Pub Date : 2023-05-09DOI: 10.1177/26345161231171846
D. Dolan, Nithya Kanagasegar, Gianna Dingillo, Christine E. Alvarado, Avanti Badrinathan, A. Bassiri, Jonathan D Rice, Jillian N. Sinopoli, Leonidas Tapias, P. Linden, C. Towe
Locoregionally advanced esophageal cancer is typically treated with neoadjuvant chemoradiation followed by surgery 4 to 8 weeks later. Occasionally surgery is delayed >12 weeks; outcomes of this approach are not well studied. We hypothesized that delayed esophagectomy after chemoradiation would have inferior long-term overall survival relative to planned trimodality esophagectomy. Adult patients with locally advanced esophageal cancer (T2−4aN0M0, T0−4aN+M0) who received multi-agent chemotherapy, radiation, and esophagectomy were identified in the 2018 National Cancer Database. Esophagectomy performed within 90 days from end of chemoradiation were categorized as “trimodality” and those ≥90 days were categorized as “delayed.” Primary outcome was overall survival measured using Kaplan-Meier estimates and Cox proportional hazard models. Secondary outcomes included surgical margin status, hospital length of stay, and readmission. Included were 19 698 patients, 3905 (19.8%) “delayed.” Median time to surgery for trimodality patients was 51 days (IQR 41-63) versus 110 days (IQR 98-131) for delayed patients. Delayed patients tended to be older, non-white, have non-private insurance, and have more comorbidities. Overall survival was shorter for delayed patients (34.8 months) versus trimodality patients (43.1 months, P ≤ .001). In multivariable analysis, delay was associated with inferior overall survival (HR 1.15, 95% CI 1.08-1.23). Length of stay and readmission rate were similar between cohorts, but delay was associated with a higher rate of positive surgical margins (6.7% vs 4.6%, P ≤ .001). In the National Cancer Database, delayed esophagectomy is associated with inferior long-term survival. Nonetheless, delayed esophagectomy may be appropriate for select patients; further research is needed to identify the optimal approach.
{"title":"Delayed Esophagectomy is Associated With Inferior Survival: A National Cancer Database Study","authors":"D. Dolan, Nithya Kanagasegar, Gianna Dingillo, Christine E. Alvarado, Avanti Badrinathan, A. Bassiri, Jonathan D Rice, Jillian N. Sinopoli, Leonidas Tapias, P. Linden, C. Towe","doi":"10.1177/26345161231171846","DOIUrl":"https://doi.org/10.1177/26345161231171846","url":null,"abstract":"Locoregionally advanced esophageal cancer is typically treated with neoadjuvant chemoradiation followed by surgery 4 to 8 weeks later. Occasionally surgery is delayed >12 weeks; outcomes of this approach are not well studied. We hypothesized that delayed esophagectomy after chemoradiation would have inferior long-term overall survival relative to planned trimodality esophagectomy. Adult patients with locally advanced esophageal cancer (T2−4aN0M0, T0−4aN+M0) who received multi-agent chemotherapy, radiation, and esophagectomy were identified in the 2018 National Cancer Database. Esophagectomy performed within 90 days from end of chemoradiation were categorized as “trimodality” and those ≥90 days were categorized as “delayed.” Primary outcome was overall survival measured using Kaplan-Meier estimates and Cox proportional hazard models. Secondary outcomes included surgical margin status, hospital length of stay, and readmission. Included were 19 698 patients, 3905 (19.8%) “delayed.” Median time to surgery for trimodality patients was 51 days (IQR 41-63) versus 110 days (IQR 98-131) for delayed patients. Delayed patients tended to be older, non-white, have non-private insurance, and have more comorbidities. Overall survival was shorter for delayed patients (34.8 months) versus trimodality patients (43.1 months, P ≤ .001). In multivariable analysis, delay was associated with inferior overall survival (HR 1.15, 95% CI 1.08-1.23). Length of stay and readmission rate were similar between cohorts, but delay was associated with a higher rate of positive surgical margins (6.7% vs 4.6%, P ≤ .001). In the National Cancer Database, delayed esophagectomy is associated with inferior long-term survival. Nonetheless, delayed esophagectomy may be appropriate for select patients; further research is needed to identify the optimal approach.","PeriodicalId":73049,"journal":{"name":"Foregut (Thousand Oaks, Calif.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-05-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49328290","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}
Pub Date : 2023-05-08DOI: 10.1177/26345161231170590
Rhea Fogla, E. Glaubitz, Sanam Bhatia, Arjun Ravishankar, C.Yang Andy, R. Niec, P. Katz
Background: Eosinophilic esophagitis (EoE) is a male predominant disease, typically presenting with dysphagia. Our goal was to investigate sex differences in clinical presentation and management of EoE. Methods: We performed a retrospective cross-sectional review of 489 EoE patients seen at NewYork Presbyterian Weill Cornell from August 2015 to August 2019. Charts were queried for age at diagnosis, symptoms at presentation, endoscopic findings, need for dilations, and medical therapy. Student t and χ2 tests were implemented to compare outcome variables of the 2 independent groups (males vs females) and logistic regressions for invariable and multivariable analyses. Results: 489 EoE patients (226 Female [F] [46.2%], 263 Male [M] [53.8%]) were reviewed. Males were more likely to present with food impaction (92 [35.8%] vs 44 [19.7%], M vs F, P < .001), have a fibrostenotic phenotype on initial endoscopy (140 [54.1%] vs 98 [45.0%], M vs F, P = .043) and undergo dilation (odds ratio [OR] = 1.985, 95% confidence interval [CI] = 1.209-3.328, P < .01). Female patients were more likely to have atopic disease (153 [67.6%] vs 153 [58.8%], F vs M, P = .044) and a reported normal index endoscopy (79 [36.2%] vs 69 [26.6%], F vs M, P = .026). Conclusion: This large retrospective review highlights clinically important differences in presentation between sexes. Increasing awareness of these differences, especially history of atopic disease, impaction, and the need for dilation, can help clinicians better identify EoE in female patients and therefore, guide initial therapy. The mechanistic underpinnings of these discrepancies are not evident from this data and will require future studies.
背景:嗜酸性粒细胞性食管炎(EoE)是一种男性常见病，典型表现为吞咽困难。我们的目的是研究EoE的临床表现和治疗的性别差异。方法:我们对2015年8月至2019年8月在纽约长老会威尔康奈尔医院(NewYork Presbyterian Weill Cornell)就诊的489例EoE患者进行了回顾性横断面分析。在图表中询问了诊断时的年龄、出现时的症状、内窥镜检查结果、是否需要扩张和药物治疗。采用Student t检验和χ2检验比较两个独立组(男性和女性)的结局变量，采用logistic回归进行不变和多变量分析。结果:共纳入489例EoE患者，其中女226例[F][46.2%]，男263例[M][53.8%]。男性更容易出现食物嵌塞(92 [35.8%]vs 44 [19.7%]， M vs F, P < 0.001)，在初次内镜检查时出现纤维狭窄表型(140 [54.1%]vs 98 [45.0%]， M vs F, P = 0.043)，并进行扩张(优势比[OR] = 1.985, 95%可信区间[CI] = 1.202 -3.328, P < 0.01)。女性患者更容易发生特应性疾病(153例[67.6%]vs 153例[58.8%]，F vs M, P = 0.044)，报告的内窥镜检查指数正常(79例[36.2%]vs 69例[26.6%]，F vs M, P = 0.026)。结论:这项大型回顾性研究突出了临床中重要的性别差异。提高对这些差异的认识，特别是对特应性疾病史、内塞和扩张术的需要的认识，可以帮助临床医生更好地识别女性患者的EoE，从而指导初始治疗。这些差异的机制基础从这些数据中并不明显，需要未来的研究。
{"title":"Sex Differences in Clinical Presentation and Management in Eosinophilic Esophagitis","authors":"Rhea Fogla, E. Glaubitz, Sanam Bhatia, Arjun Ravishankar, C.Yang Andy, R. Niec, P. Katz","doi":"10.1177/26345161231170590","DOIUrl":"https://doi.org/10.1177/26345161231170590","url":null,"abstract":"Background: Eosinophilic esophagitis (EoE) is a male predominant disease, typically presenting with dysphagia. Our goal was to investigate sex differences in clinical presentation and management of EoE. Methods: We performed a retrospective cross-sectional review of 489 EoE patients seen at NewYork Presbyterian Weill Cornell from August 2015 to August 2019. Charts were queried for age at diagnosis, symptoms at presentation, endoscopic findings, need for dilations, and medical therapy. Student t and χ2 tests were implemented to compare outcome variables of the 2 independent groups (males vs females) and logistic regressions for invariable and multivariable analyses. Results: 489 EoE patients (226 Female [F] [46.2%], 263 Male [M] [53.8%]) were reviewed. Males were more likely to present with food impaction (92 [35.8%] vs 44 [19.7%], M vs F, P < .001), have a fibrostenotic phenotype on initial endoscopy (140 [54.1%] vs 98 [45.0%], M vs F, P = .043) and undergo dilation (odds ratio [OR] = 1.985, 95% confidence interval [CI] = 1.209-3.328, P < .01). Female patients were more likely to have atopic disease (153 [67.6%] vs 153 [58.8%], F vs M, P = .044) and a reported normal index endoscopy (79 [36.2%] vs 69 [26.6%], F vs M, P = .026). Conclusion: This large retrospective review highlights clinically important differences in presentation between sexes. Increasing awareness of these differences, especially history of atopic disease, impaction, and the need for dilation, can help clinicians better identify EoE in female patients and therefore, guide initial therapy. The mechanistic underpinnings of these discrepancies are not evident from this data and will require future studies.","PeriodicalId":73049,"journal":{"name":"Foregut (Thousand Oaks, Calif.)","volume":"13 1","pages":"141 - 148"},"PeriodicalIF":0.0,"publicationDate":"2023-05-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79102158","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}
Pub Date : 2023-05-02DOI: 10.1177/26345161231170788
Olaya I. Brewer Gutierrez, David Choi, R. Hejazi, Salih Samo, Michael N. Tran, K. Chang, Glenn M. Ihde, R. Bell, N. Nguyen
Gastroesophageal reflux disease (GERD) is a chronic disease on a spectrum that has an array of management options ranging from lifestyle changes, acid suppressive therapy to laparoscopic anti-reflux surgery (LARS). Transoral incisionless fundoplication (TIF) is an endoscopic procedure in the management of GERD that re-establishes and augments the gastroesophageal flap valve (GEFV). TIF is appropriate for patients that do not have a hiatal hernia greater than 2 cm. Patients with a hiatal hernia greater than 2 cm have the option to have either a conventional LARS (laparoscopic hiatal hernia repair with complete or partial fundoplication) or a concomitant laparoscopic hiatal hernia repair with TIF, known as concomitant TIF (cTIF). This white paper summarizes the published outcome data for TIF 2.0 and cTIF to date and outline the best practice approaches including patient assessment, selection, and management for TIF and cTIF.
{"title":"American Foregut Society White Paper on Transoral Incisionless Fundoplication","authors":"Olaya I. Brewer Gutierrez, David Choi, R. Hejazi, Salih Samo, Michael N. Tran, K. Chang, Glenn M. Ihde, R. Bell, N. Nguyen","doi":"10.1177/26345161231170788","DOIUrl":"https://doi.org/10.1177/26345161231170788","url":null,"abstract":"Gastroesophageal reflux disease (GERD) is a chronic disease on a spectrum that has an array of management options ranging from lifestyle changes, acid suppressive therapy to laparoscopic anti-reflux surgery (LARS). Transoral incisionless fundoplication (TIF) is an endoscopic procedure in the management of GERD that re-establishes and augments the gastroesophageal flap valve (GEFV). TIF is appropriate for patients that do not have a hiatal hernia greater than 2 cm. Patients with a hiatal hernia greater than 2 cm have the option to have either a conventional LARS (laparoscopic hiatal hernia repair with complete or partial fundoplication) or a concomitant laparoscopic hiatal hernia repair with TIF, known as concomitant TIF (cTIF). This white paper summarizes the published outcome data for TIF 2.0 and cTIF to date and outline the best practice approaches including patient assessment, selection, and management for TIF and cTIF.","PeriodicalId":73049,"journal":{"name":"Foregut (Thousand Oaks, Calif.)","volume":"3 1","pages":"242 - 254"},"PeriodicalIF":0.0,"publicationDate":"2023-05-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"66050310","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}
Pub Date : 2023-05-02DOI: 10.1177/26345161231170660
E. M. Dowell, David H. Wang
Health disparities exist in incidence, treatment, and survival of esophageal and gastric cancer based on socioeconomic and minority racial/ethnic group status. How socioeconomic and minority status affect access and utilization of precision oncology in foregut malignancies is not well understood. Based on other cancer types, multiple intrinsic and extrinsic factors influence utilization of cancer genetic testing, participation in precision oncology clinical trials, and access to molecularly targeted therapies. As precision oncology becomes more common in the treatment of foregut malignancies, health equity will require ongoing identification of sources of disparities and proposal of practical solutions.
{"title":"Health Disparities and Precision Oncology in Foregut Malignancies","authors":"E. M. Dowell, David H. Wang","doi":"10.1177/26345161231170660","DOIUrl":"https://doi.org/10.1177/26345161231170660","url":null,"abstract":"Health disparities exist in incidence, treatment, and survival of esophageal and gastric cancer based on socioeconomic and minority racial/ethnic group status. How socioeconomic and minority status affect access and utilization of precision oncology in foregut malignancies is not well understood. Based on other cancer types, multiple intrinsic and extrinsic factors influence utilization of cancer genetic testing, participation in precision oncology clinical trials, and access to molecularly targeted therapies. As precision oncology becomes more common in the treatment of foregut malignancies, health equity will require ongoing identification of sources of disparities and proposal of practical solutions.","PeriodicalId":73049,"journal":{"name":"Foregut (Thousand Oaks, Calif.)","volume":"9 1","pages":"227 - 234"},"PeriodicalIF":0.0,"publicationDate":"2023-05-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87727691","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}
Pub Date : 2023-05-02DOI: 10.1177/26345161231170244
Shreya Chablaney, L. Brandt
The differential diagnosis of dysphagia is broad. A thorough history and physical examination are of paramount importance in determining the etiology of the patient’s dysphagia and guiding their subsequent management. This article discusses our approach to the evaluation of a patient presenting with dysphagia.
{"title":"Critical Decision Making: Dysphagia","authors":"Shreya Chablaney, L. Brandt","doi":"10.1177/26345161231170244","DOIUrl":"https://doi.org/10.1177/26345161231170244","url":null,"abstract":"The differential diagnosis of dysphagia is broad. A thorough history and physical examination are of paramount importance in determining the etiology of the patient’s dysphagia and guiding their subsequent management. This article discusses our approach to the evaluation of a patient presenting with dysphagia.","PeriodicalId":73049,"journal":{"name":"Foregut (Thousand Oaks, Calif.)","volume":"3 1","pages":"297 - 302"},"PeriodicalIF":0.0,"publicationDate":"2023-05-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"66050527","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}
Pub Date : 2023-04-28DOI: 10.1177/26345161231170586
S. Chandra, S. Reddymasu
The objective of the study was to measure the extent in which the percentage of fully vaccinated individuals during the dominant periods of Alpha, Delta, and Omicron variants have influenced mortality rates. This study was conducted using COVID-19 Centers for Disease Control and Prevention (CDC) Case Surveillance Public Data Taskforce for 57 states and United States territories between January 1, 2020 to March 20, 2022. Multivariable binary Hyperbolastic regression of type I was used to analyze the data. Seniors and ICU-admitted patients had the highest risk of death. For each additional percent increase in fully vaccinated individuals, the odds of death deceased by 1%. The odds of death prior to vaccine availability, compared to post vaccine availability, was 1.27. When comparing the time periods each variant was dominant, the odds of death was 3.45-fold higher during Delta compared to Alpha. All predictor variables had P-values less than .001. There was a noticeable difference in the odds of death among subcategories of age, race/ethnicity, sex, PMCs, hospitalization, ICU, vaccine availability, variant, and percent of fully vaccinated individuals.
{"title":"Symptoms Evaluation After Anti-Reflux Surgery—Gi Perspective","authors":"S. Chandra, S. Reddymasu","doi":"10.1177/26345161231170586","DOIUrl":"https://doi.org/10.1177/26345161231170586","url":null,"abstract":"The objective of the study was to measure the extent in which the percentage of fully vaccinated individuals during the dominant periods of Alpha, Delta, and Omicron variants have influenced mortality rates. This study was conducted using COVID-19 Centers for Disease Control and Prevention (CDC) Case Surveillance Public Data Taskforce for 57 states and United States territories between January 1, 2020 to March 20, 2022. Multivariable binary Hyperbolastic regression of type I was used to analyze the data. Seniors and ICU-admitted patients had the highest risk of death. For each additional percent increase in fully vaccinated individuals, the odds of death deceased by 1%. The odds of death prior to vaccine availability, compared to post vaccine availability, was 1.27. When comparing the time periods each variant was dominant, the odds of death was 3.45-fold higher during Delta compared to Alpha. All predictor variables had P-values less than .001. There was a noticeable difference in the odds of death among subcategories of age, race/ethnicity, sex, PMCs, hospitalization, ICU, vaccine availability, variant, and percent of fully vaccinated individuals.","PeriodicalId":73049,"journal":{"name":"Foregut (Thousand Oaks, Calif.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-04-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47846646","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}
Pub Date : 2023-04-27DOI: 10.1177/26345161231168955
Alexander T. Reddy, E. Song, R. Shimpi, S. Cantrell, D. Leiman
Ineffective esophageal motility (IEM) is a commonly identified disorder of peristalsis. Although often asymptomatic, IEM can be associated with dysphagia. Aside from treating co-existing gastroesophageal reflux disease and sources of mechanical obstruction, few options are available for management in this context. We therefore systematically reviewed the literature to identify randomized controlled trials (RCTs) for medical treatments of IEM. MEDLINE, Embase, Cochrane Library, and Web of Science were searched using controlled vocabulary and keywords to identify RCTs from inception through 9/22/2021. Prospective studies evaluating medical therapy to improve dysphagia in adults with IEM were included. The risk of bias was assessed using the revised Cochrane risk-of-bias tool. Among 1046 studies identified, 6 (0.58%) met inclusion criteria with a total of 65 patients. Most studies evaluated serotonin receptor agonists (buspirone, mosapride, prucalopride, and sumatriptan), primarily assessing changes on esophageal high-resolution manometry parameters, and only 1 study evaluated patient reported outcomes. Overall, medical therapy improved these pooled outcomes in 5 (83%) studies. Although treatment endpoints varied, the risk of bias in study reporting was low for 4 studies and uncertain for 2 studies. There are currently few therapeutic options available for IEM patients with symptomatic non-obstructive dysphagia. Our systematic review identified 6 studies utilizing medical therapy in patients with IEM, and a majority demonstrated an improvement in HRM parameters. Medical therapy may therefore be considered in this context, but additional studies are warranted to assess for similar improvement in patient symptoms.
无效的食道蠕动（IEM）是一种常见的蠕动障碍。尽管IEM通常无症状，但可能与吞咽困难有关。除了治疗同时存在的胃食管反流病和机械性梗阻外，在这种情况下，几乎没有可用的治疗方法。因此，我们系统地回顾了文献，以确定IEM药物治疗的随机对照试验（RCT）。MEDLINE、Embase、Cochrane Library和Web of Science使用受控词汇和关键词进行搜索，以确定从开始到2021年9月22日的随机对照试验。前瞻性研究评估了药物治疗改善成人IEM吞咽困难的效果。使用修订的Cochrane偏倚风险工具评估偏倚风险。在确定的1046项研究中，6项（0.58%）符合纳入标准，共有65名患者。大多数研究评估了5-羟色胺受体激动剂（丁螺环酮、莫沙必利、普卡罗必利和舒马曲普坦），主要评估食道高分辨率测压参数的变化，只有1项研究评估了患者报告的结果。总体而言，在5项（83%）研究中，药物治疗改善了这些合并结果。尽管治疗终点各不相同，但4项研究的研究报告偏倚风险较低，2项研究的偏倚风险不确定。目前，对于有症状的非阻塞性吞咽困难的IEM患者，几乎没有可用的治疗方案。我们的系统综述确定了6项在IEM患者中使用药物治疗的研究，大多数研究表明HRM参数有所改善。因此，在这种情况下可以考虑药物治疗，但需要进行额外的研究来评估患者症状的类似改善。
{"title":"Medical Therapy for Ineffective Esophageal Motility: A Systematic Review","authors":"Alexander T. Reddy, E. Song, R. Shimpi, S. Cantrell, D. Leiman","doi":"10.1177/26345161231168955","DOIUrl":"https://doi.org/10.1177/26345161231168955","url":null,"abstract":"Ineffective esophageal motility (IEM) is a commonly identified disorder of peristalsis. Although often asymptomatic, IEM can be associated with dysphagia. Aside from treating co-existing gastroesophageal reflux disease and sources of mechanical obstruction, few options are available for management in this context. We therefore systematically reviewed the literature to identify randomized controlled trials (RCTs) for medical treatments of IEM. MEDLINE, Embase, Cochrane Library, and Web of Science were searched using controlled vocabulary and keywords to identify RCTs from inception through 9/22/2021. Prospective studies evaluating medical therapy to improve dysphagia in adults with IEM were included. The risk of bias was assessed using the revised Cochrane risk-of-bias tool. Among 1046 studies identified, 6 (0.58%) met inclusion criteria with a total of 65 patients. Most studies evaluated serotonin receptor agonists (buspirone, mosapride, prucalopride, and sumatriptan), primarily assessing changes on esophageal high-resolution manometry parameters, and only 1 study evaluated patient reported outcomes. Overall, medical therapy improved these pooled outcomes in 5 (83%) studies. Although treatment endpoints varied, the risk of bias in study reporting was low for 4 studies and uncertain for 2 studies. There are currently few therapeutic options available for IEM patients with symptomatic non-obstructive dysphagia. Our systematic review identified 6 studies utilizing medical therapy in patients with IEM, and a majority demonstrated an improvement in HRM parameters. Medical therapy may therefore be considered in this context, but additional studies are warranted to assess for similar improvement in patient symptoms.","PeriodicalId":73049,"journal":{"name":"Foregut (Thousand Oaks, Calif.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46616439","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}
Pub Date : 2023-04-26DOI: 10.1177/26345161231170589
N. Narula
Gastroesophageal reflux disease (GERD) affects a large segment of the population. Initial treatment includes lifestyle changes and medications such as proton pump inhibitors (PPIs). For a more definitive option or to avoid long-term medication use, there are various effective invasive interventions. Some reasons to avoid PPIs include the risk of side effects such as infections and osteoporosis, incomplete response, or patient preference to avoid lifelong use.1 Endoscopic and surgical treatments can be offered after an appropriate workup. Historically, the procedure of choice was antireflux surgery (ARS): a hiatal hernia repair if one was present combined with a fundoplication. These are now mostly done laparoscopically or robotically as minimally invasive techniques have become widespread. Options for fundoplication include 360° full, or Nissen, fundoplication and various partial fundoplications, such as 270°, or Toupet, fundoplication or 180° anterior fundoplication. Debate as to which fundoplication is best is ongoing; a recent multi-society consensus guideline reported that subjective and objective reflux control was better with full fundoplication, whereas hiatal hernia recurrence, dysphagia, and gas/bloat was better with partial fundoplication.1 In addition to surgery, there are now several endoscopic treatment options. These include radiofrequency energy, or Stretta, and Transoral incisionless fundoplication, or TIF. TIF was initially used starting in 2006 with the EsophyX® device and is now upgraded to a 2.0 option using the EsophyX® Z+ device that allows a greater wrap to 270° to 320°.2,3 Combining a surgical hiatal hernia repair with TIF is concomitant TIF or cTIF.2 Another hybrid option is a magnetic sphincter augmentation (MSA), or LINX®. Gutierrez et al2 as part of The American Foregut Society Clinical Practice Committee TIF Working Group present a comprehensive and well-written summary of TIF and cTIF.2 They delineate some of the differences between TIF and ARS, indications for TIF, recommended workup, and delve into the steps of both TIF and cTIF. They also discuss post-procedure care, complications, and outcomes, in addition to briefly touching on reimbursement. This paper is a useful review both for those previously unfamiliar with TIF and for those with prior knowledge. There are several highlights. The first is their explanation of the physiology of the antireflux mechanism, comparing TIF and fundoplication. The second is their clear description for patient selection and recommendations for preoperative workup. They note that endoscopic treatments such as TIF offer an option of intermediate invasiveness between medications and surgery. Patients with Hill Grade I and II are candidates for TIF whereas those with Hill Grade III and IV, hiatal hernias greater than 2 cm, or patients with LA grade C and D esophagitis should be offered cTIF or ARS. Those with dysmotility may be candidates. Another feature of this review is the technica
{"title":"Invited Commentary on the American Foregut Society White Paper on Transoral Incisionless Fundoplication: Transoral Incisionless Fundoplication: Where Are We and Where Do We Go From Here?","authors":"N. Narula","doi":"10.1177/26345161231170589","DOIUrl":"https://doi.org/10.1177/26345161231170589","url":null,"abstract":"Gastroesophageal reflux disease (GERD) affects a large segment of the population. Initial treatment includes lifestyle changes and medications such as proton pump inhibitors (PPIs). For a more definitive option or to avoid long-term medication use, there are various effective invasive interventions. Some reasons to avoid PPIs include the risk of side effects such as infections and osteoporosis, incomplete response, or patient preference to avoid lifelong use.1 Endoscopic and surgical treatments can be offered after an appropriate workup. Historically, the procedure of choice was antireflux surgery (ARS): a hiatal hernia repair if one was present combined with a fundoplication. These are now mostly done laparoscopically or robotically as minimally invasive techniques have become widespread. Options for fundoplication include 360° full, or Nissen, fundoplication and various partial fundoplications, such as 270°, or Toupet, fundoplication or 180° anterior fundoplication. Debate as to which fundoplication is best is ongoing; a recent multi-society consensus guideline reported that subjective and objective reflux control was better with full fundoplication, whereas hiatal hernia recurrence, dysphagia, and gas/bloat was better with partial fundoplication.1 In addition to surgery, there are now several endoscopic treatment options. These include radiofrequency energy, or Stretta, and Transoral incisionless fundoplication, or TIF. TIF was initially used starting in 2006 with the EsophyX® device and is now upgraded to a 2.0 option using the EsophyX® Z+ device that allows a greater wrap to 270° to 320°.2,3 Combining a surgical hiatal hernia repair with TIF is concomitant TIF or cTIF.2 Another hybrid option is a magnetic sphincter augmentation (MSA), or LINX®. Gutierrez et al2 as part of The American Foregut Society Clinical Practice Committee TIF Working Group present a comprehensive and well-written summary of TIF and cTIF.2 They delineate some of the differences between TIF and ARS, indications for TIF, recommended workup, and delve into the steps of both TIF and cTIF. They also discuss post-procedure care, complications, and outcomes, in addition to briefly touching on reimbursement. This paper is a useful review both for those previously unfamiliar with TIF and for those with prior knowledge. There are several highlights. The first is their explanation of the physiology of the antireflux mechanism, comparing TIF and fundoplication. The second is their clear description for patient selection and recommendations for preoperative workup. They note that endoscopic treatments such as TIF offer an option of intermediate invasiveness between medications and surgery. Patients with Hill Grade I and II are candidates for TIF whereas those with Hill Grade III and IV, hiatal hernias greater than 2 cm, or patients with LA grade C and D esophagitis should be offered cTIF or ARS. Those with dysmotility may be candidates. Another feature of this review is the technica","PeriodicalId":73049,"journal":{"name":"Foregut (Thousand Oaks, Calif.)","volume":"3 1","pages":"255 - 256"},"PeriodicalIF":0.0,"publicationDate":"2023-04-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"66050222","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}
Pub Date : 2023-04-26DOI: 10.1177/26345161231170570
Thomas H. Shin, M. Kroh
While fundoplication as a treatment for gastroesophageal reflux disease (GERD) has been largely successful, the rise in reflux cases refractory to initial surgery presents a unique challenge in the search for more durable symptom relief. In addition to principles pertaining to medical management and reoperation, this article discusses several nuances to consider in the careful evaluation of recalcitrant GERD post-fundoplication to optimize long-term success after revisional antireflux surgery from a surgical perspective.
{"title":"Surgical Perspective on Evaluation and Management of Recurrent Reflux After Primary Antireflux Surgery","authors":"Thomas H. Shin, M. Kroh","doi":"10.1177/26345161231170570","DOIUrl":"https://doi.org/10.1177/26345161231170570","url":null,"abstract":"While fundoplication as a treatment for gastroesophageal reflux disease (GERD) has been largely successful, the rise in reflux cases refractory to initial surgery presents a unique challenge in the search for more durable symptom relief. In addition to principles pertaining to medical management and reoperation, this article discusses several nuances to consider in the careful evaluation of recalcitrant GERD post-fundoplication to optimize long-term success after revisional antireflux surgery from a surgical perspective.","PeriodicalId":73049,"journal":{"name":"Foregut (Thousand Oaks, Calif.)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-04-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42025051","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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