Durability of radiofrequency ablation for long-segment and ultralong-segment Barrett's esophagus over 10 years.

BACKGROUND: Long-term durability data for radiofrequency ablation (RFA) to prevent esophageal adenocarcinoma in long-segment (LSBE) and ultralong-segment Barrett's esophagus (ULSBE) is lacking. This study aimed to determine 10-year cancer progression, eradication, and complication rates in LSBE and ULSBE patients treated with RFA. METHODS: Single-surgeon prospective database of patients with LSBE (≥ 3 to < 8 cm) and ULSBE (≥ 8 cm) who underwent RFA (2001-2021) were retrospectively analyzed. Ten-year cancer progression calculated with Kaplan-Meier analysis. Eradication rates, including complete remission of dysplasia (CR-D) and intestinal metaplasia (CR-IM), and rates of recurrence and complications, compared between LSBE and ULSBE groups. RESULTS: Ten years after starting treatment, the cancer rate was 14.3% in 56 patients. CR-D and CR-IM rates were 87.5% and 67.9%, respectively. Relapse rates from CR-D were 1.8% and 3.6% from CR-IM. Eradication rates for dysplasia in LSBE and ULSBE patients (90.6% versus 83.3%) and IM (71.9% versus 62.5%) were not significantly different. ULSBE patients required higher mean number of ablation sessions for IM eradication (4.7 versus 3.7, p = 0.032), while complication rates including strictures (4.2% versus 6.2%), perforation (0 versus 0), and bleeding (4.2% versus 3.1%), were similar between ULSBE and LSBE patients, respectively. On multivariate analysis, shorter Barrett's segment and baseline low-grade dysplasia were associated with increased likelihood for eradication of IM and dysplasia. A total number of ablation sessions or endoscopic resections ≥ 3 was associated with reduced likelihood for eradication. CONCLUSION: RFA was durable in maintaining dysplasia and IM eradication in both LSBE and ULSBE over 10 years, and with low complication rates. IM eradication was more difficult to achieve in ULSBE. Late development of cancer occurred in 14.3%.

Risk of lymph node metastasis in T1 esophageal adenocarcinoma: a meta-analysis.

Patients with early (T1) esophageal adenocarcinoma (EAC) are increasingly having definitive local therapy endoscopically. Endoscopic resection is not able to pathologically stage or treat lymph node metastasis (LNM). Accurate identification of patients having nodal metastasis is critical to select endoscopic therapy over surgery. This study aimed to define the risk of LNM in T1 EAC. A meta-analysis of studies of patients who underwent surgery and lymphadenectomy with assessment of LNM was performed according to PRISMA. Main outcome was probability of LNM in T1a and T1b disease. Secondary outcomes were risk factors for LNM and rate of LNM in submucosal T1b (SM1, SM2, and SM3) disease. Registered with PROSPERO (CRD42022341794). Twenty cohort studies involving 2264 patients with T1 EAC met inclusion criteria: T1a (857 patients) with 36 (4.2%) node positive and T1b (1407 patients) with 327 (23.2%) node positive. Subgroup analysis of T1b lesions was available in 10 studies (405 patients). Node positivity for SM1, SM2, and SM3 was 16.3%, 16.2%, and 29.4%, respectively. T1 substage (odds ratio [OR] 7.72, 95% confidence interval [CI] 4.45-13.38, P < 0.01), tumor differentiation (OR 2.82, 95% CI 2.06-3.87, P < 0.01), and lymphovascular invasion (OR 13.65, 95% CI 6.06-30.73, P < 0.01) were associated with LNM. T1a disease demonstrated a 4.2% nodal metastasis rate and T1b disease a rate of 23.2%. Endoscopic therapy should be reserved for T1a disease and perhaps select T1b disease, which has a moderately high rate of nodal metastasis. There were inadequate data to stratify T1b SM disease into 'low-risk' and 'high-risk' based on tumor differentiation and lymphovascular invasion.

Reflux Aspiration Associated with Oesophageal Dysmotility but Not Delayed Liquid Gastric Emptying.

INTRODUCTION: Severe oesophageal dysmotility is associated with treatment-resistant reflux and pulmonary reflux aspiration. Delayed solid gastric emptying has been associated with oesophageal dysmotility; however, the role of delayed liquid gastric emptying (LGE) in the pathophysiology of severe reflux disease remains unknown. The purpose of this study is to examine the relationship between delayed LGE, reflux aspiration, and oesophageal dysmotility. METHODS: Data were extracted from a prospectively populated database of patients with severe treatment-resistant gastro-oesophageal reflux disease. All patients with validated reflux aspiration scintigraphy and oesophageal manometry were included in the analysis. Patients were classified by predominant clinical subtype as gastro-oesophageal reflux (GOR) or laryngopharyngeal reflux. LGE time of 22 min or longer was considered delayed. RESULTS: Inclusion criteria were met by 631 patients. Normal LGE time was found in 450 patients, whilst 181 had evidence of delayed LGE. Mean liquid half-clearance was 22.81 min. Reflux aspiration was evident in 240 patients (38%). Difference in the aspiration rates between delayed LGE (42%) and normal LGE (36%) was not significant (p = 0.16). Severe ineffective oesophageal motility (IOM) was found in 70 patients (35%) and was independent of LGE time. Severe IOM was strongly associated with reflux aspiration (p < 0.001). GOR dominant symptoms were more common in patients with delayed LGE (p = 0.03). CONCLUSION: Severe IOM was strongly associated with reflux aspiration. Delayed LGE is not associated with reflux aspiration or severe IOM. Delayed LGE is more prevalent in patients presenting with GOR dominant symptoms.

Modified Reflux Scintigraphy Detects Pulmonary Microaspiration in Severe Gastro-Esophageal and Laryngopharyngeal Reflux Disease.

INTRODUCTION: Previously described methodologies for detecting laryngopharyngeal reflux (LPR) have limitations. Symptoms alone are non-diagnostic, and pH-impedance studies have poor sensitivity. Pulmonary micro-aspiration is under-recognised in LPR and gastro-esophageal reflux disease (GERD). The present study aimed to describe the results of a modified technique for scintigraphic reflux studies in two groups with severe reflux: those with typical reflux symptoms and those with laryngopharyngeal manifestations of reflux. METHODS: A prospective database of severely symptomatic, treatment-resistant reflux patients was grouped based upon predominant symptom profile of typical GERD or LPR. All patients underwent reflux scintigraphy. Results were obtained for early scintigraphic reflux contamination of the pharynx and proximal esophagus, and delayed contamination of the pharynx and lungs after 2 h. RESULTS: 187 patients were studied (82 GERD, 105 LPR). The LPR patients were predominantly female (70.5% vs. 56.1%; p = 0.042) and older than the GERD group (median age 60 years vs. 55.5 years; p = 0.002). Early scintigraphic reflux was seen at the pharynx in 89.2% (GERD 87.7%, LPR 90.4%; p = 0.133), and at the proximal esophagus in 89.7% (GERD 88.9%, LPR 90.4%; p = 0.147). Delayed contamination of the pharynx was seen in 95.2% (GERD 93.9%, LPR 96.2%; p = 0.468). Delayed pulmonary aspiration was seen in 46% (GERD 36.6%, LPR 53.3%; p = 0.023). CONCLUSION: Reflux scintigraphy demonstrated a high rate of reflux-related pulmonary aspiration. Contamination of the proximal esophagus and pharynx was observed frequently in both groups of severe disease. The likelihood of pulmonary aspiration and potential pulmonary disease needs to be entertained in severe GERD and LPR.

A new diagnostic paradigm for laryngopharyngeal reflux disease: correlation of impedance-pH monitoring and digital reflux scintigraphy results.

PURPOSE: No gold-standard investigation exists for laryngopharyngeal reflux (LPR). Multichannel intraluminal impedance (MII)-pH testing has uncertain utility in LPR. Meanwhile, reflux scintigraphy allows immediate and delayed visualisation of tracer reflux in the esophagus, pharynx, and lungs. The present study aimed to correlate MII-pH and scintigraphic reflux results in patients with primary LPR. METHODS: Consecutive patients with LPR underwent MII-pH and scintigraphic reflux studies. Abnormal values for MII-pH results were defined from existing literature. MII-pH and scintigraphic data were correlated. RESULTS: 105 patients with LPR [31 males (29.5%), median age 60 years (range 20-87)] were studied. Immediate scintigraphic reflux was seen in the pharynx in 94 (90.4%), and in the proximal esophagus in 94 (90.4%). Delayed scintigraphic contamination of the pharynx was seen in 101 patients (96.2%) and in the lungs of 56 patients (53.3%). For MII-pH, abnormally frequent reflux was seen in the distal esophagus in 12.4%, proximal esophagus in 25.7%, and in the pharynx in 82.9%. Patients with poor scintigraphic clearance had higher Demeester scores (p = 0.043), more proximal reflux episodes (p = 0.046), more distal acid reflux episodes (p = 0.023), and more prolonged bolus clearance times (p = 0.002). CONCLUSION: Reflux scintigraphy has a high yield in LPR patients. Scintigraphic time-activity curves correlated with validated MII-pH results. A high rate of pulmonary microaspiration was found in LPR patients. This study demonstrated a high level of pharyngeal contamination by scintigraphy and MII-pH, which supports the use of digital reflux scintigraphy in diagnosing LPR.

Is repairing giant hiatal hernia in patients over 80 worth the risk?

Patients with giant hiatal hernia (GHH) are often symptomatic and have significantly reduced quality of life (QoL). Advanced age is a predictor of increased morbidity and mortality in open hiatal surgery, however, outcomes of laparoscopic surgery in patients over the age of 80 are limited to case reports and small case series. Data was extracted from a prospectively maintained database. Consecutive patients over the age of 80 with GHH that have undergone surgery were included. Peri-operative mortality, complications, recurrence rates, use of acid suppressive medication and QoL was analysed. Search of Ryerson index was performed to determined post-operative survival. Inclusion criteria were met by 89 patients. Mean age was 84 (80-93). The mean volume of herniated stomach was 70.9% range 30-100%; SD 27.25). There was one death in this cohort on day 30 from myocardial infarction and one mediastinal collection requiring percutaneous radiological drainage and antibiotics. There were no other major complications (Clavien-Dindo Grade III-IV). Mean post-operative survival was 74.5 months (SD 47.8). GIQLI was reduced pre-operatively (mean 91.8; SD 19.4). There was significant improvement in GIQLI scores at early (mean 101.45; SD 21.2) and late (mean 106.7; SD 19.2) post-operative follow-up (p = 0.005). Pre-operative Visick scores (mean 2.92; SD 0.98) have improved significantly in early (mean 1.94; SD 0.97; p = 0.000) and late (mean 2.03; SD 0.99; p = 0.001) post-operative periods. Satisfaction with surgery was 97% during early and 93.3% during late post-operative follow up. Laparoscopic repair of GHH in appropriately selected elderly patients is safe and results in significant improvement in quality of life.

Predictors of reflux aspiration and laryngo-pharyngeal reflux.

BACKGROUND: Gastro-esophageal reflux disease (GERD) can present with typical or atypical or laryngo-pharyngeal reflux (LPR) symptoms. Pulmonary aspiration of gastric refluxate is one of the most serious variants of reflux disease as its complications are difficult to diagnose and treat. The aim of this study was to establish predictors of pulmonary aspiration and LPR symptoms. METHODS: Records of 361 consecutive patient from a prospectively populated database were analyzed. Patients were categorized by symptom profile as predominantly LPR or GERD (98 GER and 263 LPR). Presenting symptom profile, pH studies, esophageal manometry and scintigraphy and the relationships were analyzed. RESULTS: Severe esophageal dysmotility was significantly more common in the LPR group (p = 0.037). Severe esophageal dysmotility was strongly associated with isotope aspiration in all patients (p = 0.001). Pulmonary aspiration on scintigraphy was present in 24% of patients. Significant correlation was established between total proximal acid on 24-h pH monitoring and isotope aspiration in both groups (p < 0.01). Rising pharyngeal curves on scintigraphy were the strongest predictors of isotope aspiration (p < 0.01). CONCLUSIONS: Severe esophageal dysmotility correlates with LPR symptoms and reflux aspiration in LPR and GERD. Abnormal proximal acid score on 24-h pH monitoring associated with pulmonary aspiration in reflux patients. Pharyngeal contamination on scintigraphy was the strongest predictor of pulmonary aspiration.

Does hiatal repair affect gastroesophageal reflux symptoms in patients undergoing laparoscopic sleeve gastrectomy?

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has gained popularity as a treatment of choice for morbid obesity and associated comorbidities. There has been a concern about new onset or worsening of gastroesophageal reflux (GERD) following LSG. OBJECTIVE: The objective of the study was to evaluate the effect of surgically treating hiatal weakness on GERD symptoms in patients undergoing LSG. SETTING: Single tertiary referral institution, Sydney, Australia. METHODS: A prospective observational cohort study was conducted with consecutive patients undergoing LSG. Hiatal findings, patient demographics, medications and reflux score were recorded prospectively. Patients were followed up post-operatively for a minimum of 12 months and assessed using GERD-HRQL score to quantify reflux symptoms. RESULTS: Data from 100 patients with a minimum of 1-year follow-up were analysed. Mean follow-up was 18.9 months. Overall, GERD-HRQL improved from mean 4.5 ± 5.8 pre-operatively to 0.76 ± 1.5 after 18.9 months (p = 0.0001). For those with pre-operative reflux, GERD-HRQL improved from mean (SD) 8.43 ± 6.26 pre-operatively to 0.94 ± 1.55 (p = 0.0001). All the nine patients with troublesome daily reflux significantly improved. For those without pre-operative reflux, GERD-HRQL improved from 0.88 ± 1.37 to 0.47 ± 1.25 (p-ns) post-operatively. On multivariate analysis, higher pre-operative reflux and dysphagia/bloat scores, younger age and lower percentage excess weight loss after 18.9 months were associated with GERD-HRQL improvement. CONCLUSION: In the medium term, GERD-HRQL improves following sleeve gastrectomy with meticulous hiatal assessment and repair of hiatal laxity and herniation.

Gastro-Oesophageal Reflux and Aspiration: Does Laparoscopic Fundoplication Significantly Decrease Pulmonary Aspiration?

PURPOSE: Pulmonary aspiration of gastric refluxate is one of the indications for anti-reflux surgery. Effectiveness of surgery in preventing pulmonary aspiration post-operatively has not been previously tested. The aim of this project is to assess effectiveness of anti-reflux surgery on preventing pulmonary aspiration of gastric refluxate. METHODS: Retrospective analysis of prospectively populated database of patients with confirmed aspiration of gastric refluxate on scintigraphy. Patients that have undergone anti-reflux surgery between 01/01/2014 and 31/12/2015 and had scintigraphy post-operatively were included. Objective data such as resolution of aspiration, degree of proximal aero-digestive contamination, surgical complications and oesophageal dysmotility as well as patient quality of life data were analysed. RESULTS: Inclusion criteria were satisfied by 39 patients (11 male and 28 female). Pulmonary aspiration was prevented in 24 out of 39 patients (61.5%) post-operatively. Significant reduction of isotope contamination of upper oesophagus supine and upright (p = 0.002) and pharynx supine and upright (p = 0.027) was confirmed on scintigraphy post-operatively. Severe oesophageal dysmotility was strongly associated with continued aspiration post-operatively OR 15.3 (95% CI 2.459-95.194; p = 0.02). Majority (24/31, 77%) of patients were satisfied or very satisfied with surgery, whilst 7/31 (23%) were dissatisfied. Pre-operative GIQLI scores were low (mean 89.77, SD 20.5), modest improvements at 6 months (mean 98.4, SD 21.97) and deterioration at 12 months (mean 88.41, SD 28.07) were not significant (p = 0.07). CONCLUSION: Surgery is partially effective in reversing pulmonary aspiration of gastric refluxate on short-term follow-up. Severe oesophageal dysmotility is a predictor of inferior control of aspiration with surgery.

Left atrial compression and right ventricular outflow tract diameter on echocardiography are independently associated with exercise capacity in patients with large hiatal hernia.

INTRODUCTION: Large hiatal hernia (HH) is often associated with left atrial (LA) compression, anteroposterior cardiac compression (manifesting as reduced right ventricular outflow tract (RVOT) diameter), and left ventricular (LV) compression (manifesting as systolic paradoxical outward motion (LV-PM) of the posterobasal LV segment). Exercise impairment, also common in this population, improves following HH surgery. We aimed to identify echocardiographic parameters independently associated with exercise impairment due to HH-mediated cardiogenic compression. METHODS: Patients with a large HH (>30% intra-thoracic stomach, n = 163) referred for cardiac evaluation were included. Echocardiographic parameters were retrospectively analyzed in relation to HH-related LA compression severity and the presence of LV-PM. Echocardiographic parameters independently associated with exercise capacity were identified by multivariable analysis. RESULTS: Mean baseline metabolic equivalents were reduced (70 ± 28% predicted). Moderate-severe LA compression and LV-PM were present in 91 of 163 (56%) and 65 of 162 (40%) patients, respectively. Patients with moderate-severe LA compression and LV-PM had decreased LA and LV dimensions. Moderate-severe LA compression was also associated with reduced RVOT diameter while LV-PM predicted a greater reduction in LV volumes. LA compression and RVOT diameter were independently associated with baseline exercise capacity and increased following HH surgery performed in a subgroup (n = 72, LA diameter: 14 ± 5 vs 20 ± 4 mm/m2 ; RVOT diameter: 17 ± 3 vs 19 ± 3 mm/m2 , P < .001 for both). Conversely, LV-PM was not independently associated with exercise capacity. CONCLUSION: Hiatal hernia-related cardiac compression reduces LA and RVOT dimensions. These parameters are independently associated with baseline exercise capacity and improve following HH surgery. LV-PM is associated with decreased LV volumes but not exercise capacity in this population.

Valsalva maneuver exacerbates left atrial compression in patients with large hiatal hernia.

INTRODUCTION: Hiatal hernia (HH) can cause left atrial (LA) compression and impair LA filling. We evaluated the cardiac effects of preload reduction and abdominal strain induced by Valsalva maneuver (VM) in large HH patients. METHODS: LA and left ventricular (LV) dimensions were measured using 2D transthoracic echocardiography at rest and during VM in HH patients (n=55, 70±10 years) and controls (n=22, 67±6 years). Biplane LV volumes (n=39) and mitral inflow pulse-wave Doppler parameters (n=27) were also evaluated. In HH patients, resting LA compression was graded qualitatively (none-mild or moderate-severe). RESULTS: In both controls and HH patients, VM significantly decreased LA (controls, 19±2 vs 16±3 mm/m2 ; HH, 16±5 vs 9±5 mm/m2 ) and LV diameters (22±3 vs 19±3 mm/m2 ; 21±3 vs 17±3 mm/m2 ) and LV volume (38±8 vs 26±10 mL/m2 ; 31±8 vs 19±9 mL/m2 ) (P<.001 for all). VM decreased LA diameter significantly more in HH patients than controls (-42% vs -16%, P<.001). HH patients with none-mild resting LA compression exhibited significantly greater LA diameter reduction than controls (-38±23% vs -16±13% P=.0003) despite similar resting LA diameters. LV volumes were similarly decreased by VM in HH patients and controls irrespective of resting LA compression severity indicating relative preservation of LV filling. LA diameter correlated inversely with early diastolic filling velocity during VM in HH patients (R=-.43, P=.03) but not controls (R=.18, P=.43). CONCLUSION: VM can markedly exacerbate LA compression in HH patients; however, LV filling is relatively less affected possibly due to augmented early diastolic filling. Conditions associated with decreased preload and increased intra-abdominal pressure may exacerbate the cardiac effects of large HH.

Laparoscopic common bile duct exploration: what factors determine success?

BACKGROUNDS: Laparoscopic common bile duct exploration (LCBDE) has been shown to be effective in managing choledocholithiasis whilst avoiding ERCP-related complications. However, patient and technical factors effects outcome. This study aimed to explore the matters effecting the failure of LCBDE. METHODS: All patients who underwent a laparoscopic cholecystectomy (LC) between 2007 and 2021 were identified using a prospective database. Data were collected for patients who underwent LCBDE including demographics, pre-operative investigations, intra-operative findings, technique of bile duct clearance and clearance rates, and post-operative outcomes. Predictors of failed LCBDE were identified. RESULTS: Laparoscopic cholecystectomy was performed in 3648 patients. Of these, 374 underwent LCBDE for suspected choledocholithiasis. Choledochoscopy was most frequently used (58.8%) with a success rate of 84.1%. Small cystic duct diameter (4.7 vs. 3.4 mm, P = 0.002), stone size >6 mm (P = 0.02), stone: cystic duct ratio >1 (P = 0.04), and >3 stones was associated with failed LCBDE by univariate analysis. Small cystic duct diameter (OR: 0.45, 95% CI: 0.26-0.77, P = 0.004) and stone size >6 mm (OR: 0.23, 95% CI: 0.06-0.92), P = 0.04) correlated with failure by multivariate analysis. Failed LCBDE was associated with increased length of stay (6.6 days vs. 3.1 days, P = 0.001), however the rate of serious complications or mortality was unaffected. CONCLUSION: LCBDE is safe and effective in managing choledocholithiasis. Factors such as cystic duct diameter, size and number of CBD stones, and stone: cystic duct ratio are associated with increased likelihood of inadequate clearance. The presence of these factors can help clinicians in decision making during LCBDE to improve chance of success.

Extensive lymphadenectomy may improve survival in node negative oesophageal cancer.

Lymph node metastases are a major prognostic factor in survival of patients with oesophageal cancer. The number of lymph nodes removed during oesophagectomy has been previously proven to be associated with improved survival. The aim of this study was to examine the effect of lymph node harvest on survival specifically in pathologically node negative (pN0) patients with oesophageal cancer. Data were extracted from a prospectively populated single-surgeon database of oesophageal resections for cancer. All consecutive patients with pN0 were included. Patient-specific risk adjusted analysis of overall and disease-free survival was performed to identify the number of lymph nodes associated with improved survival. Inclusion criteria were met by 137 patients (49 squamous cell carcinoma and 88 adenocarcinoma). Adjusted for cancer stage, tumour (histological type, degree of differentiation, lympho-vascular invasion, neo-adjuvant therapy) and patient related factors (age, sex), increased lymph node number was associated with significant improvement in overall (P = 0.045) and disease free (P = 0.030) survival. Lymph node count ≥ 17 was associated with improved overall and disease-free survival. In this cohort of patients with pathologically node-negative oesophageal cancer, lymph node count of 17 or above was associated with significantly improved survival.

The influence of socioeconomic disadvantage on short- and long-term outcomes after oesophagectomy for cancer: an Australian multicentre study.

BACKGROUND: Socioeconomic status (SES) affects outcomes following surgery for various cancers. There are currently no Australian studies that examine the role of socioeconomic disadvantage on outcomes following oesophagectomy for cancer. This study assessed whether SES was associated with short-term perioperative morbidity, long-term survival, and oncological outcomes following oesophagectomy across three tertiary oesophageal cancer centres in Australia. METHODS: A retrospective cohort study was performed comprising all patients who underwent oesophagectomy for cancer across three Australian centres. Patients were stratified into SES groups using the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD). Outcomes measured included perioperative complication rates, overall survival, and disease-free survival. RESULTS: The study cohort was 462 patients, 205 in the lower SES and 257 in the higher SES groups. The lower SES group presented with more advanced oesophageal cancer stage, a higher rate of T3 (52.6% versus 42.7%, P = 0.038) and N2 disease (19.6% versus 10.5%, P = 0.006), and had a higher rate of readmission within 30 days (11.2% versus 5.4%, P = 0.023). There was no difference in overall survival or disease-free survival between groups. CONCLUSION: Lower socioeconomic status was associated with more advanced stage and increased risk of early, unplanned readmission following oesophagectomy, but was not associated with a difference in overall or disease-free survival.

Sarcopenia impacts perioperative and survival outcomes after esophagectomy for cancer: a multicenter study.

BACKGROUND: The impact of sarcopenia on outcomes after esophagectomy is controversial. Most data are currently derived from Asian populations. This study aimed to correlate sarcopenia to short-term perioperative complication rates and long-term survival and recurrence outcomes. METHODS: A retrospective analysis was performed of patients undergoing esophagectomy for cancer from 3 tertiary referral centers in Australia. Sarcopenia was defined using cutoffs for skeletal muscle index (SMI), assessed on preoperative computed tomography images. Outcomes measured included complications, overall survival (OS), and disease-free survival (DFS). RESULTS: Of 462 patients (78.4% male; median age, 67 years), sarcopenia was evident in 276 (59.7%). Patients with sarcopenia had a higher rate of major (Clavien-Dindo ≥ 3b) complications (27.9% vs 14.5%; P < .001), including higher rates of postoperative cardiac arrythmia (16.3% vs 9.7%; P = .042), pneumonia requiring antibiotics (14.5% vs 9.1%; P = .008), and 30-day mortality (5.1% vs 0%; P = .002). In the sarcopenic group, the median OS was lower (37 months [95% CI, 27.1-46.9] vs 114 months [95% CI, 75.8-152.2]; P < .001), as was the median DFS (27 months [95% CI, 18.9-35.1] vs 77 months [95% CI, 36.4-117.6]; P < .001). Sarcopenia was an independent risk factor for lower survival on multivariate analysis (hazard ratio, 1.688; 95% CI, 1.223-2.329; P = .001). CONCLUSION: Patients with preoperative sarcopenia based on analysis of SMI are at a higher risk of major complications and have inferior survival and oncologic outcomes after esophagectomy for esophageal cancer.

Laparoscopic repair of giant hiatus hernia: prosthesis is not required for successful outcome.

BACKGROUND: Giant hiatus hernia (GHH) are difficult to manage effectively. This study reports a laparoscopic, prosthesis-free technique to repair of GHH. METHODS: Retrospective analysis of a prospectively populated database of a single surgeon's experience of GHH (>30 % intrathoracic stomach) repair using a novel, uniform technique was performed. Routine postoperative endoscopy, quality of life (QOL), and Visick scoring was conducted. RESULTS: Surgery was conducted in 100 patients (70F, 30 M). Mean (standard deviation [SD]) age was 69.1 (±11.4), median (interquartile range) ASA was 2 (range, 2-3), and mean (SD) body mass index (BMI) was 29.1 (±4.5). Mean follow-up was 574.1 (±240.5) days. One (1 %) patient was converted to an open procedure due to technical issues. Median stay was 2.5 days (range, 2-4). One postoperative death occurred secondary to respiratory sepsis. Eight (8 %) patients had perioperative complications: 4 major (PE, non-ST elevation MI, postoperative bleed managed conservatively, infected mediastinal fluid collection); and 4 minor (pneumothorax, asymptomatic troponin leak, subacute small bowel obstruction, and urinary retention). Ninety-nine (99 %) patients had objective screening for recurrence at 3-6 months. Two (2 %) patients have had symptomatic recurrence of their hiatus hernia; both involved a recurrent fundal herniation. Another seven (7 %) had small (<2 cm), asymptomatic recurrences diagnosed only on routine follow-up. Seven (7 %) patients have required reintervention for dysphagia with endoscopic dilatation conducted to good effect in all cases. Two (2 %) patients have required revisional surgery: one for a symptomatic recurrence at 3 months and a second for recurrent mediastinal collection. The Visick score fell from a mean (SD) of 3 (±1.1) to 1.7 (±0.8) postoperatively (p < 0.0001). The mean (SD) QOL preoperatively was 87.8 (±24) versus 109.1 (±22.3) postoperatively (p < 0.0001). CONCLUSIONS: GHH can be managed safely and effectively laparoscopically, without the use of a prosthesis.

Recurrence in Paraesophageal Hernia: Patient Factors and Composite Surgical Repair in 862 Cases.

BACKGROUND: Repair of giant paraesophageal hernia (PEH) is associated with a considerable hernia recurrence rate by objective measures. This study analyzed a large series of laparoscopic giant PEH repair to determine factors associated with anatomical recurrence. METHOD: Data was extracted from a single-surgeon prospective database of laparoscopic repair of giant PEH from 1991 to 2021. Upper endoscopy was performed within 12 months postoperatively and selectively thereafter. Any supra-diaphragmatic stomach was defined as anatomical recurrence. Patient and hernia characteristics and technical operative factors, including "composite repair" (360° fundoplication with esophagopexy and cardiopexy to right crus), were evaluated with univariate and multivariate analysis. RESULTS: Laparoscopic primary repair was performed in 862 patients. The anatomical recurrence rate was 27.3% with median follow-up of 33 months (IQR 16, 68). Recurrence was symptomatic in 45% of cases and 29% of these underwent a revision operation. Hernia recurrence was associated with younger age, adversely affected quality of life, and were associated with non-composite repair. Multivariate analysis identified age < 70 years, presence of Barrett's esophagus, absence of "composite repair", and hiatus closure under tension as independent factors associated with recurrence (HR 1.27, 95%CI 0.88-1.82, p = 0.01; HR 1.58, 95%CI 1.12-2.23, p = 0.009; HR 1.72, 95%CI 1.2-2.44, p = 0.002; HR 2.05, 95%CI 1.33-3.17, p = 0.001, respectively). CONCLUSION: Repair of giant PEH is associated with substantial anatomical recurrence associated with patient and technique factors. Patient factors included age < 70 years, Barrett's esophagus, and hiatus tension. "Composite repair" was associated with lower recurrence rate.