Esophagogastric Junction Outflow Obstruction: Are We Missing Anything?

GOALS: The authors aimed to compare preperistaltic distal esophageal pressure in patients with esophagogastric junction outflow obstruction (EGJOO) with and without reported dysphagia. BACKGROUND: Manometric EGJOO is characterized by elevated integral relaxation pressure (>15 mm Hg) without achalasia. The nomenclature inherently implies that it should be associated with impaired food bolus transit and should theoretically present clinically as dysphagia. STUDY: The authors queried an esophageal functional test database to identify patients diagnosed with EGJOO. They excluded patients who presented with ≥2 swallows with abnormal (ie, weak, failed or hypercontractile) esophageal body motility. To elucidate differences in manometric findings, the authors formed 2 cohorts of patients on the basis of a standard esophageal symptom questionnaire: those without dysphagia and those with severe or very severe dysphagia. All studies were reanalyzed to determine the distal esophageal pressure before each peristaltic wave (ie, the preperistaltic pressure) for individual swallows. The Mann-Whitney U test was used to compare categorical variables between groups. The level of significance was set to P<0.05. RESULTS: In total, 149 patients were diagnosed with EGJOO during the study period. Of these, 42 patients with ≥9 (out of 10) peristalsis (20 without dysphagia and 22 with severe/very severe dysphagia) formed the study cohorts. Patients with severe dysphagia had significantly higher median preperistaltic pressures in the distal esophagus. Preperistaltic pressure measurements showed better sensitivity and specificity for dysphagia than integral relaxation pressure. CONCLUSIONS: Elevated preperistaltic pressure is noted in symptomatic EGJOO patients. Inclusion of preperistaltic pressure in the diagnostic criteria for EGJOO may increase the clinical relevance of manometric classification.

Clinical Symptom Presentation of Hypercontractile Peristalsis in the Era of High-Resolution Manometry: A Single-Center Experience.

BACKGROUND: Hypercontractile motility of the esophagus is occasionally noted on high-resolution manometry (HRM), but its clinical correlations are unclear. We compared symptom severity and clinical presentation of patients with hypercontractile motility of the esophagus. METHODS: This was a retrospective cohort study. We queried a prospectively maintained database for patients who underwent esophageal function testing from October 1, 2016, to October 30, 2018. We included patients with jackhammer esophagus (JE; ≥2 swallows with distal contractile integral [DCI] ≥8,000 mm Hg∙cm∙s), nutcracker esophagus (NE; mean DCI 5,000-8,000 mm Hg∙cm∙s without meeting JE criteria), or esophagogastric junction outflow obstruction ([EGJOO]: abnormal median integrated relaxation pressure (>15 mm Hg) without meeting achalasia criteria, with JE [EGJOO-h], or normal motility [EGJOO-n]). HRM, endoscopy, barium esophagram, ambulatory pH studies, and symptom questionnaires were reevaluated for further analysis. Clinical parameters were analyzed using Spearman Rho correlation. Categorical variables were assessed with Fisher exact or chi-square test. RESULTS: Altogether, 85 patients met inclusion criteria. They were divided into 4 subgroups: 28 with JE, 18 with NE, 15 with EGJOO-h, and 24 with EGJOO-n. Patients with EGJOO-h were the most symptomatic overall. No correlation was seen between symptoms and mean DCI (p ≥ 0.05 all groups) or number of hypercontractile swallows (≥8,000 mm Hg∙cm∙s, p ≥ 0.05). A significant correlation was noted between dysphagia and lower esophageal sphincter pressure (LESP) and LESP integral (p ≤ 0.05). CONCLUSION: The number of hypercontractile swallows and mean DCI were not associated with patient-reported symptoms. Elevated LESP may be a more relevant contributor to dysphagia.

[Thoracodorsal artery perforator fasciocutaneous flap in the treatment of chronic hidradenitis suppurativa of axilla]. / Az arteria thoracodorsalis perforátor fasciocutan lebeny a krónikus axillaris hidradenitis suppurativa kezelésében.

BACKGROUND: The only definitive treatment of chronic axillar hidradenitis suppurativa (HS) that prevents relapses is 'in toto' excision of the infected glandular tissue. This way a deficiency emerges, which needs to be restored. Reconstruction with split skin graft (SSG) is a most common way of recovery, but thoracodorsal artery perforator (TDAP) fasciocutneous flap delivers better functional and aesthetic results. METHOD: Between May 2014 and July 2016, 14 patients underwent reconstructive surgery after excision of axillary HS, 2 of them had bilateral lesion. In 15 cases TDAP was used, in 1 case we used thoracodorsal artery capillar perforator flap (TAPcp). RESULTS: In all but 2 cases 1 dominant perforator was found. 1 flap had 2 dominant perforators and 1 flap was supplied by capillary perforators. Size of the flaps spread between 6 × 8 and 10 × 15 cm. 15 reconstructions were successful, 1 flap necrotised because of the lack of compliance of the patient. CONCLUSION: As a result of the glandular tissue excision carried out because of a chronic HS, a deficiency emerges. TDAP flap is an ideal solution for surgical reconstruction of axillar deficiencies, and a great alternative to SSG.

[Impact of antireflux surgery on gastroesophageal reflux-associated symptoms and quality of life.] / Laparoszkópos antirefluxmutétek hatása a gastrooesophagealis refluxszal járó tünetekre és a betegek életminoségére.

INTRODUCTION: Reflux disease has become endemic in the Western world. High quality hiatal reconstruction and fundoplication has a paramount importance in its therapy. While the primary goal of surgery is reducing reflux-associated disease burden, the evaluation and follow-up of disease-associated quality of life is essential. OBJECTIVE: In this study, we aimed to measure and evaluate the pre- and post-operative reflux-associated quality of life of patients undergoing surgery between 01. 12. 2015 and 31. 12. 2020 at a tertiary care hospital. METHOD: We utilized a health-related quality of life questionnaire both pre- and post-operatively. The main outcome measures were: patient-assessed heartburn, dysphagia, regurgitation, chest pain, nausea and vomiting. We also measured acid secretory medication use and patient satisfaction. RESULTS: We have assessed the pre- and post-operative questionnaries of 65 patients. All the symptoms above have decreased after surgery, and the changes were statistically significant (except for dysphagia). There was a tendency for minor weight loss after surgery. The use of acid secretion inhibitor medications decreased significantly. DISCUSSION: Our results are comparable to the outcomes of other tertiary care centers. Our workgroup has successfully adopted the diagnostic and therapeutic algorithms of the surgical care of reflux disease. CONCLUSION: If the proper indications for surgery are met, laparoscopic hiatoplasty and Toupet fundoplication are capable tools in decreasing reflux-associated symptoms and improving reflux-associated quality of life. Orv Hetil. 2023; 164(2): 57-63.

[Synchronous tumor treatment in the presence of gynecologycal cancer in three patients]. / Nogyógyászati daganatok esetén jelentkezo szinkrón tumorok együlésben való ellátása három eset kapcsán.

During the examination of patients, the probability of the occurrence of a secondary tumour is 15.2%, while that of a tertiary tumour is 1.3% [1]. The aim of this article is to draw attention to the fact that the surgical treatment of synchronous tumours in one session, if proper professional background is ensured, provides definite benefits for the patients. No protocols for the treatment of multiple tumours can be found in the relevant literature; mostly descriptions of cases are available to give orientation. The preoperative stage of the diseases, the examination protocol, the surgical procedure and the biopsy results are detailed in the study. In the article, the treatment of a triplex tumour - vulva, rectum and sigma tumour -, a large colon tumour and an endometrial adenocarcinoma with open surgery is described as well as the minimally invasive surgery of a rectal and synchronous endometrial adenocarcinoma with a patient who has gone through neoadjuvant therapy are presented. The three cases presented here prove that the surgical treatment in one session was clearly beneficial for the patients, let alone cost-efficiency. The article is not about the discussion of post-surgical or adjuvant treatments; decisions about these are to be made by the multidisciplinary professional committees of the hospitals, based on the particular situations. Orv Hetil. 2023; 164(2): 70-75.

Surgical Repair of Large Hiatal Hernias: Insight from a High-Volume Center.

BACKGROUND: Laparoscopic-assisted hiatal hernia (HH) repair is safe and effective; however, it is unclear whether hernia size affects perioperative outcomes and whether a watch-and-wait strategy is appropriate for patients with asymptomatic large HHs. We aimed to investigate these issues. METHODS: After IRB approval, we queried our prospectively maintained database for patients who underwent primary laparoscopic HH repair at our center between August 2016 and December 2019. All procedures were performed by a single surgeon (SKM). According to the intraoperative findings, HHs were divided into four groups: small (S-HH), medium (M-HH), large (L-HH), or giant (G-HH) when the percentage of herniated stomach was 0% (sliding), < 50%, 50-75%, or > 75%, respectively. Perioperative and mid-term outcomes were analyzed. RESULTS: A total of 170 patients were grouped: S-HH (n = 46), M-HH (n = 69), L-HH (n = 20), and G-HH (n = 35) with mean age of 58.5.6 ± 11.0, 61.9 ± 11.3, 70.7 ± 10.3, and 72.6 ± 9.7 years (p < 0.001), respectively. Compared to M-HH patients, L-HH patients had significantly longer hospital stays (mean 2.8 ± 3.2 vs 1.4 ± 0.91 days; p = 0.001) and more postoperative complications (6/20 [30.0%] vs 3/69 [4.3%]; OR 6.9, 95% CI 5.4-8.4, p < 0.001). At a mean follow-up time of 43.1 ± 25.0 and 43.5 ± 21.6 months for the combined S/M-HH and L/G-HH groups, GERD-Health-Related Quality of Life scores were comparable (S/M-HH: 6.5 ± 10.9 vs L/G-HH: 7.1 ± 11.3; p = 0.63). There was no perioperative mortality. CONCLUSIONS: HHs likely grow with age, reflecting their progressive nature. Laparoscopic L-HH repair was associated with higher morbidity than M-HH repair. Thus, patients with M-HH, even if less symptomatic, should be evaluated by a foregut surgeon. Regardless of HH size, good mid- and long-term quality of life outcomes can be achieved.

Factors associated with esophageal motility improvement after bilateral lung transplant in patients with an aperistaltic esophagus.

OBJECTIVES: We reported that esophageal peristalsis can improve after lung transplant (LTx), even in patients with pretransplant esophageal aperistalsis. This improvement was associated with better outcomes. We analyzed preoperative factors and sought to predict persistent aperistalsis or motility improvement in patients with pre-LTx esophageal aperistalsis. METHODS: Patients with esophageal aperistalsis who underwent LTx between January 2013 and December 2016 were included. Preoperative barium esophagrams were blinded and re-examined; subjective scores were assigned to motility and dilation patterns. Postoperative high-resolution manometry was used to divide patients into 2 groups: persistent esophageal aperistalsis (PEA) or improved esophageal peristalsis (IEP). RESULTS: We identified 29 patients: 20 with restrictive lung disease, 7 with obstructive lung disease, and 2 with pulmonary arterial hypertension. Post-LTx, 10 patients had PEA and 19 had IEP (mean age, 53.3 ± 6.6 years and 61.2 ± 10.6 years, respectively; P = .04). All 9 patients (100%) with obstructive lung disease or pulmonary arterial hypertension but only 10 of 20 patients (50%) with restrictive lung disease had IEP post-LTx (P = .01). All 4 patients with scleroderma had PEA. Nearly absent contractility on preoperative esophagrams was more prevalent in the PEA group than in the IEP group (100% vs 58.8%; P = .06). No further differences were observed between the groups. CONCLUSIONS: Patients with esophageal aperistalsis and obstructive lung disease or pulmonary arterial hypertension, but not patients with restrictive lung disease and scleroderma, are likely to have IEP post-LTx. Additional studies may determine whether subjective esophagram assessment can help predict IEP post-LTx in patients with restrictive lung disease without scleroderma.

Bilateral Lung Transplant for a Connective Tissue Disorder: Esophageal Motility and 3-year Survival.

Connective tissue disorders (CTDs) are associated with esophageal dysmotility and gastroesophageal reflux disease, which may diminish survival after lung transplantation (LTx). We studied LTx outcomes in patients with a CTD stratified by esophageal motility. We identified patients who underwent bilateral LTx from 2012 to 2017. Patients with a CTD were classified by pre-LTx diagnosis: absent esophageal motility (AEM), ineffective esophageal motility (IEM), or preserved esophageal motility (PEM). The primary endpoint was 3-year survival. Sub-analysis compared survival between the AEM group and a propensity-matched (lung allocation score), non-CTD control group. Kaplan-Meier method and log-rank test were used. In total, 495 patients underwent LTx; 33 (6.7%) had a CTD. Median (IQR) age was 62 years (55.5-67.0); 24 (72.7%) were women. Survival trended lower for recipients with a CTD than without a CTD at 1-year (84.8% vs 91.8%; p = 0.2) and 3-years (66.7% vs 73.5%; p = 0.5). Within the CTD cohort, 1- and 3-year survival was significantly higher in the PEM (100%, 87.5%) and IEM (100%, 85.7%) groups than in the AEM group (50%, 20%; p < 0.001). The AEM group had significantly lower survival at 1-year (50% vs 92.5%) and 3-years (20% vs 65%) than a lung allocation score-matched cohort of patients without a CTD. LTx recipients with a CTD and AEM had significantly lower survival than those with PEM or IEM as well as significantly lower survival than that of a propensity-matched cohort of patients without a CTD. Patients with a CTD and AEM should be considered for LTx with extreme caution and counseled appropriately.

Our experience with the laparoscopic surgery of hiatal hernias / Tapasztalataink a rekeszsérvek laparoszkópos sebészetével.

Összefoglaló. Bevezetés: A hiatus hernia egy anatómiai betegség; gyakoribb elofordulása idosebbeknél jelezheti, hogy a betegség idovel elorehalad, súlyosbodik. Elhanyagolt esetben szövodmények alakulhatnak ki, melyek növelhetik a perioperatív mortalitást. Célkituzés: A laparoszkópos hiatusrekonstrukciók sebészetében szerzett mutéti tapasztalataink ismertetése mellett igyekeztünk statisztikailag alátámasztható korrelációt találni a rekeszizom-defektus anatómiai paraméterei, valamint a betegek életkora között. Módszer: Retrospektív tanulmányunk keretében elemeztük azon betegeinket, akik laparoszkópos hiatus hernia mutéten estek át egy 58 hónapos (2016. január-2020. október) vizsgálati periódus során. A rekeszi defektus méreteit endoszkópos vonalzóval a mutét közben megmértük, a hiatus oesophagei felszínét standard matematikai formula segítségével számoltuk ki. A sürgosséggel mutétre kerülo betegeink adatait külön elemeztük. Statisztikai analízis: A defektus mérete és a betegek életkora és magassága közötti korrelációt a Spearman-féle ró (ρ)-korreláció segítségével állapítottuk meg. A szignifikanciaszint p≤0,05 volt. Eredmények: Az elektív csoportban 142 operált páciensbol 47 beteg mérési adatai feleltek meg a kritériumoknak. Az átlagéletkor 64,7 ± 12,7 év volt, 33 páciens volt no (70,2%), az átlagos testtömegindex 28,8 ± 5,5 kg/m2 volt. A defektus haránt átméroje és felszíne szignifikáns pozitív korrelációt mutatott a betegek életkorával (p≤0,05). Akut indikációval 5 beteg került mutétre; a defektus méretét illetoen hasonló eredményeket tapasztaltunk, mint az elektív csoportnál, 2 esetben azonban súlyos szövodmények alakultak ki. Következtetés: A betegség mögött húzódó anatómiai okok jobb megértése és a megfigyeléseink alapján módosított sebésztechnika reményeink szerint csökkentheti a hosszú távú kiújulások számát a jövoben. Az idoben elvégzett elektív beavatkozás alacsonyabb mortalitással, kevesebb szövodménnyel és rövidebb hospitalizációval jár együtt. Orv Hetil. 2021; 162(19): 754-759. INTRODUCTION: Hiatal hernia is an anatomical disease, and the higher incidence for elderly patients suggests that it is progressing over time. Neglected cases can cause serious complications, raising perioperative mortality. OBJECTIVE: We are presenting our experience in laparoscopic hiatal reconstructions. Our main goal is to find a statistical correlation between the anatomical parameters of the hiatal defect and the patients age. METHOD: Surgical data were reviewed retrospectively for patients who underwent laparoscopic hiatal hernia repair between January 2016 and October 2020. Dimensions of the hiatal defect were measured intraoperatively with an endoscopic ruler. The defect size was calculated using a standard formula. The acute surgeries were analyzed as a separate arm of the study. STATISTICAL ANALYSIS: The correlation between the patients age and the size of the defect were calculated using Spearman's rho (ρ) correlation. The level of significance was p≤0.05. RESULT: In the elective group, out of 142 patients 47 met the inclusion criteria. The mean age was 64.7 ± 12.7 years, 33 patients were women, and the mean BMI was 28.8 ± 5.5 kg/m2. Patient age showed significant positive correlation with the transverse dimension and the size of the hiatal defect. 5 patients underwent surgery due to acute indications. We found similarities in the size of the defects; at 2 patients we documented severe complications. CONCLUSIONS: A better understanding of the underlying anatomical disorders and the consecutively modified surgical technique will hopefully reduce the long-term recurrencies in the future. The elective surgery performed in the right time results in lower mortality, less complications and shorter hospitalization time. Orv Hetil. 2021; 162(19): 754-759.

Pathological Implications of Swallow-Associated Transient Lower Esophageal Sphincter Elevation.

BACKGROUND: The lower esophageal sphincter (LES) overlaps the crural diaphragm (CD) in patients without hiatal hernia (HH). Swallowing induces esophageal peristalsis with longitudinal esophageal shortening, causing transient elevation of the LES above the CD. This phenomenon, visible on high-resolution manometry (HRM), is called swallow-induced transient HH (tHH). METHODS: We assessed pathological implications of swallow-induced LES elevation. We included patients who underwent 24-h pH monitoring and HRM between January 1, 2017 and June 30, 2018. Patients with manometric HH were excluded. Patients were divided into 3 groups: persistent tHH, which indicated significant LES-CD separation (i.e., ≥ 1cm in ≥ 30% swallows, or ≥ 2cm in ≥ 10% swallows) at the second inspiration after the conclusion of swallow-induced esophageal peristalsis; incidental tHH, which indicated significant LES-CD separation at the first inspiration after peristalsis without meeting persistent tHH criterion; and non-tHH. RESULTS: In total, 107 patients were included. There were 18 patients in the persistent tHH group, 54 in the incidental tHH group, and 35 in the non-tHH group. No differences were observed in esophageal body motility or LES antireflux barrier parameters among groups. However, patients with persistent tHH had significantly higher DeMeester scores, longer acid exposure time, and poorer acid clearance. Prevalence of pathological reflux was 83.3% in the persistent tHH cohort. Esophagogastroduodenoscopy showed that 76.9% of patients with persistent tHH had no HH. Endoscopic findings of the esophagogastric junction were similar among groups. CONCLUSIONS: Persistent tHH seems to be a pathological finding associated with pathological reflux.

Simple Manometric Index for Comprehensive Esophagogastric Junction Barrier Competency Against Gastroesophageal Reflux.

BACKGROUND: The esophagogastric junction (EGJ) is an anatomic and physiologic barrier against gastroesophageal reflux. Comprehensive evaluation of EGJ barrier parameters using high-resolution manometry in patients with GERD has not been well established. We propose a simple index for comprehensive EGJ antireflux competency. STUDY DESIGN: Patients who underwent high-resolution manometry and 24-hour pH monitoring between January 2017 and September 2018 were included. Of these, patients with normal esophageal motility were selected. EGJ antireflux competency was assessed based on the following 3 categories: anatomic configuration of the EGJ complex (ie EGJ morphology), backflow-preventive pressure on the lower esophageal sphincter (LES) (ie LES pressure integral), and backflow-promotive pressure across the LES (ie thoracoabdominal pressure gradient). Each category was scored on a scale of 0 to 2, applying clinically meaningful divisions, and a cumulative score was calculated (EGJ index: 0 to 6 points). DeMeester score > 14.72 indicated GERD. RESULTS: In total, 259 patients met study criteria. Of these, GERD was noted in 109 patients (42.1%). The pH parameters were gradually exacerbated, depending on the EGJ index. Good correlations were seen between EGJ index and previously proposed parameters for EGJ disruption, including LES length, LES pressure, and LES pressure integral (area under the curve > 0.9 [excellent validation]). No patient had GERD if the EGJ index score was 0. However, GERD was seen in as high as 85.7% of patients with the highest score of 6. CONCLUSIONS: EGJ disruption severity was clearly graded based on a simple scoring method, which can improve evaluation and development of clinical strategies for GERD.

Esophageal aperistalsis and lung transplant: Recovery of peristalsis after transplant is associated with improved long-term outcomes.

OBJECTIVE: Esophageal aperistalsis has been considered a relative contraindication for lung transplant because of a higher risk of allograft dysfunction secondary to reflux and aspiration induced by poor esophageal clearance. We previously reported that esophageal motility improves in some patients after lung transplant. We reviewed the clinical course of lung transplant recipients diagnosed with an aperistaltic esophagus on pretransplant testing. METHODS: We identified patients diagnosed with pretransplant aperistaltic esophagus on high-resolution manometry who underwent lung transplant. Recipients with normal esophageal motility before lung transplant were used as the propensity score-matched control group. High-resolution manometry was repeated after lung transplant, and patients with aperistalsis were further divided into 2 subgroups: improved esophageal peristalsis and nonimproved peristalsis (ie, persistent aperistalsis after lung transplant). RESULTS: Esophageal aperistalsis was seen in 31 patients (mean age, 59.0 years; 21 men). The 1-, 3-, and 5-year post-lung transplant survivals in the aperistalsis group were 80.6%, 51.2%, and 34.9%, respectively, which was significantly lower than in the control group (90.3%, 73.4%, and 58.8%, respectively; P = .038). Post-lung transplant high-resolution manometry was performed for 29 patients in the aperistalsis group, 19 of whom demonstrated improved esophageal motility (65.5%). The 1-, 3-, and 5-year survivals after lung transplant of patients with recovery of peristalsis were similar to those of the control group (89.5%, 65.0%, and 48.8%, respectively; P = 1.000), whereas the nonimproved peristalsis group had lower survival (80.0%, 36.0%, and data unavailable, respectively; P = .012). CONCLUSIONS: Esophageal aperistalsis is not necessarily a contraindication for lung transplant. Improved peristalsis can be expected in up to two-thirds of these patients and is associated with good outcomes.

Autologous Dermis Graft Implantation: A Novel Approach to Reinforcement in Giant Hiatal Hernias.

OBJECTIVES: Nonreinforced tensile repair of giant hiatal hernias is susceptible to recurrence, and the role of mesh graft implantation remains controversial. Creating a new and viable choice without the use of high-cost biological allografts is desirable. This study presents the application of dermis graft reinforcement, a cost-efficient, easily adaptable alternative, in graft reinforcement of giant hiatal hernia repairs. METHODS: A 62-year-old female patient with recurrent giant hiatal hernia (9 × 11 cm) and upside down stomach, immediately following the Belsey repair done in another department, was selected for the pilot procedure. The standard three-stitch nonabsorbable reconstruction of diaphragmatic crura was undertaken via laparoscopic approach. A 12 × 6 cm dermis autograft was harvested from the loose abdominal skin. "U" figure onlay reinforcement of diaphragm closure was secured with titanium staples. The procedure was completed with a standard Dor fundoplication. One- and seven-month follow-ups were conducted. RESULTS: No short-term postoperative complications were observed. One-month follow-up showed normal anatomical location of abdominal viscera on computed tomography imaging. High-resolution manometry showed normal lower esophageal sphincter pressure. Preoperative abdominal complaints were resolved. Procedural costs were lower than the average cost following mesh graft reinforcement. CONCLUSION: Dermis graft reinforcement is a cheap, easily adaptable procedure in the repair of giant hiatal hernias, even in the setting of laparoscopic reoperative procedure.