Accuracy of anterior segment optical coherence tomography for pre-operative localization of insertions of extraocular recti muscles.

INTRODUCTION: To study the accuracy of anterior segment optical coherence tomography (AS-OCT) function of Cirrus HD-OCT 500 (Carl Zeiss Meditec, Dublin, CA) in calculating the insertion of rectus muscles from the limbus in patients undergoing primary squint surgery. METHODOLOGY: A prospective, double-masked, observational study was conducted on 128 muscles of 46 patients with strabismus who were planned for strabismus surgery between January 2019 and December 2019. Insertion distance from limbus was measured using AS-OCT function of Cirrus HD-OCT 500 preoperatively. Intraoperative measurements were taken using Castroviejo caliper. A Bland-Altman analysis was performed to determine the agreement between the readings. RESULTS: A total of 128 muscles were successfully imaged and evaluated, including 13 superior recti (10.15%), 23 inferior recti (17.96%), 35 medial recti (27.34%) and 57 lateral recti (44.53%). 124 muscles (96.9%) were within 1mm difference, which was considered clinically acceptable. Bland-Altman plots showed the level of agreement between the two methods was good. CONCLUSION: Anterior segment scan function of Cirrus HD-OCT 500 is an accurate method to detect the insertion of extraocular recti muscles in patients of primary strabismus surgery.

Surgical outcomes of augmented bilateral lateral rectus recession with conjunctival recession in patients of intermittent exotropia.

PURPOSE: To evaluate the surgical outcome of augmented BLR recession with conjunctival recession in cases of IXT. METHOD: A total of 15 patients of the basic type of IXT were included in this prospective study. The patients underwent augmented BLR recession with conjunctival recession and on the basis of postoperative deviation, the outcome was assessed in terms OF orthophoria/success (< or =10 PD exotropia and < or =5 PD esotropia), residual exotropia/undercorrection (>10 PD exotropia), and overcorrection (>5 PD esotropia). RESULTS: Preoperative primary horizontal deviation was 30.80 ± 9.56 PD (16-42 PD) for near (0.3 m) and was 33.93 ± 9.97PD (15-45 PD) for distance (6 m). The mean postoperative primary horizontal deviation was 5.6 ± 1.5 PD (4-8 PD) for distance and 6.73 ± 2.15 PD (4-10 PD) for near at 6 months follow-up. After 12 weeks of surgery, 12 (80%) of the patients were orthophoric, 2 (13.3%) of the patients were overcorrected and 1 (6.7%) of the patient was undercorrected for near and all 15 (100.0%) patients were orthophoric for distance. This alignment was maintained till 6 months of follow-up. CONCLUSIONS: Although fornix-based incisions for squint surgery are preferred these days augmented BLR recession with conjunctival recession by limbal-based incision leads to good surgical outcome and prevents undercorrection and recurrence.

Total external ophthalmoplegia: First clinical manifestation of Sjögren's syndrome.

Sjögren's syndrome (SS) is an autoimmune disease causing destruction of the exocrine glands secondary to lymphocytic infiltration. Common clinical symptoms of SS are xerostomia, xerophthalmia, myalgia, arthritis, and vasculitis. Neurological symptoms may precede the diagnosis of SS by up to 2 years in about 80% of patients. A 28-year-old female presented to us with complaints of horizontal and vertical diplopia along with inability to move the right eye and sudden drooping of the right upper eyelid. She was a recently diagnosed case of type 2 diabetes mellitus and had a history of foreign body sensation in both eyes for 4 months. Schirmers I test revealed less than 5 mm of wetting in both eyes after 5 min, suggesting dry eyes. On immunological blood investigations, serum c-peptide was normal, rheumatoid factor was negative, antinuclear antibodies were positive, and proliferating cell nuclear antigens were positive. Extractable Nuclear Ag profile RO 52 was strongly positive suggestive of primary SS. Lip biopsy revealed mild-to-moderate chronic inflammation showing irregular acanthotic epidermis, and dermis had perivascular lymphocytic infiltrate. Thus, the possible diagnosis of primary SS with type 2 diabetes mellitus and right-sided total external ophthalmoplegia was made. Patient was prescribed subcutaneous insulin, multivitamins, tear substitutes and alternate patching. Later on insulin was replaced by oral hypoglycemics. The external ophthalmoplegia completely resolved within 6 weeks. So, total external ophthalmoplegia can be added to the spectrum of central nervous system involvement in SS.

Extraocular Myoplasty: Surgical Remedy For Intraocular Implant Exposure.

BACKGROUND: Evisceration and nucleation are commonly performed ophthalmic surgeries for painful blind eye, disfiguring blind eye, endophthalmitis etc. After both these surgeries it is important to replace the lost volume in the orbit with implant. Implant is associated with many complications such as major discharge, exposure with discharge and implant exposure. The main surgical management of implant exposures basically primary revision or patch grafting with or without removal of the implant. CASE: A 60 years old man presented to ophthalmic OPD with complaint of foreign body sensation and irritation in left eye. There was history of evisceration with silicon ball implant in left eye done one month back for painful blind eye at another hospital. On ophthalmic examination, there was a 3 × 4 mm of implant exposure most probably dueto tight closure. As per records the size of implant was 22mm. The patient was planned for extra-ocular myoplasty with buccal mucosal graft under general anesthesia. OBSERVATION: After sterile prepping and draping, 360˚ degrees peritomy was performed and care was taken to dissect between tenons and orbital implant. Medialand lateral recti were isolated and dissected upto 10-12mm from insertion site. Both the recti were secured with 6-0 vicryl suture and were detached from their respective insertions, advanced and approximated over the site of implant exposure. Thus the exposed implant was covered with a vascularized base which was reinforced with amucosal graft harvested from the buccal mucosa and secured with absorbable sutures. After 1 year of follow up patient was asymptomatic. CONCLUSION: Extraocular myoplasty with buccal mucosal graft is a good surgical remedy for orbital implant exposure implant.

Thoracoabdominal pressure gradient and gastroesophageal reflux: insights from lung transplant candidates.

Advanced lung disease is associated with gastroesophageal reflux disease (GERD). The thoracoabdominal pressure gradient (TAPG) facilitates gastroesophageal reflux, but the effects of TAPG on gastroesophageal reflux in patients with pulmonary disease have not been well defined. Patients diagnosed with end-stage lung disease are expected to have the most extreme derangement in respiratory mechanics. The aim of this study is to explore the relationship between TAPG and reflux in lung transplant (LTx) candidates. We reviewed LTx recipients who underwent pretransplant esophageal high-resolution manometry and a 24-hour pH study. Patients were excluded if they were undergoing redo LTx, had manometric hiatal hernia, or had previously undergone foregut surgery. TAPG was defined as the intra-abdominal pressure minus the intrathoracic pressure during inspiration. Adjusted TAPG was calculated by the TAPG minus the resting lower esophageal sphincter (LES) pressure (LESP). Twenty-two patients with normal esophageal function tests (i.e., normal esophageal motility with neither manometric hiatal hernia nor pathological reflux on 24-hour pH monitoring) were selected as the pulmonary disease-free control group. In total, 204 patients underwent LTx between January 2015 and December 2016. Of these, 77 patients met inclusion criteria. We compared patients with obstructive lung disease (OLD, n = 33; 42.9%) and those with restrictive lung disease (RLD, n = 42; 54.5%). 2/77 patients (2.6%) had pulmonary arterial hypertension. GERD was more common in the RLD group than in the OLD group (24.2% vs. 47.6%, P = 0.038). TAPG was similar between the OLD group and the controls (14.2 vs. 15.3 mmHg, P = 0.850); however, patients in the RLD group had significantly higher TAPG than the controls (24.4 vs. 15.3 mmHg, P = 0.002). Although TAPG was not correlated with GERD, the adjusted TAPG correlated with reflux in all 77 patients with end-stage lung disease (DeMeester score, rs = 0.256, P = 0.024; total reflux time, rs = 0.259, P = 0.023; total number of reflux episodes, rs = 0.268, P = 0.018). Additionally, pathological reflux was seen in 59.1% of lung transplant candidates with adjusted TAPG greater than 0 mmHg (i.e., TAPG exceeding LESP); GERD was seen in 30.9% of patients who had an adjusted TAPG ≤ 0 mmHg. In summary, TAPG varies based on the underlying cause of lung disease. Higher adjusted TAPG increases pathological reflux, even if patients have normal antireflux anatomy and physiology (i.e., no hiatal hernia and manometrically normal LES function). Adjusted TAPG may provide further insights into the pathophysiology of GERD.

Simultaneous Superior Rectus Recession and Anterior Transposition of Inferior Oblique Muscle as a Surgical Option for Traumatically Lost Inferior Rectus Muscle.

PURPOSE: To evaluate the role of simultaneous superior rectus (SR) recession and anterior transposition of inferior oblique (ATIO) muscle in patients with traumatically lost inferior rectus (IR) muscle. METHODS: Six patients with history of ocular trauma, followed by sudden onset vertical diplopia along with marked hypertropia (HT) and limitation of depression in abduction in the affected eye suggestive of IR disinsertion, were included in this prospective study. The patients were treated by simultaneous SR recession and ATIO muscle in the affected eye by limbal conjunctival approach under local anesthesia. RESULTS: Preoperatively, primary position HT of 40-50 (mean 44.16 ± 4.91) prism diopters (PD) was present in all cases which increased to 65-70 (mean 65.83 ± 5.84) PD in down and in the ipsilateral gaze along with marked limitation of depression in abduction and A pattern. On exploration, the IR could not be traced in four cases. Fibrotic muscle sheath with retracted IR was found 10-12 mm away from the limbus in rest of the two patients. ATIO (6.5 mm from the limbus) with simultaneous recession of ipsilateral SR was done under local anesthesia. At 12 weeks postoperatively, three patients were orthophoric in primary position and vertical alignment with in 4-7 PD in primary position was achieved in rest of the three patients. CONCLUSION: Simultaneous SR recession with ATIO seems to be a good alternative to achieve satisfactory vertical alignment for patients with traumatically lost inferior rectus muscle.

Swallow-induced esophageal shortening in patients without hiatal hernia is associated with gastroesophageal reflux.

Longitudinal esophageal body shortening with swallow-induced peristalsis has been reported in healthy individuals. Esophageal shortening is immediately followed by esophageal re-elongation, and the lower esophageal sphincter (LES) returns to the baseline position. High-resolution manometry (HRM) allows for objective assessment of extent of shortening and duration of shortening. In patients without hiatal hernia at rest, swallow-induced esophageal shortening can lead to transient hiatal hernia (tHH) which at times may persist after the completion of swallow. This manometric finding has not been investigated in the literature, but a question arises whether this swallow-induced transient herniation can effect on the likelihood of gastroesophageal reflux. This study aims to assess the relationship between gastroesophageal reflux and the subtypes of swallow-induced esophageal shortening, i.e. tHH and non-tHH, in patients without hiatal hernia at rest. After Institutional Review Board (IRB) approval, we queried a prospectively maintained database to identify patients who underwent HRM evaluation and 24-hour pH study between January to December 2015. Patients with type-I esophagogastric junction (EGJ) morphology (i.e. no hiatal hernia) according to the Chicago classification v3.0 were included. The patterns of the esophageal shortening with swallows were divided into two subtypes, i.e. tHH and non-tHH. tHH was defined as an EGJ double high-pressure zones (≥1 cm) at the second inspiration after the termination of swallow-induced esophageal body contraction. The number of episodes of tHH was counted per 10 swallows and tHH size was measured for each patient. In total, 41 patients with EGJ morphology Type-I met the inclusion criteria. The mean age was 47.2 years, 35 patients (85.4%) were women, and the mean body mass index was 33.9 kg/m2. The mean number of tHH episodes was 3 out of 10 swallows; mean maximal tHH size was 1.3 cm. Patients who had tHH in ≥3 out of 10 swallows (n = 16; 39.0%) were more likely to have abnormal DeMeester scores than patients with <3 swallows (56% vs. 28%; P = 0.070). Patients with maximal tHH ≥2 cm in at least 1 swallow (n = 17; 41.5%) were more likely to experience pathological reflux than patients with maximal tHH <2 cm (59% vs. 25%; P = 0.029). In conclusion, we showed that, in a subset of patients with Type-I EGJ morphology, swallowing induced transient EGJ double high-pressure zones (≥1 cm) after peristalsis. We have named this new manometric finding the swallow-induced tHH. A high prevalence of pathological reflux disease was observed in patients with maximal tHH ≥2 cm. The degree of swallow-induced tHH could be an early indicator of lower esophageal sphincter dysfunction in patients without manometric hiatal hernia.

Chronic Discharging Sinus of Upper Lid Due to the Missed Wooden Foreign Body.

BACKGROUND: Foreign bodies of the orbit can have a diverse range of clinical presentations, which may be perplexing to the most Ophthalmologists. Wooden foreign bodies can remain quiescent for a long time, before presenting with various complications. We report a case of Post-traumatic chronic non-healing discharging sinus in the left upper lid, which on exploration revealed the presence of the missed wooden foreign body. CASE: A 48-year-old male, presented to Ophthalmic OPD with a complaint of discharge from the left upper eyelid for 18 months. The patient had a history of minor trauma to the left upper eyelid while collecting wood in the forest, 18 months back. The patient was misdiagnosed on previous examinations elsewhere. The diagnosis of retained wooden foreign body was made at our center and surgical exploration was done to remove the same. OBSERVATION: On clinical examination, there was a 2-3mm long sinus in the left upper eyelid with purulent discharge and granulation tissue. Surrounding skin showed hyperpigmentation and excoriation. CT scan orbit was inconclusive. MRI orbit revealed a peripherally enhancing extraconal/conal collection in the left orbit with a central hypo intense structure suggestive of a foreign body. Surgical exploration of the wound was done and a small wooden foreign body measuring 9mm was removed with excision of the sinus tract. CONCLUSION: A history of trauma followed by chronic discharging sinus should evoke suspicion of a retained foreign body. Prompt imaging, followed by surgical exploration should be done to prevent misdiagnosis and inappropriate management.

Lacrimal gland-derived IL-22 regulates IL-17-mediated ocular mucosal inflammation.

Inflammatory damage of mucosal surface of the eye is a hallmark of dry eye disease (DED) and, in severe cases, can lead to significant discomfort, visual impairment, and blindness. DED is a multifactorial autoimmune disorder with a largely unknown pathogenesis. Using a cross-sectional patient study and a well-characterized murine model of DED, herein we investigated the immunoregulatory function of interleukin-22 (IL-22) in the pathogenesis of DED. We found that IL-22 levels were elevated in lacrimal fluids of DED patients and inversely correlated with severity of disease. Acinar cells of the lacrimal glands (LGs), not inflammatory immune cells, are the primary source of IL-22, which suppresses inflammation in ocular surface epithelial cells upon desiccating stress. Moreover, loss of function analyses using IL-22 knockout mice demonstrated that IL-22 is essential for suppression of ocular surface infiltration of Th17 cells and inhibition of DED induction. Our novel findings elucidate immunoregulatory function of LG-derived IL-22 in inhibiting IL-17-mediated ocular surface epitheliopathy in DED thus making IL-22 a new relevant therapeutic target.

Classification for esophagogastric junction (EGJ) complex based on physiology.

We propose a new classification for esophagogastric junction (EGJ) incorporating both physiologic and morphologic characteristics. Additionally, we contrast it with the Chicago v 3.0 EGJ classification. With Institutional Review Board (IRB) approval, prospectively maintained database was queried to identify patients who underwent high-resolution manometry (HRM) and pH-study between October 2011 and October 2015. Patients with prior foregut intervention, pH study on acid suppression, esophageal dysmotility, or lower esophageal sphincter-crural diaphragm separation of >5 cm were excluded. We classified patients into three groups-Type-A: Complete overlap of lower esophageal sphincter-crural diaphragm (single high-pressure zone); Type-B: Double high-pressure zone with pressure inversion point (PIP) at or above lower esophageal sphincter; Type-C: Double high-pressure zone with PIP below lower esophageal sphincter. A total of 214 included patients were divided into Type-A (n = 101), Type-B (n = 32), and Type-C (n = 81). Abdominal lower esophageal sphincter length (AL), lower esophageal sphincter pressure (LESP), and lower esophageal sphincter pressure integral (LESPI) were significantly lower in Type-C than both Type-A and Type-B [AL(cm): 0.2 vs. 2(P < 0.001) vs. 1.6(P <0.001); LESP(mmHg): 20.1 vs. 32.1(P < 0.001) vs. 29.2(P < 0.001); LESPI(mmHg.cm.s): 187 vs. 412(P < 0.001) vs. 343(P < 0.05)] while overall lower esophageal sphincter length(OL) and Integrated Relaxation Pressure (IRP) were significantly lower in Type-C than Type-A [OL(cm): 2.9 vs. 3.6(P < 0.001); IRP(mmHg): 8.2 vs. 9.6(P < 0.05)]. Type-C patients had significantly higher positive pH score (>14.7) than Type-A and Type-B [72% vs. 47% (P < 0.05) vs. 41% (P < 0.001)]. In Type-C morphology, there is both anatomical and physiological deterioration, weakest lower esophageal sphincter function (abdominal length, lower esophageal sphincter pressure, and lower esophageal sphincter pressure integral) and is most likely to be associated with pathological reflux. This proposed classification incorporates both physiological and morphological derangements in a graded fashion.

High-resolution manometry findings in symptomatic post-Nissen fundoplication patients with normal endoscopic configuration.

The aim of this study was to investigate high-resolution manometry (HRM) findings in symptomatic post-fundoplication patients with normal endoscopic configuration. A retrospective review of a prospectively maintained database was conducted to identify patients who underwent evaluation with HRM and endoscopy for symptom evaluation after previous fundoplication. Study period extends from September 2008 to December 2012. Only patients with complete 360° fundoplication (Nissen) were included, and patients with partial fundoplication were excluded. Patients with endoscopic abnormality or patients who underwent Collis procedure were also excluded. Additionally, contrast study and 24-hour pH study if done were reviewed. Symptoms were graded using a standard questionnaire with symptoms graded on a scale of 0-3. Symptom grade 2 or 3 was considered a significant symptom. One hundred seventy-nine symptomatic patients with previous Nissen fundoplication underwent HRM and endoscopy during the study period. Of these, 136 patients were excluded (51 had recurrent hiatal hernia, 2 had disrupted fundoplication, 68 had slipped fundoplication, 10 had twisted fundoplication, 2 had esophageal stricture, and 3 had Collis procedure). Remaining forty-three patients met inclusion criteria (mean age of 56.0 ± 14.8, 32 females).The most common symptom was dysphagia (67%). Patients with dysphagia had a significantly longer length of distal esophageal high pressure zone (HPZ) and a higher integrated relaxation pressure (IRP) than patients without dysphagia (P = 0.020, 0.049). Especially, patients who had shorter HPZ (≤2 cm) were less likely to have significant dysphagia. Twenty-three patients (53%) had heartburn. There was no significant difference in HRM findings between patients with and without heartburn. Only 4 of 28 patients with concomitant pH study showed abnormal DeMeester score (>14.7), and there was no correlation between results of pH study and lower esophageal sphincter pressure/length and IRP. Longer HPZ complex length and higher IRP as measured with HRM is associated with post-Nissen fundoplication dysphagia in patients with normal endoscopic configuration. No HRM parameters are associated with reported heartburn or a positive pH score.

Identification and characterization of a highly pathogenic H5N1 avian influenza A virus during an outbreak in vaccinated chickens in Egypt.

Highly pathogenic avian influenza A (HPAI) H5N1 viruses continue to be a major veterinary and public health problem in Egypt. Continued surveillance of these viruses is necessary to devise strategies to control the spread of the virus and to monitor its evolutionary patterns. This is a report of the identification of a variant strain of HPAI H5N1 virus during an outbreak in 2010 in vaccinated chicken flocks in a poultry farm in Assiut, Egypt. Vaccination of chickens with an oil-emulsified inactivated A/chicken/Mexico/232/94 (H5N2) vaccine induced high levels of hemagglutination inhibition (HI) antibody titers reaching up to 9 log2. However, all flocks irrespective of the number of vaccine doses and the resultant HI titer levels came down with severe influenza infections. The qRT-PCR and rapid antigen test confirmed the influenza virus to be from H5N1 subtype. Sequencing of the hemagglutinin (HA) gene fragment from ten independent samples demonstrated that a single H5N1 strain was involved. This strain belonged to clade 2.2.1 and had several mutations in the receptor-binding site of the HA protein, thereby producing a variant strain of HPAI H5N1 virus which was antigenically different from the parent clade 2.2.1 virus circulating in Egypt at that time. In order to define the variability in HPAI H5N1 viruses over time in Egypt, we sequenced another H5N1 virus that was causing infections in chickens in 2014. Phylogenetic analysis revealed that both viruses had further distanced from the parent virus circulating during 2010. This study highlights that the antigenic mutations in HPAI H5N1 viruses represent a definitive challenge for the development of an effective vaccine for poultry. Overall, the results emphasize the need for continued surveillance of H5N1 outbreaks and extensive characterization of virus isolates from vaccinated and non-vaccinated poultry populations to better understand genetic changes and their implications.

Variation in bowel habits of healthy indian children aged up to two years.

OBJECTIVE: To study the normal bowel habits of healthy Indian children up to 2 y of age. METHODS: This cross sectional study was conducted in medical college associated teaching hospital in Delhi. Ethical clearance was obtained from Institutional Ethical Committee. A total of 500 infants and toddlers up to 2 y of age were recruited for the study. Data were collected by interviewing parents of the eligible children who came for immunisation using pre designed Performa. RESULTS: There was steady decline in stool frequency with increasing age. Maximum decline in stool frequency was noted after 1 mo of age. Variation in stool frequency between children was maximum in 0-3 mo of age and decreased with increasing age. Stools at 4 wk were usually semiliquid, watery and semisolid. By 6 mo of age 55 % infants were passing semisolid stools and 40 % were passing formed stools. At 24 mo of age, 89.2 % children usually passed formed stools. CONCLUSIONS: This is the first study in India to date documenting the frequency and consistency of the stools of young children. These results make an important contribution to defining normal stool patterns in young Indian children.

Neonatal Bartter syndrome associated with ileal atresia and cystic fibrosis.

A rare case of neonatal Bartter syndrome presenting with severe hyperkalemia is reported in a preterm child born to consanguineous parents. This child also had ileal atresia, and meconium plugs were found at laparotomy. The diagnosis of cystic fibrosis was subsequently made on genetic testing. Despite full intensive care management and surgical interventions, he died of respiratory failure after 70 days. This is the first reported case of such conglomeration of pathologies in a newborn child. Second, in highlighting this case we want clinicians to be aware that a subtype of neonatal Bartter syndrome can present with initial hyperkalemia so that an erroneous diagnosis of pseudohypoaldosteronism is not made when this is seen in combination with hyponatraemia and hyperrenin hyperaldosteronism [corrected].

Incidence of diaphragmatic hernias following minimally invasive versus open transthoracic Ivor Lewis McKeown esophagectomy.

OBJECTIVES: To compare the incidence of post-operative hiatal herniation after open and minimally invasive Ivor Lewis McKeown esophagectomy for malignant disease. METHODS: All patients undergoing esophageal resection were entered into a prospectively maintained database. After Institutional Review Board approval, the database was queried to identify patients who underwent minimally invasive (MIE) and open transthoracic (TTE) Ivor Lewis McKeown esophagectomy (transthoracic three-hole) with gastric pull-up for malignant disease. The cohorts were compared for the incidence of hiatal hernia on routine CT scan for cancer surveillance. Data up to 24 months post-operatively was included. Patients undergoing trans-hiatal or hybrid procedures as well as intra-thoracic anastomosis were excluded as were patients in whom jejunum or colon was used for reconstruction. RESULTS: Between 2003 and 2009, 19 MIEs and 20 open TTEs met the inclusion criteria. There was no significant difference in age, co-morbidity, pathology or perioperative morbidity and mortality between the two groups. During routine follow-up, para-gastric hiatal hernia was noted on CT scan in 5(26%) patients following MIE at a mean of 13.8 months postoperatively, with incidence ranging from 3 to 20 months postoperatively (19, 20, 18, 3, and 9 months, respectively). Hernia contents in these patients were omentum in one case and colon in the other four cases. None of the patients undergoing TTE were noted to have herniation (P = 0.01). All hernias were asymptomatic; three were repaired electively. CONCLUSIONS: There was a significantly higher incidence of para-gastric hiatal hernia after Ivor Lewis McKeown minimally invasive esophagectomy compared to similar open procedures. Additional precautions to prevent para-gastric hernia should be taken during laparoscopic resection.

Diffuse esophageal spasm: has the term lost its relevance? Analysis of 217 cases.

Diffuse esophageal spasm (DES) has been reported as a potential cause of dysphagia or chest pain; however, the patho-physiology of DES is unclear. The aim of this study was to examine the manometric correlates of dysphagia and chest pain in this patient population. All patients undergoing manometry at our institution are entered into a prospectively maintained database. After institutional review board approval, the database was queried to identify patients meeting criteria for DES (≥20% simultaneous waves with greater than 30 mm Hg pressure in the distal esophagus). The patient-reported symptoms and manometric data, along with the results of a 24-hour pH study (if done), were extracted for further analysis. Out of 4923 patients, 240 (4.9%) met the manometric criteria for DES. Of these, 217 patients had complete manometry data along with at least one reported symptom. Of the patients with DES, 159 (73.3%) had dysphagia or chest pain as a reported symptom. Patients reporting either dysphagia or chest pain had significantly higher lower esophageal sphincter (LES) pressure than patients without these symptoms (P= 0.007). Significant association was noted between reported dysphagia and percentage of simultaneous waves. Chest pain did not correlate with percent of simultaneous waves, mean amplitude of peristalsis, or 24-hour pH score. The origin of reported chest pain in patients with DES is not clear but may be related to higher LES pressure. Simultaneous waves were associated with reported dysphagia. Using current diagnostic criteria, the term DES has no clinical relevance.

Outcomes after repair of the intrathoracic stomach: objective follow-up of up to 5 years.

INTRODUCTION: Laparoscopic surgery is a viable treatment option for intrathoracic stomach (ITS); however, doubts have been raised regarding its efficacy. Routine use of mesh has been advocated. The aim of this study is to look at long-term objective and symptomatic outcomes after repair of ITS with selective use of mesh and fundoplication. MATERIALS AND METHODS: A retrospective review of prospectively collected data was performed for patients who underwent surgical treatment of ITS from January 2004 to April 2009. ITS was defined as herniation of greater than 75% of the stomach into the chest on barium swallow. A standardized foregut symptom questionnaire was administered along with contrast study at 1, 3, and 5 years post surgery. RESULTS: Seventy-three patients with intrathoracic stomach were included in the study. Mean age was 70.6±10.4 (44-88) years, and two-thirds were females. There were 7 transthoracic and 66 transabdominal repairs (64 laparoscopic, 1 open, and 1 laparoscopic to open conversion). There was one intraoperative death, due to bleeding. Antireflux surgery was performed in 43 patients (20 Nissen, 18 Toupet, 1 Dor, and 4 Roux-en-Y gastric bypass (RNYGB)). Ten patients had Collis gastroplasty for short esophagus. Mesh was used in ten (13.7%) patients for crus reinforcement. Objective follow-up was available for 88%, 78%, and 92% patients at 1, 3, and 5 years, respectively. There were 5% (3/61), 11% (4/36), and 17% (2/12) radiological failures at these intervals. There was no significant difference in mean symptom and satisfaction scores or use of proton pump inhibitor (PPI) between patients with and without antireflux surgery. Mean satisfaction scores were 9.1, 9.0, and 9.0 at 1, 3, and 5 years, respectively. CONCLUSION: Laparoscopic repair of ITS with selective use of mesh and fundoplication is feasible, safe, and durable, resulting in a high degree of patient satisfaction.