Laparoscopic antireflux surgery or PPIs in the management of reflux-related esophageal stricture.

BACKGROUND: Gastroesophageal reflux disease (GERD) is often associated with esophageal stricture, particularly benign esophageal stricture. We aimed to evaluate the effects of balloon catheter dilation (BD) combined with laparoscopic fundoplication (LF) surgery and proton pump inhibitors (PPIs) in patients with reflux-induced esophageal strictures. METHODS: We retrospectively analyzed 116 patients with reflux-induced benign esophageal strictures who underwent balloon dilatation therapy combined with PPIs (BD-PPIs group, n = 58) and balloon dilatation combined with LF (BD-LF group, n = 58). Patients were followed up for 24 months. The outcomes of the patients were monitored, including clinical success, symptom improvement, adverse events, and the frequency of esophagitis. RESULTS: At the latest follow-up, the rate of clinical success was higher in BD-LF group than in BD-PPIs group (80.4% vs. 57.7%, P = 0.011). The patients in the BD-PPIs group required more dilation sessions to achieve successful dilation, as compared to those in the BD-LF group (2.1 ± 1.2 vs. 0.7 ± 0.8, P < 0.001). The DeMeester score, number of reflux episodes for which pH was < 4, and lower esophageal sphincter pressure were significantly better in the BD-LF group than in the BD-PPIs group (all P < 0.001). The incidence of reflux esophagitis was higher in the BD-PPIs group than in the BD-LF group, at 24 months (58.8% vs. 18.2%, P = 0.003). CONCLUSIONS: Balloon dilatation with concomitant LF is effective and safe for esophageal stricture secondary to GERD. Moreover, antireflux surgery techniques, such as Nissen or Toupet procedure, should be added for reflux-induced benign esophageal stricture.

Endoscopic cardial constriction with band ligation in the treatment of refractory gastroesophageal reflux disease: a preliminary feasibility study.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a common digestive disease, could cause extra-esophageal symptoms. Peroral endoscopic cardial constriction with band ligation (PECC-b) is a minimally invasive method for the treatment of GERD in recent years. The goals of this study were to evaluate the clinical efficacy of PECC-b to treat gastroesophageal reflux-related symptoms. METHODS: A retrospective study of patients undergoing PECC-b between January 2017 and December 2018 at a single institution was conducted. All patients confirmed GERD by endoscopy, esophageal PH-impedance monitoring, esophageal manometry and symptom questionnaires. The outcome measures included reflux-related scores, patients' satisfaction and drug independence after 12 months following surgery. RESULTS: A total of 68 patients, with follow-up of 12 months post surgery, were included in the final analysis. The symptom scores were all significantly decreased as compared with preoperation (P < 0.05). The esophageal symptom scores showed a better improvement than extra-esophageal symptoms (P < 0.001). Fifty-three (77.9%) patients achieved complete drug therapy independence and 52 (76.5%) patients were completely or partially satisfied with the symptom relief following surgery. CONCLUSIONS: The PECC-b is a safe, effective and recommended approach for the control of GERD-related symptoms. Further multicenter prospective studies are required to confirm these outcomes.

The Role of Gastroesophageal Reflux in Provoking High Blood Pressure Episodes in Patients With Hypertension.

GOALS: We assessed the relationship between gastroesophageal reflux disease (GERD) and hypertension and whether antiacid therapy could be used to control blood pressure (BP) on hypertension in patients with GERD. BACKGROUND: Gastroesophageal reflux disease (GERD) may provoke cardiovascular disease. Many factors are involved in the development of essential hypertension, but whether GERD has a role needs further study. STUDY: Patients with essential hypertension (n=86) were studied by 24-hour continuous BP monitoring and esophageal impedance and pH monitoring. Patients fulfilling the GERD criteria received 14-day therapy with omeprazole (20 mg twice a day), and the effect on BP was studied. RESULTS: Of the 86 essential hypertension patients, 38 (44.2%) had GERD. Among these 38 patients, 494 episodes of pathologic reflux (PR), and 684 episodes of high BP were recorded. PR was significantly more common at nighttime especially when supine. Of the 684 episodes of hypertension, 102 (14.9%) were synchronous with PR. GERD patients had significantly higher nocturnal BP than non-GERD patients. Antiacid therapy brought about significant reduction in all esophageal monitoring parameters as well as in BP parameters in GERD patients. CONCLUSIONS: This study demonstrated that there is significant correlation between hypertension and GERD. Antiacid therapy can restore normal esophageal pH and help maintain normal BP.

Mesoatrial Shunt for Budd-Chiari Syndrome.

BACKGROUND: The long-term efficacy of mesoatrial shunt (MAS) for Budd-Chiari syndrome (BCS) is not well studied. The purpose of our study was to investigate the long-term outcome and efficacy of MAS for BCS. METHODS: We retrospectively evaluated 11 patients who underwent MAS for BCS from April 1986 to November 1995. Records of patients' clinical presentations, laboratorial investigation, Doppler duplex ultrasonography, radiologic image, and treatment outcomes were all retrieved and analyzed. RESULTS: Follow-up intervals ranged from 1 year and 2 months to 30 years and 2 months (mean, 17 years and 8 months). Portal pressure decreased significantly from 35.72 ± 3.52 cm H2O to 27.86 ± 5.83 cm H2O post-MAS (P = 0.001). The 5-year, 10-year, and 20-year patency were 72.7%, 54.5%, 36.4%, respectively; 63.3% of patients had survived for more than 10 years and 45.5% for more than 20 years. A male has been alive with patent shunt for 28 years and 1 month. CONCLUSIONS: The MAS with enforced rings is an effective therapeutic modality for BCS with cautious perioperative management.

Endovascular Treatment of an Unusual Membranous Obstruction of the Inferior Vena Cava in Budd-Chiari Syndrome Complicated by Mural Portal Vein Thrombosis.

We describe the case of a patient with Budd-Chiari syndrome who presented with an unusual membranous obstruction of the inferior vena cava complicated by massive portal vein thrombosis (PVT). The patient underwent percutaneous transluminal balloon angioplasty through the right groin and was prescribed oral warfarin for 6 months. Treatment resulted in the complete disappearance of the PVT. This therapeutic strategy should be considered in the management of other cases of this rare, complex disease.

Experimental study on the construction of small three-dimensional tissue engineered grafts of electrospun poly-ε-caprolactone.

Studies on three-dimensional tissue engineered graft (3DTEG) have attracted great interest among researchers as they present a means to meet the pressing clinical demand for tissue engineering scaffolds. To explore the feasibility of 3DTEG, high porosity poly-ε-caprolactone (PCL) was obtained via the co-electrospinning of polyethylene glycol and PCL, and used to construct small-diameter poly-ε-caprolactone-lysine (PCL-LYS-H) scaffolds, whereby heparin was anchored to the scaffold surface by lysine groups. A variety of small-diameter 3DTEG models were constructed with different PCL layers and the mechanical properties of the resulting constructs were evaluated in order to select the best model for 3DTEGs. Bone marrow mononuclear cells were induced and differentiated to endothelial cells (ECs) and smooth muscle cells (SMCs). A 3DTEG (labeled '10-4%') was successfully produced by the dynamic co-culture of ECs on the PCL-LYS-H scaffolds and SMCs on PCL. The fluorescently labeled cells on the 3DTEG were subsequently observed by laser confocal microscopy, which showed that the ECs and SMCs were embedded in the 3DTEG. Nitric oxide and endothelial nitric oxide synthase assays showed that the ECs behaved normally in the 3DTEG. This study consequently provides a new thread to produce small-diameter tissue engineered grafts, with excellent mechanical properties, that are perfusable to vasculature and functional cells.

The in vivo characterization of electrospun heparin-bonded polycaprolactone in small-diameter vascular reconstruction.

OBJECTIVE: To evaluate the possibility of using heparin-bonded polycaprolactone grafts to replace small-diameter arteries. METHODS: Polycaprolactone was bonded with heparin. The activated partial thromboplastin time of heparin-bonded polycaprolactone grafts was determined in vitro. Small-diameter grafts were electrospun with heparin-bonded polycaprolactone and polycaprolactone and were implanted in dogs to substitute part of the femoral artery. Angiography was used to investigate the patency and aneurysm of the grafts after transplantation. After angiography, the patent grafts were explanted for histology analysis. The degradation of the grafts and the collagen content of the grafts were measured. RESULTS: Activated partial thromboplastin time tests in vitro showed that heparin-bonded polycaprolactone grafts exhibit obvious anticoagulation. Arteriography showed that two heparin-bonded polycaprolactone and three polycaprolactone grafts were obstructed. Other grafts were patent, without aneurysm formation. Histological analysis showed that the tested grafts degraded evidently over the implantation time and that the luminal surface of the tested grafts had become covered by endothelial cells. Collagen deposition in heparin-bonded polycaprolactone increased with time. There were no calcifications in the grafts. Gel permeation chromatography showed the heparin-bonded polycaprolactone explants at 12 weeks lose about 32% for Mw and 24% for Mn. The collagen content on the heparin-bonded polycaprolactone grafts increased over time. CONCLUSION: This preliminary study demonstrates that heparin-bonded polycaprolactone is a suitable graft for small artery reconstruction. However, heparin-bonded polycaprolactone degrades more rapidly than polycaprolactone in vivo.

Long-term outcomes of patients with refractory gastroesophageal reflux disease following a minimally invasive endoscopic procedure: a prospective observational study.

BACKGROUND: Gastroesophageal reflux disease (GERD) is the most common digestive disease, affecting one third of the world's population. The minimally invasive endoscopic Stretta procedure is being increasingly used as an alternative strategy to manage refractory GERD. However, long-term benefits of this procedure have to be further evaluated in clinical settings. This prospective observational study was therefore conducted to evaluate the outcome of patients with refractory GERD 5 years after the Stretta procedure. METHODS: A total of 152 patients with refractory GERD underwent the Stretta procedure in our department between April 2007 and September 2008. They were followed up for 5 years, during which the primary outcome measures including symptom scores of heartburn, regurgitation, chest pain, cough and asthma and the secondary outcome measures including proton pump inhibitor (PPI) use and patients' satisfaction were analysed at 6, 12, 24, 36, 48 and 60 months respectively. RESULTS: Of the 152 patients, 138 completed the designated 5-year follow-up and were included in the final analysis. At the end of the 5-year follow-up, the symptom scores of heartburn (2.47 ± 1.22 vs. 5.86 ± 1.52), regurgitation (2.23 ± 1.30 vs. 5.56 ± 1.65), chest pain (2.31 ± 0.76 vs. 4.79 ± 1.59), cough (3.14 ± 1.43 vs. 6.62 ± 1.73) and asthma (3.26 ± 1.53 vs. 6.83 ± 1.46) were all significantly decreased as compared with the corresponding values before the procedure (P < 0.001). After the Stretta procedure, 59 (42.8%) patients achieved complete PPI therapy independence and 104 (75.4%) patients were completely or partially satisfied with the GERD symptom control. Moreover, no severe complications were observed except for complaint of abdominal distention in 12 (8.7%) patients after the Stretta procedure. CONCLUSION: The Stretta procedure may achieve an effective and satisfactory long-term symptom control and considerably reduce the reliance on medication without significant adverse effects in adult patients with refractory GERD, thereby having profound clinical implications.

Portal, mesenteric, and splenic vein thromboses after endovascular embolization for gastrointestinal bleeding caused by a splenic arteriovenous fistula.

We present an unusual case of portal, mesenteric, and splenic vein thromboses after endovascular embolization for gastrointestinal bleeding caused by a splenic arteriovenous fistula. The thromboses were successfully treated with anticoagulation therapy. The patient was a 37-year-old woman who presented with portal hypertension manifested by gastrointestinal bleeding with no evidence of liver disease. Splenic arteriography confirmed the presence of a high-flow arteriovenous fistulous communication from the splenic artery directly into the splenic vein. The arteriovenous fistula was successfully treated with percutaneous transarterial embolization by embolization coils and the patient achieved effective hemostasis. Low-molecular-weight heparin and warfarin were administrated to prevent thrombosis in the portal venous system after the procedure. Although anticoagulants were immediately administered, thromboses of the portal, mesenteric, and splenic veins were diagnosed by contrast-enhanced computed tomography after 10 days. Complete recanalization of the portal venous system confirmed by contrast-enhanced computed tomography was achieved by administering warfarin orally for 3 months.

Spontaneous intrahepatic portosystemic shunt in Budd-Chiari syndrome.

Budd-Chiari syndrome (BCS) caused by hepatic venous outflow obstruction may result in portal hypertension and the development of intrahepatic collaterals that bypass the obstruction. Spontaneous intrahepatic portosystemic venous shunt (SIPSVS) is uncommon and may be associated with portal hypertension. SIPSVS is extremely rare in patients with BCS and has not been well documented. We report a case of SIPSVS in a 42-year-old woman with BCS caused by membranous obstruction and chronic thrombosis in the inferior vena cava (IVC). A direct vascular communication between the left portal vein and IVC was confirmed by sonography and a computed tomography angiography scan. The patient underwent successful percutaneous balloon angioplasty of the IVC. Surgical or endovascular treatment for SIPSVS was not carried out because the patient was asymptomatic and remained asymptomatic in terms of encephalopathy at a 1-year follow-up.

Meso-cavo-jugular shunt for complicated portal hypertension: a case report with 8 years of follow-up.

BACKGROUND: The treatment of portal hypertension caused by an occlusive lesion in the retrohepatic inferior vena cava and terminal portal venules is complicated because both portal and system venous flow are compromised. METHODS: A 47-year-old woman presented with this issue, and we reasoned that the only way to achieve successful management was to create a meso-cavo-jugular shunt. This patient was referred to us after undergoing a splenectomy for hypersplenism, which made her ascites intractable. She had a retrohepatic vena caval stenosis and noncirrhotic portal hypertension. Percutaneous transluminal angioplasty of the inferior vena cava stenosis failed. She underwent substernal placement of a 14-mm ringed GoreTex graft (WL Gore and Associates, Flagstaff, AZ) with end-to-side connections to the superior mesenteric vein, internal jugular vein, and vena cava. RESULT: Her ascites resolved, and at follow-up 8 years later her graft was patent. CONCLUSION: The meso-cavo-jugular shunt can simultaneously decompress both portal and systemic venous systems and is worth considering in the rare circumstance of suprahepatic vena caval obstruction coupled with occlusion of the portal venules.

Endovascular treatment for extrahepatic portal vein bifurcation stenosis after a Whipple procedure using the kissing stents technique.

A 57-year-old man presented with a rare extrahepatic portal vein bifurcation scar stenosis involving the proximal splenic vein and superior mesenteric vein after a Whipple procedure. He was treated with endovascular coil embolization for the gastroesophageal varices and kissing stents for the portal vein bifurcation stenosis. This case illustrates a rarely seen complication after the Whipple procedure and a novel management strategy that can be considered in the management of this complex disease.

Endovascular treatment of an unusual primary arterioportal fistula complicated by cavernous transformation of the portal vein caused by portal thrombosis.

We describe an elderly woman who presented with an unusual primary arterioportal fistula and cavernous transformation of the portal vein caused by portal thrombosis, which were subsequently managed with endovascular coil embolization and transjugular intrahepatic portosystemic shunt using 2 stents after balloon remodeling. This case shows a rarely seen condition in the elderly and a novel management strategy that should be considered in the management of this complex disease.

Gastroesophageal reflux in chronic cough and cough syncope and the effect of antireflux treatment: case report and literature review.

OBJECTIVE: This study aimed to evaluate the efficacy of antireflux treatment on gastroesophageal reflux (GER)-related cough syncope. METHODS: The method used was a retrospective review of the outcomes of antireflux treatment with proton pump inhibitor (PPI), Stretta radiofrequency (SRF), or laparoscopic fundoplication (LF) of 8 patients with chronic cough and cough syncope that was clinically evaluated to be GER related over a period of 2 to 5 years. RESULTS: In the 8 selected cases, the typical GER symptoms disappeared in 7 cases and were significantly eased in 1 case. The chronic cough diminished to mild and occasional occurrence in 6 cases and was completely relieved in 2 cases. Meanwhile, the cough syncope disappeared in all cases. Seven of the patients resumed physical and social functions after the antireflux treatments, except for 1 person, who had a stroke due to other causes. CONCLUSION: For chronic cough and cough syncope of unknown cause, the GER assessment could be valuable. In treating well-selected GER-related chronic cough and cough syncope, PPI, SRF, and LF can be considered. Moreover, satisfactory restoration of physical and social functions could be achieved after effective antireflux therapy.

Midterm results of intentional celiac artery coverage during TEVAR for type B aortic dissection.

PURPOSE: To report the outcome of intended celiac artery coverage during thoracic endovascular aortic repair (TEVAR) for type B aortic dissection with an intimal tear near the celiac artery (CA) orifice. METHODS: Between 2007 and 2011, 13 patients (10 men; mean age 61.3 years, range 46-70) with type B aortic dissection underwent primary (n=9) or secondary (n=4) TEVAR with intentional CA coverage. Preoperative imaging was performed to confirm the existence of collateral circulation between the celiac artery and superior mesenteric artery. A short stent-graft was then deployed to cover both the entry tear and the CA. Follow-up was at 2 weeks; 1, 3, and 6 months; and every year thereafter. Preoperative diameters of the true and false lumens at the CA level, 8 cm above the CA, and at the aortic bifurcation, along with the maximum aortic diameter in the dissected segment, were compared to similar measurements at 6 months. RESULTS: All stent-graft procedures were successful and without complication. No immediate or delayed endoleak was identified in 8 of 13 patients over a mean 25-month follow-up (range 3-38). The other 5 patients had type II endoleak on completion imaging; these all resolved within 3 months after operation. Postoperative blood liver function and amylase assays were normal in all patients. No abdominal symptoms or signs of spinal cord ischemia were discovered. Expansion of the true lumen after TEVAR was statistically significant vs. at baseline in both groups (primary p<0.001, secondary p=0.023). Both the false lumen and the entire aorta showed signs of shrinkage after TEVAR in the 2 groups as well, although only the secondary group showed significant change (p<0.005) vs. baseline. CONCLUSION: TEVAR with intentional CA coverage is effective in excluding an infradiaphragmatic entry tear near the CA level. The incidence of abdominal ischemia is low if collateral circulation has been confirmed preoperatively. Type II endoleak is a major complication, yet most cease under observation.

Gastroesophageal reflux in bronchiectasis and the effect of anti-reflux treatment.

BACKGROUND: Bronchiectasis is a progressive and fatal disease despite the available treatment regimens. Gastroesophageal reflux (GER) may play an important role in the progression of bronchiectasis. However, active anti-reflux intervention such as Stretta radiofrequency (SRF) and/or laparoscopic fundoplication (LF) have rarely been used to treat Bronchiectasis. CASE PRESENTATION: Seven patients' clinical outcomes for treating GER-related deteriorated bronchiectasis were retrospective reviewed. All patients were treated by SRF and/or LF, and had follow-up periods ranging from one to five years. Typical GER symptoms, respiratory symptoms, medication consumption and general health status were assessed during the follow-ups. At the latest follow-up all patients were alive. The typical GER symptoms disappeared in five people and were significantly improved in the other two. Two had complete remissions of both respiratory symptoms and bronchiectasis exacerbations; four had significantly improved respiratory symptoms to mild/moderate degrees as well as reduced or zero bronchiectasis exacerbations, which allowed them to resume the physical and social functions; one's respiratory symptoms and bronchiectasis exacerbations were not much improved, yet she was in stable condition and satisfied with the results. CONCLUSIONS: Potentially, GER plays an important role in some patients with bronchiectasis, and active anti-reflux treatments can be beneficial. Future clinical studies are suggested to clarify GER's role in bronchiectasis and to further determine whether anti-reflux interventions for GER can improve the outcomes of patients with bronchiectasis.

Right bronchopleural fistula treated with a novel, Y-shaped, single-plugged, covered, metallic airway stent.

BACKGROUND: Bronchopleural fistula (BPF) is an infrequent but life-threatening complication after pneumonectomy. The incidence of BPF reported in the literature varies from 0.3% to 20%. PURPOSE: To determine the feasibility and efficacy of using Y-shaped, single-plugged, covered, metallic stents to treat right bronchopleural fistulas. MATERIAL AND METHODS: We have designed a Y-shaped, single-plugged, covered, self-expandable, metallic airway stent to fit the specific anatomy of the right main bronchus. The stent has a main tube and two branches, resembling an inverted "Y". One of the branches is closed (plugged) and bullet-shaped; the other one tubular and open. The entire stent is encased in a nitinol wire mesh. Stent size can be individualized using multislice spiral computed tomography (MSCT) measurements of the airways. Under fluoroscopic guidance, we have implanted 15 Y-shaped stents in 15 patients with right bronchopleural fistulas. RESULTS: Stent insertion was successful in all patients. All fistulas were successfully closed immediately after stent placement. Follow-up was performed for 1-34 months. Positive clinical outcomes were seen in 13 of 15 patients. Two patients died of intractable pulmonary infection and multiorgan failure. The fistula completely healed and the stent could be removed in five patients; however, two of them were left with a small, aseptic, residual right lung cavity. The remaining eight patients are still alive with the stent in situ. CONCLUSION: The placement of Y-shaped, single-plugged, covered, self-expandable metallic airway stents seems to be a feasible and safe method for the treatment of bronchopleural fistulas involving the right main bronchus. This stent is a promising therapeutic alternative for bronchopleural fistulas involving the right main bronchus.

Nutcracker syndrome due to left-sided inferior vena cava compression and treated with superior mesenteric artery transposition.

Left renal vein hypertension secondary to left renal vein compression has been described as a cause of persistent hematuria in nutcracker syndrome. Malformation of the inferior vena cava (IVC), although rare and frequently asymptomatic, may also result in left renal vein hypertension, with resultant hematuria when it is severely compressed. We report a 20-year-old man with persistent hematuria due to compression of left-sided IVC. The patient was successfully treated by means of superior mesenteric artery (SMA) transposition and division of the fibrous bundle at the origin of the SMA. His postoperative course was uneventful. Compression of the left IVC is a unique form of nutcracker syndrome. SMA transposition, together with division of a fibrous bundle at the origin of the SMA if present, is a safe and effective surgical procedure for this special entity.

Mesocavoatrial shunt for Budd-Chiari syndrome: a case report with long-term follow-up.

BACKGROUND: A case of mesocavoatrial shunting for the treatment of Budd-Chiari syndrome (BCS) with long-term follow-up is reported. METHODS: A 25-year-old man with stage II BCS was treated with a mesocavoatrial shunt to decompress the portal and IVC hypertension. During the 6-year follow-up, the patient was able to resume work as a salesperson and has since led a normal life. His graft remains patent. CONCLUSION: A mesocavoatrial shunt can simultaneously decompress portal and IVC hypertension and has satisfactory long-term patency. A mesocavoatrial shunt can be used to treat patients with severe BCS who could not be successfully treated with medical therapy and intervention.

Surgical treatment of multivessel lesions in Takayasu's arteritis: report of a case.

Takayasu's arteritis (TA) is a chronic vasculitis involving the aorta and its main branches, the pulmonary arteries, and the coronary tree. Here we report a case of TA complicated by severe stenosis of the left coronary ostium with multivessel brachiocephalic involvement. A combination of these abnormalities could complicate underlying illness in patients, posing an increased risk of surgical morbidity. Simultaneous surgical treatment of the ascending aorta to left carotid artery bypass and coronary artery bypass using the great saphenous vein were performed. We discuss the choice of simultaneous surgery and the options for surgical treatment of complicated lesions due to TA.