Diseases of the Esophagus最新文献

Understanding patients' beliefs about their medical condition is of significant importance as they drive individuals' attempts to cope with that condition. This study aimed to examine the beliefs patients with supragastric belching (SGB) have about their condition and the relationship between these beliefs, symptom report, and clinical and demographic variables. One hundred eight patients (67.6% female, mean age 44.07, range 18-80), with a consultant confirmed diagnosis of SGB following high resolution oesophageal manometry and 24-hour pH monitoring studies completed the Brief-Illness Perceptions Questionnaire, which assesses beliefs about the symptoms, chronicity, consequences, personal and treatment control, illness coherence, perceived causes, and patients' emotional response to their SGB. A range of demographic and illness-related variables was also collated. Template analysis was undertaken on the 324 free-text responses relating to patients' perceived causes of SGB. Fourteen percent of patients reported not knowing what had caused their SGB. The top four causes identified by the remaining 93 patients were dietary, behavioral, other GI conditions, and psychological. Only 34% considered behavioral factors of importance. There were no significant associations between gender and age in relation to illness beliefs. Patients who believed in a behavioral cause of their SGB had significantly stronger beliefs in having personal control over their SGB (U = 980, z = -2.18, P = 0.03). This study has progressed our understanding of patients' personal beliefs about SGB and provides insights into important cognitive components to address in any intervention. Simple messages around the cause of SGB and correction of misinformation may help in the effective management of this condition.

Non-obstructive esophageal dysphagia (NOD) is a benign condition frequently encountered in clinical practice, often associated with motility disorders, with consequences surpassing the physical dimension and extending to the patient's personal life. However, its characterization, particularly focusing on its impact on quality of life (QoL), remains limited. This prospective study aimed to characterize this population regarding epidemiological, clinical, and manometric aspects. From September 2021 to February 2024, 250 NOD patients were recruited from seven centers. All subjects underwent a comprehensive diagnostic work-up, including upper endoscopy with biopsies, high-resolution esophageal manometry, and timed barium esophagogram, when applicable. Epidemiological and clinical data were collected using the Eckardt, Gerd-Q, and the Portuguese versions of Euro-Qol-5D-3L (EQ-5D) and PROMIS Gastrointestinal Disrupted Swallowing (PDS) scales. Patients were predominantly female (60.8%) with a median age of 63 years [IQR 20]. According to Chicago v4.0, normal esophageal motility was the most frequent diagnosis (n = 93, 37.2%), followed by esophagogastric junction (EGJ) outflow disorders (79 achalasia, 4 EGJ outflow obstruction). Among motility disorders, Eckardt and PDS scores were higher in EGJ outflow disorders (median 5 and mean T-score 64.1, respectively; P < 0.001), although their ability to primarily identify these conditions was limited. Regarding patient-reported QoL, no significant differences were found in EQ-5D, both for time trade-off and visual analog scale values. In summary, normal esophageal motility was the most frequent manometric finding in NOD patients. Although symptom severity was worse in EGJ outflow disorders, QoL appeared equally affected across all motility profiles.

Delayed gastric conduit emptying (DGCE) is a common functional syndrome after esophagectomy. The clinical phenotype is characterized by regurgitation, reflux, and the inability to meet caloric requirements by oral intake. Diagnosis and cause-directed therapy are often challenging because of variable underlying pathomechanisms. Against this background and based on our clinical experience, we propose a classification that categorizes DGCE according to the predominant case-specific pathophysiology: Class I: functional-DGCE due to impaired antro-pyloric motilityClass II: conduit-related-DGCE caused by specific patho-anatomical features of the conduitClass III: hiatal-DGCE resulting from mechanical obstruction at the diaphragmatic hiatusClass IV: other-Other causes of DGCE at or distal to the pylorus (e.g. luminal occlusion, intestinal adhesions or peritoneal carcinomatosis) We believe that this classification has the potential to promote a better understanding of the symptom spectrum of DGCE and to facilitate cause-oriented, focused treatment. Moreover, we are convinced that a structured definition of DGCE according to pathophysiology will improve the comparability of different patient cohorts and thus promote future collaborative research.

Esophageal food impaction (EFI) is the leading complication in patients with undiagnosed eosinophilic esophagitis (EoE). Limited data exists on pre-hospital care, in-hospital management, and post-hospital follow-up in suspected EoE-associated EFI. This study aims to assess deviations between real-life management and guideline-based recommendations in suspected EoE-associated EFI. This retrospective multicenter study analyzed data from four major Swiss gastroenterology units on patients with EoE-associated EFI. Patients with GERD-related strictures or esophageal cancer were excluded. Data on demographics, emergency department (ED), endoscopy management, and follow-up were obtained from electronic health records. Associations between clinical factors and odds of biopsy were analyzed using logistic regression. Between January 2015 and December 2020, 198 EFI cases (median age 51 years, 29.8% female, 28% with previous EFI) were recorded. Patient delay-the time between symptom onset and ED admission-was ~ 270 minutes. Nearly all patients (94%) required endoscopic bolus removal. The median time from ED presentation to endoscopy was ~150 minutes. Esophageal biopsies were taken in just over half of the individuals (n = 97, 52%), leading to a new EoE diagnosis in 71 (68.9% of those biopsied). Biopsy odds decreased significantly with older age (OR 0.96; 95% CI 0.94-0.98, P < 0.05) and known EoE (OR 0.26; 95% 0.09-0.69, P < 0.05). Although EoE is a leading cause of EFI, too few patients with a high baseline probability of EoE undergo biopsy in the emergency setting. Among those biopsied, the majority received a new EoE diagnosis, highlighting the importance of histological assessment.

Background: The optimal time to resume oral intake after esophagectomy remains debated, with practices varying across centers.

Methods: This single-center, retrospective cohort study compared early and late oral feeding regimens after esophagectomy. Perioperative care was identical except for the feeding regimen. Early oral feeding began immediately post-surgery, while late oral feeding started on postoperative day 4 after swallow examination, with jejunostomy for early enteral tube feeding. Propensity score matching was used to reduce confounding. The primary outcome was overall survival. Secondary outcomes included complications, need for an alternative feeding route, hospital stay, readmission, and 90-day mortality.

Results: Between May 2017 and October 2023, 406 patients underwent an esophagectomy (312 transthoracic; 94 transhiatal). After matching, 139 patients were included in both the early and late oral feeding groups. Overall complication rates did not significantly differ (84.9% vs. 77.7%; P = 0.124), but the late oral feeding group had less severe complications (48.9% vs. 36.7%; P = 0.039). The late oral feeding group showed lower leakage rates in intrathoracic anastomosis (33.3% vs. 13.3%; P = 0.008), but no differences for cervical anastomosis. The late oral feeding group had a shorter median hospital stay (12 vs. 11 days, P = 0.008). No differences in overall survival rates were found (Kaplan-Meier: P = 0.604, Cox regression: HR: 1.020, 95% CI 0.729-1.427, P = 0.907).

Conclusions: Early and late oral feeding showed similar survival rates, but late oral feeding was associated with fewer severe complications, lower anastomotic leakage, and shorter hospital stay. Therefore, despite no survival difference, late oral feeding with jejunal feeding may lead to better postoperative outcomes.

With advances made in the care for esophagectomy patients, the need for routine postoperative intensive care unit (ICU) admission needs reassessment. We developed a preoperative prediction model to distinguish patients requiring routine ICU admission from those who can be cared for in a post-anesthesia care unit (PACU). This retrospective cohort study included consecutive adults undergoing elective esophagectomy between January 2011 and June 2021 in the UMC Utrecht. Firth's corrected multivariable logistic regression was used for model development and internal validation using bootstrapping was performed to obtain optimism-corrected performance metrics. Among the 619 patients included, 380 (61%) received critical care support beyond the first morning following surgery: 83 (13%) were on invasive mechanical ventilation and 338 (55%) needed cardiovascular support (with 174 [28%] receiving only low-dose norepinephrine). Predictors retained in the final model included age, diabetes mellitus, hemoglobin level, kidney function, forced expiratory volume in 1 second, tumor stadium, type of neoadjuvant therapy and surgical approach. Discrimination was acceptable (adjusted c-statistic 0.67, 95% CI 0.62-0.71) with good calibration (O:E ratio 1.00). Using the model, approximately 50% of ICU beds could be conserved, at the cost of misallocating 22% of patients to a PACU (with only 12% of PACU-allocated patients requiring mechanical ventilation). Between one- and two-thirds of elective esophagectomy patients do not need routine ICU admission, depending on whether hemodynamic support can be provided in another high-dependency unit. Our model can help rationalize perioperative patient allocation and reduce ICU bed claims by roughly half.

In-hospital mortality following esophagectomy for cancer has markedly decreased over the last few decades, with reported death rates below 5% considered a benchmark for quality of care. Although large registry studies have focused on reaching this benchmark, little is known about the underlying cause of death and the possibility of preventing a lethal outcome. The aim of this multicenter study was to perform an in-depth analysis of in-hospital mortality following esophagectomy for cancer. Data were obtained from four European esophageal cancer centers analyzing their prospective databases between January 2010 and June 2020. All patients with an in-hospital lethal postoperative course (Clavien-Dindo V) following elective transthoracic esophagectomy were included. Data collection comprised baseline characteristics, preoperative comorbidities, surgical procedures, postoperative complications, and their management. In each participating center, cases were retrospectively assessed for (1) the selection of patients for esophagectomy based on their individual comorbidities, (2) intraoperative, and (3) postoperative complications and their management to finally classify the management of each section as adequate, non-adequate, or undetermined. One hundred and twenty-one out of 3899 patients died following esophagectomy, amounting to an in-hospital mortality rate of 3.1%. Patients deceased on a median of 32 days after surgery (IQR: 18-60). Following surgery, a total of 294 major complications were identified in the 121 patients (mean 2.4 ± 1.2) with anastomotic leakage (AL) reported most often in 65 patients (53.7%). AL was considered as leading cause of death in 44 patients (36.4%) followed by acute respiratory distress syndrome (ARDS) in 15 patients (12.4%). Assessment of preoperative patient selection revealed a non-adequate workup in only two patients (1.4%). During surgery, six patients (4.6%) suffered complications, which were deemed adequately treated in retrospective assessment. In eight patients (6.6%), postoperative management was deemed non-adequate; in seven of eight cases, recognition and initiation of treatment for AL were considered delayed. Despite technical advances, AL remains the leading cause of death following esophagectomy, contributing to a significantly prolonged clinical course and lethal outcome. In contrast to other published series, assessment of this homogenous patient cohort in expert centers revealed only a low rate of preventable mortality with respect to the preoperative patient selection and postoperative complication management. However, modification of AL management might be considered to reduce the overall death rate.