not indicate a significant difference between the two groups. The Child-Pugh score was 6.6 ± 0.1 in the elderly group and 7.1 ± 0.2 in the non-elderly group, indicating that the score was significantly lower in the elderly group (P < 0.05). Our investigation of the patients’ medical history pertaining to liver complications indicated that 32.3% of the subjects in the non-elderly group were alcoholics, as compared to 14.8% in the elderly group, indicating a significantly higher percentage of alcoholics in the non-elderly group (P < 0.01). Our investigation of the efficacy of the treatment of varices indicated that the recurrence rate within 1 year was 29.2% in the elderly group and 28.0% in the non-elderly group, indicating that there was no significant difference between the two groups.

Conclusion

Our study comparing the endoscopic treatment of esophageal varices in the elderly and the non-elderly revealed that there were no significant differences in the increase in the risk of complications or the efficacy of treatment. Therefore, we believe aggressive treatment shouldmay be considered even for elderly patients to avoid the risk of variceal rupture and bleeding.

Disclosure

All authors have declared no conflicts of interest.
PS01.048: LAPAROSCOPIC ANTIREFLUX SURGERY IN MORBIDLY OBESE PATIENTS
Authors: Migaczewski Marcin , Rubinkiewicz Mateusz , Pędziwiatr Michał , Major Piotr , Dworak Jadwiga , Natkaniec Michał , Budzyński Andrzej
Published: September 2018

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been proved to be effective bariatric procedure for the treatment of morbidly obese patients with gastroesophageal reflux disease (GERD). In contrast, the indication for laparoscopic sleeve gastrectomy (LSG) in these group of patients is still not clear. LSG with simultaneous crural repair it can be a new, safe and effective therapautic approach.

Methods

A total of 60 obese patients with GERD operated on in 2016–2018 were included in the study. 20 patients were qualified for LRYBG. In the rest LSG was performed, of which half with simultaneous crural repair.

Results

GERD symptoms complete control was observed in 18/20 (90%) patients after LRYGB and 17/20 (85%) after LSG with simultaneous crural repair. The same effect occurred only in 8/20 patients direct after simple LSG. ‘De novo’ GERD symptoms developed in 10% of the patients undergoing alone LSG during 12 months follow up.

Conclusion

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is still effective bariatric procedure for the treatment of morbidly obese patients with gastroesophageal reflux disease (GERD). Doubts remain in the situation of young patients without diabetes. If we additionally deal with a large hiatal hernia, the qualification for LRYGB remains debatable. In this situation, it is worth considering LSG. Simple sleeve gastrectomy not only does not guarantee a good anti-reflux effect, but it can also produce de-novo GERD. Laparoscopic simultanous crurolasty in the time of LSG, represents a valuable option for the treatment of morbid obesity with gastroesophageal reflux disease

Disclosure

All authors have declared no conflicts of interest.
PS01.051: EFFICACY OF 20-MG VONOPRAZAN ON-DEMAND THERAPY AS A MAINTENANCE THERAPY FOR PATIENTS WITH MILD REFLUX ESOPHAGITIS
Authors: Tanabe Tomohide , Kawami Noriyuki , Hoshino Shintaro , Hoshikawa Yoshimasa , Nana Takenouchi , Umezawa Mariko , Kaise Mitsuru , Iwakiri Kastuhiko
Published: September 2018

Background

The aim of this study is to investigate the efficacy of on-demand therapy with 20-mg Vonoprazan (VPZ) as a maintenance therapy for patients with mild RE.

Methods

On-demand therapy of orally taking one 20-mg tablet of VPZ only when reflux symptoms occurred was carried out in 30 patients with mild RE who were in a state of endoscopic remission on maintenance therapy using PPI and answered ‘very satisfied’ or ‘satisfied’ to an overall satisfaction survey. Patients who were remission on 24 weeks after the initiation of on-demand therapy continued the on-demand therapy for a total of 48 weeks. RE symptoms were assessed at 24 and 48 weeks after the initiation of on-demand therapy. Patient satisfaction, symptoms (F-scale), and gastrin level before breakfast were compared before and after the on-demand therapy. In addition, the number of VPZ tablets taken and the frequency (regular, temporary, rare) of its administration were examined.

Results

One of the 30 patients dropped out of on-demand therapy 1 week after its initiation. At the 24-week follow-up, recurrence of RE was found in 13.8% of the patients. There were no significant differences in the level of the F-scale score, overall level of satisfaction, and gastrin level before and after the on-demand therapy. During the 24-week on-demand therapy, patients took 33 (median) VPZ tablets. 31.0% of the patients took VPZ on a regular basis (at least 2 tablets a week); the remaining patients took VPZ on a temporary or rare basis. After additional 24 weeks, 21 of 25 patients who maintained remission completed the 48-week study. 15.4% had recurrent disease (grade A and B). There were no significant differences in the F-scale score, overall level of satisfaction, and gastrin level before and 48 weeks after the on-demand therapy. At the end of the 48-week on-demand therapy, patients had taken 69 VPZ tablets, and 42.9% of the patients took VPZ on a regular basis.

Conclusion

Discussion: On-demand therapy with 20-mg VPZ is an effective alternative for PPI maintenance therapy for mild RE.

Disclosure

All authors have declared no conflicts of interest.
PS01.057: THYROIDECTOMY AND LARYNGO-PHARYNGEAL REFLUX: WHAT’S NEW
Authors: Macaione Ina , Cusimano Alessia , Cipolla Calogero , Graceffa Giuseppa , Pantuso Gianni , Fiorentino Eugenio
Published: September 2018

Background

‘Local neck symptoms’ may be related to goiter; a persistence of those symptoms after an uncomplicated total thyroidectomy (TT) might be referred to the laryngo-pharyngeal reflux (LPR). Our previous study found a correlation between goiter and LPR in selected patients with local neck symptoms; the purpose of our current study is to investigate the presence of a laringopharyngitis in patients with goiter, before and after TT, even in the absence of local neck symptoms, assessing whether the presence of LPR may play a role at the outset of the symptomatology.

Methods

Two groups of patients were considered and they differred for the presence or absence of local neck symptoms: group A (25 patients) and group B (40 patients). The clinical evaluation was standardized using the reflux symptom index. The patients were subjected to videolaringoscopy (VLS) and to esophageal videoflurography (VFGE) before and three months after surgery.

Results

Before surgery all the patients in group A showed a normal vocal chord motility and laryngitis findings at the VLS. The VFGE was positive to abnormal swallowing in 86% of patients. The laryngitis findings at VLS, were found in 38% of cases in group B. At VFGE 96% of the patients were positive to the test. The symptoms reported in the pre-operative were unchanged after surgery in group A. In group B 63% of patients remained positive; at VFGE 73% had a clear pathological condition.

Conclusion

In 2010 ‘Amelita’ study concluded that LPR should be taken into account as a possible movens of post-thyroidectomy clinical picture, both in the diagnosis and in the therapeutic management of those patients who complained about local neck symptoms, since the only TT hadn’t been effective. The collected data of the current study are consistent with those of the previous study: symptoms persisted or increased in laryngopharingeal reflux-positive patients, while in the control group the symptoms were absent or the new appearance symptomatic pictures were moderate. It is a shared view that we shouldn’t wait for the overt clinical picture, but prevent it. It is essential to identify, through a careful pre-operative evaluation, patients positive to LPR.

Disclosure

All authors have declared no conflicts of interest.
PS01.061: LAPAROSCOPIC ENDOSTIM PLACEMENT: CASE REPORT
Authors: Morales Morales Carlos , Aguirre Mar David , Ballí Jorge , Serrano Berta
Published: September 2018

Background

GERD is a mechanical disorder that is caused by a dysfunction of the LES, dysfunction of the gastric emptying or an anomalous esophageal peristalsis.

Methods

We present the case of a 36-year-old male patient with intermittent heartburn, regurgitation, retrosternal pain and dysphagia. UE reports grade D esophagitis, manometry and pHmetry reporting DeMeester 21.1, acid percentage of 5.8%. Normal Motility and LES in 9 mmHg. Nissen-type fundoplication was performed without complications and with resolution of symptoms. 4 years later the patient begins with recurrent symptoms. Esophagitis in UE. DeMeester 20. EEI 7.7 mmHg. 80% Useful Motility. Nissen type fundoplication is redo. Nine years later the patient starts again with symptoms. Progressive deterioration of esophageal motility in manometry is documented. UE with grade D esophagitis, DeMeester 10, manometry reporting LES with normal resting pressure and coordinated relaxation with pharyngeal contraction. Peristalsis wave failure of 100% of swallows, in relation to absent peristalsis;

Results

Placement of Endostim was performed and patient was discharged without complications, Patient 1 month later without GERD symptoms.

Conclusion

Approximately 10 to 40% of patients with GERD fail to respond in their symptomatology despite medical treatment. Surgical indications for GERD consist of failure to medical treatment, poor adherence to the patient's treatment, high volume reflux, severe esophagitis, benign stenosis and Barret's esophagus. Treatment consists of fundoplication in its different variants. However 10% to 20% of patients present with persistent symptoms and 3% to 5% require surgical reoperation. Endostim is a minimally invasive therapy which normalizes the function of the LES through neurostimulation.

Disclosure

All authors have declared no conflicts of interest.
PS01.064: LAPAROSCOPIC FUNDOPLICATION: NEW ASPECTS IN NEURAL ANATOMY OF THE ESOPHAGOGASTRIC JUNCTION
Authors: Gehwolf Philipp , Renz Olver , Brenner Erich , Fritsch Helga , Wykypiel Heinz
Published: September 2018

Background

In laparoscopic fundoplication the mobilisation of the distal esophagus and the proximal stomach are mandatory in order to obtain enough intraabdominal esophageal length and to enable a posterior fundoplication. In surgical literature and in most anatomic illustrations there are no nerves described between diaphragm and stomach. Moreover the mechanism of the so-called postfundoplication complaints is not fully understood yet. We intraoperatively observed small nerve branches penetrating the left crus of the diaphragm lateral of the hiatus, presumably going into the stomach. Their course (from lateral to medial) suggested that they could be branches of the splanchnic nerves or phrenic nerves rather than branches of the vagus. It was the aim of the study to find these nerves in cadavers and to describe their origin and their target organ.

Methods

53 cadavers (23 male 30 female, age range: 35–103 years) were dissected with special attention to the course of the nerves penetrating the left crus of the diaphragm. The whole course of the nerves was documented with drawings and photos.

Results

In 17 out of 53 cadavers, one or two splanchnic nerves were found. Seen from below, they penetrated the left crus of the diaphragm in mean at the 4 o`clock (range: 2–5) position, in mean at a distance of 2cm (range: 0–5) from the hiatus, all of them going into the stomach (cardia or fundus). Ten out of them had an additional branch going into the coeliac ganglion.

In 14 cadavers, a branch of the phrenic nerve was found, penetrating the left crus at a 4 o`clock position, in mean at a distance of 7,3cm (range: 3–10). These phrenic nerves mostly went into the stomach (fundus), but in two cases, additional branches going to the coeliac ganglion were found.

Conclusion

Branches of the splanchnic nerves and of the phrenic nerve, penetrating the left crus of the diaphragm at the 3–5 o`clock position are regularily found. Most of them go to the stomach, and some also have branches to the coeliac ganglion.

The role of these nerves is not clear yet, but they all are cut regularily during a laparoscopic (posterior) fundoplication.

Disclosure

All authors have declared no conflicts of interest.
PS01.066: LAPAROSCOPIC PARA-HIATAL HERNIA REPAIR
Authors: Hui Benedict , Hughes Timothy , Chow Geoffrey
Published: September 2018

Description

This is a video submission showing laparoscopic repair of a parahiatal hernia. The patient is a 44 year old female who presented with heartburn, regurgitation and chest pain. EGD and CT showed a type 3 paraesophageal hernia. Intra-operatively, we discovered instead a diaphragmatic defect adjact to the hiatus through which the stomach had herniated. Although this has been reported in some case reports it is uncommon. We approached the repair laparoscopically with dissection of the right and left crus followed by dissection of the parahiatal hernia and reduction of the stomach. We then repaired the hernia defect and reinforced the repair with mesh. We concluded with a Nissen fundoplication.

Disclosure

All authors have declared no conflicts of interest.
PS01.070: EVALUATION OF THE EFFECTIVENESS OF ROBOTIC FUNDOPLICATIONS IN THE TREATMENT OF GERD
Authors: Koshkin Mikhail , Vasnev Oleg , Belousov Alexandr , Mikhnevich Mikhail , Baychorov Magomet , Domrachev Sergey
Published: September 2018

Background

Surgical treatment is one of the most effective options for treatment of gastroesofageal reflux disease. Laparoscopic approach became is a ‘gold standard’ over the time demonstrating all advantages of minimally invasive techniques over the open procedures. However the utility of robotic antireflux operations still remains controversial.

Methods

Since the January till the December of 2017 thirty operations were operated on. Mean age was 57,2 (35–76), among them 21 (70%) were female and 9 (30%) were males. Mean BMI was 29,4 (24,1–41,0). Laparoscopic procedures were performed in15 patients (1st group), robotic procedures with DaVinci system were performed in 15 patients of the second group. Chernousov modified Nissen fundoplication was performed in 25 patients, Toupet fundoplication was used for 4 patients, Nissen type was performed in 4 cases.

Results

The median operative time in laparoscopic group was 125 min (80–200 min), in robotic group - 124 min (90–210 min). There were no statistical differences between two groups (P = 0,93).Blood loss was minimal in both groups. Mean postoperative hospital stay was 4 days (2–7 days) in the 1st group and 4 days (2–6 days) in the second. There were no statistical differences between two groups (P = 0,19). Postoperative course was uneventful in all patients of both groups.

Conclusion

Robotic antireflux operations are safe and effective in treatment of patients with reflux-esophagitis. There were no statistically significant differences in short-term results of laparoscopic and robotic operations.

Disclosure

All authors have declared no conflicts of interest.
PS01.073: HIATAL HERNIA—DIAGNOSIS AND RELEVANCE—THE CONUNDRUM CONTINUES….
Authors: Balaji Nagammapudur , Bradbury Carl , Evans Stephanie , Rao Vittal
Published: September 2018

Background

Upper GI endoscopy and barium swallow are the commonly used diagnostic modalities and Oesophageal manometry of late has contributed to the diagnosis of hiatal hernias. It is known that there exist considerable limitations within each modality in the diagnosis of this seemingly common condition. Aims To assess the correlation between the commonly used investigations of Upper GI Endoscopy and Barium studies and selective use of Esophageal physiology studies in the diagnosis of hiatal hernias.

Methods

92 patients who had both an Upper GI endoscopy and Barium swallow in a University hospital formed the study population. There was a subgroup of 29 patients who also underwent a manometry and pH study as a part of their workup. A mix of endoscopists (Physicians, GPs, Surgeons, Supervised trainees and Nurses) performed the upper GI endoscopies. The barium studies were performed by specialist radiographers based on a standard protocol. GI physiology studies were performed by a single GI physiologist with over 25 years of experience. Correlation was performed in varied combinations based on the presence/absence and the size of hernias on different investigations.

Results

74% (68) of patients were diagnosed to have a hiatal hernia on endoscopy whereas only 55% of the same group had a hiatal hernia on Barium studies. Of the 29 patients who had all the 3 investigations a hiatal hernia was diagnosed in 82% on endoscopy, 34% on Barium swallow and 48% on High resolution manometry. Only 21% of patients had correlation between all 3 studies. 62 percent had correlation between any 2 modalities and 17% did not have any correlation between any of the diagnostic modalities. The correlation in-between studies was greater for the moderate to large hernias and least for the small/absent hernias.

Conclusion

There exists considerable variation between the commonly performed procedures for this relatively presumed common condition. There is a greater observed tendency to diagnose a hiatal hernias on endoscopies and less on barium swallows based on the above study. The gold standard for the diagnosis is debatable, considering known limitations based on criteria for diagnosis, dynamic of the Oesophagogastric junction and operator variability.

Disclosure

All authors have declared no conflicts of interest.
PS01.076: LAPAROSCOPIC REMOVAL OF A SLIPPED ANGELCHIK ANTIREFLUX PROSTHESIS
Authors: Masuda Takahiro , Mittal Sumeet
Published: September 2018

Background

The Angelchik prosthesis is c-shaped silicone ring designed to prevent acid reflux. The device, which is fitted around the gastroesophageal junction, was popular in 1980s and over 25,000 devices were placed in patients worldwide. However, follow-up showed a high frequency of undesirable results, including device migration and esophageal erosion. The use of this device was therefore abandoned in the early 1990s.

Methods

A 70-year-old man with a body mass index of 36 kg/m2 presented to us with persistent dysphagia and progressively increasing heartburn. He had undergone placement of an Angelchik prosthesis 37 years earlier. He said that he had experienced dysphagia since it was implanted, but had accepted it. His past medical history included hypertension, hyperlipidemia, sleep apnea, atrial fibrillation, cerebrovascular accident, and benign prostatic hypertrophy. Upper gastrointestinal endoscopy, contrast esophagram, and high-resolution manometry showed a slipped Angelchik device on the stomach with moderately impaired esophageal body motility.

Results

The patient underwent laparoscopic removal of the Angelchik prosthesis, followed by a Roux-en-Y gastric bypass for antireflux. After laparoscopic access, adhesions from previous laparotomy were taken down and standard laparoscopic foregut surgery ports were placed. A fibrous calcified capsule encircling the Angelchik prosthesis was noted around the proximal stomach. The anterior wall of the capsule was peeled off using a Harmonic scalpel, and the Angelchik prosthesis was removed in one piece. Given the patient's esophageal dysmotility and scarring around the fundus, we proceeded with Roux-en-Y gastric bypass. The alimentary and biliary limbs were tailored to 80 cm and 30 cm in length, respectively. Using linear staplers, the gastric pouch was created by dividing the proximal stomach just below the level of the scarred tissue created by the Angelchik device. The distal stomach was left in situ. The operation lasted 160 minutes, and the intraoperative blood loss was 150 mL. Barium swallow on postoperative day 1 showed no leakage, and a liquid diet was initiated. The patient was discharged on postoperative day 2. The patient now reports resolved dysphagia and reflux.

Conclusion

Laparoscopic removal of the Angelchik prosthesis and Roux-en-Y gastric bypass was performed safely with good outcomes.

Disclosure

All authors have declared no conflicts of interest.
PS01.077: GASTRIC NECROSIS WITH PERFORATION AS LATE COMPLICATION OF NISSEN FUNDUPLICATION
Authors: De Vega Marta , Miliani Carlos , Antonio Martinez-Piñeiro Juan , Acin Debora , Pereira Fernando
Published: September 2018

Background

Gastric necrosis and perforation after Nissen funduplication is a rare and life-treatening complication. Prompt diagnosis of acute gastric dilatation is mandatory to avoid gastric necrosis. A tight funduplication can cause a gastric dilatation because of the inability to vomit. Other causes of gastric dlatation include trauma, volvulus, anorexia and bulimia diabetes, polyphagia, acute infections and others.

Methods

A 56-year-old man was admited to emergency room with acute-onset epigastric pain and persistent nausea for the past 4 hours. Nine years ago he underwent a laparosocpic Nissen-Rossetti funduplication for a reflux disease.The examination showed abdominal distension and defense. Computed tomography of the abdomen (TAC) show a important pneumoperitoneum distributed diffusely throughout the abdomen, marked gastric distension with abundant content inside. Free intraperitoneal fluid and postsurgical changes in relation to Nissen fundoplication. An emergentcy laparotomy was indicated.

Results

Emergency laparotomy showed free peritoneal fluid with gastric dilatation and two areas of necrosis and perforation (localized in fundus and gastric body). We performed a total gastrectomy with esophagojejunal anastomosis. The patient sufferd a pulmonary embolism 8 days after laparotomy Pathological examination reported gastric dilatation and two areas of ischemia and trasnmural necrosis with perforation and peritonitis.

Conclusion

If the intragastric pressure excede gastric venous pressure can result in ischaemia and infarctation.Increased intragastric pressure is usually the result of a closed loop, secondary to mechanical compresion of the cardio-esophageaal and pyloroduodenal junctions, as can occur in patients with a Nissen procedure. CONCLUSION: Early diagnosis of gastric dilatation in these patients is mandatory to avoid major complications.

Disclosure

All authors have declared no conflicts of interest.
PS01.083: NEGATIVE INTRALUMINAL PRESSURE FOR COMPLEX ESOPHAGEAL PERFORATIONS OR ANASTOMOTIC LEAKS
Authors: Flood Mike , Boland Patrick , Arumugasamy Mayilone , Walsh Thomas
Published: September 2018

Background

Dehiscence of esophago-gastric or esophago-jejunal anastomosis and spontaneous esophageal perforation are life threatening conditions due to the likelihood of breakdown following repair and the sequelae of sepsis. No unit has a large experience in the management of these problems and many approaches are described. Negative intraluminal pressure therapy (NIPT) is a method of minimally invasive operative management described by Berrisford and colleagues (Eur J Cardio-Thoracic Surg 33;2008;742–744). Despite its success, few institutions have reported on its use.

Methods

We reviewed our experience with the management of complex esophageal and anastomotic leaks and identified those that failed stenting, or where the diagnosis of major clinical anastomotic leaks was delayed. In this unit NIPT is the treatment of choice for these at risk patients. NIPT involves the open or endoscopic placement of an intra-luminal drainage tube with multiple side-holes, which is placed across the esophageal defect and brought through the stomach or jejunum and through the upper abdominal wall. A 10cm negative pressure of H20 is applied and the patency of the tube is maintained by the patient orally ingesting sterile water continuously. Nutrition may be provided parenterally or jejunally.

Results

Eleven patients were identified who were treated with NIPT for either esophageal perforation or delayed anastomotic failure over a 7 year period. Four patients had anastomotic leaks, 4 had iatrogenic perforations (2 failed stenting and 1 delayed diagnosis) and 3 had Boerhaave's syndrome. Of the 11 patients, 8 were male. Age ranged from 19–71 years. The median duration of drain application was 19 days. For 5 of the 11 patients, NIPT was combined with some degree of formal operative intervention. Operative video footage was taken and archived where possible. Complete restoration of the GI tract continuity was achieved in all patients. There was no significant procedural morbidity and there were no mortalities.

Conclusion

NIPT is a minimally invasive treatment option for complex esophageal/anastomotic leaks and we advocate its use, alone or as an adjunct to surgical intervention, in the above patient cohort. We have increasingly inserted the tube successfully under sedation alone, reducing the perioperative complications of general anaesthesia.

Disclosure

All authors have declared no conflicts of interest.
PS01.085: TREATMENT STRATEGY FOR AORTO-ESOPHAGEAL FISTULA
Authors: Takahashi Kozue , Taniyama Yusuke , Sakurai Tadashi , Heishi Takahiro , Sato Chiaki , Takaya Kai , Okamoto Hiroshi , Maruyama Shota , Unno Michiaki , Kamei Takashi
Published: September 2018

Background

Aorto-esophageal fistula (AEF) is relatively rare, but life-threatening condition. AEF is usually caused in the patients with thoracic aortic diseases, such as aneurysms, or after thoracic aortic surgery. We present our surgical strategy for AEF.

Methods

From May 2004 to November 2017, 12 patients with AEF were treated at our hospital. The age ranges from 44 to 83 years, and the number of male/female was 9/3. Five patients had previous thoracic endovascular aortic repair (TEVER) in the descending aorta, four patients had descending or total arch replacement. Two patients caused by rupture of thoracic aortic aneurysm, and one patient had penetration of esophagus caused by aspiration of Press Through Package. As the first procedures for surgical treatment, we perform TEVAR in order to prevent the fatal hemorrhage from aortic pseudoaneurysm. At the same day, removal of esophagus with debridement of adjacent infected tissues is performed by open thoracic procedure. After a few days, excision of the infected graft or the aorta followed by new graft replacement with omental flap installation is performed. Four patients used homograft and four patients used rifampicin-soaked graft. After the patient's general condition improve, we plan to perform open surgery for reconstruction of esophagus.

Results

A 3-year survival rate was 50%, and perioperative mortality was 25%. Hospital mortality was noted in 3 patients due to sepsis, brainstem infarction and pulmonary hemorrhage (6–117 days after the first surgery). Late death occurred in 4 patients (n = 2: ileus, n = 1: carcinoma, n = 1: pneumonia). Eight patients could undergo esophagus reconstruction, by colon graft in 4 patients, a pedicled jejunum and a gastric tube in 2 patients, respectively. The duration from esophageal resection to reconstruction was 1–11 months.

Conclusion

Because AEF usually accompanied with hemodynamic instability, immediate surgical intervention is regarded as the only effective treatment. Corporation between gastrointestinal surgeons and cardiovascular surgeons is necessary to achieve this treatment. We share our experiences of AEF treatment and discuss surgical strategy.

Disclosure

All authors have declared no conflicts of interest.
PS01.087: SINGLE STEP TREATMENT OF ESOPHAGEL PERFORATION CAUSED BY HUGE FOREIGN BODY
Authors: Choi Soohwan , Kil Park Jae , Yoon Seungkeun
Published: September 2018

Background

If a clinician encounters a foreign body in thoracic esophagus, flexible endoscopy is the first treatment modality that comes up in mind. But if the foreign body is too huge to pass the upper esophageal sphincter or stuck in esophageal wall, removal is not easy and could result in iatrogenic injury. Furthermore, esophageal perforation is clinically fatal situation and mandates prompt surgical intervention. Here, we report our successful single step treatment of esophageal perforation caused by huge foreign body. The procedure proceeded in operating room with endoscopic assistance.

Methods

Medical chart review.

Results

69 years old male patient admitted to emergency department complaining of neck pain. About 4 days ago, he had ingested a crab. Since then, foreign body sensation and neck pain had been persisted. Computed Tomography (CT) and endoscopy revealed perforation of cervical esophagus. We performed a surgical exploration. With left cervical collar incision, we were able to exposure the injured esophagus. Simultaneously, a gastroenterologist performed an endoscopic inspection. Foreign bodies had migrated to the thoracic esophagus. With endoscopic forceps, most of foreign bodies were removed through the patient's mouth (including the longest one, about 4centimeter; cm). But, 2.8cm sized foreign body was not able to pass the upper esophageal sphincter. Thus, the gastroenterologist pulled the foreign body to level of perforated esophagus and we removed it without difficulty. Finally, the gastroenterologist checked the total length of esophagus. There was no other perforation. Then, we did primary repair of esophagus. The patient discharged at post operation day 11 without complication.

Conclusion

In our case, some of foreign body was situated perpendicularly in thoracic esophagus. Therefore, it couldn’t pass the upper esophageal sphincter, which the longer one could. With endoscopic assistance in operating room, single step treatment (foreign body removal and perforation repair) was possible. In addition, full inspection of total length of esophagus was possible, simultaneously. We think this single step approach is feasible in terms of avoiding unnecessary thoracic approach and multistep procedures (endoscopy followed by surgery).

Disclosure

All authors have declared no conflicts of interest.
PS01.088: CERVICOSTERNOTOMY COMBINED WITH LAPAROSCOPY FOR RESECTION OF UPPER THORACIC ESOPHAGUS: AN INSTITUTIONAL EXPERIENCE
Authors: Hua Rong , Guo Xufeng , Gu Haiyong , Li Bin , Yang Yu , Ye Bo , Li Zhigang , Mao Teng
Published: September 2018

Background

Access to the cervicothoracic junction, whether by lower anterior cervical or transthoracic approach, is particularly difficult. It has been found that the cervicosternotomy allows exposure of the upper thoracic esophagus to the level of the carina. Our goal in this study is to summarize the experience in resection of the upper segment of the esophagus through cervicosternal splitting approach combined with laparoscopy and to discuss the choice of surgical approach, the clearance of lymph node and the treatment of postoperative complications.

Methods

From January 2016 to February 2018, 7 patients with esophageal disease underwent cervicosternotomy as part of a larger procedure. The lesion of the upper esophagus was resected by the direct anterior approach and the lower segmeat of the thoracic esophagus was freed by laparoscopic transesophageal hiatus. The stomach was taken up to the neck through the bed of esophagus and anastomoted between the stomach and esophagus. We analyzed these patients to determine the utility of this means, the ability to achieve complete resection and the outcomes.

Results

Of the 7 patients, 4 patients underwent radical resection for esophageal squamous cell carcinoma, 2 for esophagectomy and laryngectomy, 1 for benign stricture of the esophagus, 6 for cervical and mediastinal node dissection.The lesion of esophagus was resected in all cases. Recurrent laryngeal nerve injury in one patient with carcinoma, the only major postoperative complication in this group. There was no operative death.

Conclusion

The cervicosternal splitting approach can offer good exposure, high rate of resectability and low incidence of postoperative complications for the pathology of the upper segment of esophagus. Careful evaluation of the patient, focusing on the type, extent, and location of the abnormality relative to the level of the carina, often indicates that cervicosternotomy combined with laparoscopy is a safe and effective method of upper thoracic esophagectomy.

Disclosure

All authors have declared no conflicts of interest.