Current practice of pharmacological treatment for hyperactive delirium in terminally ill cancer patients: results of a nationwide survey of Japanese palliative care physicians and liaison psychiatrists.

OBJECTIVE: The objective of this survey was to identify areas where doctors have divergent practices in pharmacological treatment for hyperactive delirium in terminally ill patients with cancer. METHODS: We conducted a survey of Japanese palliative care physicians and liaison psychiatrists. Inquiries were made regarding: (i) choice of drug class in the first-line treatment, (ii) administration methods of the first-line antipsychotic treatment, (iii) starting dose of antipsychotics in the first line treatment and maximum dose of antipsychotics in refractory delirium, and (iv) choice of treatment when the first-line haloperidol treatment failed. Respondents used a five-point Likert scale. RESULTS: Regarding choice of drug class in the first-line treatment, more doctors reported that they 'frequently' or 'very frequently' use antipsychotics only than antipsychotics and benzodiazepine (oral: 73.4 vs. 12.2%; injection: 61.3 vs. 11.6%, respectively). Regarding administration methods of the first-line antipsychotic treatment, the percentage of doctors who reported that they used antipsychotics as needed and around the clock were 55.4 and 68.8% (oral), 49.2 and 45.4% (injection), respectively. There were different opinions on the maximum dose of antipsychotics in refractory delirium. Regarding the choice of treatment when the first-line haloperidol treatment failed, the percentage of doctors who reported that they increased the dose of haloperidol, used haloperidol and benzodiazepines, and switched to chlorpromazine were 47.0, 32.1 and 16.4%, respectively. CONCLUSIONS: Doctors have divergent practices in administration methods of the first-line antipsychotic treatment, maximum dose of antipsychotics, and choice of treatment when the first-line haloperidol treatment failed. Further studies are needed to determine the optimal treatment.

Risk factors for the occurrence of peptic esophagitis following laparoscopic Heller-Dor surgery for esophageal achalasia.

Peptic esophagitis can occur as a complication of laparoscopic Heller-Dor surgery (LHD) among patients with esophageal achalasia. The goal of this study was to identify the characteristics of patients who have developed peptic esophagitis following LHD surgery along with the risk factors associated with the occurrence of peptic esophagitis. Among the 447 cases consisting of esophageal achalasia patients who underwent LHD as the primary surgery, we compared the patient background, pathophysiology, symptoms, and surgical outcomes according to whether or not peptic esophagitis occurred following surgery. We also attempted to use univariate and multivariate analyses to identify the risk factors for peptic esophagitis occurring following surgery. Esophagitis following surgery was confirmed in 67 cases (15.0%). With respect to the patient backgrounds for cases in which peptic esophagitis had occurred, a significantly higher number were male patients, with a significantly high occurrence of mucosal perforation during surgery in terms of surgical outcomes, along with a high occurrence of esophageal hiatal hernias in terms of postoperative course (P = 0.045, 0.041, and 0.022, respectively). However, there were no significant differences in terms of age, BMI, disease duration, preoperative symptoms, esophageal manometric findings, esophageal barium findings, and esophageal clearance. A multivariate analysis indicated independent risk factors for the occurrence of peptic esophagitis following LHD as being male, the occurrence of mucosal perforation during surgery, and the occurrence of esophageal hiatal hernias. Peptic esophagitis occurred following LHD in 15% of cases. Independent risk factors for the occurrence of peptic esophagitis following LHD included being male, the occurrence of mucosal perforation during surgery, and the occurrence of esophageal hiatal hernias following surgery.

Correlation between our symptom-based scoring system and the Eckardt score for assessing patients with esophageal achalasia.

PURPOSE: The Eckardt score (ES) is a famous scoring system used for assessing achalasia patients. We studied the correlation between our scoring system and the ES and examined the relationship between each score and the pathophysiology of achalasia. METHODS: The subjects were 143 patients with diagnosed achalasia. We assessed the frequency and degree of dysphagia, regurgitation (vomiting), and chest pain on a 5-point scale from 0 to 4, with the product of the frequency and degree score defined as each symptom score (0-16). The sum of the three symptom scores was the Total Symptom Score (TSS). We then studied the correlation between the TSS and the ES, including whether these scores reflected the pathophysiology. RESULTS: The median scores were 20 for TSS and 6 for the ES, indicating a high correlation between the two scores (r = 0.7280, p < 0.0001). A relationship was found between the morphologic type and both scores (TSS: p = 0.002, ES: p = 0.0036). On creating a receiver operating characteristic (ROC) curve for the Straight type and each score, the AUC was 0.6740 for TSS and 0.6628 for ES. CONCLUSIONS: A high positive correlation was found between the TSS and the ES. Both scoring systems reflected the morphologic type well, demonstrating that the TSS was a scoring system comparable to the ES.

Redo laparoscopic Heller myotomy and Dor fundoplication versus rescue peroral endoscopic myotomy for esophageal achalasia after failed Heller myotomy: a single-institution experience.

PURPOSE: To compare the surgical outcomes of redo laparoscopic Heller-Dor procedure and rescue peroral endoscopic myotomy for patients with failed Heller myotomy. METHODS: We identified patients who had undergone redo laparoscopic Heller-Dor procedure or rescue peroral endoscopic myotomy from August 1996 to September 2019 and assessed the patients' characteristics, timed barium swallow results, symptom scores before/after surgery, surgical outcomes, and postoperative outcomes. RESULTS: Eleven patients underwent redo laparoscopic Heller-Dor procedure, and 14 underwent rescue peroral endoscopic myotomy. Blood loss (p = 0.001) and intraoperative complications rate (p = 0.003) were lower and the operative time (p > 0.001) and observation period (p = 0.009) shorter in patients who underwent rescue peroral endoscopic myotomy than in patients who underwent redo laparoscopic Heller-Dor procedure. Patients who underwent rescue peroral endoscopic myotomy had a higher rate of postoperative reflux esophagitis (p = 0.033) than those who underwent redo laparoscopic Heller-Dor procedure. After the interventions, the dysphagia symptoms were improved for both groups. Furthermore, both groups expressed satisfaction with their respective procedures. CONCLUSIONS: Rescue peroral endoscopic myotomy was associated with better surgical outcomes than redo laparoscopic Heller-Dor for patients with failed Heller myotomy. However, rescue peroral endoscopic myotomy had higher rates of postoperative reflux esophagitis.

Relationship between esophageal achalasia subtypes and esophageal clearance.

BACKGROUND: The diagnosis and pathological evaluation of esophageal achalasia have been improved dramatically by the development of high-resolution manometry. It is currently known to be divided into three subtypes. However, the differences between subtypes in terms of esophageal clearance remain unclear. AIMS: To compare the pathology of subtypes in patients with esophageal achalasia from the perspective of esophageal clearance. METHODS: We classified the patients diagnosed with esophageal achalasia into three subtypes based on the high-resolution manometry findings and compared the patient background, esophagography findings, esophageal manometry findings, timed barium esophagogram (TBE) findings, and their symptoms. We also calculated the esophageal clearance rate from TBE to investigate the relationship with the subtypes. RESULTS: There were 71 cases of Type I, 140 cases of Type II, and 10 cases of Type III. No differences by subtype were found in patient background or symptoms. Regarding the esophageal manometry findings, the integrated relaxation pressure was high in Type II (p = 0.0006). The esophagography revealed a mild degree of esophageal flexion in Type III (p = 0.0022) and a high degree of esophageal dilation in Type I and II (p = 0.0227). The esophageal clearance rate in descending order was: Type III, II, and I (height: p = 0.0302, width: p = 0.0008). CONCLUSIONS: The subtypes by high-resolution manometry diagnosis had an association with the esophagography findings and best reflected the esophageal clearance, with no correlation to the patient backgrounds and symptoms.

Over ten-year outcomes of laparoscopic Heller-myotomy with Dor-fundoplication with achalasia: single-center experience with annual endoscopic surveillance.

BACKGROUND: Laparoscopic Heller-myotomy with Dor-fundoplication (LHD) is the standard surgical treatment for achalasia; however, surgical outcomes over a period greater than 10 years have not been well-explored. The objective of this study was to evaluate the long-term outcomes of LHD for achalasia based on a single-center experience. METHODS: Patients who underwent LHD between 1994 and 2019 were included. Of these, we excluded patients who had undergone foregut surgery or whose follow-up data were unavailable. Esophagogastroduodenoscopy (EGD) findings and postoperative persistent and/or recurrent symptoms had been assessed annually. Disease-free rates were calculated using Kaplan-Meier analysis. RESULTS: A total of 530 patients (mean age 45.0 years with 267 men) were included. The median follow-up period was 50.5 months. More than 10 years' data were available in 78 patients (14.7%). The cumulative rates of freedom from dysphagia, vomiting, chest pain, and Eckardt score > 3 at 10 years after LHD were 80.1%, 97.5%, 96.3%, and 73.5%, respectively. Probability of esophagitis during 10 years after surgery was 34.4% of patients based on Kaplan-Meier estimation. Approximately 3/4th of patients who had post-LHD esophagitis showed mild esophagitis of Los Angeles classification grade A. Fifteen patients (2.8%) were required a revision of primary LHD. Six patients (1.2%) developed esophageal cancer with an incidence was as high as 219.8/100,000 person-year. All patients with esophageal cancer were found to have early stage tumors that were successfully resected. CONCLUSIONS: Symptomatic relief post-LHD lasted for over 10 years. The incidence rate of esophageal cancer was high. Regular EGD surveillance seems to be helpful for early detection of esophageal cancer early.

The patient characteristics of esophageal carcinoma following laparoscopic myotomy for esophageal achalasia.

BACKGROUND: It is common knowledge that esophageal achalasia patients have a high risk of developing esophageal carcinoma. The present study assessed the characteristics of esophageal carcinoma patients following laparoscopic Heller-Dor surgery (LHD) for esophageal achalasia. METHOD: Among 622 cases which were esophageal achalasia patients and underwent LHD as the primary surgery, we compared the patient background, pathophysiology, symptoms, and surgical outcomes according to whether or not esophageal carcinoma occurred following surgery. RESULTS: Six cases (0.96%) of postoperative esophageal carcinoma were confirmed. The characteristics of the cases in which esophageal carcinoma occurred were older age, longer disease duration (p = 0.0362 and 0.0028, respectively), decreased sphincter pressure of the lower esophagus, a high rate of sigmoid esophagus, and a long esophagus lateral diameter (p = 0.0214, 0.001, and 0.0416, respectively). Moreover, no differences in surgical outcomes were confirmed and there were no differences in symptoms from before and following surgery. CONCLUSION: The characteristics of esophageal carcinoma patients with achalasia following laparoscopic myotomy were an older age, longer disease duration, and greater progression of disease pathophysiology.

Is esophageal manometry essential for the diagnosis of achalasia? Identifying patients with achalasia by the esophageal clearance method.

BACKGROUND AND AIM: Achalasia is a disease characterized by inadequate relaxation of the lower esophageal sphincter (LES) and impaired peristalsis, for which esophageal motor function testing is essential in making a definitive diagnosis. However, the diffusion rate of esophageal pressure testing in Japan is low. We, therefore, examined whether achalasia could be identified by esophageal clearance testing with low-density barium (Timed Barium Esophagogram: TBE). MATERIALS AND METHODS: 126 cases (62 males, median age of 46 years), excluding those who had not undergone TBE during their initial laparoscopic Heller-Dor surgery, were chosen as the subjects from among those who were diagnosed with achalasia from November 2012 when HRM was introduced. The type of dilation, maximum esophageal transverse diameter, and esophageal clearance measurements by TBE were retrospectively examined. With respect to TBE, 200 mL of 45 weight% low-density barium was ingested as quickly as possible, after which the barium column heights (H0, H1, H2, and H5) were measured 1 min, 2 min, and 5 min following ingestion. RESULTS: The types of dilation indicated included: straight type (105 cases, 83%); sigmoid type (20 cases, 16%); and advanced sigmoid type (1 case, 1%). The maximum transverse diameter of the esophagus was 45 (34-54) mm, with Grade I (d < 30 mm) in 33 cases, Grade II (35 mm < d < 60 mm) in 75 cases, and Grade III (d < 60 mm) in 18 cases. The values for H0, H1, H2, and H5 were 162 (117-201) mm, 142 (98-199) mm, 130 (94-183) mm, and 119 (77-178) mm, respectively. 114 cases (90.5%) were not cleared after 5 min, while 12 cases (9.5%) were cleared by 5 min later (H1 = 0 + H2 = 0 + H5 = 0) and 7 cases (5.6%) by 2 min later (H1 = 0 + H2 = 0), with only 6 cases (4.8%) having complete clearance within 1 min (H1 = 0). Moreover, the degree of dilatation in patients with complete clearance within 1 min was three patients (2.4%) each for Grade I and Grade II, respectively. CONCLUSIONS: Approximately 2.4% of achalasia cases had mostly normal esophageal clearance and no esophageal dilation. Based on the state of esophageal clearance by TBE and the maximum transverse diameter of the esophagus, it seems by and large possible to identify achalasia cases.

Therapeutic effect of laparoscopic fundoplication for patients with GERD from the viewpoint of Lyon Consensus.

BACKGROUND AND OBJECTIVES: The Lyon Consensus was conducted in 2017, leading to a revision of the diagnostic criteria of GERD. Conclusive GERD was defined as cases in which the distal esophageal acid exposure time (AET) is greater than 6% and there exists either peptic esophagitis, constriction, or long-segment Barrett's mucosa with a Los Angeles classification of grade C or D. Borderline GERD is defined as cases in which AET is between 4 and 6% and there exists peptic esophagitis with a Los Angeles classification of either grade A or B. All other cases were defined as Inconclusive GERD. We conducted a retrospective investigation of the treatment results of laparoscopic fundoplication (LF) for GERD according to the Lyon Consensus and evaluated whether or not it is an effective treatment predictor. MATERIALS AND METHODS: From among the cases of primary LF conducted on patients with GERD-related illnesses at our university hospital from June 2008 to March 2020, the subjects included 215 individuals who underwent upper gastrointestinal endoscopy and 24 h multichannel intraluminal impedance pH (MII-pH) testing prior to surgery. We compared the pathophysiology of the Conclusive GERD Group (Group A), Borderline GERD Group (Group B), and Inconclusive GERD Group (Group C), and then investigated the treatment results of each group. We used AFP classification for pathophysiological evaluation. For the acid reflux evaluation, we conducted MII-pH measurements using Sleuth, manufactured by Sandhill. The postoperative evaluation period was set to 3 months following surgery. The data are expressed using median values, with a statistical significance defined as p < 0.05 using the Kruskal-Wallis, Mann-Whitney, Wilcoxon signed-rank, and Chi-squared tests. RESULTS: Group A: 92 cases (43%, male 69 cases, age 57), Group B: 48 cases (22%, male 20 cases, age 52), and Group C: 75 cases (35%, male 69 cases, age 57). Regarding the patient backgrounds, while there were no significant differences in terms of gender or disease duration, those in Group A were significantly older than the other two groups, and there was a significant difference in Body Mass Index (BMI) between Group A and Group C. The results of each factor were: A factor (1 vs.1 vs. 1, p < 0.001), F factor (2 vs. 0 vs. 0, p < 0.001), and P factor (2 vs. 1 vs. 0, p < 0.001), with AET of 10.0 vs. 2.9 vs. 0.6, p < 0.001, and the disease had progressed more in Group A. There were also no differences in terms of surgical methods, hemorrhage volume, and intraoperative/postoperative complications; however, the use of mesh was higher and surgery duration was longer in Group A. There were obvious improvements in the A, F, and P factors and AET of each group following surgery (other than F and P of Group C, p < 0.001). The rate of recurrence was 15% in Group A, 8% in Group B, and 6% in Group C. It tended to be higher in Group A, but this was not statistically significant. CONCLUSION: The classification of GERD pathophysiology based on the Lyon Consensus is satisfactory, with no significant differences in the rate of effect of LF. The Lyon Consensus is effective for ascertaining the severity and pathophysiology of GERD; however, we were unable to forecast the treatment results of LF.

Needlescopic versus conventional laparoscopic Heller-Dor procedure for achalasia: a propensity score-matched analysis.

PURPOSE: To compare the treatment results of needlescopic surgery with those of the conventional method for achalasia, using propensity score-matching. METHODS: Propensity score-matching was performed based on five factors: age, gender, body mass index, extended form, and maximum expansion diameter, to extract 28 cases each for a needlescopic group and a conventional group. RESULTS: There were no significant differences between the needlescopic group and the conventional group, in operative time (165 min vs. 170 min, p = 0.682), estimated blood loss (both ≒ 0 ml, p = 0.426), or post-operative hospital stay (4 vs. 4 days, p = 0.248). Although the follow-up period was significantly longer in the conventional group (6 vs. 105 months, respectively; p < 0.001), there was no difference in the post-operative symptom scores for difficulty in swallowing and chest pain or the degree of satisfaction (p = 0.563, p = 0.142, p = 0.342, respectively). Furthermore, there was no difference in the post-operative clearance rate, with both groups found to be favorable (p = 0.758, p = 0.790, p = 1.000, p = 1.000, respectively). CONCLUSIONS: The short-term results of needlescopic surgery for achalasia were good and equivalent to those of the conventional method.

The evaluation of recumbent reflux by multichannel intraluminal impedance pH testing for patients with gastroesophageal reflux disease and sleep disturbance.

BACKGROUND AND AIM: The relationship between gastroesophageal reflux disease (GERD) and sleep disturbance has recently been pointed out and is garnering substantial attention. Although there are reports that point out the effectiveness of medical treatment for sleep disturbance associated with GERD, examinations of the pathological condition, including reflux during sleep, are inadequate. In the present study, we evaluated the recumbent reflux in patients with GERD and sleep disturbance using multichannel intraluminal impedance pH (MII-pH), and attempted to suppress recumbent reflux by surgical treatment to examine the pathophysiology of patients with GERD and sleep disturbance. MATERIALS AND METHODS: Of the 47 patients with GERD-related diseases in whom laparoscopic fundoplication was performed at The Jikei University Hospital from January 2016 to June 2017, 31 patients (average age: 55.9 ± 13.8 years, male in 25), excluding 9 with surgical indications only for esophageal hiatal hernia and 7 without postoperative evaluation, were the subjects of this study. All surgical procedures were performed by the Toupet method. We used the Pittsburgh Sleep Quality Index (PSQI) to evaluate sleep disturbance, setting 5.5 as the cut-off value, based on the report by Doi et al., with any conditions beyond this value deemed sleep disturbance. The evaluation of gastroesophageal reflux was carried based on the MII-pH using the Sleuth, manufactured by Sandhill Corporation, with an automatic analysis carried out by computer. Furthermore, recumbent abnormal reflux was defined as recumbent all reflux (times) > 7. All evaluations were performed preoperatively and at 3 months after the operation. The data were expressed in medians and interquartile ranges, with p < 0.05 defined as statistically significant by the Mann-Whitney, Wilcoxon, or Chi-squared test. RESULTS: Although sleep disturbance was found in 19 cases (61%), 8 (42%) of which were actually confirmed as nighttime abnormal reflux, of whom 5 cases (63%) showed significant improvement in their sleep disturbance following the operation, with a PSQI score of lower than 5.5. Among these 5 cases, postoperative recumbent abnormal reflux was also significantly reduced as compared with the preoperative condition (17 vs. 2 times/day, p = 0.042). Furthermore, sleep disturbance improved and recumbent abnormal reflux also decreased in two cases, with sleep disturbance improved by controlling the nighttime reflux via surgery in a total of 7 cases (87.5%). Although the PSQI score was as high as 14 points before and after the operation in one case, the rate of recumbent abnormal reflux was remarkably reduced, with sleep disturbance and recumbent reflux considered irrelevant. Furthermore, regarding the frequency of recumbent acid/non-acid reflux, while non-acid reflux was significantly more frequent in the patients with recumbent reflux complications (9 vs. 1 time/day, p < 0.001), there was no marked difference in the frequency of acid reflux. CONCLUSIONS: Among cases with GERD and sleep disturbance, approximately one-third of them showed findings suggestive of the involvement of recumbent reflux in sleep disturbance, with reflux characterized by non-acid reflux.

Therapeutic efficacy of laparoscopic Heller-Dor surgery for chest pain in patients with achalasia: a single institutional experience.

BACKGROUND: Chest pain reduces the quality of life of patients with achalasia. Although laparoscopic Heller-Dor surgery (LHD) is a standard surgical treatment for achalasia, its therapeutic efficacy for chest pain is not clear. The present study evaluated the therapeutic efficacy of LHD for chest pain and tried to identify factors associated with the relief of chest pain. METHODS: The study included 244 patients with preoperative chest pain who underwent LHD as the first surgical intervention. The questionnaire-based symptom frequency score was multiplied by the severity score, and the calculated metric was defined as the symptom score. The study population was stratified, by the change in the chest pain symptom score, into Complete Remission (CR), Partial Remission (PR), and No Remission (NR) groups, which were compared for patient background and surgical outcome. Multivariate analysis was also performed to determine factors associated with the relief of chest pain. RESULTS: As for preoperative clinicopathological conditions, the CR subgroup was older (p = 0.0169) with fewer previous balloon dilatations (p = 0.009). Although no difference was detected in the surgical outcome, the NR group had higher postoperative symptom scores for both difficulty in swallowing and vomiting and a lower score for patient satisfaction with surgery (p = 0.0141). Multivariate analysis detected two factors associated with CR: disease duration over 60 months and less than two previous balloon dilatations. CONCLUSIONS: LHD improved chest pain symptoms in 90% of patients with achalasia. The patients who achieved relief of chest pain were characterized by disease duration over 60 months and less than two previous balloon dilatations.

Effect of Low-Dose Aspirin on Chronic Acid Reflux Esophagitis in Rats.

BACKGROUND: Clinical role of low-dose aspirin (LDA) in pathogenesis of gastroesophageal reflux disease is by far controversial. This can be attributed to the paucity of basic research detailing the mechanism of LDA-induced esophageal mucosal injury (EI) on underlying chronic acid reflux esophagitis (RE). AIM: The aim of this study was to clarify the effect of LDA on chronic RE in rats. METHODS: Esophagitis was induced in 8-week-old male Wistar rats by ligating the border between forestomach and glandular portion with a 2-0 silk tie and covering the duodenum with a small piece of 18-Fr Nélaton catheter. Seventy-eight chronic RE rat models were divided into five treatment groups, consisting of orally administered vehicle (controls), and aspirin doses of 2, 5, 50 or 100 mg/kg once daily for 28 days. EI was assessed by gross area of macroscopic mucosal injury, severity grade of esophagitis and microscopic depth of infiltration by inflammatory cells. RESULTS: Area of esophagitis in animals with aspirin dose of 100 mg/kg/day showed a 36.5% increase compared with controls, although it failed to achieve statistical significance (p = 0.812). Additionally, the rate of severe EI was increased in animals with aspirin dose of 100 mg/kg/day as compared with controls (p < 0.05). The grade of severity correlated with the depth of inflammation (r s = 0.492, p < 0.001). CONCLUSIONS: Maximal dose aspirin (100 mg/kg/day) contributed in exacerbating preexisting EI. LDA (2 and 5 mg/kg/day), on the other hand, did not affect chronic RE in this model. LDA seems to be safe for use in patients with chronic RE.

Effects of the body mass index (BMI) on the surgical outcomes of laparoscopic fundoplication for gastro-esophageal reflux disease: a propensity score-matched analysis.

PURPOSE: In the present study, we examined how the body mass index (BMI) affected the outcomes of laparoscopic fundoplication for GERD in patients, whose backgrounds were matched in a propensity score-matched analysis. METHODS: We divided the patients into two groups (BMI <25 kg/m2 and BMI ≥25 kg/m2). The following background information was matched for the propensity score-matched analysis: sex, age, degree of esophageal hiatal hernia, acid exposure time, and degree of reflux esophagitis. In total, 105 subjects were extracted in each group. The surgical outcomes and postoperative outcomes of patients with BMI <25 kg/m2 (Group A) and those with BMI ≥25 kg/m2 (Group B) were compared and examined. RESULTS: There were no differences in the surgical procedure, intraoperative complications, or estimated blood loss (p = 0.876, p = 0.516, p = 0.438, respectively); however, the operative time was significantly prolonged in Group B (p = 0.003). The rate of postoperative recurrence in Group A was 17% (15/87 patients), while that in Group B was 11% (12/91 patients), and did not differ to a statistically significant extent (p = 0.533). CONCLUSIONS: Although the operative time for GERD in obese patients was prolonged in comparison with non-obese patients, there was no difference in the rate of postoperative recurrence.

Effect of preoperative balloon dilation on treatment outcomes of laparoscopic Heller-Dor surgery for achalasia: a propensity score matched study.

PURPOSE: There is some debate about whether preoperative balloon dilation influences the outcomes of laparoscopic Heller-Dor surgery (LHD), with no consensus opinion as yet. Thus, we investigated if preoperative dilation influences the treatment outcomes of LHD for achalasia. METHODS: The subjects of this study were 526 patients with achalasia who underwent LHD as an initial treatment between August 1994 and February 2017. The patients were roughly classified by the status of preoperative balloon dilation and matched with propensity scores for age, sex, BMI, morphologic type, and maximum esophageal transverse diameter. Consequently, 94 subjects each were assigned to the balloon dilation (BD) group and to the non-balloon dilation (non-BD) group. We evaluated patient backgrounds, surgical outcomes, and incidence of postoperative reflux esophagitis. RESULTS: No differences were found in surgical time, intraoperative blood loss, incidence of intraoperative mucosal injury, or postoperative hospital stay between the BD and non-BD groups. The mean patient satisfaction was significantly higher in the non-BD group (4.9) than in the BD group (4.7) and the incidence of postoperative esophagitis was significantly lower in the non-BD group (1.1%) than in the BD group (7.4%). CONCLUSIONS: Preoperative balloon dilation had no effect on intraoperative complications but did increase the incidence of postoperative reflux esophagitis in patients undergoing LHD for achalasia.

Impact of reflux esophagitis on the esophageal function before and after laparoscopic fundoplication.

BACKGROUND: High-resolution manometry (HRM), which is breakthrough testing equipment to evaluate esophageal motor function, was developed in Europe and United State and has garnered attention. Moreover, multichannel intraluminal impedance pH (MII-pH) testing has allowed us to grasp all liquid/gas reflux including not only acid but also non-acid reflux. We examined the impact of the presence of reflux esophagitis (RE) on esophageal motor function before and after laparoscopic fundoplication. MATERIALS AND METHODS: The subjects included 100 patients (male: 63 patients, mean age: 54.1 ± 15.8) among 145 patients who underwent laparoscopic fundoplication for GERD associated diseases during a 4-year period from October 2012 to September 2016, excluding 6 patients who underwent further surgery, 32 patients on whom HRM was not performed, 3 patients who had technical errors during testing, and 4 patients for whom the status of RE was unknown. Regarding HRM, Mano Scan from Given Imaging Ltd. was used, and for the analysis, Mano View version 3.0 from the same company was used, after which data was calculated based on the Chicago Classification advocated by Pandolfino et al. Moreover, for the MII-pH testing, Sleuth manufactured by Sandhill Scientific. Inc. was used and automatic analysis was conducted by a computer. Postoperative assessments were conducted 3 months following surgery for all. Data was described in the median value and inter-quartile range, with a statistically significant difference defined as p < 0.05 by Chi square, Mann-Whitney, and Wilcoxon tests. RESULTS: RE+ group (Los Angeles classification A:B:C:D = 7:9:16:12 patients) included 44 patients (44%), of older age compared to the RE- group (62 vs. 50 years, p = 0.012) and a higher Body Mass Index value (24.0 vs. 22.5, p = 0.045); however, no differences were observed in terms of gender and duration of symptoms. In the preoperative findings on MII-pH, the RE+ group demonstrated significantly longer acid reflux time (4.7 vs. 1.3%, p = 0.005), while in the HRM findings, the RE- group demonstrated a significantly longer abdominal esophagus (0 vs. 0.4 cm, p = 0.049) and maintained esophageal body motor function (DCI: 1054 vs. 1407 mmHg s cm, p = 0.021, Intact peristalsis ratio: 90 vs. 100%, p = 0.037). As to the comparison of the treatment effect before and after laparoscopic fundoplication (Toupet fundoplication for all), significant improvements were observed in both groups in various parameters regarding reflux including acid reflux time, total number of liquid reflux episodes and total number of reflux episodes. Moreover, for both groups, the total length of the lower esophageal sphincter (LES) (RE+ group: 2.7 vs. 3.2 cm, p = 0.001, RE- group: 3.0 vs. 3.4 cm, p = 0.003) and the total length of the abdominal esophagus (RE+ group: 0 vs. 1.6 cm, p < 0.001, RE- group: 0 vs. 1.8 cm, p = 0.001) were significantly extended following surgery; however, no change was observed in DCI before and after surgery. CONCLUSIONS: Regardless of the presence of RE, cardiac function and LES function were improved following laparoscopic Toupet fundoplication, but no changes were observed in esophageal body motor function.

Surgical results of laparoscopic Toupet fundoplication for gastroesophageal reflux disease with special reference to recurrence.

BACKGROUND: Surgical results of GERD have mainly been reported from the Western countries, with a few reports found in Japan. We examined the surgical results of laparoscopic Toupet fundoplication and clarify the characteristics of recurrent cases. METHODS: The subjects included 375 patients who underwent laparoscopic Toupet fundoplication from June 1997 to December 2016 as the initial surgery. Patient characteristics, pathophysiology, and surgical results were examined. In addition, we compared the patient characteristics and pathophysiology of recurrent cases in comparison with non-recurrent cases. RESULTS: Age 59 (43-70) and male 211 (56.3%). The operation time was 141 min (113-180) and intraoperative complications were found to have onset in 13 subjects (3.5%). Dysphagia after surgery was found in 18 cases (4.8%). The A factor (the degree of hiatal hernia), P factor (the degree of esophagitis), and pH < 4 holding time significantly improved after surgery compared with prior to surgery (p < 0.001 for all), while the LES lengths and abdominal LES lengths were extended (p < 0.001 for each). Recurrence was found in 48 patients (15.1%) among the 318 patients for whom we could confirm the presence or absence of recurrence. The A factor, P factor, and pH < 4 holding time prior to surgery were, respectively, higher in the recurrence group (p = 0.031, p < 0.001, p < 0.001). CONCLUSIONS: Laparoscopic Toupet fundoplication for GERD could be performed safely, with a response rate as good as 85%. Compared with non-recurrent cases, preoperative clinical conditions such as esophageal hiatal hernia, reflux esophagitis, and acid reflux time were all advanced in recurrent cases.

Impact of preoperative balloon dilatation on outcomes of laparoscopic surgery in young patients with esophageal achalasia.

BACKGROUND: Balloon dilatation is reportedly less effective for young patients with esophageal achalasia than for older patients. However, there is no consensus on the impact of prior balloon dilatation on outcomes of surgical treatment. This study investigated the significance of preoperative balloon dilatation on surgical outcomes in young patients with esophageal achalasia. METHODS: Of patients aged less than 40 years who had undergone a laparoscopic Heller-Dor operation for esophageal achalasia, 201 with a postoperative follow-up period of at least 1 year were included. They were divided into two groups with and without a history of balloon dilatation, and compared preoperative pathological conditions and surgical outcomes. RESULTS: This study included 100 men and 101 women with a median age of 31 years, of whom 158 patients without a history of pneumatic dilatation (79%, non-PD group) and 43 with a history of pneumatic dilatation (21%, PD group) The preoperative symptom scores for dysphagia and regurgitation were significantly higher in the non-PD group. Although no differences were observed in surgical outcomes or postoperative course, the esophageal clearance rates calculated on preoperative and postoperative timed barium esophagograms were lower in terms of both height and width of the barium column in the PD group than in the non-PD group. Subjectively, both groups expressed equally high satisfaction. CONCLUSIONS: In patients aged less than 40 years with esophageal achalasia, although preoperative balloon dilatation did not affect subjective levels of satisfaction with surgery, postoperative improvement in esophageal clearance in the lower esophagus was inhibited.

Comparison of the multichannel intraluminal impedance pH and conventional pH for measuring esophageal acid exposure: a propensity score-matched analysis.

BACKGROUND: The modalities for evaluating acid reflux in medical care for gastroesophageal reflux disease (GERD) include conventional pH (C-pH), wireless pH (Bravo®) and multichannel intraluminal impedance pH (MII-pH), which have been reported to vary with respect to the duration of acid reflux. In this study, we examined the difference between the acid reflux in C-pH and MII-pH among patients with GERD. METHODS: Prior to initial laparoscopic fundoplication carried out on 297 cases from December 1994 to April 2016, an upper gastrointestinal endoscopy and C-pH or MII-pH were conducted. A propensity score-matched analysis was carried out about five factors including age, sex, BMI, the extent of reflux esophagitis (Los Angeles classification), and the presence of hiatal hernia (HH), ultimately leading to the creation of a C-pH group (81 cases) and MII-pH group (81 cases) as the subjects. RESULTS: Concerning pH < 4 holding time (18.9 vs. 7.3%, p < 0.001), DeMeester score (58.5 vs. 24.4, p < 0.001), and the number of times reflux continued for longer than 5 min (8.8 vs. 4.1 times/day, p = 0.002), the C-pH group had significantly higher values for each, while the positive rate of acid reflux (Positive pH) was significantly higher in the C-pH group (p < 0.001), at 80% in the C-pH group and 42% in the MII-pH group. In terms of the correlation between the extent of reflux esophagitis and pH < 4 holding time, a moderate level of positive correlation was seen in both the C-pH group and MII-pH group (r of each = 0.427, r = 0.408); moreover, regardless of the presence of HH, the holding time was significantly higher in the C-pH group than the MII-pH group (p of each <0.001, p = 0.040). CONCLUSION: While the values of each parameter regarding acid reflux are calculated as lower in MII-pH than in C-pH, there is no difference in the evaluation of the pathology between the two modalities.

Comparison of laparoscopic Nissen and Toupet fundoplication using a propensity score matching analysis.

PURPOSE: Laparoscopic fundoplication (LF) has become a standard operative procedure for GERD-related diseases in Japan, although meta-analyses have mainly evaluated findings from Western countries. The propensity score matching method was used to compare and investigate the treatment outcomes of two fundoplication procedures (the Nissen and Toupet methods). METHODS: Among 474 patients who underwent initial LF from December 1994 to April 2016, we extracted 401 cases (Nissen: 92 cases, Toupet: 309 cases), excluding 73 patients in whom follow-up was insufficient. We then matched 126 of these patients (63 per group). RESULTS: The esophageal acid reflux time (%) was 12.2:2.8, being higher in the Nissen group than in the Toupet group (p < 0.001). Regarding the surgical outcome, the amount of bleeding was higher in the Nissen group (p = 0.001), and the number of hospitalization days following surgery was longer (p = 0.003). Furthermore, a significantly rate of postoperative difficulty in swallowing (%) was observed in the Nissen group, at 13:0 (p = 0.004). The recurrence rate (%) was 8:3, with no difference between the two groups (p = 0.243). CONCLUSIONS: Although there was no marked difference in the recurrence rate between the two procedures, postoperative dysphagia was observed at a higher frequency with the Nissen method than the Toupet method.