bluuebunny/crossref_metadata_2025 huggingface dataset:
FA05.02: AN ANALYSIS OF SURVIVAL TRENDS IN 471 PATIENTS AFTER ESOPHAGECTOMY FOR ESOPHAGEAL ADENOCARCINOMA
Authors: Lada Michal , Peyre Christian , Wizorek Joseph , Watson Thomas , Peters Jeffrey , Jones Carolyn
Published: September 2018

Background

Five-year survival after the surgical treatment of esophageal cancer has traditionally been reported to be as low as 15%. More recently, the improvement of clinical staging involving PET/CT and the introduction of neoadjuvant chemo-radiation have each altered the survival outcomes of patients with this lethal disease. The impact of these factors on survival trends has not been well described in literature. The aim of this study was to analyze the survival trends after esophagectomy for esophageal adenocarcinoma at a high-volume center.

Methods

The study population consisted of 471 consecutive patients undergoing esophagectomy for esophageal adenocarcinoma at a university-based medical center between January 1, 2000 and July 31, 2017. Clinical variables were collected for three groups based on the date of esophagectomy and were compared (Group 1: 2000–2004, Group 2: 2005–2011, Group 3: 2012–2017). Survival was compared via the Kaplan-Meier (KM) method.

Results

The 471 patients had a median age of 64.0 years (range 27.0–86.2) and 395/471 (84%) were male. Dysphagia (282/471, 60%), heartburn (63/471, 13%) and chest pain (29/471, 6%) were the most common presenting symptoms. The majority of the patients underwent transhiatal esophagectomy (n = 279, 59.1%) and en-bloc esophagectomy (n = 85, 18.0%). Staging with PET/CT was utilized in 316/471 patients (67%) with 6% of Group 1, 76% of Group 2 and 100% of Group 3, P < 0.001. Neoadjuvant therapy was utilized in 44% of patients, 209/357 (0% of Group 1, 45% of Group 2 and 76% of Group 3, P < 0.001). The median survival for the entire cohort was 30.0 months (range 0.3–208.0) with 5-year KM survival of 30% for Group 1, 43% for Group 2 and 47% for Group 3, P < 0.001, Figure. When comparing Group 1 and Group 2, the 10-year KM survival improved from 23% to 37%, P < 0.001.

Conclusion

This analysis reveals an improvement in 5-year survival after esophagectomy from 30% to 47% over the past two decades. Similarly, 10-year survival has improved from 23% to 37%. The evolution of better clinical staging and advancements in neoadjuvant therapy likely played a vital role in these trends. In contrast to the earliest cohort, PET/CT is now routinely utilized in the staging of esophageal cancer. Further, other than those with early stage disease, all patients are currently evaluated for neoadjuvant chemo-radiation. Notably, the 5-year survival rate for the most recent cohort (2012–2017) approaches 50% and would likely be higher if patients with esophageal adenocarcinoma treated endoscopically were included. Improvements in staging and treatment paradigms for esophageal adenocarcinoma have resulted in significant progress towards cure.

Disclosure

All authors have declared no conflicts of interest.
FA05.03: EFFECT OF EPHEDRINE ON GASTRIC CONDUIT PERFUSION MEASURED BY LASER SPECKLE CONTRAST IMAGING (LSCO) AFTER ESOPHAGECTOMY: A PROSPECTIVE IN-VIVO COHORT STUDY
Authors: Jansen Sanne , De Bruin Daniel , Strackee Simon , Van Berge Henegouwen Mark I , Van Leeuwen Ton , Gisbertz Suzanne
Published: September 2018

Background

Compromised perfusion due to ligation of arteries and veins in esophagectomy with gastric tube reconstruction often (5–20%) results in necrosis and anastomotic leakage, which relate to high morbidity and mortality (3–4%). Ephedrine is used widely in anesthesia to treat intra-operative hypotension and may improve perfusion by the increase of cardiac output (CO) and mean arterial pressure (MAP). This study tests the effect of ephedrine on perfusion of the future anastomotic site of the gastric conduit, measured by Laser Speckle Contrast Imaging (LSCI).

Methods

This prospective, observational, in-vivo pilot study includes 26 patients undergoing esophagectomy with gastric tube reconstruction from October 2015 to June 2016 in the Academic Medical Center (Amsterdam). Perfusion of the gastric conduit was measured with LSCI directly after reconstruction and after an increase of MAP by ephedrine 5 mg. Perfusion was quantified in flux (LSPU) in four perfusion locations, from good perfusion (base of the gastric tube) towards decreased perfusion (fundus). Intra-patient differences before and after ephedrine in terms flux were statistically tested for significance with a paired t-test.

Results

LSCI was feasible to image gastric microcirculation in all patients. Flux (LSPU) was significantly higher in the base of the gastric tube (791 ± 442) compared to the fundus (328 ± 187) (P < 0.001). After administration of ephedrine, flux increased significantly in the fundus (P < 0·05) measured intra-patients. Three patients developed anastomotic leakage. In these patients, the difference between measured flux in the fundus compared to the base of the gastric tube was high.

Conclusion

This study presents the effect of ephedrine on perfusion of the gastric tissue measured with LSCI in terms of flux (LSPU) after esophagectomy with gastric tube reconstruction. We show a small but significant difference between flux measured before and after administration of ephedrine in the future anastomotic tissue (313 ± 178 vs. 397 ± 290). We also show a significant decrease of flux towards the fundus.

Disclosure

All authors have declared no conflicts of interest.
FA06.04: SURVIVAL BENEFIT OF MULTIMODAL LOCAL THERAPY FOR REPEAT RECURRENCE OF THORACIC ESOPHAGEAL SQUAMOUS CELL CARCINOMA AFTER THORACOSCOPIC ESOPHAGECTOMY
Authors: Ninomiya Itasu , Okamoto Koichi , Oyama Katsunobu , Kinoshita Jun , Fushida Sachio , Ohta Tetsuo
Published: September 2018

Background

This study was performed to clarify the optimal therapeutic strategy for recurrent disease after thoracoscopic esophagectomy (TE). We especially focused on the prognostic impact of multimodal local therapy for localized recurrence.

Methods

We investigated the prognosis of 49 patients who developed recurrence among 140 patients who underwent TE at Kanazawa University Hospital. The prognostic factors after recurrence were examined by univariate and multivariate analysis.

Results

The patterns of initial recurrence included hematological recurrence in 24 patients (17.1%), lymphatic recurrence in 26 (18.6%), pleural dissemination in 5 (3.6%), peritoneal dissemination in 2 (1.4%), and local recurrence in 4 (2.9%). Of these 49 recurrences, 26 (53.0%) were localized within 3 regions. As the treatment for initial recurrence, 34 patients (including all 26 patients with localized recurrence) underwent local therapy comprising surgery and radiation therapy. Among them, 23 (67.6%) showed disappearance of the targeted region or diminishment without regrowth indicating local therapy successful. Sixty-six local therapies were performed for repeated recurrence. In total, 49 (74.2%) of the 66 localized recurrences were successfully managed by multimodal local therapy. The 14 patients treated by surgery as the initial therapy showed the most favorable survival. The 23 patients who underwent successful local therapy showed better survival than the other patients (P < 0.001). An age of > 70 years and a noncurative initial TE were statistically significant negative variables for survival after recurrence by the univariate analysis. A recurrence pattern with liver metastasis, more than four lung metastases, and pleural metastasis were also statistically significant negative variables. Localized recurrence, performance of local therapy, successful local therapy, and performance of surgery as the initial therapy for recurrence were statistically significant positive variables. Multivariate analysis showed that successful local therapy at the recurrence site and a noncurative initial TE were the only statistically significant positive and negative independent variables, respectively.

Conclusion

The minimal invasiveness of TE might contribute the performance of multimodal local therapy after recurrence. Multimodal local therapy for repeat recurrence contributes the improvement of survival after recurrence.

Disclosure

All authors have declared no conflicts of interest.
FA07.01: COMPARISON OF PERIOPERATIVE OUTCOMES AFTER ESOPHAGEAL RESECTION OR BYPASS FOR CORROSIVE STRICTURES OF THE ESOPHAGUS: A RANDOMIZED CONTROL STUDY
Authors: Dash Nihar
Published: September 2018

Background

Esophageal resection following corrosive stricture is projected to be associated with higher morbidity and mortality in comparision to bypass in the esophagus. Therefore perioperative risk of resection should be weighed against the long term risk of bypassed esophagus.

Methods

All fit patients of corrosive esophageal strictures without fistula or perofration were included. Randomisation was done after induction inside operation theatre. Stomach was the prefered conduit in both the groups. Right colon was the next prefered one. All cases were followed up for 6 months. Intraoperative anaesthetic events, complications related to technique, post operative complications and parameters related to recovery were studied.

Results

58 patients were recruited. 8 of them were excluded because of various reasons. 21 patients with resection and 29 patients with bypass were included in the study. The physiochemical parameters were comparable. The resection group had significant more mediastenal dissection time. There was no difference in the operative time, blood loss, hospital stay, dysphagia, anastomotic leak, nerve injury and pulmonary complications. Only 1 out of 50 patient died in the bypass group. In 1 patient thoracotomy was done again in the bypass group.

Conclusion

From this interim analysis we conclude that both surgical options are comparable with respect to the perioperative outcomes. Since the patients are young and the there is definite risk of malignancy in the injured esophagus, resection procedure can be safely undertaken.

Disclosure

All authors have declared no conflicts of interest.
FA07.02: ESOPHAGEAL PERFORATION: A RETROSPECTIVE, SINGLE CENTER OUTCOMES
Authors: Kovacs Balazs , Masuda Takahiro , Bremner Ross , Smith Michael , Huang Jasmine , Hashimi Samad , Patel Chirag , Ahmed Shair , Mittal Sumeet
Published: September 2018

Background

Esophageal perforation (EP) though uncommon has high morbidity and mortality. Aim of this study is to evaluate the outcomes at a tertiary referral hospital.

Methods

After IRB approval patients with EP between May 2014 and Sept 2017 were identified. Retrospective chart review was done to collect data. Exclusion criteria were: age under 18, leak following esophageal resection and esophageal stenting in previous year. Pittsburgh esophageal perforation severity score (PS) was calculated for each patient.

Results

During study period 56 patients (70% men) with EP met inclusion and exclusion criteria with a mean age and BMI of 60 Yrs. 27.1 kg/m2 respectively. Most common causes were iatrogenic (43%) and Boerhaave's (21%). Nearly 3/4th patients presented to the hospital within 24h of onset. The site of perforation was thoracic (67.9%), cervical (16.1%) and abdominal (16.1%). Overall mortality within 1 month was 5.7% (3 cases) compared to predicted (5.8 cases, 10.4%) based on Pittsburgh score (P > 0.05). See Table 1 for PS at presentation, management and ICU stay.

Conclusion

In our single center experience the leading cause of EP are iatrogenic injury and Boerhaave's syndrome. PS correlated well with need for aggressive surgical intervention and length of ICU stay. Use of endoluminal stents was higher than previously reported. Stents with or without additional surgical intervention can be a viable option in a subset of patients.

Disclosure

All authors have declared no conflicts of interest.
FA07.04: THE ROLE OF ENDOSCOPIC DILATION AND STENTS IN THE REFRACTORY BENIGN ESOPHAGEAL STRICTURES: A RETROSPECTIVE ANALYSIS
Authors: Lu Qing , Lei Tiantian , Yan Hailin , Yang Jinlin , Ma Hongsheng
Published: September 2018

Background

The outcomes of patients with refractory benign esophageal strictures (RBES) was unclear and lacking in relative researches on the clinical efficacy of dilation compared with stent placement. Our objective was to explore the role of endoscopic dilation and stents in the management of RBES.

Methods

This study including patients with RBES (recurrence of dysphagia despite endoscopic therapy more than 3 sessions) by dilation and stents between January 2009 and December 2017. Endoscopic therapy success was defined as: before the end of the follow-up, no need for endoscopic interventions for at least 6 months. The primary outcome was to assess clinical effectiveness and adverse events. Secondary outcome was to identify factors that predicted the dysphagia-free period (the time interval of two subsequent endoscopic interventions). Multivariate analysis was used to estimate the risk factors influencing the treatment success. To explore the trend of dysphagia-free period along with times used hierarchical linear models.

Results

75 patients (54 male; median age, 59 years) with RBES, 39 (52%), 20 (26.7%), 3 (4%), 10(13.3%), and 3(4%) were post-surgical, post-ESD, achalasia of cardia, caustic and mixed etiology, respectively. The median times of endoscopic therapy was 5 times (range 3, 21). Self-expandable metal stents (SEMSs) were placed in 20 patients (26.7%), and the success rate of patients treated with dilation (70.9%, 39/55) was higher than with stents (35%, 7/20). Fifteen patients died during follow-up. Nineteen patients had adverse events after endoscopic therapy. In total, the mean dysphagia-free period was 3.4 months (95% CI, 2.5–4.3). The dysphagia-free period of patients treated with dilation was 3.7months (95% CI, 2.7–5), and with stents was 2.3 months (95% CI, 1.5–3). The dysphagia-free period has linear growth trend with times, increased by 12 days per endoscopic therapy.

Conclusion

The dysphagia-free period increased by 12 days per endoscopic therapy, so the endoscopic dilation and stents tended to be effective in patients with RBES. Before the end of follow-up, nearly half of patients required continuing endoscopic dilation and stents, therefore, the patients with RBES may have negative long-term results. Stents therapy tended to not reduce the times and frequency of dilation.

Disclosure

All authors have declared no conflicts of interest.
PS01.004: UTILIZATION OF HIGH RESOLUTION IMPEDANCE MANOMETRY FOR LIVER TRANSPLANTATION PATIENTS WITH CHRONIC INFLAMMATORY DEMYELINATING POLYNEUROPATHY AND DYSPHAGIA
Authors: Huang Hsu-Kai
Published: September 2018

Background

Chronic inflammatory demyelinating polyneuropathy(CIDP) is a rare problem in liver transplantation recipients. We observed three patients with slowly progressive muscle weakness and dysphagia with body weight loss.

Methods

We describe the clinical features and high resolution impedance manometry(HRiM) results of 3 patients with liver transplantation who developed CIDP. Two patients had orthotopic liver transplantation and the other had living-donor liver transplantation.

Results

All 3 patients developed muscle weakness, dysphagia and body weight loss in the period of tapering immune suppressants. Diagnosis of CIDP were checked by neurologist consultation. All patients had immunosuppressive therapy with tacrolimus. Prednisolone in two cases and everolimus in one case were noted. Telbivudine treatment for chronic hepatitis B were given in all 3 patients. After HRiM evaluation, decreased functional oral intake scale(FOIS), distal contractile integral(DCI) and complete bolus rate were discovered. Plasma exchange were done and the follow up HRiM result showed obvious improved FOIS and DCI.

Conclusion

HRiM is a feasible and effective tool for evaluation of dysphagia in CIDP patients. This exam can be utilized before and after proper treatment.

Disclosure

All authors have declared no conflicts of interest.
PS01.005: HIGH-RESOLUTION MANOMETRY GUIDING SURGICAL PROCEDURE FOR TREATMENT OF ACHALASIA OF THE ESOPHAGUS. LONG-TERM RESULTS OF A PROSPECTIVE STUDY
Authors: Triantafyllou Tania , Doulami Georgia , Theodoropoulos Charalampos , Zografos Georgios , Theodorou Dimitrios
Published: September 2018

Background

Laparoscopic myotomy and fundoplication for the treatment of achalasia presents with 90% success rate. The intraoperative use of manometry during surgery has been previously introduced to improve the outcome. Recently, we presented our pilot study proposing the use of the HRM during surgery. The aim of this study is to evaluate the long-term outcome of the intraoperative use of High-Resolution Manometry (HRM) in achalasia patients.

Methods

In this prospective study, consecutive achalasia patients underwent laparoscopic myotomy and fundoplication along with real-time use of HRM. Eckardt scores (ES) and HRM results were collected before and after surgery.

Results

Twenty-three achalasia patients (22% Type I, 57% Type II, 22% Type III, according to Chicago Classification v3.0) with a mean age 48 years underwent calibrated and uneventful myotomy and fundoplication. Eleven myotomies were further extended, while sixteen fundoplications were intraoperatively modified, according to manometric findings. During postoperative follow-up, mean resting and residual pressures of the LES were significantly decreased after surgery (16,1 vs. 41,9, P = 0 and 9 vs. 28,7, P = 0, respectively). The ES was also diminished (1 vs. 7, P = 0).

Conclusion

The intraoperative use of HRM during laparoscopic myotomy and fundoplication for the treatment of achalasia of the esophagus is a safe, promising and efficient approach aiming to individualize both myotomy and fundoplication for each achalasia patient.

Disclosure

All authors have declared no conflicts of interest.
PS01.006: ROLE OF HIGH RESOLUSION MANOMETRY FOR DIAGNOSIS OF ESOPHAGEAL SPASTIC DISORDERS
Authors: Kameyama Hisako , Masaoka Tatsuhiro , Yamane Tsuyoshi , Takeuchi Hiroya , Kawakubo Hirofumi , Suzuki Hidekazu , Kitagawa Yuko , Kanai Takanori
Published: September 2018

Background

Esophageal spastic disorders such as spastic (Type III) achalasia, distal esophageal spasm, and Jackhammer esophagus are rare clinical condition. Moreover, symptoms associated with esophageal spastic disorders such as dysphagia, chest pain, regurgitation, and heartburn is not specific to esophageal spastic disorders (Gastroenterol Clin North Am. 42:27–43, 2013.). Therefore, it is difficult to diagnose esophageal spastic disorders from symptoms. The aim of this study is to clarify diagnostic strategy for esophageal spastic disorders.

Methods

Patients who underwent all of esophagogastroduodenoscopy (EGD), High resolution manometry (HRM: Starlet®)) and esophagography in our Hospital for evaluation of symptoms such as dysphagia, chest pain, regurgitation, and heartburn from November 2013 to November 2017 were involved in the study. After approval by the research ethical committee (No.20150081), we retrospectively reviewed the clinical findings of these patients. Based on the Chicago classification (CC) v3.0 (Neurogastroenterol Motil. 27:160–174, 2015), findings obtained by HRM were classified. Patients who had past history of upper-gastrointestinal surgery were excluded from analysis.

Results

174 patients (Mean age of 58.6 ± 15.4; 70male) were finally analyzed. Based on findings obtained by HRM, patients were classified as 25 achalasia, 15 Jackhammer esophagus, 0 distal esophageal spasm, 25 Esophagogastric junction outflow obstruction, 25 weak peristalsis, 6 failed peristalsis, 78 normal. Moreover, 23 patients with achalasia were classified as 8 Type I, 13 Type II, 4 Type III. In each subtype of achalasia, prevalence of esophageal dilation in EGD was 100%, 85%, 0%, respectively. In each subtype of achalasia, prevalence of liquid pool in esophagus in EGD was 100%, 69%, 0%, respectively. In esophagography, Compared with no findings group (15.5 ± 4.3cm), diameter of esophagus in patients with Type III achalasia(12.3 ± 4.8cm) were comparable, however that in patients with Type I(38.9 ± 18.6cm, P < 0.05) or Type II(32.0 ± 10.4cm, P < 0.01) achalasia were significantly wider. In patients with Jackhammer esophagus, prevalence of ring contractions in EGD and prevalence of corkscrew esophagus in esophagography were 33% and 13%, respectively.

Conclusion

With only EGD and esophagography, it was difficult to find visible findings which suggest esophageal spastic disorders. This suggests efficacy of HRM for diagnosis of this disorder and possibility of hidden esophageal spastic disorders in patients presumed as refractory GERD.

Disclosure

All authors have declared no conflicts of interest.
PS01.007: THE ROLE OF HIGH RESOLUTION MANOMETRY AFTER TOUPET-FUNDOPLICATION: COMPARING THE RESULTS WITH THE SYMPTOMS REMAINED 6 MONTHS AFTER SURGERY
Authors: Csucska Máté , Kovács Balázs , Ozorai Lilla , Patai Árpád , Lóderer Zoltán , Juhász Árpád
Published: September 2018

Background

Fundoplication is a well accepted method in treatment of gastro-esophageal reflux disease. High Resolution Manometry (HRM) is essential in diagnosis of functional esophageal diseases. The aim of our study was to find the place and value of HRM after 6 months of Toupet-fundoplication, and find correlation in symptoms remained, if any.

Methods

In 2016–2017 98 Toupet-fundoplications were performed by single surgeon. Surgeries were after HRM, EGD and pre-operative reflux symptom questionnaire performed in our Esophageal Center. Six months after surgery EGD, HRM and post-operative symptom questionnaire was planned to manage in each patients.

Results

Until Feb/01/2018 74/98 patients were more than 6 months after their operation. 72/74 patients completed the questionnaire and the EGD as well. 28/72 patients absolved HRM also. 25/28 patients had no complains and pre-operative symptoms relieved completely requiring neither PPI nor H2 blockers. 2/28 patients had gastric emptying problems, and 1/28 had moderate reflux associated symptom. Compared to that 22/28 patients HRM verified abnormal values mostly in DCI, however these 22 patients were asymptomatic. It has to be mentioned that DCI was better pre-operatively than post-operatively in 12 out of 22 cases.

Conclusion

Post-operative HRM can qualify and describe the wrap objectively (its location and basic pressure) however the latest Chicago-criteria was not developed for after-surgery states. We can conclude that post-operative routine HRM can mislead the physician, has importance only in patients with significant complains.

Disclosure

All authors have declared no conflicts of interest.
PS01.008: LOWER ESOPHAGEAL SPHINCTER PRESSURE (LESP) AS A MEASURE OF ANTI-REFLUX BARRIER IN PATIENTS WITH HIATUS HERNIA
Authors: Kovacs Balazs , Masuda Takahiro , Bremner Ross , Mittal Sumeet
Published: September 2018

Background

Hiatus Hernia (HH), with its anatomical/physiological derangement of esophagogastric junction (EGJ) barrier function is a risk factor for pathological gastro-esophageal reflux (GER). However, a subset of patients with HH do not have reflux. The aim of this study is to explore Lower Esophageal sphincter parameters and GER across the EGJ in patients with manometeric type C hiatal hernia (LES-Crural Diaphragm separation > 1cm, and Pressure Inversion Point below LES).

Methods

An IRB approved, prospectively maintained esophageal testing registry was queried to identify patients who underwent High Resolution Manometry and 24h pH study (within 1 week) between 11/01/2016 and 11/01/2017. HRM characteristics of the EGJ (LES-CD separation, overall length, LESP, LESPI), 24 hour pH score, and pH < 4 holding time were extracted. Spearman's Rho correlation was calculated for all parameters and Receiver operating characteristic (ROC) curve was applied for parameters with significant correlation.

Results

A total of 1139 patients underwent HRM during the study period, of these 416 also had 24 hour pH study. 76 Patients met criteria for EGJ morphology Type C. After excluding patients with major disorders of peristalsis (16) the remaining 60 patients form the cohort of this study. Hiatal hernia size, overall length of LES, and LESPI did not correlate with 24 hour pH score or pH < 4 holding time. LESP had a significant negative correlation both with 24 hour pH score (R: -0.322; P = 0.011), and total acid holding time (R: -0.348; P = 0.006). A LESP cut-off value of 24.4 mmHg had a sensitivity of 53.8% and a Specificity of 91.2% for predicting pathological reflux.

Conclusion

A higher LESP (> 24.4 mmHg) appears to provide an effective barrier to pathological GER even when normal EGJ function is compromised by a hiatal hernia.

Disclosure

All authors have declared no conflicts of interest.
PS01.012: LAPAROSCOPIC REMEDIAL MYOTOMY FOR RECURRENT ESOPHAGEAL ACHALASIA
Authors: Capovilla Giovanni , Salvador Renato , Briscolini Dario , Nicoletti Loredana , Perazzolo Anna , Valmasoni Michele , Merigliano Stefano , Costantini Mario
Published: September 2018

Background

Revisional surgery is sometimes necessary after failed laparoscopic Heller myotomy for esophageal achalasia. We evaluated the feasibility complications and final outcome of laparoscopic revisional myotomy (LRM) for recurrent esophageal achalasia.

Methods

Post-operative outcome after LRM at our Institution between 2000 and 2017 was assessed by a symptom questionnaire, endoscopy, barium swallow and pH-monitoring.

Results

Forty-one patients underwent LRM: 7 from our series, 34 from elsewhere. Primary treatments included laparoscopic (20 pts) or open (5) Heller-Dor; laparoscopic (6) or open (7) Heller-Nissen; 3 pts had open myotomy only. Thirty-four pts (83%) underwent a median of 3 (1–6) pneumatic dilations (PD) between primary operation and LRM. All the operations were performed laparoscopically. The median operating time was 180 minutes (65–260). One patient was converted to open for a mucosal lesion. The fundoplication was dismounted, when present. A new myotomy, longer than the previous one (especially on the gastric side), was performed in a healthy tissue, on a different quadrant of the esophageal wall. A fundoplication was reconstructed in 29 patients (70.7%) by performing a Dor (24 pts) or a Toupet (5) procedure. Two patients needed laparoscopic revision on 2nd post-operative day (POD) for radiological evidence of an obstructive fundoplication. One patient required revision on 2nd POD for a leakage, treated by suture and conversion from a Toupet to a Dor. Median follow-up time was 76 months (2–179). After revisional surgery, 27 pts had a resolution of their symptoms (66%), whereas other 6 (14.6%) needed further PD to achieve a satisfactory outcome. Other 4 patients (9.8%) still need periodic PD and 3 patients (7.3%) required esophageal resection. Endoscopic gastrostomy was necessary in one patient (2.4%) who wasn’t suitable for resection. Reflux was detected in 11 patients (26.8%).

Conclusion

LRM is feasible when primary surgery has failed. One-third of the patients still require repeat dilations or esophagectomy, especially in case of megaesophagus. Albeit this is a more difficult operation and carries significant morbidity, LRM may provide the resolution of symptoms to an overall 80% of this group of patients, highly refractory to standard treatments.

Disclosure

All authors have declared no conflicts of interest.
PS01.015: TIMED BARIUM ESOPHAGRAM (TBE) IS RELIABLE IN DEFINING RESPONSE TO TREATMENT AFTER HELLER-DOR FOR ACHALASIA: INITIAL SINGLE CENTER EXPERIENCE
Authors: Zanoni Andrea , Verlato Giuseppe , Ventura Luisa , Armelao Franco , Lauro Enrico , Bonadies Enzo , Scudo Giovanni , Zanella Simone , Mazzetti Cristian , Preciso Elisabetta , De Pretis Giovanni , Della Sala Sabino , Ricci Francesco
Published: September 2018

Background

Routine timed barium esophagram (TBE), before and after Heller myotomy and Dor funduplication for achalasia, could offer the unique opportunity to objectively measure the outcome of the surgical procedure. In an initial single center experience we aimed at comparing pre-operative and post-operative TBE to objectively measure esophageal emptying and dilation, and to look for possible factors related to surgery results.

Methods

From 2016 to 2017, 11 patients underwent Heller myotomy and Dor funduplication for achalasia at a single center; all had a pre-operative and post-operative TBE after one month of surgery. TBE measured height and width of barium column at 1 and 5 minutes. All patients were staged according to radiological achalasia staging system: 1 patient was stage 1 (pre-operative esophageal width between 2 and 3 cm), 4 stage 2 (4–6 cm) and 6 stage 3 (> 6 cm). TBE height and width at 1 and 5 minutes were compared between pre-operative and post-operative TBE by the Wilcoxon signed-rank test. Moreover the association between surgery results and possible risk factors was evaluated by Spearman's rho.

Results

TBE height and width at 1 minute decreased in median by 79% (range 17–100%) and 57% (37–100%), respectively, from pre-operative to post-operative TBE. The decrease was more pronounced at 5 minutes, where it was 85% (40–100%) and 71% (40–100%), respectively. Although all patients reported a significant subjective improvement in symptoms, radiological stage was associated to esophageal emptying: the 4 subjects in stage 2 and the subject in stage 1 had complete or near complete emptying at 5 minutes, while the 6 patients in stage 3 had a median percent decrease at 5 min in height of 75% (40–86%) and in width of 50% (40–71%) (Spearman's rho for height = -0.87, P < 0.001; Spearman's rho for width = -0.88, P < 0.001).

Conclusion

TBE is essential post myotomy, particularly if a substantial esophageal dilatation occurs pre-operatively (stage 3). Initial stage is associated with surgical outcomes, advanced stages being related to poorer emptying and more dilated esophagus after surgery. TBE is a reliable system to objectively define surgical outcomes and preserved esophageal function after Heller-Dor procedure.

Disclosure

All authors have declared no conflicts of interest.
PS01.016: ESOPHAGEAL DYSMOTILITY CAUSED BY ESOPHAGEAL EOSINOPHILIA REGULATES PATIENTS’ SYMPTOMS AND TREATMENT REQUIREMENTS
Authors: Hosaka Hiroko , Kuribayashi Shiko , Shimoyama Yasuyuki , Kawamura Osamu , Kusano Motoyasu , Uraoka Toshio
Published: September 2018

Background

Only a few studies –none from Asia– have been reported on high-resolution manometry (HRM) assessment of esophageal motor function in eosinophilic esophagitis (EoE). This study aimed to evaluate esophageal motility in Japanese patients with esophageal eosinophil infiltration and to clarify the association between esophageal dysmotility and symptoms, endoscopic findings, severity of eosinophilic infiltration, blood eosinophil count, and response to treatment.

Methods

Ninety-two patients underwent both esophageal manometry and endoscopic biopsy to determine eosinophil infiltration in esophageal mucosa, looking for esophageal motility disorders, between 2009 and 2016. Of these 92 patients, 18 patients (9 males, mean age, 52.5 years) who had esophageal eosinophilia (≥ 15 eosinophils per high power field)w ere enrolled in this study. Characteristic endoscopic findings included circular rings, linear furrowing, and white exudates. HRM [ManoScan; Given Imaging] was performed and evaluated by Chicago classification ver. 3.

Results

HRM revealed that 15 patients (83%) had esophageal motility disorders (7 achalasia, 2 esophagogastric junction outflow obstruction (EGJOO), 2 jackhammer esophagus, 1 diffuse esophageal spasm (DES), 3 Ineffective esophageal motility (IEM). Dysphagia was observed in all the patients with achalasia or EGJOO. GERD symptoms like regurgitation or heartburn occurred in most of the patients with EGJOO or IEM. Endoscopic findings of EoE did not differ among types of dysmotility. Severity of esophageal eosinophilia did not correlate with hypercontractile motility disorders. Four patients had blood eosinophilia; none of the achalasia patients or those with normal motility had blood eosinophilia. All the patients, except those with achalasia, were treated with a proton pump inhibitor (PPI). None of the patients with jackhammer esophagus or DES responded to PPI, but one (1/2, 50%) with EGJOO, one (1/3, 33%) with IEM, and two patients (2/3, 66%) with normal motility had their symptom relieved after PPI therapy. Seven patients, including 2 with achalasia, needed steroid therapy either by prednisolone or topical steroid orally. The patients with achalasia showed good temporary response to steroid, though they underwent ordinal myotomy afterwards. One with jackhammer esophagus did not respond to steroid therapy and needed repeated myotomy.

Conclusion

Symptom was a possible factor to predict a type of esophageal dysmotility. Presence of esophageal dysmotility may affect treatment strategy.

Disclosure

All authors have declared no conflicts of interest.
PS01.017: CLINICAL SPECTRUM AND PRESENTATION OF PATIENTS WITH APERISTALSIS
Authors: Kovacs Balazs , Masuda Takahiro , Bremner Ross , Mittal Sumeet
Published: September 2018

Background

Primary aperistalsis is an uncommon finding on high resolution manometry (HRM), and has been linked to autoimmune disorders. The goal of the study is to describe and explore clinical spectrum and presentation of this group of patients.

Methods

An IRB approved, prospectively maintained esophageal testing registry was queried to identify patients with aperistalsis between 08/01/2016 and the 11/10/2017. HRM studies were reevaluated. Patients with poor studies, or insufficient clinical information were excluded. Patients with history of previous foregut surgery or esophagram consistent with achalasia were also excluded.

Results

A total of 1225 patients underwent HRM during the study period of which 36 (2.9%) met inclusion criteria and form the cohort of this study. In this group 30 patients also had UGI contrast study and endoscopy, while foregut symptom questionnaire was available for 24 patients. There were 16 (44%) females. The mean age was 57.6(± 13.58) Yrs. and mean BMI 26.28 (± 5.4) kg/m2. More than half (21/36) of the patients were undergoing lung transplant evaluation. 26 patients (72.2%) had history of autoimmune or immune mediated diseases (including 6 with Scleroderma and 11 interstitial lung disease). On symptom questionnaire, 75% (18/24) of patients reported heartburn, and 50% (12/24) reported dysphagia while 9 (37.5%) patients reported both. 9 of 36 patients had hiatal hernia on HRM, median IRP 4s was 4.8mmHg, average LESP was 21mmHg. On ambulatory pH-monitoring, 9/19 had pathological DeMeester scores. Endoscopic biopsy results showed columnar intestinal metaplasia in 16.7% (5/30) of patients. Esophageal candidiasis was confirmed in 2 (6.7%) cases. On esophagogram two (6.7%) were additionally diagnosed with Zenker's diverticula.

Conclusion

Aperistalsis on HRM is rare and covers a wide array of diseases; the usual clinical presentation is reflux and/or dysphagia. Interestingly only half these patients with absent motility have dysphagia. In our study a large number of patients were undergoing pre-lung transplant evaluation, this could either be due to causative underlying disease process or a result of deranged pulmonary dynamics affecting esophageal motility.

Disclosure

All authors have declared no conflicts of interest.
PS01.020: OPTIMISTIC PATIENTS AND ITS HIDDEN PERILS: A REVIEW OF ACID REFLUX IN INDIVIDUALS POST PER-ORAL ENDOSCOPIC MYOTOMY (POEM)
Authors: Zhi Lim Tian , Qi Leong Wei , Chin Teo Siok , Chen Elya , Wei Kim Guo , Shabbir Asim , Yan Bok , So Jimmy
Published: September 2018

Background

Per-Oral Endoscopic Myotomy (POEM) has been adopted as a treatment option for Achalasia, with similar efficacy and safety profile as laparoscopic Heller Myotomy. However, issues of acid reflux and reflux oesophagitis have often plagued these patients. We aim to evaluate the clinical outcomes and resolution of reflux disease among individuals post-POEM.

Methods

A prospective review was performed for all patients who have undergone POEM from January 2014 to December 2017, with individuals analysed at the 1 year mark post-POEM. Subjective assessment of reflux was performed using self-administered questionnaires, with 24h pH impedence test and high resolution manometry providing objective correlation.

Results

Forty-three individuals underwent POEM during the 4 year period. The median age was 52 years (range, 24–78), with half being males (53.5%). The individuals had a median ASA score of 2 (range, 1–3). Majority of the individuals had type II achalasia (58.1%) followed by type I (34.9%) and type III (7%). Patients presented with dysphagia (88.4%) and reflux (10%); symptomatic for a median of 36 months (range, 3–540). One-third required the use of proton pump inhibitors (PPI) for symptomatic relief, with 35% receiving prior interventions for achalasia. These patients had a median Integrated Relaxation Pressure (IRP) of 23.6 mmHg (range, 4.6–160) and a median Eckardt score of 6 (range, 1 -11). One-third developed complications such as mucosal injury (18.6%), carbon dioxide pneumoperitoneum (16.3%) and bleeding (4.7%). The median length of stay was 3 days (range, 1–6). At the 1 year mark, 86% reported improvement in dysphagia (p: 0.043) with 66% having reduction in ratings for their severity (p: 0.002) and frequency (p: 0.05) of reflux. The median IRP (23 vs 13 mmHg) was also significantly lower (p: 0.005). However, only 38.5% correlated with a normal acid exposure on the impedence test (p: 0.592).

Conclusion

POEM is a promising solution in the management of achalasia given good clinical response for dysphagia and reflux. However, excessive lower oesophageal acid exposure may still be present in almost half of these patients, which may be alleviated with the use of long term use of PPI.

Disclosure

All authors have declared no conflicts of interest.
PS01.022: EVALUATION OF THE EFFECT OF THE HORMONE STATUS ON GASTROESOPHAGEAL REFLUX DISEASE, ESOPHAGEAL MOTILITY DISORDERS AND GASTROINTESTINAL SYMPTOMS
Authors: Weitzendorfer Michael , Wahl Lisa , Emmanuel Klaus , Koch Oliver
Published: September 2018

Background

The aim of the study was to evaluate, if gastroesophageal reflux disease (GERD), esophageal motility disorders and gastrointestinal symptoms are influenced by the levels of hormones.

Methods

One-hundred patients with symptoms of GERD were included in the study. All patients routinely underwent 24-hours esophageal impedance pH-monitoring (MII-pH) and high-resolution esophageal manometry (HRM). Symptoms were evaluated using the Reflux-symptom index (RSI) and symptom check list (SCL) questionnaire. Blood samples were taken to analyze the levels of thyroid stimulating hormone (TSH), free triiodothyronine (FT3), free tetraiodothyronine (FT4), gastrin, vasoactive intestinal peptide (VIP) and calcitonin. According to the results of HRM, patients were subdivided into three motility disorder groups: patients with EGJ (esophageal gastric junction) outflow obstruction or major motility disorders (group I), patients with minor motility disorders (group II) and patients with normal esophageal motility (group III). According to the results of 24h-pH-impedence-monitoring patients were divided in patients with and without objective GERD.

Results

Complete data was available from 86/100 patients (44 men, 42 women with a median age of 56 years). Motility disorders were found in 38/86 patients (22 in group I, 16 in group II). A pathological DeMeester score was found in 45/86 patients (median score 35). No correlation between different hormone levels and DeMeester score, LES-pressure and patients with motility disorders (group I, II) was found. A significant difference regarding calcitonin level was found between group I and III (P = 0043). Furthermore a strong inverse relation between calcitonin and the Integrated Relaxation Pressure (IRP) was found (r = -0492; P = 0000). Positive correlations were found between VIP and GI-Symptoms (r = 0298; P = 0011), as well as correlations between FT3 and dysphagia (r = 0283, P = 0016).

Conclusion

Calcitonin could have an effect on the function of the EGJ and esophageal motility. The hormones TSH, FT3, FT4, VIP and gastrin do not affect the motility of the esophagus and the EGJ. The levels of the evaluated hormones do not influence distal acid exposure. Thyroid hormones, as well as VIP seem to influence gastrointestinal symptoms.

Disclosure

All authors have declared no conflicts of interest.
PS01.024: ENDOSTIMTM THERAPY IN PATIENTS WITH ESOPHAGEAL MOTILITY DISORDERS
Authors: Matthias Corvinus Florian , Hadzijusufovic Edin , Babic Benjamin , Lang Hauke , Grimminger Peter
Published: September 2018

Background

Electric stimulation of the lower esophageal sphincter is a new surgical option for patients with gastroesophageal reflux disease (GERD) and a diaphragmatic hernia less than 3 cm. In comparison to standard anti-reflux procedures like Nissen or Toupet fundoplication the procedure`s advantage is that there had been no report on postoperative dysphagia. Esophageal motility disorders can increase the risk of dysphagia after fundoplication. Therefor EndostimÔ might be an alternative for these patients.

Methods

Between December 2015 and November 2017 twelve patients with GERD received Endostim™ therapy. All patients underwent endoscopy, high resolution impedance manometry (HRIM), 24 hour impedance pH-monitoring and a barium swallow. Quality of life was assessed by GERD-HRLQ a validated questionnaire.

Results

Seven patients with an esophageal motility disorder received an Endostim™ due to symptomatic GERD. Three patients had an esophageal hypomotility, 2 patients had a CREST syndrome and 2 patients showed a functional outflow obstruction in HRIM. There were no postsurgical complications. No dysphagia, regurgitation or retrosternal pain was reported. After a follow up of 6 months all patients are satisfied with the procedure and report an increase of their quality of life.

Conclusion

These results demonstrate the feasibility of an Endostim™ therapy in patients with esophageal motility disorders for the first time.

Disclosure

All authors have declared no conflicts of interest.
PS01.026: CHANGES IN SURGICAL PROCEDURES AND SHORT-TERM OUTCOMES FOR ACHALASIA SINCE THE INTRODUCTION OF POEM
Authors: Yano Fumiaki , Omura Nobuo , Tsuboi Kazuto , Hoshino Masato , Yamamoto Se-Ryung , Akimoto Shunsuke , Masuda Takahiro , Nishikawa Katsunori , Mitsumori Norio , Kashiwagi Hideyuki , Matsui Hiroaki , Sumiyama Kazuki , Yanaga Katsuhiko
Published: September 2018

Background

In our institution, laparoscopic Heller-Dor procedure (LHD) has been the first-line surgical procedure for achalasia since the introduction in August 1994, and 578 patients underwent LHD until January 2018. In January 2016, per-oral endoscopic myotomy (POEM) was started, taking into patients’ needs into consideration. Since then, treatment options have expanded to include balloon dilation, conventional LHD, LHD by reduced port surgery (RPS), LHD by needlescopic surgery (NS), and POEM. Here, we report changes we have observed in surgical procedures and short-term outcomes since the introduction of POEM.

Methods

The subjects were 82 patients (mean age 47.4 ± 14.7 years, 39 women) who underwent surgery for achalasia from January 2016 to January 2018. After explaining the advantages and disadvantages, the choice of surgical procedure was decided by the patient.

Results

The surgical procedures consisted of LHD in 57 (including 1 RPS and 33 NS) and POEM in 25 patients. A total of 7 peri-operative complications (POEM = 1) were observed in 7 patients (9%), consisting of gastroesophageal mucosal injury (7%, LHD) and injuring of esophageal longitudinal muscles (2%, POEM), while dysphagia improved in all patients. Postoperative reflux esophagitis was observed in 9 patients with POEM (36%), which was significantly higher than 6 patients (11%) in LHD (P = 0.0173).

Conclusion

While 30% of patients underwent POEM, reflux esophagitis occurred at a higher rate in POEM as compared to LHD.

Disclosure

All authors have declared no conflicts of interest.
PS01.029: QUALITY OF LIFE IN PATIENTS WITH ESOPHAGEAL ACHALASIA AFTER VIDEO-LAPAROSCOPIC SURGERY
Authors: Jiménez Raul , Roque González Rosalba , Angel Martínez Miguel , Anido Vivianne , Neri Pinol Felipe
Published: September 2018

Background

Achalasia is the most frequent motor disorder of the esophagus associated with dysphagia, regurgitation, weight loss and a decline in the quality of live. Videolaparoscopic surgery remains the gold standard, however health related quality of live measurements still necessary to asses treatment results and the impact on their lives. Asses health related quality of live in patients with esophageal achalasia after videolaparoscopic surgery.

Methods

Observational descriptive longitudinal and prospective study, by using GIQLI questionnaire before, three months and a year after videolaparoscopic surgery in patients with achalasia from January to December 2015 in the National Center of Minimally Invasive Surgery. Percentages for qualitative variables, means ± SD of the mean for quantitative variables. To asses health related quality of live a variance analysis of repetitive measures was made (ANOVA) with level of statistical significance α = 0.05.

Results

34 patients included; 14 men (41,2%); 20 women (58,8%), with a median age of 44,8 years, preoperative median GIQLI score 85,6 (± 20,9), median GIQLI at follow-up of three months was 125,2 (± 12,4) and twelve months was 134,0 (± 9,6) P = 0000.

Conclusion

Videolaparoscopic surgery improve health related quality of live in patients with esophageal achalasia.

Disclosure

All authors have declared no conflicts of interest.
PS01.032: OUTCOMES OF MINIMALLY INVASIVE MYOTOMY FOR THE TREATMENT OF ESOPHAGEAL ACHALASIA
Authors: Roque González Rosalba , Angel Martínez Miguel , Anido Vivianne , Torres Rafael , Jiménez Raul , Neri Pinol Felipe , Bencil Samira
Published: September 2018

Background

Laparoscopic Heller myotomy and fundoplication is considered today the treatment of choice for achalasia. The primary objective of this study was to review our experience in minimally invasive myotomy as primary therapy for the treatment of esophageal achalasia.

Methods

A retrospective analysis of a prospective database was made in which 253 clinical histories of patients diagnosed with EA were reviewed. These patients underwent primary laparoscopic Heller´s myotomy from January 2010 to December 2016. Duration of symptoms, previous endoscopic treatments, degree of dilation of the esophagus and clinical progress were some of the variables assessed. Postoperative assessment was obtained through the attending physicians’ consultations and recorded in the clinical history at six months and one year. Vantrappen and Helleman´s classification was used.

Results

253 Heller´s myotomies were performed by laparoscopic approach. The mean age of the patients was 47 years (range, 16 to 86). Duration of the symptoms was between 7 and 360 months, with an average of 54 months. The mean operative time was 100 minutes (range 90–210). Average hospital stay was one day. There were no conversions and no mortalities. Four patients (1,1%) underwent redo surgery. The clinical progress was excellent in 98,5% of patients.

Conclusion

Laparoscopic myotomy is the first line of treatment of esophageal achalasia. In this series of patients, laparoscopic Heller´s myotomy was an effective and safe treatment for esophageal achalasia.

Disclosure

All authors have declared no conflicts of interest.