G. Boxel, N. Carter, B. Knight, V. Fajksova, N. Jenkins, K. Akbari, S. Mercer
Background: Robotic assisted minimally invasive esophagectomy (RAMIE) is gaining increased popularity for the surgical treatment of esophageal cancer. Following resection of the specimen an anastomosis is formed between the gastric conduit, formed from the stomach, and the remaining esophagus. The method used for constructing this anastomosis varies widely between units—broadly speaking surgeons use a circular stapled, linear stapled or handsewn technique. Methods: Using a prospectively maintained database, we reviewed the first consecutive 30 RAMIE cases performed at our Centre. Outcomes, with particular focus on the anastomosis, were reviewed. We also describe in detail the technical steps involved in the formation of a fully robotic linear stapled, side-to-side, anastomosis. Results: We report on the first 30 patients undergoing RAMIE at our Centre, all of whom had a robotic linear stapled anastomosis. The patient characteristics were comparable to similar cancer cohorts reported on previously in terms of disease stage, age, sex and neoadjuvant treatment. Thirty- and 90-day mortality was 0%. The technique appears to have a steep learning curve with a 50% leak rate in the first 10 cases, reducing to 15% in the subsequent 20 cases. Conclusions: Robotic linear stapled anastomosis following esophagectomy is safe and feasible. The apparent learning curve appears similar to handsewn and circular stapled techniques.
{"title":"Linear stapled technique for robotic assisted minimally invasive esophagectomy","authors":"G. Boxel, N. Carter, B. Knight, V. Fajksova, N. Jenkins, K. Akbari, S. Mercer","doi":"10.21037/AOE-21-2","DOIUrl":"https://doi.org/10.21037/AOE-21-2","url":null,"abstract":"Background: Robotic assisted minimally invasive esophagectomy (RAMIE) is gaining increased popularity for the surgical treatment of esophageal cancer. Following resection of the specimen an anastomosis is formed between the gastric conduit, formed from the stomach, and the remaining esophagus. The method used for constructing this anastomosis varies widely between units—broadly speaking surgeons use a circular stapled, linear stapled or handsewn technique. Methods: Using a prospectively maintained database, we reviewed the first consecutive 30 RAMIE cases performed at our Centre. Outcomes, with particular focus on the anastomosis, were reviewed. We also describe in detail the technical steps involved in the formation of a fully robotic linear stapled, side-to-side, anastomosis. Results: We report on the first 30 patients undergoing RAMIE at our Centre, all of whom had a robotic linear stapled anastomosis. The patient characteristics were comparable to similar cancer cohorts reported on previously in terms of disease stage, age, sex and neoadjuvant treatment. Thirty- and 90-day mortality was 0%. The technique appears to have a steep learning curve with a 50% leak rate in the first 10 cases, reducing to 15% in the subsequent 20 cases. Conclusions: Robotic linear stapled anastomosis following esophagectomy is safe and feasible. The apparent learning curve appears similar to handsewn and circular stapled techniques.","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49334779","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A. Kammili, J. Ramirez-Garcialuna, C. Mueller, J. Spicer, L. Ferri, J. Cools-Lartigue
Division of Thoracic and Upper Gastrointestinal Surgery, Department of Surgery, McGill University Health Centre, Montréal, Quebec, Canada; Division of General Surgery, Department of Surgery, McGill University Health Centre, Montréal, Quebec, Canada Contributions: (I) Conception and design: J Cools-Lartigue, L Ferri; (II) Administrative support: A Kammili; (III) Provision of study materials or patients: L Ferri, C Mueller, J Spicer, J Cools-Lartigue; (IV) Collection and assembly of data: A Kammili; (V) Data analysis and interpretation: A Kammili, J Ramirez-GarciaLuna; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Anitha Kammili, MD, MSc (ORCID: 0000-0003-4909-205X). Division of Thoracic and Upper Gastrointestinal Surgery, Department of Surgery, McGill University Health Centre, L8 505-1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada. Email: anitha425@gmail.com.
{"title":"Personalized surgical management of esophagogastric junction cancers: retrospective cohort study at a Canadian institution","authors":"A. Kammili, J. Ramirez-Garcialuna, C. Mueller, J. Spicer, L. Ferri, J. Cools-Lartigue","doi":"10.21037/AOE-20-50","DOIUrl":"https://doi.org/10.21037/AOE-20-50","url":null,"abstract":"Division of Thoracic and Upper Gastrointestinal Surgery, Department of Surgery, McGill University Health Centre, Montréal, Quebec, Canada; Division of General Surgery, Department of Surgery, McGill University Health Centre, Montréal, Quebec, Canada Contributions: (I) Conception and design: J Cools-Lartigue, L Ferri; (II) Administrative support: A Kammili; (III) Provision of study materials or patients: L Ferri, C Mueller, J Spicer, J Cools-Lartigue; (IV) Collection and assembly of data: A Kammili; (V) Data analysis and interpretation: A Kammili, J Ramirez-GarciaLuna; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Anitha Kammili, MD, MSc (ORCID: 0000-0003-4909-205X). Division of Thoracic and Upper Gastrointestinal Surgery, Department of Surgery, McGill University Health Centre, L8 505-1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada. Email: anitha425@gmail.com.","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42756495","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
At present, standard treatment for potentially curable esophageal cancer includes neoadjuvant chemoradiotherapy followed by esophagectomy with lymphadenectomy. One of the complications with potentially serious consequences after esophagectomy is an anastomotic leakage. This complication is associated with prolonged hospital stay, morbidity, and mortality. In the postoperative period it can be challenging to recognize this complication and make a differentiation from other complications, such as pneumonia. Early recognition is a prerequisite for prompt treatment, which is known to lead to improved results. Nowadays, most centers performing esophagectomies use a standardized enhanced recovery after surgery (ERAS) program to treat patients peri-operatively. These programs should also include strategies to early detect and treat anastomotic leakage. This article describes the ERAS program developed at the upper GI unit of the University Medical Centre Utrecht, the Netherlands. It explores the various aspects of such a pathway, such as postoperative monitoring, nasogastric tube management, feeding protocols, early warning signs and diagnostics to be used in case of suspicion of a complication. In addition, the ERAS program is clarified with available relevant literature on different topics of the perioperative management for esophagectomy patients. The main focus of this article is the early recognition and detection of anastomotic leakage, which enables aggressive treatment.
{"title":"Enhanced recovery after surgery pathway in esophagectomy in a high volume center: clinical keys to early leak diagnosis after esophagectomy","authors":"J. W. Berg, S. Horst, R. Hillegersberg, J. Ruurda","doi":"10.21037/AOE-21-10","DOIUrl":"https://doi.org/10.21037/AOE-21-10","url":null,"abstract":"At present, standard treatment for potentially curable esophageal cancer includes neoadjuvant chemoradiotherapy followed by esophagectomy with lymphadenectomy. One of the complications with potentially serious consequences after esophagectomy is an anastomotic leakage. This complication is associated with prolonged hospital stay, morbidity, and mortality. In the postoperative period it can be challenging to recognize this complication and make a differentiation from other complications, such as pneumonia. Early recognition is a prerequisite for prompt treatment, which is known to lead to improved results. Nowadays, most centers performing esophagectomies use a standardized enhanced recovery after surgery (ERAS) program to treat patients peri-operatively. These programs should also include strategies to early detect and treat anastomotic leakage. This article describes the ERAS program developed at the upper GI unit of the University Medical Centre Utrecht, the Netherlands. It explores the various aspects of such a pathway, such as postoperative monitoring, nasogastric tube management, feeding protocols, early warning signs and diagnostics to be used in case of suspicion of a complication. In addition, the ERAS program is clarified with available relevant literature on different topics of the perioperative management for esophagectomy patients. The main focus of this article is the early recognition and detection of anastomotic leakage, which enables aggressive treatment.","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43243602","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Interstitial lung disease (ILD) encompasses a heterogeneous group of acute and chronic disorders characterized by diffuse pulmonary infiltrates with histologic features of pulmonary inflammation, dyspnea, and restrictive lung patterns. Gastroesophageal reflux disease (GERD) and ILD are two pathological conditions often strictly related, even if a clear relationship of causality has not been demonstrated. The mechanisms leading to ILD are not completely understood, although it is recognized that different factors are involved. In recent years, it has been suggested that acid gastroesophageal reflux is an important cause of both systemic sclerosis (SSc)-ILD and idiopathic pulmonary fibrosis (IPF). It has been hypothesized that micro aspiration of gastric material may play a fundamental role in the fibrotic transformation of pulmonary parenchyma. According to that, some studies have described antireflux procedures for patients affected by ILD and GERD. However, although some studies reported good results in terms of improvement of lung function, the role of antireflux surgery remains uncertain as well as not univocal. An extensive literature search was performed from January 1970 to 31 December 2020 in PubMed and the Cochrane Central Register of Controlled Trials. The research was limited to English-language studies. The aim of the present study was to summarize the effect of antireflux surgery for the treatment of abnormal acid GER on the natural history of this disease.
{"title":"A narrative review of minimally invasive fundoplication for gastroesophageal reflux disease and interstitial lung disease","authors":"N. Tamburini, C. Andolfi, P. Fisichella","doi":"10.21037/AOE-21-7","DOIUrl":"https://doi.org/10.21037/AOE-21-7","url":null,"abstract":"Interstitial lung disease (ILD) encompasses a heterogeneous group of acute and chronic disorders characterized by diffuse pulmonary infiltrates with histologic features of pulmonary inflammation, dyspnea, and restrictive lung patterns. Gastroesophageal reflux disease (GERD) and ILD are two pathological conditions often strictly related, even if a clear relationship of causality has not been demonstrated. The mechanisms leading to ILD are not completely understood, although it is recognized that different factors are involved. In recent years, it has been suggested that acid gastroesophageal reflux is an important cause of both systemic sclerosis (SSc)-ILD and idiopathic pulmonary fibrosis (IPF). It has been hypothesized that micro aspiration of gastric material may play a fundamental role in the fibrotic transformation of pulmonary parenchyma. According to that, some studies have described antireflux procedures for patients affected by ILD and GERD. However, although some studies reported good results in terms of improvement of lung function, the role of antireflux surgery remains uncertain as well as not univocal. An extensive literature search was performed from January 1970 to 31 December 2020 in PubMed and the Cochrane Central Register of Controlled Trials. The research was limited to English-language studies. The aim of the present study was to summarize the effect of antireflux surgery for the treatment of abnormal acid GER on the natural history of this disease.","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42810310","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
: To assess the indications, safety, and results of cricopharyngeal myotomy (CPM) and toxin botulinum injection (TBI) for the treatment of upper esophageal sphincter (UES) abnormalities. The UES disorders can provoke overwhelming consequences such as bronchopulmonary aspiration, malnutrition, impaired quality of life or even death. The best treatment modality for UES disorders remains unclear. The purpose of this review was to assess indications and outcomes of CPM and TBI for the treatment of UES abnormalities. We performed a review of the literature regarding the outcomes of CPM and TBI for UES disorders. All articles between 1990 and 2020 describing CPM, TBI, or those comparing both techniques were analyzed. Treatment indications, safety, and outcomes of both procedures were evaluated as primary endpoints. Quality of life improvement was evaluated as a secondary endpoint. Outcomes after CPM and TBI for UES disorders are heterogeneously reported. Data suggest that both surgical and endoscopic CPM are safe and have encouraging long-lasting results in terms of symptoms relief and quality of life improvement. TBI is also a safe procedure, with good but temporary postoperative results. Current data are heterogeneous and show that both CPM and TBI are safe and effective treatment modalities for UES disorders. Better long-lasting effects, however, seem to be achieved with CPM.
{"title":"Cricopharyngeal myotomy and toxin botulinum injection for the treatment of upper esophageal sphincter disorders: a narrative review","authors":"F. Laxague, F. Herbella, F. Schlottmann","doi":"10.21037/AOE-21-8","DOIUrl":"https://doi.org/10.21037/AOE-21-8","url":null,"abstract":": To assess the indications, safety, and results of cricopharyngeal myotomy (CPM) and toxin botulinum injection (TBI) for the treatment of upper esophageal sphincter (UES) abnormalities. The UES disorders can provoke overwhelming consequences such as bronchopulmonary aspiration, malnutrition, impaired quality of life or even death. The best treatment modality for UES disorders remains unclear. The purpose of this review was to assess indications and outcomes of CPM and TBI for the treatment of UES abnormalities. We performed a review of the literature regarding the outcomes of CPM and TBI for UES disorders. All articles between 1990 and 2020 describing CPM, TBI, or those comparing both techniques were analyzed. Treatment indications, safety, and outcomes of both procedures were evaluated as primary endpoints. Quality of life improvement was evaluated as a secondary endpoint. Outcomes after CPM and TBI for UES disorders are heterogeneously reported. Data suggest that both surgical and endoscopic CPM are safe and have encouraging long-lasting results in terms of symptoms relief and quality of life improvement. TBI is also a safe procedure, with good but temporary postoperative results. Current data are heterogeneous and show that both CPM and TBI are safe and effective treatment modalities for UES disorders. Better long-lasting effects, however, seem to be achieved with CPM.","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47473458","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
: Endoscopic therapy is recommended as the first line treatment for Barrett’s esophagus (BE) with high-grade dysplasia, low-grade dysplasia or BE with nodular lesions. Historically, open or laparoscopic surgery was the only option that could be offered to patients with the above conditions. Although it seemed the logical option, Esophagectomy is associated with increased morbidity and mortality as well as significant lifestyle modifications. Appropriately selecting patients for endoscopic therapy ensures curative resection, better survival, improved quality of life following the procedure and decrease risk of future recurrence. To review recent evidence and approaches for endoscopic treatment of Barrett’s esophagus. Selecting the best approach is tailored to the lesion, If BE is flat, ablation using radiofrequency ablation or cryoablation is indicated. In case of nodular BE, endoscopic resection using endoscopic mucosal resection or endoscopic submucosal dissection should be performed first, based on lesion size and available expertise. Following endoscopic resection, ablation of the remaining flat epithelium is indicated to ensure complete remission of BE. Data regarding training and quality benchmarks for ESD in the management of esophageal adenocarcinoma and Barrett’s esophagus is needed. Combining ESD with other modalities in the management of early esophageal adenocarcinoma extending to the submucosa (T1b) needs to be explored.
{"title":"A narrative review of endoscopic therapy for Barrett’s esophagus","authors":"Yahya Ahmed, Mohamed O. Othman","doi":"10.21037/aoe-21-18","DOIUrl":"https://doi.org/10.21037/aoe-21-18","url":null,"abstract":": Endoscopic therapy is recommended as the first line treatment for Barrett’s esophagus (BE) with high-grade dysplasia, low-grade dysplasia or BE with nodular lesions. Historically, open or laparoscopic surgery was the only option that could be offered to patients with the above conditions. Although it seemed the logical option, Esophagectomy is associated with increased morbidity and mortality as well as significant lifestyle modifications. Appropriately selecting patients for endoscopic therapy ensures curative resection, better survival, improved quality of life following the procedure and decrease risk of future recurrence. To review recent evidence and approaches for endoscopic treatment of Barrett’s esophagus. Selecting the best approach is tailored to the lesion, If BE is flat, ablation using radiofrequency ablation or cryoablation is indicated. In case of nodular BE, endoscopic resection using endoscopic mucosal resection or endoscopic submucosal dissection should be performed first, based on lesion size and available expertise. Following endoscopic resection, ablation of the remaining flat epithelium is indicated to ensure complete remission of BE. Data regarding training and quality benchmarks for ESD in the management of esophageal adenocarcinoma and Barrett’s esophagus is needed. Combining ESD with other modalities in the management of early esophageal adenocarcinoma extending to the submucosa (T1b) needs to be explored.","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47497674","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The management of Barrett’s esophagus (BE) is a rapidly evolving field of study with numerous technologies and management strategies continuously falling in and out of favor due to the rapid pace of research and development in this arena. This review aims to distill and synthesize the vast amount of available primary data and society guidelines in order to present the most current and widely used practices and therapies available today. Below, we aim to discuss the diagnosis, screening, surveillance, and medical and interventional therapies. We present the following article in accordance with the Narrative Review reporting checklist (available at https://dx.doi.org/10.21037/aoe-21-31). Review Article
{"title":"Management of Barrett’s esophagus: a narrative review","authors":"Samik Shah, R. Bhuta, Z. Malik","doi":"10.21037/aoe-21-31","DOIUrl":"https://doi.org/10.21037/aoe-21-31","url":null,"abstract":"The management of Barrett’s esophagus (BE) is a rapidly evolving field of study with numerous technologies and management strategies continuously falling in and out of favor due to the rapid pace of research and development in this arena. This review aims to distill and synthesize the vast amount of available primary data and society guidelines in order to present the most current and widely used practices and therapies available today. Below, we aim to discuss the diagnosis, screening, surveillance, and medical and interventional therapies. We present the following article in accordance with the Narrative Review reporting checklist (available at https://dx.doi.org/10.21037/aoe-21-31). Review Article","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43995236","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Venkata Kollimarla, Akhila Rachakonda, J. Myers, Steven Knox, S. Thompson
Background: Laparoscopic adjustable gastric banding (LAGB) is a common procedure to treat obesity. A potential complication of LAGB is pseudoachalasia (an esophageal motility disorder). In select individuals, a LAGB may create high outflow resistance, leading to a high-pressure environment in the distal esophagus, which then leads to progressive weakness and dilatation. Treatment of pseudoachalasia hinges on reversing the underlying cause. Case Description: A 64-year-old female, with morbid obesity [body mass index (BMI) 41 kg/m 2 ] and a hiatus hernia, underwent laparoscopic insertion of a gastric band. As part of her procedure, a hiatal repair was performed with permanent braided sutures. Post-operatively, the patient lost 30 kg, however began to notice regurgitation and dysphagia. The laparoscopic band was removed a year later, but this did not alleviate her symptoms. Endoscopy showed an abnormal, dilated, fluid-filled esophagus. The patient underwent four endoscopic dilations over the next 24 months, with minimal benefit. On the fourth dilatation, the patient aspirated and developed aspiration pneumonia, resulting in a lengthy admission. Finally, the underlying cause was addressed with a laparoscopic takedown of the anterior hiatal repair and removal of the capsule (from the LAGB). Unfortunately, the patient’s symptoms failed to improve over the next 12 months, and a difficult laparoscopic cardiomyotomy was performed. The patient subsequently improved and was then able to tolerate a normal diet. Conclusions: This case report highlights the critical nature of reversing all potential underlying causes when dealing with pseudoachalasia (i.e., removal of the LAGB and fibrotic capsule; takedown of a prior hiatal repair and/or fundoplication). As well, and of utmost importance, this case report reminds the reader that in a patient with severe symptoms of regurgitation and dysphagia, the airway must be protected during endoscopy to prevent aspiration.
{"title":"Pseudoachalasia following insertion of a laparoscopic gastric band: a case report","authors":"Venkata Kollimarla, Akhila Rachakonda, J. Myers, Steven Knox, S. Thompson","doi":"10.21037/aoe-22-5","DOIUrl":"https://doi.org/10.21037/aoe-22-5","url":null,"abstract":"Background: Laparoscopic adjustable gastric banding (LAGB) is a common procedure to treat obesity. A potential complication of LAGB is pseudoachalasia (an esophageal motility disorder). In select individuals, a LAGB may create high outflow resistance, leading to a high-pressure environment in the distal esophagus, which then leads to progressive weakness and dilatation. Treatment of pseudoachalasia hinges on reversing the underlying cause. Case Description: A 64-year-old female, with morbid obesity [body mass index (BMI) 41 kg/m 2 ] and a hiatus hernia, underwent laparoscopic insertion of a gastric band. As part of her procedure, a hiatal repair was performed with permanent braided sutures. Post-operatively, the patient lost 30 kg, however began to notice regurgitation and dysphagia. The laparoscopic band was removed a year later, but this did not alleviate her symptoms. Endoscopy showed an abnormal, dilated, fluid-filled esophagus. The patient underwent four endoscopic dilations over the next 24 months, with minimal benefit. On the fourth dilatation, the patient aspirated and developed aspiration pneumonia, resulting in a lengthy admission. Finally, the underlying cause was addressed with a laparoscopic takedown of the anterior hiatal repair and removal of the capsule (from the LAGB). Unfortunately, the patient’s symptoms failed to improve over the next 12 months, and a difficult laparoscopic cardiomyotomy was performed. The patient subsequently improved and was then able to tolerate a normal diet. Conclusions: This case report highlights the critical nature of reversing all potential underlying causes when dealing with pseudoachalasia (i.e., removal of the LAGB and fibrotic capsule; takedown of a prior hiatal repair and/or fundoplication). As well, and of utmost importance, this case report reminds the reader that in a patient with severe symptoms of regurgitation and dysphagia, the airway must be protected during endoscopy to prevent aspiration.","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42243032","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
V. Porziella, E. Zanfrini, D. Tabacco, L. Pogliani, M. Vita, L. Petracca-Ciavarella, E. Meacci, M. Congedo, M. Chiappetta, S. Margaritora, D. Nachira
Zenker diverticula are due to a disorder in the opening of the upper oesophageal sphincter, causing the protrusion of mucosa through the posterior pharyngoesophageal wall. The incidence of Zenker diverticula is estimated between 0.01% and 0.11% and classically occur in males and the elderly. Therapeutic management of the patient with Zenker diverticulum is fundamentally influenced by the presence or absence of symptoms, the size and location of the diverticulum. Operative treatment should be reserved only for symptomatic patients and for large diverticula (>2 cm), in order to improve the quality of life and avoid complications. For many decades, Zenker diverticula was treated with an open surgical approach. Traditionally, surgical management has been the mainstay of treatment, but endoscopic approach has now become accepted as a viable minimally invasive treatment option with a lower rate of complications. The resolution of symptoms with the open approach is estimated in 93–95% of cases and the relapse rate is 2.9%. Compared with endoscopic treatments, the morbidity and mortality rates are higher. In this paper we reviewed the current literature on surgical approach to Zenker’s diverticula in terms of clinical results and
{"title":"Surgical treatment of Zenker diverticula","authors":"V. Porziella, E. Zanfrini, D. Tabacco, L. Pogliani, M. Vita, L. Petracca-Ciavarella, E. Meacci, M. Congedo, M. Chiappetta, S. Margaritora, D. Nachira","doi":"10.21037/AOE-2020-25","DOIUrl":"https://doi.org/10.21037/AOE-2020-25","url":null,"abstract":"Zenker diverticula are due to a disorder in the opening of the upper oesophageal sphincter, causing the protrusion of mucosa through the posterior pharyngoesophageal wall. The incidence of Zenker diverticula is estimated between 0.01% and 0.11% and classically occur in males and the elderly. Therapeutic management of the patient with Zenker diverticulum is fundamentally influenced by the presence or absence of symptoms, the size and location of the diverticulum. Operative treatment should be reserved only for symptomatic patients and for large diverticula (>2 cm), in order to improve the quality of life and avoid complications. For many decades, Zenker diverticula was treated with an open surgical approach. Traditionally, surgical management has been the mainstay of treatment, but endoscopic approach has now become accepted as a viable minimally invasive treatment option with a lower rate of complications. The resolution of symptoms with the open approach is estimated in 93–95% of cases and the relapse rate is 2.9%. Compared with endoscopic treatments, the morbidity and mortality rates are higher. In this paper we reviewed the current literature on surgical approach to Zenker’s diverticula in terms of clinical results and","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47624520","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
: The Ivor Lewis MIE has been growing in popularity globally ever since it was made popular among the Western population by J. D. Luketich at the University of Pittsburgh Medical Center (UPMC). Most patients in the West present with distal esophageal or esophago-gastric junction cancers, which favour the Ivor Lewis MIE, and an intrathoracic anastomosis as the operation of choice. However, the debate continues over which type of esophago-gastric anastomosis should be performed. The end-to-side stapled intrathoracic esophago-gastric anastomosis with a 28 or 29 mm circular stapler, and covering the anastomosis with an omental flap, is a well-established standardised technique at the UPMC and Norwich. In experienced hands, this technique is easy to execute once the anvil is inserted into the esophagus and the two purse-string sutures are tied. It has a low leak rate (<5%) when executed correctly. In the rare occurrence of a leak, the exact site of the leak can be visualised with a computerised tomography scan, since the titanium staples are easily identified radiologically. As a result, the defect at the circular anastomosis is easily located endoscopically. In addition, the leak is often small. Altogether, these factors favour the use of an EndoVac to treat the leak from a circular stapler. Hence, the authors advocate doing the circular stapled end-to-side esophago-gastric anastomosis, which is covered with an omental patch under a pleural tent.
：自从匹兹堡大学医学中心的J.D.Luketich在西方人群中流行以来，Ivor Lewis MIE在全球范围内越来越受欢迎。西方的大多数患者都患有食管远端或食管-胃交界处癌症，这有利于Ivor Lewis MIE，并将胸内吻合作为首选手术。然而，关于应该进行哪种类型的食管胃吻合的争论仍在继续。在UPMC和Norwich，用28或29毫米圆形吻合器端侧缝合胸内食管胃吻合，并用网膜瓣覆盖吻合，是一种公认的标准化技术。对于经验丰富的人来说，一旦将铁砧插入食道并绑上两条荷包线，这项技术就很容易实施。正确执行时，泄漏率较低（<5%）。在罕见的泄漏情况下，可以通过计算机断层扫描来显示泄漏的确切位置，因为钛钉很容易通过放射学识别。因此，环形吻合处的缺陷很容易在内镜下定位。此外，泄漏通常很小。总之，这些因素有利于使用EndoVac治疗圆形缝合器的泄漏。因此，作者主张进行环形吻合食管胃端侧吻合术，该吻合术在胸膜帐篷下覆盖网膜贴片。
{"title":"End to side anastomosis with a circular stapler for minimally invasive Ivor Lewis esophagectomy—how I do it","authors":"E. Cheong, J. Luketich","doi":"10.21037/aoe-21-35","DOIUrl":"https://doi.org/10.21037/aoe-21-35","url":null,"abstract":": The Ivor Lewis MIE has been growing in popularity globally ever since it was made popular among the Western population by J. D. Luketich at the University of Pittsburgh Medical Center (UPMC). Most patients in the West present with distal esophageal or esophago-gastric junction cancers, which favour the Ivor Lewis MIE, and an intrathoracic anastomosis as the operation of choice. However, the debate continues over which type of esophago-gastric anastomosis should be performed. The end-to-side stapled intrathoracic esophago-gastric anastomosis with a 28 or 29 mm circular stapler, and covering the anastomosis with an omental flap, is a well-established standardised technique at the UPMC and Norwich. In experienced hands, this technique is easy to execute once the anvil is inserted into the esophagus and the two purse-string sutures are tied. It has a low leak rate (<5%) when executed correctly. In the rare occurrence of a leak, the exact site of the leak can be visualised with a computerised tomography scan, since the titanium staples are easily identified radiologically. As a result, the defect at the circular anastomosis is easily located endoscopically. In addition, the leak is often small. Altogether, these factors favour the use of an EndoVac to treat the leak from a circular stapler. Hence, the authors advocate doing the circular stapled end-to-side esophago-gastric anastomosis, which is covered with an omental patch under a pleural tent.","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49568506","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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