Abnormal performance of peroral endoscopic myotomy (POEM): a case misdiagnosed as achalasia of cardia.

BACKGROUND: Pseudoachalasia is a rare disease that behaves similarly to achalasia (AC), making it sometimes difficult to differentiate. CASE PRESENTATION: We report a case of 49-year-old male with adenocarcinoma of the gastroesophageal junction misdiagnosed as achalasia. No obvious abnormalities were found in his initial examinations including upper digestive endoscopy, upper gastrointestinal imaging and chest computed tomography (CT). During the subsequent introduced-peroral endoscopic myotomy (POEM), it was found that the mucosal layer and the muscular layer had severe adhesion, which did not receive much attention, delayed the clear diagnosis and effect treatment, and ultimately led to a poor prognosis for the patient. CONCLUSIONS: This case suggests that when patients with AC found mucosal and muscular adhesions during POEM surgery, the possibility should be considered that the lesion may be caused by a malignant lesion.

Intraoperative esophageal washout reduces free intraluminal tumor cells during resection of carcinomas of the esophagus and cardia.

OBJECTIVE: Intraluminally shed viable tumor cells might contribute to anastomotic recurrence in cancer of the esophagus and the cardia. The study aimed to establish a method of esophageal washout and, hence, to reduce intraluminal cancer cells before esophageal anastomosis. METHODS: Forty-eight consecutive patients with esophago-gastric resection for histologically proven cancer of the esophagus or the cardia were included in a prospective, interventional study. Before transection, the esophagus was clamped proximally to the tumor and rinsed with 1:10 diluted povidone-iodine-solution (10 × 30 ml) applied by a transorally inserted 24F-Foley catheter. The first, fifth and tenth portion of the lavage fluid were sent to cytological examination. RESULTS: Intraoperative frozen sections confirmed clear proximal resection margins of the esophagus. The cytological examination of the fluid recovered from the esophageal washout revealed malignant cells in 13/48 patients (27%). The presence of malignant cells was significantly less likely in patients with neoadjuvant treatment than in patients without neoadjuvant treatment: 2/23 (9%) vs. 11/25 (44%) (p = 0.009). Repetitive washout reduced the probability of detectable malignant cells from 13 to 8 (62%) patients after 5, and further to 4 patients (30%) after 10 washout maneuvers. CONCLUSIONS: Free malignant cells may be present in the esophageal lumen following intraoperative manipulation of cancers of the esophagus or cardia. Transoral washout of the esophagus is novel, feasible and enables reduction or even elimination of these tumor cells. The reliability of this procedure raises with increasing washout volume. Esophageal washout might be especially worthwhile in patients who do not receive neoadjuvant therapy.

Short-Term Prognostic Effect of Comprehensive Complication Index in Patients With Gastric Cardia Adenocarcinoma.

INTRODUCTION: The Clavien-Dindo Classification (CDC) has been traditionally used for assessing postoperative complications. Recently, the Comprehensive Complication Index (CCI) has been introduced as a new tool. However, its prognostic significance in Gastric Cardia Adenocarcinoma (GCA) is yet to be determined. METHODS: The CCI and CDC of 203 patients who underwent radical surgery for GCA at Jinling Hospital from 2016 to 2023 were evaluated. Primary outcome variables included Hospital Length of Stay, duration of intensive care unit stay postoperatively, time to return to normal activities, and total hospitalization cost. The area under the curve was used to measure the correlation strength of the CCI and CDC for these outcomes. RESULTS: The CCI demonstrated superior association strength, indicated by higher area under the curve values for all primary outcome variables compared to the CDC: Hospital Length of Stay (0.956 versus 0.910), intensive care unit stay duration (0.969 versus 0.954), time to return to normal activities (0.983 versus 0.962), and total hospitalization cost (0.925 versus 0.911). CONCLUSIONS: The CCI showed a stronger positive association than the CDC with short-term postoperative complications in GCA. It has potential implications for improving postoperative patient management.

Long-term outcomes of laparoscopic Heller's myotomy with angle of His accentuation in patients of achalasia cardia.

BACKGROUND: Laparoscopic Heller's myotomy (LHM) is an established treatment for achalasia cardia. Anti-reflux procedures (ARP) are recommended with LHM to reduce the post-operative reflux though the optimal anti-reflux procedure is still debatable. This study reports on the long-term outcomes of LHM with Angle-of-His accentuation (AOH) in patients of achalasia cardia. METHODS: One hundred thirty-six patients of achalasia cardia undergoing LHM with AOH between January 2010 to October 2021 with a minimum follow-up of one year were evaluated for symptomatic outcomes using Eckardt score (ES), DeMeester heartburn (DMH) score and achalasia disease specific quality of life (A-DsQoL) questionnaire. Upper gastrointestinal endoscopy, high resolution manometry (HRM) and timed barium esophagogram (TBE) were performed when feasible and rates of esophagitis and improvement in HRM and TBE parameters evaluated. Time dependent rates of success were calculated with respect to improvement in ES and dysphagia-, regurgitation- and heartburn-free survival using Kaplan-Meier analysis. RESULTS: At a median follow-up of 65.5 months, the overall success (ES ≤ 3) was 94.1%. There was statistically significant improvement in ES, heartburn score and A-DsQoL score (p < 0.00001, p = 0.002 and p < 0.00001). Significant heartburn (score ≥ 2) was seen in 12.5% subjects with 9.5% patients reporting frequent PPI use (> 3 days per week). LA-B and above esophagitis was seen in 12.7%. HRM and TBE parameters also showed a significant improvement as compared to pre-operative values (IRP: p < 0.0001, column height: p < 0.0001, column width: p = 0.0002). Kaplan-Meier analysis showed dysphagia, regurgitation, and heartburn free survival of 75%, 96.2% and 72.3% respectively at 10 years. CONCLUSIONS: LHM with AOH gives a lasting relief of symptoms in patients of achalasia cardia with heartburn rates similar to that reported in studies using Dor's or Toupet's fundoplication with LHM. Hence, LHM with AOH may be a preferred choice in patients of achalasia cardia given the simplicity of the procedure.

Fibrin sealant for closure of mucosal penetration at the oesophagus or cardia during submucosal tunnelling endoscopic resection for gastrointestinal submucosal tumours.

BACKGROUND AND STUDY AIM: To assess the efficacy and safety of a fibrin sealant for the prevention of leak resulting from mucosal penetration at the esophagus or cardia during a STER procedure to remove gastrointestinal submucosal tumors (SMTs). PATIENTS AND METHODS: Between April 2014 and October 2022, a total of 290 patients with oesophageal or cardiac SMTs underwent STER at our centre. We retrospectively identified patients with oesophageal or cardia SMTs who underwent STER and experienced mucosal penetration of the cardia or oesophagus during the procedure. A total of 31 mucosal penetrations in 30 procedures were included. Of the 31 mucosal penetrations, 12 occurred in the cardia, and the other 19 occurred in the oesophagus. All 31 sites received the fibrin sealant to close the mucosal penetration. Clinical characteristics, procedure-related parameters, detailed data of the mucosal penetrations, and treatment outcomes using the fibrin sealant were reviewed for all 30 patients to assess the efficacy and safety of the fibrin sealant for closure of mucosal penetration at the cardia or oesophagus. RESULTS: For the 31 mucosal penetrations, the mean size was 0.08 ± 0.06 cm2 (range 0.01-0.25 cm2). Mucosal closure using the fibrin sealant was performed successfully in all 31 mucosal penetrations. Of the 31 mucosal penetrations, clips were used in 13 cases. All 30 patients were discharged after a median of 7 days (range 4-20 day) postoperatively. During a mean 62 months (range 6-107 months) follow-up, all 31 mucosal penetrations successfully healed without the occurrence of infection, ulcer, oesophagitis, chest infection or abdominal infection. CONCLUSION: For the closure of mucosal penetration during STER at the cardia or oesophagus, a fibrin sealant is both safe and efficacious. It is necessary to conduct more research on the viability, effectiveness, and safety of using a fibrin sealant to close wider mucosal penetrations.

Conventional versus oblique fiber-sparing endoscopic myotomy for achalasia cardia: a randomized controlled trial (with videos).

BACKGROUND AND AIMS: GERD is common after peroral endoscopic myotomy (POEM). Selective sparing of oblique fibers may reduce the incidence of reflux esophagitis after POEM. In this study, we compared the incidence of GERD between conventional myotomy (CM) versus oblique fiber-sparing (OFS) myotomy in patients with achalasia. METHODS: Eligible patients with type I and II achalasia who underwent POEM from January 2020 to October 2020 were randomized into 2 groups (CM and OFS myotomy). Exclusion criteria were type III achalasia, sigmoid esophagus, and history of Heller's myotomy. The primary study outcome was incidence of reflux esophagitis (at least grade B) in the 2 groups. Secondary outcomes were reflux symptoms, esophageal acid exposure, clinical success, and adverse events. RESULTS: One hundred fifteen patients were randomized into CM (n = 58) and OFS myotomy (n = 57) groups. POEM was technically successful in all patients. Overall, reflux esophagitis was found in 56 patients (48.7%). The incidence of at least grade B esophagitis was similar in both groups (CM vs OFS myotomy: 25.9% vs 31.6%, P = .541). The mean number of reflux episodes (48.2 ± 36.6 vs 48.9 ± 40.3, P = .933), increased esophageal acid exposure >6% (45.5% vs 31.7%, P = .266), and high DeMeester scores (38.6% vs 41.5%, P = .827) were similar in both groups. There was no difference in the rate of symptomatic reflux (GERD questionnaire score >7) or use of proton pump inhibitors at 1 year. CONCLUSIONS: Sparing of sling fibers has no significant impact on the incidence of significant reflux esophagitis after POEM. Novel strategies need to be explored to prevent reflux after POEM. (Clinical trial registration number: NCT04229342.).

[Application value of CT examination of lymph node short diameter in evaluating cardia-left gastric lymph node metastasis in thoracic esophageal squamous cell carcinoma].

Objective: To investigate the application value of computed tomography (CT) examination of lymph node short diameter in evaluating cardia-left gastric lymph node metastasis in thoracic esophageal squamous cell carcinoma (ESCC). Methods: A total of 477 patients with primary thoracic ESCC who underwent surgical treatment in the Affiliated Cancer Hospital of Zhengzhou University from January 2013 to December 2017 were collected. All of them underwent McKeown esophagectomy plus complete two-field or three-field lymph node dissection. Picture archiving and communication system were used to measure the largest cardia-left gastric lymph node short diameter in preoperative CT images. The postoperative pathological diagnosis results of cardia-left gastric lymph node were used as the gold standard. Receiver operating characteristic (ROC) curve was used to evaluate the efficacy of CT lymph node short diameter in detecting the metastasis of cardia-left gastric lymph node in thoracic ESCC, and determine the optimal cut-off value. Results: The median short diameter of the largest cardia-left gastric lymph node was 4.1 mm in 477 patients, and the largest cardia-left gastric lymph node short diameter was less than 3 mm in 155 cases (32.5%). Sixty-eight patients had cardia-left gastric lymph node metastases, of which 38 had paracardial node metastases and 41 had left gastric node metastases. The lymph node ratios of paracardial node and left gastric node were 4.0% (60/1 511) and 3.3% (62/1 887), respectively. ROC curve analysis showed that the area under the curve of CT lymph node short diameter for evaluating cardia-left gastric lymph node metastasis was 0.941 (95% CI: 0.904-0.977; P<0.05). The optimal cut-off value of CT examination of the cardia-left gastric lymph node short diameter was 6 mm, and the corresponding sensitivity, specificity and accuracy were 85.3%, 91.7%, and 90.8%, respectively. Conclusion: CT examination of lymph node short diameter can be a good evaluation of cardia-left gastric lymph node metastasis in thoracic ESCC, and the optimal cut-off value is 6 mm.

Transgastric Single-Incision Laparoscopic Resection for a Gastric Submucosal Tumor Located at the Cardia.

INTRODUCTION: Surgical treatment of gastric submucosal tumors (SMTs) located near the gastroesophageal junction can be technically challenging, especially regarding preservation of the integrity and function of the lower esophageal sphincter. We introduce a novel minimally invasive surgery, successfully performed in a patient with a gastric SMT located at the cardia. A 24-year-old lady presenting with acid reflux for 1 year underwent esophagogastroscopy that showed a gastric SMT located at the cardia. Endoscopic ultrasonography showed a 20×19 mm homogeneous hypoechoic lesion originating from the muscularis propria layer. Transgastric single-incision laparoscopic resection of the tumor was performed. CONCLUSION: Transgastric single-incision laparoscopic resection of gastric SMTs is technically feasible and safe. This presents an alternative surgical choice for resection for gastric SMTs located in difficult regions such as the fundus, cardia, or prepyloric antrum.

Prevention and treatment of a positive proximal margin after gastrectomy for cardia cancer.

A tumour-positive proximal margin (PPM) after extended gastrectomy for oesophagogastric junction (OGJ) adenocarcinoma is observed in approximately 2-20% of patients. Although a PPM is an unfavourable prognostic factor, the clinical relevance remains unclear as it may reflect poor tumour biology. This narrative review analyses the most relevant literature on PPM after gastrectomy for OGJ cancers. Awareness of the risk factors and possible measures that can be taken to reduce the risk of PPM are important. In patients with a PPM, surgical and non-surgical treatments are available but the effectiveness remains unclear.

An unexpected gastric cardia submucosal lesion.

An esophagogastroduodenoscopy revealed a submucosal lesion in the gastric cardia of a 55-year-old man.Endoscopic ultrasonography showed a hypoechoic echo lesion originated from the muscularis propria layer considering a leiomyoma or stromal tumor.a submucosal tunneling endoscopic resection was successfully performed to remove the lesion and the diagnosis is hepatoid adenocarcinoma.This is the first report on a case of gastric HAC originated from submucous layer.

[Effectiveness of laparoscopic esophagocardiomyotomy combined with various modifications of fundoplication in the treatment of achalasia cardia]. / Sravnitel'naya otsenka effektivnosti laparoskopicheskoi ezofagokardiomiotomii v sochetanii s razlichnymi modifikatsiyami fundoplikatsii v lechenii akhalazii kardii.

OBJECTIVE: To analyze the results of laparoscopic esophagocardiomyotomy with original fundoplication and Dor fundoplication. MATERIAL AND METHODS: Laparoscopic esophagocardiomyotomy with fundoplication was performed in 196 patients with achalasia cardia. Patients with achalasia stage 2 comprised 48.5% (95/196), stage 3 - 51.5% (101/196). Two groups were distinguished depending on surgery: Dor fundoplication (group 1, n=53) and Allakhverdyan fundoplication (group 2, n=143). Statistical analysis of data was carried out. RESULTS: Surgery time in the first group was longer by 35 minutes (p=0.000), blood loss - by 30 ml (p=0.000), postoperative hospital-stay - by 3 days. Pulmonary complications occurred in 34% and 2% of patients, respectively (p=0.002). In the first group, reflux esophagitis in 3 months after surgery was found in 62% of patients, after 6 months - 72%, after a year - in 74% of patients. In the second group, these values were 24%, 8% and 3%, respectively. Dysphagia developed in 2% and 1% of cases, respectively (p=0.767). CONCLUSION: Dor fundoplication demonstrates unsatisfactory long-term results and should be currently considered as historical stage in surgical treatment of achalasia cardia.

[Laparoscopic transhiatal resection of the lower third of the esophagus for late recurrence of achalasia cardia after laparoscopic esophagocardiomyotomy: a 12-year follow-up]. / Rezektsiya nizhnei treti pishchevoda laparoskopicheskim transkhiatal'nym dostupom po povodu pozdnego retsidiva akhalazii kardii posle laparoskopicheskoi ezofagokardiomiotomii: 12 let nablyudeniya.

The choice of treatment for recurrence after esophagocardiomyotomy is individual. Repeated esophagocardiomyotomy is appropriate in patients without malignancy and significant deposition of food masses in distal esophagus followed by severe pulmonary complications. Esophagectomy is desirable in case of unadvisable or failed repeated esophagocardiomyotomy. The authors presents laparoscopic transhiatal resection of the lower third of the esophagus (2019) in a patient with recurrent achalasia of the cardia stage 3-4 and cicatricial peptic stricture of the lower third of the esophagus after previous laparoscopic esophagocardiomyotomy with fundoplication (2009). The immediate results of redo surgery and physical status of the patient after 3 years (12-year follow-up) are described.

Transthoracic, thoracoabdominal, and transabdominal surgical approaches for gastric cardia adenocarcinomas: a survival evaluation based on a cohort of 7103 patients.

BACKGROUND: This study compared the survival outcomes of different surgical approaches to determine the optimal approach for gastric cardia adenocarcinoma (GCA) and aimed to standardize the surgical treatment guidelines for GCA. METHODS: A total of 7103 patients with GCA were enrolled from our previously established gastric cardia and esophageal carcinoma databases. In our database, when the epicenter of the tumor was at or within 2 cm distally from the esophagogastric junction, the adenocarcinoma was considered to originate from the cardia and was considered a Siewert type 2 cancer. The main criteria for the enrolled patients included treatment with radical surgery, no radio- or chemotherapy before the operation, and detailed clinicopathological information. Follow-up was mainly performed by telephone or through home interviews. According to the medical records, the surgical approaches included transthoracic, thoracoabdominal, and transabdominal approaches. Kaplan-Meier and Cox proportional hazards regression models were applied to correlate the surgical approach with survival in patients with GCA. RESULTS: There were marked differences in age and tumor stage among the patients who underwent the three surgical approaches (P < 0.001). Univariate analysis showed that survival was related to sex, age, tumor stage, and N stage (P < 0.001 for all). Cox regression model analysis revealed that thoracoabdominal approach (P < 0.001) and transabdominal approach (P < 0.001) were significant risk factors for poor survival. GCA patients treated with the transthoracic approach had the best survival (5-year survival rate of 53.7%), and survival varied among the different surgical approaches for different tumor stages. CONCLUSION: Thoracoabdominal approach and transabdominal approach were shown to be poor prognostic factors. Patients with (locally advanced) GCA may benefit from the transthoracic approach. Further prospective randomized clinical trials are necessary.