Diseases of the Esophagus最新文献

Background: Empiric elimination diets remain a cornerstone of treatment for eosinophilic esophagitis (EoE). Immunoglobulin E (IgE) mediated allergic reactions have been sparsely reported during the food reintroduction phase, raising concerns both for patients and physicians. We aimed to assess the physician reported rates of new-onset IgE mediated reactions in EoE associated elimination diets (NIMREEDs), physician awareness of NIMREEDs, and how awareness impacts physician and patient treatment selection.

Methods: An international REDCap based questionnaire was distributed via interest groups, gastroenterologist server lists, and professional societies. Physicians were asked about their personal awareness and experience with NIMREEDs and how their knowledge affects physician and patient treatment decisions when contemplating elimination diets (ED) for treatment of EoE.

Results: Between January and July 2023, 145 responses were included in this analysis. Of the 12,698 patients with EoE cared for in all responding centers, 4903 (38.6%) had attempted ED. NIMREEDs were reported in 43/4903 (0.88% [95% CI 0.5-1.2%]). Ninety-six (66.2%) physicians were aware of potential reactions, however only 71/96 (73.9%) discussed them with patients. Knowledge of NIMREEDs deter 17/96 (17.7%) physicians from recommending ED for EoE, and 15/71 (21.1%) of those who informed patients, reported reluctance of patients to undertake ED.

Conclusion: NIMREEDs following food re-introduction in the treatment of EoE are uncommon, nevertheless they are not widely recognized by physicians. Knowledge concerning NIMREEDs may affect both patient and physician treatment decisions and preferences, as they have potential to negatively affect quality of life, emphasizing the need for increased awareness to NIMREEDs in EoE patients.

Achalasia treatment outcomes are often assessed using the Eckardt score, which has not been formally validated and is not designed as a patient-reported outcome (PRO) tool. To address this unmet clinical need, a group of healthcare providers developed the International Patient-oriented tool for Achalasia Symptom Score (I-PASS), which aims to record both symptom severity and frequency in a patient-oriented manner. Using the RAND/ University of California, Los Angeles, Appropriateness Methodology, a 16-member international, multidisciplinary panel identified key symptomatic domains through three Delphi rounds. Dysphagia, regurgitation (daytime and nocturnal), and chest pain were selected as primary domains, with weight loss included as an additional factor. Severity and frequency scoring were agreed upon, resulting in a maximum composite score of 53. The pretreatment I-PASS was pilot-tested in 118 treatment-naïve achalasia patients in the UK and Italy. Comprehension, completion time, acceptability, and correlation with the standard Eckardt score were assessed. All the patients completed the I-PASS. Most (96.5%) reported full comprehension, the median completion time was 10 minutes, and 98% expressed willingness to complete it again. The median I-PASS score was 29 (IQR 20-36), compared with a median Eckardt score of 7 (IQR 5-9). A strong correlation was observed between I-PASS and Eckardt (ρ = 0.68, P < 0.0001). Regression analysis confirmed that each one-point increase in Eckardt corresponded to a 3.1-point increase in I-PASS. The I-PASS questionnaire is feasible, well accepted, and provides a more comprehensive assessment of achalasia symptoms than the Eckardt score. Future studies will evaluate its reliability, responsiveness, and validity as a standardized PRO instrument.

Esophageal food impaction (EFI) is a gastrointestinal emergency that often requires urgent endoscopy. Predictors of recurrence and adverse events remain understudied and inconsistently reported. We conducted a systematic review and meta-analysis to identify predictors of recurrence and adverse events in EFI. We systematically searched PubMed, Embase, and the Cochrane Library on March 1, 2025. We included any observational studies or clinical trials that evaluated EFI outcomes in adults. The primary outcomes were EFI recurrence and adverse events, assessed according to underlying esophageal pathology, biopsy practices, follow-up, and timing of endoscopy. Effect sizes were evaluated using odds ratios (ORs), and a random-effects model was applied. A total of 14 studies were included with 3116 patients. Male gender was modestly associated with a higher risk of EFI recurrence (OR 1.45; 95% CI 1.01-2.10; P = 0.05), and patients with eosinophilic esophagitis (EoE) had a markedly increased risk of recurrence (OR 3.28; 95% CI 2.09-5.14; P < 0.001). No significant associations with recurrence were observed for biopsy (OR 1.44; 95% CI 0.98-2.11; P = 0.06), those who underwent follow-up (OR 1.10; 95% CI 0.37-3.32; P = 0.74), gastroesophageal reflux disease (GERD) (OR 1.22; 95% CI 0.46-3.23; P = 0.68), or hiatal hernia (OR 1.84; 95% CI 0.51-6.65, P = 0.35). For any adverse events, neither a history of prior EFI (OR 1.80; 95% CI 0.26-12.26) nor the timing of endoscopy (OR 0.89; 95% CI 0.49-1.64) was significantly associated with increased risk. Similarly, gender, EoE, and GERD were not associated with increased risk of adverse events. Only the male gender and EoE were significantly associated with a higher risk of EFI recurrence. Other factors, including GERD, hiatal hernia, follow-up, and biopsy status, were not. Delayed endoscopy and prior EFI were not associated with increased adverse events. Large-scale studies are needed to define risk factors better and strengthen the risk-stratification guide for preventive strategies.

Patient-reported outcome measures (PROs) in eosinophilic esophagitis (EoE) have been utilized as research tools to assess outcomes in clinical trials. To our knowledge, adult and pediatric EoE PROs have not previously been analyzed from a health literacy perspective. We aimed to evaluate the readability of the most utilized EoE PROs for adult and pediatric populations and assess whether these PROs met national health literacy recommendations of readability at or below the sixth-grade level. We conducted a readability analysis of thirteen EoE PROs using four readability measures: Flesch-Kincaid Grade Level, Gunning Fog, Simple Measure of Gobbledygook, and FORCAST. Across these four individual metrics, the mean readability levels (years of education required) for PROs were 4.1, 5.5, 7.1, and 9.6, respectively. The four pediatric EoE PROs (PedsQL EoE module parent report for teens, PedsQL EoE module teen report, PEESS children and teen report, and PEESS parent report) included in this study had mean readability levels of 6.4, 6.2, 5.9 and 6.0, respectively. The nine included adult EoE PROs (EoE-QoL-A, BEDQ, DSQ, EoE-IQ, EEsAI, EoE-SQ, PiEAQ, PROMIS Scale v1.0-Gastrointestinal Disrupted Swallowing, and Straumann Dysphagia Instrument) had mean readability levels ranging from 5.3 to 8.7 with a standard deviation of 1.2. The average readability for all included EoE PROs was 6.6. In conclusion, current EoE PROs as research tools are slightly above recommended readability levels. Future EoE PRO development could be strengthened by using shorter sentences, writing for the target audience, and utilizing input from age-appropriate patients.

Esophageal cancer (EC) remains a leading cause of cancer-related mortality worldwide. For patients with locally advanced, non-metastatic EC, advances in perioperative care, and surgical techniques have led to improved outcomes; however, significant variation persists, and standardization remains limited. This study aimed to characterize current practice patterns among expert surgeons at high-volume European centers through a structured, in-depth survey. Eight expert upper gastrointestinal surgeons from European centers performing >60 esophagectomies annually participated in comprehensive interviews. Topics included preoperative care pathways for distal esophageal/gastroesophageal junction adenocarcinoma, technical aspects of Ivor Lewis esophagectomy, and postoperative recovery protocols. Additional focus areas included multidisciplinary team involvement, allied health integration, research program participation, and follow-up strategies. Widespread agreement (7-8 of 8 centers) was observed in several domains: national EC care regionalization, multidisciplinary cancer conference review of all patients, institutional EC research programs, use of prospective national/international databases, application of CROSS chemoradiotherapy for squamous cell carcinoma, and perioperative FLOT chemotherapy for adenocarcinoma. Common surgical techniques included minimally invasive Ivor Lewis esophagectomy, two-field lymphadenectomy with en-bloc thoracic duct ligation, nasogastric tube placement, omental wrap of the anastomosis, and Enhanced Recovery After Surgery-based postoperative protocols. The majority of centers (5-6/8) performed routine preoperative optimization (nutrition, smoking cessation, frailty screening, oral hygiene/microbiome assessment), jejunostomy placement, and postoperative contrast swallow studies. Areas with notable variability (≤4/8 centers) included intraoperative crural closure, pyloric drainage procedures, gastric conduit sizing, postoperative pain management, and follow-up imaging timelines. High-volume European centers demonstrated strong alignment in several programmatic and perioperative elements of EC care, particularly around enhanced recovery pathways and preoperative optimization. Nonetheless, key intraoperative and postoperative variations persist, highlighting opportunities for future research, consensus building, and standardization to improve patient outcomes.

Esophageal high-resolution manometry (HRM) is the gold standard for evaluating esophageal motility disorders but can be limited by patient intolerance. With increasing use of glucagon-like peptide-1 receptor agonists (GLP-1RAs) for obesity and type 2 diabetes, delayed gastric emptying raises concerns for HRM feasibility and safety. This study assessed HRM tolerability in patients on GLP-1RAs. We conducted a retrospective case-control study of adult patients who underwent HRM at our tertiary care center between January 2014 and November 2024. Patients actively taking GLP-1RAs during HRM were identified as cases, while an equal number of consecutive eligible patients not on GLP-1RAs served as controls. Patients with established gastrointestinal dysmotility, prior foregut surgery, esophageal mechanical obstruction, large hiatal hernias, malignancy, or recent opioid use were excluded. From a prospective database of 7194 HRM attempts, 83 cases and 83 matched controls were identified. Among 166 patients, 15 (9.0%) had incomplete HRM due to intolerance, with similar rates between GLP-1RA users and controls (10.84% vs. 7.2%, P = 0.59). Predictors of incomplete HRM included younger age (44.9 ± 17.4 vs. 60.4 ± 13.7 years, P < 0.01), globus (P = 0.02), dyspepsia (P = 0.02), and depression (P = 0.04). No aspiration or adverse events occurred in either group. Duration of HRM before abortion was similar between cases and controls. GLP-1RA use was not associated with increased risk of HRM abortion or adverse events, suggesting these medications do not significantly impact HRM feasibility or safety.

Background: Chemoradiotherapy using proton beam therapy is a novel and promising option for patients with esophageal squamous cell carcinoma (ESCC) who do not prefer surgical treatment.

Materials and methods: This was a single-center retrospective cohort study. Patients diagnosed with thoracic ESCC, clinical Stages I, II, or III, who underwent definitive proton-based chemoradiotherapy (PBC) or surgery-based treatment (SBT) between 2009 and 2020 were included. Patients intolerant to surgery or palliative radiotherapy were excluded. PBC was defined as radical-intent chemoradiotherapy using a proton beam with chemotherapy, and a combination of photon radiation was allowed. SBT was defined as subtotal esophagectomy with lymph node dissection with or without adjuvant chemotherapy. The propensity score matching was performed using potential confounding factors as covariates. The primary endpoints were the hazard ratio (HR) and 5-year overall survival (5yOS).

Results: This study included 247 patients (112 with SBT and 135 with PBC). Survival outcomes were compared between the 95 patients in each group using propensity score matching. The mean observation period was 57.5 months. The 5yOS was 62.0% in the SBT and 55.3% in the PBT group (P = 0.421). The adjusted HR for PBC was 1.22 (0.79-1.90). No treatment-related deaths occurred in the PBC group. Serious adverse events included neutropenia (n = 5), esophageal ulcer (n = 3) in the early phase, and esophageal fistula (n = 3), pleural effusion (n = 1), and pericardial effusion (n = 1) in the late phase.

Conclusion: Radical chemoradiotherapy using proton beams is a promising treatment option for patients with ESCC who do not prefer surgery in terms of safety and efficacy.

Esophageal squamous cell carcinoma (ESCC) often metastasizes to supraclavicular lymph nodes (SCLNs), which are potentially curable distant metastases by SCLN dissection during esophagectomy. Prophylactic SCLN dissection should be based on an accurate preoperative assessment of SCLN metastasis. We evaluated 199 patients who received neoadjuvant chemotherapy, followed by esophagectomy with three-field lymph node dissection for ESCC. For each patient, the largest SCLN was measured on the left and right sides. Long- and short-axis diameters of 398 SCLNs were measured using computed tomography (CT), and long-to-short-axis ratio was calculated. Diagnostic accuracies of the long- and short-axis diameters and long-to-short-axis ratio were determined using area under the curve (AUC) of the receiver operating characteristic plot. Of the 199 patients, 16.6% had pathological SCLN metastasis. AUCs of the short-axis diameter had the most significant values in the left and right sides compared with the other variables, at 0.93 (95% confidence interval [CI]: 0.89-0.97) for the left side and 0.92 (95% CI: 0.87-0.97) for the right side. When the short-axis diameter was <5 mm after chemotherapy, negative predictive value was sufficiently high (99.4% and 98.2% for the left and right SCLNs, respectively). In contrast, when the diameter exceeded 8 mm, positive predictive value increased to 71.4% and 83.3% in the left and right SCLNs, respectively. The short-axis diameter of the largest SCLN on CT after neoadjuvant chemotherapy appears to be a helpful indicator for diagnosing SCLN metastasis in patients with ESCC after neoadjuvant chemotherapy.

Background: In esophageal squamous cell carcinoma, three-field lymph node dissection (3FLND) is not commonly performed after neoadjuvant chemoradiotherapy (nCRT) due to the high morbidity associated with the procedure and the poor long-term survival of patients with cervical/supraclavicular lymph node metastasis. This study aims to evaluate the long-term survival outcomes of patients who underwent 3FLND combined with nCRT.

Methods: Between 2013 and 2021, patients who underwent esophagectomy and 3FLND after nCRT for advanced thoracic esophageal squamous cell carcinoma, either with (n = 41) or without (n = 65) clinical cervical/supraclavicular lymph node metastasis, were included in this study.

Results: The Ivor Lewis and McKeown procedures were performed in 22 patients (20.8%) and 84 patients (79.2%), respectively. The rates of major complications (Grade ≥ IIIb) and 90-day mortality were 6.6% and 2.8%, respectively. A pathological complete response was observed in 26 patients (24.5%), whereas residual cervical/supraclavicular lymph node metastasis was identified in 30 patients (28.3%). The five-year overall survival rates for patients with and without preoperative cervical/supraclavicular lymph node metastasis were 51.5% and 41.4%, respectively. Multivariable analysis of survival in patients with preoperative cervical/supraclavicular lymph node metastasis identified residual cervical/supraclavicular lymph node metastasis (hazard ratio [HR] = 7.885, P < 0.001) and major complications (HR = 74.581, P = 0.001) as significant risk factors for overall survival.

Conclusions: 3FLND combined with nCRT can achieve favorable long-term survival even in patients with esophageal cancer and cervical/supraclavicular lymph node metastasis. Downstaging of cervical lymph node metastasis is a key factor in improving survival outcomes for these patients.

Background: Lymphocytic esophagitis (LyE) is a novel rare esophageal disorder characterized by intraepithelial lymphocytic infiltration of the esophagus in a peripapillary distribution, without the involvement of granulocytes. The optimal treatment strategy for this condition remains uncertain. We aimed to synthesize the current evidence for the treatment of lymphocytic esophagitis.

Methods: We performed a systematic review according to PRISMA guidelines, searching MEDLINE, Embase, and Google Scholar. Studies with non-primary data or insufficient treatment data were excluded. Descriptive statistics were performed on patient demographics and treatment outcomes.

Results: Thirty nine articles from 2012-2024 were included (154 patients total). Proton pump inhibitors (PPIs) were the most common initial therapy for LyE (n = 65), followed by topical steroids (n = 23). A greater proportion of patients experienced a symptomatic, endoscopic, and histologic response from the initial use of topical steroids as monotherapy or part of combination therapy (with PPIs) compared to PPIs alone. Symptomatic recurrence was more common after initial use of topical steroids compared to PPIs. Balloon dilation was effective in relieving symptomatic esophageal dysphagia. Other therapies included biologics, endoscopic botulinum injections, sucralfate, and tacrolimus. The average follow-up duration was 8.98 months.

Conclusions: For patients with LyE, topical steroids seem to provide greater symptomatic and histologic benefit compared to PPIs, although recurrence is more common. For patients not already on acid suppression therapy, PPIs may still be a reasonable first-line option, especially when prioritizing safety. Further prospective studies are needed to formally assess the comparative safety and efficacy of the various treatment modalities, including novel immunosuppressive therapies.