[Surgical treatment of hiatal hernia complicated by short esophagus: a prospective study]. / Khirurgicheskoe lechenie gryzh pishchevodnogo otverstiya diafragmy, oslozhnennykh korotkim pishchevodom.

OBJECTIVE: To analyze immediate and long-term postoperative results in patients with hiatal hernia complicated by short esophagus. MATERIAL AND METHODS: We prospectively analyzed postoperative outcomes in 113 patients with hiatal hernia who underwent surgery between 2013 and 2021. The main group consisted of 54 patients with length of intra-abdominal segment of esophagus <4 cm who underwent Collis procedure or esophagus >4 cm and indications for Nissen fundoplication cuff. The control group consisted of 59 patients and indications for esophageal lengthening procedure only if length of intra-abdominal segment of esophagus was less than 2 cm. This surgery was started with anterolateral vagotomy, and Collis procedure was performed in case of ineffective vagotomy. Nissen fundoplication was performed for abdominal segment of esophagus >2 cm. RESULTS: In the main group, 17 (31.5%) patients with intra-abdominal segment of esophagus <4 cm required Collis procedure. In the control group, length of intra-abdominal segment of esophagus <2 cm was observed in 6 (10.2%) patients. In all cases, anterolateral vagotomy was performed. Surgery time was 189 (80-290) and 136 (90-320) min, respectively (p=0.001). Postoperative complications in the main group occurred in 8 (14.8%) patients, in the control group - 4 (6.8%) patients (p=0.281). One (1.7%) patient died in the control group. The follow-up period was 38 (12-66) months. In long-term period, recurrence developed in 2 (3.7%) and 11 (20%) patients, respectively (p=0.026). High satisfaction with postoperative outcomes was observed in 51 (94.4%) and 46 (79.3%) patients, respectively (p=0.038). CONCLUSION: Uncorrected shortening of the esophagus can be one of the main risk factors of recurrence in long-term period. Expanding the indications for Collis gastroplasty can reduce the incidence of poor outcomes without affecting the incidence of postoperative complications.

Outcomes of Standardized Protocols in Supercharged Pedicled Jejunal Esophageal Reconstruction.

BACKGROUND: This study evaluated clinical and patient-reported outcomes (PROs) of long-segment supercharged pedicled jejunal (SPJ) interposition after implementation of a dedicated multidisciplinary pathway and technical refinements. METHODS: This study was a 6-year review of consecutive patients who underwent complex esophageal reconstruction with SPJ interposition. Clinical data were abstracted, and PRO data were collected prospectively by using the Upper Digestive Disease mobile application (UDD App). This standardized questionnaire comprised domains for mental and physical health, pain, dysphagia, reflux, hypoglycemia dumping, and gastrointestinal dumping symptoms. Operative refinements were comprehensively established by 2018. RESULTS: A total of 19 patients were included in the study, 15 of whom had a history of esophageal malignant disease and neoadjuvant chemoradiation. Most patients (18; 95%) underwent delayed reconstruction after diversion. There was no 90-day mortality or flap loss. Most patients (18; 95%) achieved an enteral diet. Seven patients (37%) experienced early complications (<90 days) requiring procedural intervention. The incidence of any medical or surgical complication was similar in the earlier (2015-2017) and late (2018-2020) cohorts, but aspiration events, surgical site infections, anastomotic leak rates, and median hospital stay (reduced from 15 days [IQR, 10-21 days] to 9 days [IQR, 9-13 days]) improved in the contemporary cohort. PRO data were collected in 14 of 15 (93%) living patients. Severe symptoms in at least 1 domain were reported by most patients (11; 79%) and improved over time. CONCLUSIONS: Dedicated care pathways allow standardization of complex procedures, and targeted modifications may optimize recovery and patient outcomes. This cohort of patients may report severe symptoms that require ongoing monitoring and intervention.

Black esophagus.

A 76-year-old man with multiple cardiovascular risk factors (hypertension, DM2, LD, smoker) and severe peripheral arterial disease (iliofemoral bypass, supracondylar amputation) came to the emergency with coffee ground emesis and mild anemia. Urgent gastroscopy showed diffuse circumferential black mucosa covered by fibrin affecting the middle and distal esophageal third. Acute esophageal necrosis is a rare cause of gastrointestinal bleeding that should be suspected in patients with cardiovascular risk factors with an image of a black esophagus that is abruptly interrupted at the EGJ.

A Rare Complication of Esophageal Exclusion: Esophageal Mucocele.

Bipolar esophageal exclusion is a "Hail Mary" procedure for control of leak and persistent mediastinal soilage from esophageal injury. Usually, the esophageal remnant scars down without negative consequences. Esophageal mucocele is a rare complication of bipolar esophageal exclusion. This is a case report of an iatrogenic esophageal transection and the subsequent treatment course. A retrospective chart review of the patient's medical and surgical history was performed. After a robotic hiatal hernia repair at an outside institution, the patient suffered an esophageal leak and was surgically treated with esophageal exclusion, wide drainage of the mediastinum, and decortication of the resulting empyema. She subsequently underwent retrosternal gastric conduit for esophageal reconstruction 4 months later. Three years after this, she developed a rare complication of esophageal exclusion, a symptomatic esophageal mucocele that required resection.

Gastroesophageal intussusception in a 4-week-old German shepherd puppy.

The surgical treatment of a gastroesophageal intussusception (GEI) in a 4-week-old male intact German shepherd puppy is described in this report. Bilateral gastropexies were performed; an incisional gastropexy on the right and a gastrostomy tube gastropexy on the left. The dog recovered well and is thriving long-term with no clinical signs of persistent megaesophagus. With the combination of early detection and surgical correction of GEI, mortality rates may be lower than the 95% mortality rate that has been reported in previous literature and supports new studies that have reported a 65% survival rate long-term. Key clinical message: Young animals presenting with vague clinical signs require thorough evaluation to identify uncommon, yet life-threatening diseases such as GEI. Early detection and interventions can subsequently lead to successful outcomes.

Intussusception gastro-oesophagienne chez un chiot berger allemand de 4 semaines. Le traitement chirurgical d'une intussusception gastro-oesophagienne (GEI) chez un chiot berger allemand mâle intact âgé de 4 semaines est décrit dans ce rapport. Des gastropexies bilatérales ont été réalisées; une gastropexie incisionnelle à droite et une gastropexie par tube de gastrostomie à gauche.Le chien a bien récupéré et se porte bien à long terme sans aucun signe clinique de mégaoesophage persistant.Avec la combinaison de la détection précoce et de la correction chirurgicale de la GEI, les taux de mortalité peuvent être inférieurs au taux de mortalité de 95 % qui a été rapporté dans la littérature antérieure et soutient de nouvelles études qui ont rapporté un taux de survie à long terme de 65 %.Message clinique clé :Les jeunes animaux présentant des signes cliniques vagues nécessitent une évaluation approfondie pour identifier des maladies rares, mais potentiellement mortelles, telles que la GEI. Une détection et des interventions précoces peuvent ensuite conduire à des résultats positifs.(Traduit par Dr Serge Messier).

[Minimally invasive esophagectomy for benign esophageal diseases: results of a two-center study]. / Minimal'no invazivnaya ezofagektomiya pri dobrokachestvennykh zabolevaniyakh pishchevoda: rezul'taty dvukhtsentrovogo issledovaniya.

OBJECTIVE: To analyze the results of thoracoscopic esophagectomy for benign esophageal diseases. MATERIAL AND METHODS: The study included 78 patients who underwent thoracoscopic esophagectomy between 2011 and 2019. Peptic and burn strictures of the esophagus were diagnosed in 53 patients, achalasia - in 24 patients. Minimally invasive esophagectomy and esophagoplasty with isoperistaltic gastric tube and esophagogastrostomy on the neck was performed in 68 patients, Ivor Lewis esophagectomy - in 1 patient, coloesophagoplasty - in 9 patients. We used manual technique of anastomosis in 58 patients, stapling device - in 19 patients. In 1 case, surgery was finished with esophagostomy and gastrostomy. RESULTS: Mean blood loss was 200 ml (10-1200), surgery time - 450 min (265-765 min). Early postoperative complications occurred in 37 patients including anastomotic leakage in 24 cases. In long-term period, anastomotic strictures developed in 9 patients. No mortality was observed. CONCLUSION: Minimally invasive esophagectomy for benign esophageal diseases ensures favorable clinical outcomes. However, no consensus in the choice of surgical approach and indications, as well as small number of these patients cause challenges in implementation of this technique. There are different opinions regarding technique of anastomosis on the neck and surgical access in thoracoscopic esophagectomy.

Acute esophageal necrosis syndrome. The 2021 update from an Italian survey and personal experience.

AIM: Black esophagus, or acute esophageal necrosis, is a rare entity with multifactorial aetiology. Modern theories suggest a combination of ischemia, compromised mucosa defences and corrosive agent's injury. MATERIAL AND METHODS: We investigated black esophagus by means of a retrospective review of 26 cases in literature. A Medline overview is performed until May 2021 by considering the Italian results. The search terms were "black esophageal syndrome in Italy", "black esophagus in Italy", "black esophageal necrosis in Italy", and "Gurvits syndrome in Italy". To complete these case reports, we illustrate our first experience of the syndrome successfully treated with esophagectomy, cervical diversion and gastrostomy. RESULTS: Black esophagus is common in adult males (M/F: 21/5) (Range: 47-89 years; Average: 70.6 year-old). The most common symptoms are hematemesis, epigastric pain and dysphagia. Endoscopically, diffuse involvement of acute esophageal necrosis is diagnosed in 42.3% of cases. The treatment consisted on red blood cell transfusions, sucralfate administration, proton pump-inhibition, enteral nutrition and antimicrobial agents. Overall mortality was 38.4% and only one case underwent surgery for acute bleeding. CONCLUSIONS: Black esophagus is often reversible both anatomically and functionally. Its treatment is based on supported therapies and hemodynamic resuscitation. This syndrome shows high mortality related to the coexisted medical conditions rather than acute esophageal necrosis. Only in selected cases, surgical treatment is indicated. KEY WORDS: Acute necrotizing esophagitis, Black esophagus, Ischemia.

Isolated oesophageal Crohn's disease mimicking oesophageal carcinoma treated by Merendino procedure.

Oesophageal involvement is a very rare presentation of Crohn's disease. It can occur as an isolated mass causing dysphagia and can be mistaken for malignancy. Here, we report a case of a 75-year-old woman presenting with dysphagia and weight loss. Gastroscopy showed an ulcerating mass, and her barium swallow showed a bird beak appearance at the level of the gastro-oesophageal junction (GEJ). Repetitive biopsies were inconclusive. Fluorodeoxyglucose-positron emission tomography showed high glucose uptake (standardised uptake value: 10.2) at the level of the GEJ. Endoscopic ultrasound classified the lesion as uT3N1. Step-by-step surgical exploration revealed an oesophageal mass. A frozen section examination showed an absence of malignancy and the presence of inflammatory tissue. A partial oesophagogastrostomy was performed, and reconstruction was achieved by a Merendino procedure. Definitive histopathological examination revealed isolated oesophageal Crohn's disease.

Evolution, lessons learned, and contemporary outcomes of esophageal replacement with jejunum for children.

BACKGROUND: The jejunal interposition is our preferred esophageal replacement route when the native esophagus cannot be reconstructed. We report the evolution of our approach and outcomes. METHODS: The study was a single-center retrospective review of children undergoing jejunal interposition for esophageal replacement. Outcomes were compared between historical (2010-2015) and contemporary cohorts (2016-2019). RESULTS: Fifty-five patients, 58% male, median age 4 years (interquartile range 2.4-8.3), with history of esophageal atresia (87%), caustic (9%) or peptic (4%) injury, underwent a jejunal interposition (historical cohort n = 14; contemporary cohort n = 41). Duration of intubation (11 vs 6 days; P = .01), intensive care unit (22 vs 13 days; P = .03), and hospital stay (50 vs 27 days; P = .004) were shorter in the contemporary cohort. Anastomotic leaks (7% vs 5%; P = .78), anastomotic stricture resection (7% vs 10%; P = .74), and need for reoperation (57% vs 46%; P = .48) were similar between cohorts. Most reoperations were elective conduit revisions. Microvascular augmentation, used in 70% of cases, was associated with 0% anastomotic leaks vs 18% without augmentation; P = .007. With median follow-up of 1.9 years (interquartile range 1.1, 3.8), 78% of patients are predominantly orally fed. Those with preoperative oral intake were more likely to achieve consistent postoperative oral intake (87.5% vs 64%; P = .04). CONCLUSION: We have made continuous improvements in our management of patients undergoing a jejunal interposition. Of these, microvascular augmentation was associated with no anastomotic leaks. Despite its complexity and potential need for conduit revision, the jejunal interposition remains our preferred esophageal replacement, given its excellent long-term functional outcomes in these complex children who have often undergone multiple procedures before the jejunal interposition.

Exploring the concept of centralization of surgery for benign esophageal diseases: a Delphi based consensus from the European Society for Diseases of the Esophagus.

Surgery for benign esophageal diseases may be complex, requiring specialist training, but currently, unlike oncologic surgery, it is not centralized. The aim of the study was to explore the opinion of European surgeons on the centralization of surgery for benign esophageal diseases. A web-based questionnaire, developed through a modified Delphi process, was administered to general and thoracic surgeons of 33 European surgical societies. There were 791 complete responses (98.5%), in 59.2% of respondents, the age ranged between 41 and 60 years, 60.3% of respondents worked in tertiary centers. In 2017, the number of major surgical procedures performed for any esophageal disease by respondents was <10 for 56.5% and >100 for 4.5%; in responder's hospitals procedures number was <10 in 27% and >100 in 15%. Centralization of surgery for benign esophageal diseases was advocated by 83.4%, in centers located according to geographic/population criteria (69.3%), in tertiary hospitals (74.5%), with availability of advanced diagnostic and interventional technologies (88.4%), in at least 10 beds units (70.5%). For national and international centers accreditation/certification, criteria approved included in-hospital mortality and morbidity (95%), quality of life oriented follow-up after surgery (88.9%), quality audits (82.6%), academic research (58.2%), and collaboration with national and international centers (76.6%); indications on surgical procedures volumes were variable. The present study strongly supports the centralization of surgery for benign esophageal diseases, in large part modeled on the principles that have underpinned the centralization of cancer surgery internationally, with emphasis on structure, process, volumes, quality audit, and clinical research.

[Initial experience of robot-assisted minimally invasive McKeown esophagectomy]. / Pervyi opyt robot-assistirovannykh subtotal'nykh rezektsii pishchevoda po McKeown.

OBJECTIVE: To report our initial experience of robot-assisted McKeown esophagectomy with stapled cervical esophagogastrostomy. MATERIAL AND METHODS: There were 5 robot-assisted McKeown esophagectomies in patients with benign end-staged and malignant diseases of the esophagus for the period from October 2019 to February 2020. RESULTS: No conversions and intraoperative complications were observed. Mean surgery time was 406±48 min, total intraoperative blood loss - 108±45 ml. Four patients had minor complications (wound infection, atelectasis, pneumothorax) that required conservative treatment. We have controlled anastomosis in 2-3 postoperative days with water-soluble contrast, none patient had an anastomotic leakage. Mean hospital-stay was 5 days. Complete (R0) resection was accomplished in all patients with malignant neoplasms. CONCLUSIONS: Our first experience showed that robot-assisted McKeown esophagectomy is a safe and feasible surgical option for esophageal diseases. Robot-assisted interventions require advanced endoscopic surgical experience.

How high is too high? Extensive mediastinal dissection in patients with hiatal hernia repair.

BACKGROUND: Approximately 10% of patients receiving anti-reflux procedures present with shortened esophagus. Collis gastroplasty (CG) is the current gold standard for esophageal lengthening, but mediastinal esophageal mobilization without gastroplasty may be an alternative approach. This study assesses preoperative and intraoperative hernia characteristics and mediastinal dissection impact in patients with large hiatal hernia repair (HHR). METHODS: A single-institution, prospectively collected database was reviewed for adults who underwent laparoscopic HHR with mesh and anti-reflux surgery between 2005 and 2016, hernia ≥ 5 cm. Preoperative hernia and follow-up were assessed using upper endoscopy and barium swallow. Intraoperative hernia characteristics were collected from the operative note. Esophageal symptom scores were collected pre- and postoperatively. Analyses were conducted using SPSS v26.0. RESULTS: Among 662 patients who had anti-reflux surgery in this period, a total of 205 patients who underwent HHR with mesh met the inclusion criteria and were included in study. Mean age was 61.7 ± 13.6 years, and majority of patients were female and Caucasian. Mean BMI was 29.9 ± 6.0 kg/m2. Median hernia size was 6.5 cm [5.0-12.0 cm], and intra-thoracic stomach had a prevalence of 21.9%. Analysis of preoperative barium swallow revealed an average of elevated gastroesophageal junction above the diaphragm of 4.10 ± 1.67 cm. Radiographically, average hernia size was 6.34 ± 1.93 cm and 6.38 ± 1.92 cm in the anterior-posterior and obliquus view, respectively. Median follow-up time was 2.7 years [1-9 years]. Esophageal symptoms improved in all patients (p < 0.05). 45% of patients had radiographic recurrence, but only four presented symptomatic or were on PPI. CONCLUSIONS: CG has been the standard for ensuring adequate esophageal length prior to anti-reflux surgery. Our results support that CG is unnecessary in the majority of cases, and extensive mediastinal dissection was successfully used instead of CG with durable, long-term outcomes. Extended mediastinal dissection may mitigate CG risks in patients requiring additional intra-abdominal esophagus.

Open, Minimally Invasive, and Robotic Approaches for Esophagectomy: What Is the Approach Algorithm?

Esophageal cancer requires a multimodality treatment approach, with surgical resection a key component in many cases. When it comes to esophagectomy, several approaches and techniques exist, including transhiatal versus transthoracic and open versus minimally invasive. Each approach has its associated risks and advantages. When determining the optimal approach and technique, several variables need to be considered. The key variables include patient and tumor characteristics, as well as surgeon comfort and experience with each approach. Regardless of the approach, the goal should remain the same, that is, performing a safe operation without compromise of oncologic principles.

Pattern of esophageal injuries and surgical management: A retrospective review.

BACKGROUND: The consequence of significant injury to the esophagus is devastating. The initial management when timely and appropriate is rewarding and often prevents lethal complications. The objective of this study is to describe the etiology of esophageal injury in our institution, the management procedures and the mid-term results. METHOD: Consecutive patients diagnosed and managed for esophageal injury from January 2005 to March 2015 were retrospectively reviewed. RESULTS: One hundred and eleven patients were seen and treated during this period; 85 (76.6%) predominantly children were corrosive esophageal injuries who accidentally ingested caustic soda and 26 (24.4%) were traumatic esophageal injuries. Patients with corrosive esophageal injuries were predominantly male (2:1), mean age 12.8 ± 14.2 years (2-58 years) and predominantly children (53% ≤5 years; 18.8% ≥ 18 years). Patients with non-corrosive esophageal injury were also predominantly male (4:1) with a mean age of 34.4 ± 20.1 years (1-73 years). The treatment procedures for corrosive esophageal injuries included esophagocoloplasty 64 (75.3%), colopharyngoplasty 10 (11.8%), colon-flap augmentation pharyngo-esophagoplasty 4 (4.7%), colopharyngoplasty with tracheostomy 4 (4.7%) and esophagoscopy and dilatation 3 (3.5%). Mortality was 5.9% and 5 patients were lost to follow-up. In patients with noncorrosive esophageal injury, esophageal perforation from instrumentation accounted for 14 (53.9%), foreign body impaction 11 (42.3%) and spontaneous perforation 1 (3.8%) making up the rest. Management of these patients included esophagotomy and removal of foreign body 7 (26.9%), esophagectomy, cervical esophagostomy and feeding gastrostomy 10 (38.6%), primary repair 7 (26.9%), Ivor Lewis procedure 1 (3.8%) and emergency esophagectomy with colon replacement 1 (3.8%). Mortality in this group of patients was 7.7% and 4 patients were lost to follow-up. CONCLUSION: Corrosive esophageal injuries were the most frequent form of esophageal injury at our center due to unrestricted access to corrosive substances. Generally, appropriate surgical intervention in patients with esophageal injury based on individualization of care yields excellent early and mid-term results.

What are the Particularities of Oesophageal Surgery in Cirrhotic Patients.

The aim of this paper was to review the entire literature on esophageal surgery to best define the surgical indications and the specifics of their management. The bibliographic research was carried out on Pubmed between January 1995 and June 2015, using French and English as publication languages.

An Animal Study of Implantation of an Esophageal Pacemaker Based on Per-Oral Endoscopic Myotomy Approach for Alleviation of Esophageal Peristalsis Disorders.

BACKGROUND To restore esophageal peristalsis of achalasia patients by sequenced electric stimulation, an appropriate method must be established to implant the electrodes and pacemaker safely and effectively. We combined POEM (per-oral endoscopic myotomy) and abdominal wall puncture in pigs in order to explore a feasible procedure for the implantation. MATERIAL AND METHODS Five healthy male pigs were used in the present study with the permission of the Ethics Committee of Tianjin Medical University General Hospital. The electrodes were implanted in esophageal submucosal tunnel by POEM with the end of the electrode deposited in the abdominal cavity using NOTES technique. A pacemaker was then positioned under the skin of the abdomen. Finally, the electrodes were connected with the pacemaker with the help of endoscopy in the abdominal cavity. Esophageal peristalsis of these pigs after implantation was monitored for esophageal intraluminal pressure changes using electronic gastroscopy and a high-resolution manometry (HRM). The observation lasted for 6 h. RESULTS The procedure was effective to implant the electrode and the pacemaker using POEM and NOTES techniques. The connection of the 2 devices was also successful. Esophageal intraluminal pressure changes after electrical stimulation were recorded using HRM. Vital signs of the pigs were stable during the 6-h follow-up. CONCLUSIONS From this small-sample, short follow-up animal study, it was found that the implantation of esophageal electrodes and pacemaker based on POEM and NOTES is feasible, safe, and effective. Nevertheless, there is urgent need for long-term follow-up to confirm or disprove the safety of the procedure.

Age at Initiation and Frequency of Screening to Prevent Esophageal Squamous Cell Carcinoma in High-risk Regions: an Economic Evaluation.

The aim of this study was to identify the economic screening strategies for esophageal squamous cell carcinoma (ESCC) in high-risk regions. We used a validated ESCC health policy model for comparing different screening strategies for ESCC. Strategies varied in terms of age at initiation and frequency of screening. Model inputs were derived from parameter calibration and published literature. We estimated the effects of each strategy on the incidence of ESCC, costs, quality-adjusted life-year (QALY), and incremental cost-effectiveness ratios (ICERs). Compared with no screening, all competing screening strategies decreased the incidence of ESCC from 0.35% to 72.8%, and augmented the number of QALYs (0.002-0.086 QALYs per person) over a lifetime horizon. The screening strategies initiating at 40 years of age and repeated every 1-3 years, which gained over 70% of probabilities that was preferred in probabilistic sensitivity analysis at a $1,151/QALY willingness-to-pay threshold. Results were sensitive to the parameters related to the risks of developing basal cell hyperplasia/mild dysplasia. Endoscopy screening initiating at 40 years of age and repeated every 1-3 years could substantially reduce the disease burden and is cost-effective for the general population in high-risk regions.