Diseases of the Esophagus最新文献

Endoscopic eradication therapy using radiofrequency ablation (RFA) is considered an acceptable alternative to surveillance monitoring for Barrett's esophagus with low-grade dysplasia (LGD). This study aimed to estimate whether RFA for LGD is cost-effective and to determine which factors influence cost-effectiveness. A Markov model was developed to estimate the incremental cost per quality-adjusted life year (QALY) gained for RFA compared with endoscopic surveillance. An Australian longitudinal cohort study (PROBE-NET) provides the basis of the model. Replacing surveillance with RFA yields 10 fewer cases of HGD and 9 fewer esophageal adenocarcinoma (EAC)-related deaths per 1000 patients' treatment, given on average 0.192 QALYs at an additional cost of AU$9211 (€5689; US$6262) per patient (incremental cost-effectiveness ratio AU$47,815 per QALY). The model is sensitive to the rate of EAC from LGD health state, the utility values, and the number of RFA sessions. Hence, the incremental benefit ranges from 0.080 QALYs to 0.198 QALYs leading to uncertainty in the cost-effectiveness estimates. When the cancerous progression rate of LGD falls <0.47% per annum, the cost-effectiveness of RFA becomes questionable. RFA treatment of LGD provides significantly better clinical outcomes than surveillance. The additional cost of RFA is acceptable if the LGD to EAC rate is >0.47% per annum and no more than three RFA treatment sessions are provided. Accurate estimates of the risk of developing EAC in patients with LGD are needed to validate the analyses.

Background: Minimally invasive hiatal hernia (HH) repair is the gold standard for correcting mechanical defects of the crural diaphragm due to its safety and favorable clinical outcomes (i.e., relief of patient symptoms). However, several operative factors, including HH size, may negatively affect the postoperative course. We sought to determine if an increase in HH size was associated with an increased risk of perioperative complications, ICU admission, or hospital readmissions after minimally invasive HH repair.

Methods: We conducted a retrospective observational cohort study of patients who underwent primary HH repair by an experienced foregut surgeon between September 2016 and July 2023. Four groups were defined based on the percentage of stomach at the thorax determined during surgery (small-HH: <25%, moderate-HH: 25-49%, large-HH: 50-74%, and intrathoracic stomach [ITS]: ≥75%). Covariates were compared between the groups, and logistic regressions were performed to identify factors associated with postoperative morbidity.

Results: A total of 391 patients (73.7% female; mean age, 64.4 ± 12.5 years) comprised the groups: small-HH (n = 160), moderate-HH (n = 63), large-HH (n = 64), and ITS (n = 104). Patients with ITS were older (p < 0.001), had longer operations (p < 0.001), greater blood loss (p < 0.001), longer hospital stays (p < 0.001), and an increased risk of early postoperative complications (aOR 2.59 [CI95: 1.28-5.25], p = 0.009) and ICU admission (aOR 13.3 [CI95: 3.10-57.06], p < 0.001).

Conclusion: An increase in HH size was associated with an increased risk of early postoperative complications, ICU admission, and a trend toward higher 30- and 90-day hospital readmissions, likely due to the progressive nature of the disease.

Enhanced Recovery After Surgery (ERAS) protocols are evidence-based care improvement pathways which are perceived to expedite patient recovery following surgery. Their utility in the setting of oesophagectomy remains unclear. The aim of this study was to perform a systematic review and meta-analysis of randomised clinical trials (RCTs) to evaluate the impact of ERAS protocols on recovery following oesophagectomy compared to standard care. A systematic review was performed in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines. Meta-analysis was performed using Review Manager (Version 5.4). Six RCTs including 850 patients were included in this meta-analysis. Overall complication rate (Odds Ratio (OR): 0.35, Confidence Interval (CI): 0.21, 0.59, P < 0.0001), pulmonary complications (OR: 0.40, CI: 0.24, 0.67, P = 0.0005), post-operative length of stay (LOS) (OR -1.88, CI -2.05, -1.70, P < 0.00001) and time to post-operative flatus (OR: -5.20, CI: -9.46, -0.95, P = 0.02) favoured the ERAS group. There was no difference noted for anastomotic leak (OR: 0.55, CI: 0.24, 1.28, P = 0.17), cardiac complications (OR: 0.86, CI: 0.30, 2.46, P = 0.78), gastrointestinal complications (OR: 0.51, CI: 0.23, 1.17, P = 0.11), wound complications (OR: 0.85, CI: 0.28, 2.58, P = 0.78), mortality (OR: 1.37, CI: 0.26, 7.4, P = 0.71), and 30-day re-admission rate (OR: 1.29, CI: 0.30, 5.47, P = 0.73) between ERAS and standard care groups. ERAS implementation improved post-operative complications, LOS, and time to flatus following oesphagectomy. These results support the robust adoption of ERAS in patients indicated to undergo oesphagectomy.

The most common functional challenge after Ivor-Lewis esophagectomy is delayed emptying of the gastric conduit. One of the primary endoscopic treatment strategies is performing a pyloric dilatation. However, the effects of dilation have never been scientifically proven. A novel method to detect pyloric distensibility (DI) is the endoluminal functional lumen imaging probe (EndoFlip™). The purpose of this study is to analyze the effects of pyloric dilatation using an EndoFlip™ measurement. Forty-nine patients after Ivor-Lewis esophagectomy were included retrospectively from June 2021 to August 2023 at University Hospital Cologne, Germany. All patients suffered from early delayed emptying of the gastric conduit (DGCE). DI was measured before and after endoscopic dilatation using EndoFlip™ at 40, 45, and 50 mL balloon filling. The Student's t-test and Chi-Squared test were used. All tests were two-sided, with statistical significance set at P ≤ 0.05. EndoFlip™ measurement and pyloric dilatation were feasible in all patients and no adverse events were recorded. DI proved to be smaller in patients before dilatation compared to patients after dilatation. For 40, 45, and 50 mL balloon filling, the mean DI was 5.0 versus 10.0, 4.5 versus 9.1, and 4.0 and 7.5 mm2/mmHg before versus after dilatation. The differences were significant in all balloon fillings. Endoscopic dilatation of the pylorus is the primary endoscopic treatment strategy in patients suffering from DGCE. Currently, the success of dilatation can only be measured with clinical data. This study could demonstrate that EndoFlip™ can be used as an additional diagnostic tool to rate the success of pyloric dilatation.

This study investigated the clinical outcomes of gastric conduits for esophageal reconstruction in esophageal squamous cell carcinoma (ESCC) patients who had previously undergone endoscopic resection of the stomach. From January 2006 to April 2023, a total of 1964 patients underwent surgery for esophageal cancer at our institution. After initially excluding 125 of these cases due to a histology other than ESCC, we identified 147 patients in the remaining population who had previously undergone a gastric endoscopic resection, among which 56 patients (67.0 ± 6.5 years) were included in the present study cohort. A gastric conduit event was defined as any new lesions at the gastric conduit. The diagnoses of a previous gastric lesion included early gastric cancer (EGC) in 32 patients (57.1%), adenoma in 23 patients (41.1%), and dysplasia in 1 (1.8%) patient. The endoscopic procedures involved an endoscopic submucosal dissection (ESD) in 36 patients (64.3%) and an endoscopic mucosal resection in 20 patients (35.7%). The 10-year event-free survival rate for the gastric conduit was 43.7%. Five patients were diagnosed with metachronous gastric neoplasm (EGC in two and adenoma in three patients). Endoscopic procedures were available for all five cases, but one patient with a metachronous EGC required a colon interposition with a total gastrectomy. In ESCC patients who have undergone an endoscopic resection of their gastric lesions, subsequent esophageal reconstruction with a gastric conduit could be a viable option if followed by regular endoscopic surveillance for the early detection and endoscopic curability of any lesions.

Managing esophageal squamous cell carcinoma (ESCC) in patients with a history of cervical radiotherapy for a head and neck cancer (HNC) often requires a careful evaluation of esophagectomy due to concerns regarding complications and prognosis. This study evaluates the periesophagectomy and oncological outcomes of such patients. Patients diagnosed with ESCC between January 2010 and August 2023 and who had undergone esophagectomy with cervical anastomosis were retrospectively reviewed. Patients were categorized into two groups based on the presence (group 1) or absence (group 2) of a history of radiotherapy for as HNC. After 1: 2 propensity score matching, the perioperative and oncological outcomes, including overall survival (OS) and recurrence-free survival (RFS), were evaluated. A total of 481 patients, 32 in group 1 and 449 in group 2, were included. After matching, group 1 patients and 64 patients in the group 2 were analyzed. All the patients in group 1 were males, and their mean age was 56 years. The median radiation dose was 69 Gy. The rates of anastomosis leakage, pneumonia, respiratory failure, and reoperation were comparable between the two groups. However, vocal cord palsy occurred more frequently in group 1, particularly in those with recurrent laryngeal nerve lymph node dissection (37.5%). The 3-year OS (69.6% vs. 75.2%; p = 0.26) and RFS (50.8% vs. 55.9%; p = 0.63) were similar between groups 1 and 2. In conclusion, perioperative and oncological outcomes were comparable between ESCC patients with and without prior HNC radiotherapy, supporting esophagectomy as a feasible option.

Several proton pump inhibitor (PPI) dosing regimens that vary by strength and frequency (once [Qday] or twice [BID] daily) are available to treat gastroesophageal reflux disease (GERD). We performed an updated systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the impact of various PPI regimens on esophageal healing and GERD and heartburn symptoms. To identify relevant studies, we searched EMBASE and PubMed in January 2023, which yielded 1381 records. Eligible RCTs included those that enrolled adults diagnosed with GERD and compared different dosing regimens within the same PPI. The outcomes were esophageal healing and resolution of GERD and heartburn symptoms within 12 weeks (i.e. short-term) and > 12 weeks (i.e. long-term). Meta-analysis pooling of the odds ratios with 95% confidence intervals were estimated using the random-effects inverse-variance model. Overall, a total of 38 RCTs across 20 countries (N = 15,540 patients, mean age 50 years, 55% male) were included. Most PPI trials compared half standard dose Qday versus standard dose Qday or standard dose Qday versus double standard dose Qday. In general, when considering daily dosing, higher PPI strength significantly improved esophageal healing and relief of GERD symptoms both in the short- and long-term. Fewer trials compared Qday versus BID dosing; the impact of BID dosing on outcomes was inconsistent across the different PPI strength comparisons. In conclusion, this meta-analysis revealed that increasing PPI Qday dosages led to improved GERD outcomes. However, few studies compared Qday to BID dosing; as twice daily PPI usage is common in clinical practice, further studies are warranted to determine whether such dosing improves clinical outcomes.