Novel three-dimensional acellular dermal matrix for prepectoral breast reconstruction: First year in review with BRAXON® Fast.

Implant-based breast reconstruction is part of breast cancer treatment, and increasingly optimized reconstructive procedures exploit highly biocompatible materials to ensure enhanced aesthetic-functional results. Acellular dermal matrices (ADMs) are collagen-based materials that made prepectoral implant placement possible, thanks to their bioactive antifibrosis action. Recently, the first three-dimensional ADM, BRAXON® Fast, has been produced. Its 3D design represents the technological evolution of BRAXON® ADM, a flat collagen matrix, and allows for a time-saving complete wrapping of the synthetic prosthesis, thus creating a total biological interface on the implant with patient's tissues. Here, we report our experience on the first 23 eligible patients who received BRAXON® Fast-assisted prepectoral reconstruction. On a total of 27 breasts, the overall complication rate was 11.1%, including one minor seroma (3.7%), one case of necrosis (3.7%), and one implant removal due to infection. As new-generation devices, 3D ADMs showed an effective performance, allowing to reduce the overall exposure time for implant preparation and providing an optimal safety profile.

Dermopigmentation of the nipple-areola complex in a dedicated breast cancer centre, following the Treviso Hospital (Italy) LILT model.

BACKGROUND: Dermopigmentation, also known as medical tattooing, is a complementary technique in the reconstruction of the nipple-areola and an adjuvant procedure to improve colour mismatch. In 2009, tattooing of the nipple-areola complex (NAC) was introduced by Treviso Hospital through a project conducted in cooperation with the local section of the Italian Anti-Cancer League (LILT). METHODS: From 2010 to 2016, 169 patients treated for breast cancer underwent dermopigmentation treatments. Patients were selected by the hospital plastic and breast surgeons. Dermopigmentation was performed at the LILT (Lega Italiana per la Lotta contro i Tumori, Italian Cancer League) facility following a specific procedure to ensure safety. A sterile disposable surgical set was used. RESULTS: Of 169 patients treated in 309 treatment sessions, no serious complications were reported after tattooing, with only three cases seen of minor complications. Patients expressed a high level of satisfaction (90%) with the aesthetic results. CONCLUSION: The study found that dermopigmentation of the NAC is a safe approach, providing benefits both to the patients and the hospital itself. Medical tattooing of the NAC is a simple and safe nonsurgical technique that reduces missed workdays and increases the time available for other commitments. This ultimately translates into savings for society and the healthcare system.

Interval between neoadjuvant chemoradiotherapy and surgery for squamous cell carcinoma of the thoracic esophagus: does delayed surgery have an impact on outcome?

OBJECTIVE: Aim of this study was to evaluate whether delayed surgery after neoadjuvant chemoradiotherapy (CRT) affects postoperative outcomes in patients with locally advanced squamous cell carcinoma (SCC) of the thoracic esophagus. BACKGROUND: Esophagectomy is usually recommended within 4 to 6 weeks after completion of neoadjuvant CRT. However, the optimal timing of surgery is not clearly defined. METHODS: A total of 129 consecutive patients with locally advanced esophageal cancer, treated between 1998 and 2007, were retrospectively analyzed using prospectively collected data. Patients were divided into 3 groups on the basis of timing to surgery: group 1, ≤30 days (n = 17); group 2, 31 to 60 days (n = 83); and group 3, 61 to 90 days (n = 29). Subsequently, only 2-numerically more consistent-groups were studied, using the median value of timing intervals as a cutoff level: group A, ≤46 days (n = 66); and group B, >46 days (n = 63). RESULTS: Groups were comparable in terms of patient and tumor characteristics, type of neoadjuvant regimen, toxicity, postoperative morbidity and mortality rates, tumor downstaging, and pathologic complete responses. The overall 5-year actuarial survival rate was 0% in group 1, 43.1% in group 2, and 35.9% in group 3 (P = 0.13). After R0 resection (n = 106), the 5-year actuarial survival rate was 0%, 51%, and 47.3%, respectively (P = 0.18). Tumor recurrence after R0 resection seemed to be inversely related, even if not significantly (P = 0.17), to the time interval between chemoradiation and surgery: 50% in group 1, 40.6% in group 2, and 21.7% in group 3. When considering only 2 groups, the overall 5-year survival was 33.1% in group A and 42.7% in group B (P = 0.64); after R0 resection, the 5-year survival was 37.8% and 56.3%, respectively (P = 0.18). The rate of tumor recurrence was significantly lower in group B (25%) than in group A (48.3%) (P = 0.02). CONCLUSION: Delayed surgery after neoadjuvant chemoradiation does not compromise the outcomes of patients with locally advanced SCC of the esophagus. Delaying surgery up to 90 days offers relevant advantages in the clinical management of the patients, can reduce tumor recurrences, and may improve prognosis after complete R0 resection surgery.

The preoperative manometric pattern predicts the outcome of surgical treatment for esophageal achalasia.

BACKGROUND: A new manometric classification of esophageal achalasia has recently been proposed that also suggests a correlation with the final outcome of treatment. The aim of this study was to investigate this hypothesis in a large group of achalasia patients undergoing laparoscopic Heller-Dor myotomy. METHODS: We evaluated 246 consecutive achalasia patients who underwent surgery as their first treatment from 2001 to 2009. Patients with sigmoid-shaped esophagus were excluded. Symptoms were scored and barium swallow X-ray, endoscopy, and esophageal manometry were performed before and again at 6 months after surgery. Patients were divided into three groups: (I) no distal esophageal pressurization (contraction wave amplitude <30 mmHg); (II) rapidly propagating compartmentalized pressurization (panesophageal pressurization >30 mmHg); and (III) rapidly propagating pressurization attributable to spastic contractions. Treatment failure was defined as a postoperative symptom score greater than the 10th percentile of the preoperative score (i.e., >7). RESULTS: Type III achalasia coincided with a longer overall lower esophageal sphincter (LES) length, a lower symptom score, and a smaller esophageal diameter. Treatment failure rates differed significantly in the three groups: I = 14.6% (14/96), II = 4.7% (6/127), and III = 30.4% (7/23; p = 0.0007). At univariate analysis, the manometric pattern, a low LES resting pressure, and a high chest pain score were the only factors predicting treatment failure. At multivariate analysis, the manometric pattern and a LES resting pressure <30 mmHg predicted a negative outcome. CONCLUSION: This is the first study by a surgical group to assess the outcome of surgery in 3 manometric achalasia subtypes: patients with panesophageal pressurization have the best outcome after laparoscopic Heller-Dor myotomy.

Aurora kinase A in Barrett's carcinogenesis.

In Barrett's mucosa, both aneuploidy and TP53 mutations are consistently recognized as markers of an increased risk of Barrett's adenocarcinoma. Overexpression of the mitotic kinase encoding gene (AURKA) results in chromosome instability (assessed from the micronuclei count) and ultimately in aneuploidy. Eighty-seven esophageal biopsy samples representative of all the phenotypic lesions occurring in the multistep process of Barrett's carcinogenesis (gastric metaplasia in 25, intestinal metaplasia in 25, low-grade intraepithelial neoplasia in 16, high-grade intraepithelial neoplasia in 11, and Barrett's adenocarcinoma in 10) were obtained from long segments of Barrett's mucosa. Twenty-five additional biopsy samples of native esophageal mucosa were used for control purposes. In all tissue samples, the immunohistochemical expression of both AURKA and TP53 gene products was scored; and the micronuclei index was calculated. AURKA immunostaining increased progressively and significantly along with dedifferentiation of the histologic phenotype (P < .001). Nine of 10 Barrett's adenocarcinomas showed AURKA immunostaining. AURKA expression correlated significantly with p53 expression and the micronuclei index (both Ps < .001). AURKA overexpression is significantly associated with Barrett's mucosa progressing to Barrett's adenocarcinoma and contributes to esophageal carcinogenesis via chromosome instability. The identification of AURKA as a novel molecular target of cancer progression in Barrett's mucosa provides a lead for the development of new therapeutic approaches in Barrett's mucosa patients.

Programmed cell death 4 protein in esophageal cancer.

Screening for genes down-regulated in esophageal cancers (Oncomine database) pinpointed programmed cell death 4 (PDCD4) as one of the most consistently involved. PDCD4 is a new putative tumor suppressor gene implicated in cell transformation, tumorigenesis, and invasiveness. Based on such a biological rationale, the aim of the present study was to evaluate the prognostic value of PDCD4 in esophageal cancers. The immunohistochemical expression of PDCD4 protein was assessed in 111 consecutive esophageal cancers (63 adenocarcinomas and 48 squamous cell carcinomas) and paired non-cancerous samples. PDCD4 immunostaining was significantly lower in cancer samples than in non-cancerous mucosa (p<0.001). In all cases, the native esophageal epithelium consistently expressed nuclear PDCD4, which was significantly less expressed (37/111 cases) or completely lacking (31/111 cases) in the cancer samples. A significant inverse correlation emerged between nuclear PDCD4 expression and tumor stage (p=0.002), pT (p<0.001), nodal metastasis (p=0.038), and with both vascular (p=0.005) and perineural invasion (p=0.004). Nuclear PDCD4 expression was associated with a longer disease-free (p=0.011) and overall (p=0.021) survival. PDCD4 expression predicts the patient outcome in esophageal cancers. Additional functional studies should look into the role of PDCD4 in the multistep process of esophageal oncogenesis also inquiring on the clinical usefulness of the protein expression as prognostic marker in esophageal precancerous lesions.

CDX2 hox gene product in a rat model of esophageal cancer.

BACKGROUND: Barrett's mucosa is the precursor of esophageal adenocarcinoma. The molecular mechanisms behind Barrett's carcinogenesis are largely unknown. Experimental models of longstanding esophageal reflux of duodenal-gastric contents may provide important information on the biological sequence of the Barrett's oncogenesis. METHODS: The expression of CDX2 hox-gene product was assessed in a rat model of Barrett's carcinogenesis. Seventy-four rats underwent esophago-jejunostomy with gastric preservation. Excluding perisurgical deaths, the animals were sacrificed at various times after the surgical treatment (Group A: <10 weeks; Group B: 10-30 weeks; Group C: >30 weeks). RESULTS: No Cdx2 expression was detected in either squamous epithelia of the proximal esophagus or squamous cell carcinomas. De novo Cdx2 expression was consistently documented in the proliferative zone of the squamous epithelium close to reflux ulcers (Group A: 68%; Group B: 64%; Group C: 80%), multilayered epithelium and intestinal metaplasia (Group A: 9%; Group B: 41%; Group C: 60%), and esophageal adenocarcinomas (Group B: 36%; Group C: 35%). A trend for increasing overall Cdx2 expression was documented during the course of the experiment (p = 0.001). CONCLUSION: De novo expression of Cdx2 is an early event in the spectrum of the lesions induced by experimental gastro-esophageal reflux and should be considered as a key step in the morphogenesis of esophageal adenocarcinoma.

Four hundred laparoscopic myotomies for esophageal achalasia: a single centre experience.

OBJECTIVE: Laparoscopic myotomy is the currently preferred treatment for achalasia. Our objectives were to assess the long-term outcome of this operation and preoperative factors influencing said outcome. METHODS: Demographic and clinical characteristics and data on long-term outcome were prospectively collected on patients undergoing laparoscopic myotomy for achalasia at our institution from 1992 to 2007. Treatment failure was defined as a postoperative symptom score higher than the 10th percentile of the preoperative score (>9). Logistic regression analysis was used to identify independent preoperative factors associated with successful myotomy. RESULTS: Four hundred seven consecutive patients (220 men, 187 women) underwent the laparoscopic Heller-Dor procedure during the study period; 89 (22%) of them had previously had endoscopic treatment(s). The mortality rate was 0; the conversion and morbidity rates were 1.5% and 1.9%, respectively. The operation failed in 10% of patients (39/407) and the 5-year actuarial probability of being asymptomatic was 87%. Most failures (25/39, 64%) occurred within 12 months of the operation and can be considered as technical failures (incomplete myotomy). Pneumatic dilation overcome the dysphagia in 75% of patients whose surgery was unsuccessful. Considering both the primary surgery and this ancillary treatment, the operation was effective in 97% of achalasia patients. The frequency of sigmoid esophagus, lower esophageal sphincter (LES) resting pressures, and chest pain scores differed statistically between patients with and without recurrences. At multivariate analysis, high preoperative LES pressures (>30 mm Hg) was an independent predictor of a good response. The presence of chest pain and of sigmoid esophagus independently predicted the failure of the procedure. CONCLUSION: Laparoscopic myotomy can durably relieve dysphagia symptoms. High preoperative LES pressures represent the strongest predictor of a positive outcome, probably reflecting a less severely damaged esophageal muscle.

Zenker's diverticula: feasibility of a tailored approach based on diverticulum size.

BACKGROUND: Zenker's diverticula (ZD) can be treated by transoral diverticulostomy or open surgery (upper esophageal sphincter myotomy and diverticulectomy or diverticulopexy). The aim of this study was to compare the effectiveness of a minimally invasive (group A) versus a traditional open surgical approach (group B) in the treatment of ZD. MATERIAL AND METHODS: Between 1993 and September 2007, 128 ZD patients underwent transoral diverticulostomy (n = 51) or cricopharyngeal myotomy and diverticulectomy or diverticulopexy (n = 77). All patients were evaluated for symptoms using a detailed questionnaire. Manometry recorded upper esophageal sphincter (UES) pressure, relaxations, and intrabolus pharyngeal pressure. The size of the pouch was measured on the barium swallow. The choice of treatment was based on the size of the diverticulum and the patients' preference. Long-term follow-up data were available for 121/128 (94.5%) patients with a median follow-up of 40 months (interquartile range, 17-83). RESULTS: Mortality was nil. Three patients in group A (5.8%) and ten in group B (13%) had postoperative complications (p = n.s.). Hospital stays were markedly shorter for patients after diverticulostomy (p < 0.01). Postoperative manometry showed a reduction in UES pressure, improved UES relaxation, and lower intrabolus pressure in both groups (p < 0.05). Four patients in the open surgery group (5.2%) complained of severe dysphagia after surgery (three of them required endoscopic dilations). In the transoral diverticulostomy group, 11 patients (21.5%) required additional septal reduction (n = 8) or a surgical myotomy (n = 3) for persistent symptoms (p < 0.01); nine of these 11 patients had a ZD < or = 3 cm in size. After primary and complementary treatments, symptoms disappeared or improved significantly at long-term follow-up in 93.5% of patients in group A and 96% of those in group B. CONCLUSION: Diverticulostomy is safe, quick, and effective for most patients with medium-sized ZD, but open surgery offers better long-term results as a primary treatment and should be recommended for younger, healthy patients, especially those with small diverticula. Small ZD may represent a formal contraindication to the transoral approach because an excessively short septum prevents a complete division of the sphincter fibers.

Long-term outcome of operated and unoperated epiphrenic diverticula.

INTRODUCTION: The natural history of esophageal epiphrenic diverticula (ED) is not entirely clear; the decision whether to operate or not is often based on the personal preference of the physician and patient. The aim of this study was to evaluate the long-term fate of operated and unoperated patients with ED. MATERIALS AND METHODS: Clinical, radiological, and motility findings, and operative morbidity and long-term outcome of 41 patients with ED (January 1993 to December 2005) were analyzed. All patients were reviewed at the outpatient clinic or interviewed over the phone. A symptom score was calculated using a standard questionnaire and subjective patient assessment. The radiological maximum diameter of the ED was measured. RESULTS: Twenty-two patients (12M:10F; median age, 60 years) were operated. One underwent surgery for spontaneous rupture of a large diverticulum. Operative mortality was nil; postoperative morbidity was 22.7%, the most severe complication being suture leakage (4 patients, all managed conservatively); median follow-up was 53 months. Nineteen patients (9M, 10F; median age 70 years) were not operated: 3 received pneumatic dilations; median follow-up was 46 months. None of the patients in either group died for reasons related to their ED. Symptoms decreased in all operated patients and, to a lesser extent, also in unoperated patients. ED recurrence was observed in one operated patient. Four patients had GERD symptoms with esophagitis and/or positive pH-metry after surgery and 3 patients had persistent dysphagia/regurgitation and were dissatisfied with the outcome of surgery. DISCUSSION: Surgery is an effective treatment for ED, but carries a significant morbidity related mainly to suture leakage. Even in the long-term, unoperated patients do not die of their ED, though a better subjective symptom outcome is reported by operated patients. A non-interventional policy can safely be adopted in cases of small, mildly symptomatic ED.

T cells in the myenteric plexus of achalasia patients show a skewed TCR repertoire and react to HSV-1 antigens.

OBJECTIVE: The loss of myenteric neurons in the lower esophageal sphincter (LES) characterizes achalasia, an esophageal motor disorder. Because the presence of lymphocytic infiltrates suggests an immuno-mediated mechanism ongoing at the sites of disease, we investigated the T-cell receptor (TCR) repertoire and the ability to recognize human herpes virus type 1 (HSV-1) antigens of LES-infiltrating T lymphocytes in achalasia patients. METHODS: Fifty-nine patients with idiopathic achalasia and 38 heart-beating cadaveric multiorgan donors (controls) were studied. By flow cytometry evaluation and CDR3 length spectratyping analysis, the lymphocytes of 18 patients and 15 controls were analyzed, whereas 41 patients and 23 controls were employed for functional assays. RESULTS: Achalasia patients were characterized by a significantly higher esophagus lymphocytic infiltrate than controls (24.71%+/- 3.11 and 9.54%+/- 1.34, respectively; P < 0.05), mainly represented by CD3+CD8+ T cells. The characterization of TCR beta chain repertoire of CD3+ cells showed the expression of a limited number of TCR beta variable (BV) gene families (from two to five out of 26), with highly restricted spectratypes, suggesting a disease-associated oligoclonal selection of T cells. Furthermore, lymphocytes from achalasia LES specifically responded to exposure to HSV-1 antigens in vitro as showed by increased proliferation and Th-1 type cytokines release. CONCLUSIONS: These data suggest that the oligoclonal lymphocytic infiltrate within the LES of achalasia patients may represent the trace of an immune-inflammatory reaction triggered by HSV-1 antigens and that the Th1-type cytokines released by the activated lymphocytes may contribute to establish the neuronal damage accounting for the clinical features of idiopathic achalasia.

Vagal-sparing esophagectomy: the ideal operation for intramucosal adenocarcinoma and barrett with high-grade dysplasia.

OBJECTIVE: Our aim was to compare outcome of vagal-sparing esophagectomy with transhiatal and en bloc esophagectomy in patients with intramucosal adenocarcinoma or high-grade dysplasia. SUMMARY BACKGROUND DATA: Intramucosal adenocarcinoma and high grade dysplasia have a low likelihood of lymphatic or systemic metastases and esophagectomy is curative in most patients. However, traditional esophagectomy is associated with significant morbidity and altered gastrointestinal function. A vagal-sparing esophagectomy offers the advantages of complete disease removal with the potential for reduced morbidity and a better functional outcome. METHOD: Retrospective review of outcome in patients with intramucosal adenocarcinoma or high grade dysplasia that had a vagal-sparing (n=49), transhiatal (n=39) or en bloc (n=21) esophagectomy. RESULTS: The length of hospital stay and the incidence of major complications was significantly reduced with a vagal-sparing esophagectomy compared with a transhiatal or en bloc resection. Further, postvagotomy dumping and diarrhea symptoms were significantly less common, and weight was better maintained postoperatively with a vagal-sparing esophagectomy. Recurrent cancer has developed in only 1 patient. CONCLUSION: Survival with intramucosal adenocarcinoma or Barrett's with high-grade dysplasia is independent of the type of resection. A vagal-sparing esophagectomy is associated with significantly less perioperative morbidity and a shorter hospital stay than a transhiatal or en bloc esophagectomy. Further, late morbidity including weight loss, dumping, and diarrhea are significantly less likely after a vagal-sparing approach. Consequently a vagal-sparing esophagectomy is the preferred procedure for patients with intramucosal adenocarcinoma or high grade dysplasia.

Long-term results (6-10 years) of laparoscopic fundoplication.

Most papers report excellent results of laparoscopic fundoplication but with relatively short follow-up. Only few studies have a follow-up longer than 5 years. We prospectively collected data of 399 consecutive patients with gastroesophageal reflux disease (GERD) or large paraesophageal/mixed hiatal hernia who underwent laparoscopic fundoplication between January 1992 and June 2005. Preoperative workup included symptoms questionnaire, videoesophagogram, upper endoscopy, manometry, and pH-metry. Postoperative clinical/functional studies were performed at 1, 6, 12 months, and thereafter every other year. Patients were divided into four groups: GERD with nonerosive esophagitis, erosive esophagitis, Barrett's esophagus, and large paraesophageal/mixed hiatal hernia. Surgical failures were considered as follows: (1) recurrence of GERD symptoms or abnormal 24-h pH monitoring; (2) recurrence of endoscopic esophagitis; (3) recurrence of hiatal hernia/slipped fundoplication on endoscopy/barium swallow; (4) postoperative onset of dysphagia; (5) postoperative onset of gas bloating. One hundred and forty-five patients (87 M:58 F) were operated between January 1992 and June 1999: 80 nonerosive esophagitis, 29 erosive esophagitis, 17 Barrett's esophagus, and 19 large paraesophageal/mixed hiatal hernias. At a median follow-up of 97 months, the success rate was 74% for surgery only and 86% for primary surgery and 'complementary' treatments (21 patients: 13 redo surgery and eight endoscopic dilations). Dysphagia and recurrence of reflux were the most frequent causes of failure for nonerosive esophagitis patients; recurrence of hernia was prevalent among patients with large paraesophageal/mixed hiatal hernia. Gas bloating (causing failure) was reported by nonerosive esophagitis patients only. At last follow-up, 115 patients were off 'proton-pump inhibitors'; 30 were still on medications (eight for causes unrelated to GERD). Conclusion confirms that laparoscopic fundoplication provides effective, long-term treatment of gastroesophageal reflux disease. Hernia recurrence and dysphagia are its weak points.

Surgical options and outcomes in Barrett's esophagus.

PURPOSE OF REVIEW: Barrett's esophagus is a complication of chronic gastroesophageal reflux that results in the replacement of normal stratified squamous epithelium in the distal esophagus by metaplastic columnar mucosa and it carries a 30-fold to 125-fold risk of progression to esophageal adenocarcinoma. RECENT FINDINGS: Laparoscopic antireflux surgery has proved durable and effective in treating reflux and reflux-related symptoms in patients with Barrett's esophagus. Recent studies have also focused on the histological changes induced in Barrett's epithelium by antireflux surgery. This article reviews the current literature, analysing the impact of antireflux surgery on both the clinical and the histopathological outcomes. SUMMARY: Recent studies have disproved the widely held assumption that, once established, Barrett's esophagus does not change. Antireflux surgery can achieve a regression of intestinal metaplasia to cardiac mucosa in patients with Barrett's esophagus and may thus alter the natural history of the disease.

Clinical biology and surgical therapy of intramucosal adenocarcinoma of the esophagus.

BACKGROUND: Mucosal ablation and endoscopic mucosal resection have been proposed as alternatives to surgical resection as therapy for intramucosal adenocarcinoma (IMC) of the esophagus. Acceptance of these alternative therapies requires an understanding of the clinical biology of IMC and the results of surgical resection modified for treatment of early disease. STUDY DESIGN: Retrospective review of 78 patients (65 men, 13 women; median age 66 years) with IMC who were treated with progressively less-extensive surgical resections (ie, en bloc, transhiatal, and vagal-sparing esophagectomy) from 1987 to 2005. RESULTS: The tumor was located in a visible segment of Barrett's esophagus in 65 (83%) and in cardia intestinal metaplasia in 13 (17%). A visible lesion was present in 53 (68%) and in all but 4 the lesion was cancer. In those patients with visible Barrett's, the tumor was within 3 cm of the gastroesophageal junction in 66% and within 1 cm in 37%. Esophagectomy was en bloc in 23, transhiatal in 31, vagal-sparing in 20, and transthoracic in 4. Operative mortality was 2.6%. Vagal-sparing esophagectomy had less morbidity, a shorter hospital stay, and no mortality. Of the patients who had en bloc resection, a median of 41 nodes were removed. One patient had one lymph node metastasis on hematoxylin and eosin staining and two others, normal on hematoxylin and eosin staining, had micrometastases on immunohistochemistry. Actuarial survival at 5 years was 88% and was similar for all types of resections. Two patients died from systemic metastases and seven from noncancer causes. CONCLUSIONS: IMC occurred in cardia intestinal metaplasia and in Barrett's esophagus. Two-thirds of patients with IMC had a visible lesion. Most tumors occurred near the gastroesophageal junction. Node metastases were uncommon, questioning the need for lymphadenectomy. A vagal-sparing technique had less morbidity than other forms of resection and no mortality. Survival after all types of resection was similar. Outcomes of endoscopic techniques should be compared with this benchmark.

Barrett's epithelium after antireflux surgery.

Barrett's epithelium (BE), defined as endoscopically visible, histologically proved intestinal-type epithelium in the esophagus, is considered the ultimate consequence of long-standing gastro(duodeno)esophageal reflux disease (GERD). Recent reports suggest that effective antireflux therapy may promote the regression of this metaplastic process. This study aimed to establish whether antireflux surgery (laparoscopic fundoplication) can induce any endoscopic and/or histologic changes in BE. Thirty-five consecutive cases of BE (11 short-segment [SBE] and 24 long-segment [LBE]) were considered. All patients underwent extensive biopsy sampling before and after surgery (mean follow-up, 28 months; range, 12-99 mo). In all cases, (a) intestinal metaplasia (IM) extension (H&E), (b) IM phenotype (high-iron diamine [HID]), and (c) Cdx2 immunohistochemical expression were histologically scored in the biopsy material obtained before and after fundoplication. After surgery, a significant decrease in IM extension and a shift from incomplete- to complete-type IM were documented in SBE. No significant changes occurred in the LBE group in terms of IM extension or histochemical phenotype. A drop in the immunohistochemical expression of Cdx2 protein was also only documented in the SBE group. Antireflux surgery significantly modifies the histologic phenotype of SBE, but not of LBE.

Long-term outcome of laparoscopic Heller-Dor surgery for esophageal achalasia: possible detrimental role of previous endoscopic treatment.

Laparoscopic Heller myotomy has recently emerged as the treatment of choice for esophageal achalasia. Previous unsuccessful treatments (pneumatic dilations or botulinum toxin [BT] injections) can make surgery more difficult, causing a higher risk of mucosal perforation and jeopardizing the outcome. The study goal was to evaluate the effects of prior endoscopic treatments on laparoscopic Heller myotomy. Between January 1992 and February 2005, 248 patients (130 males and 118 females; median age, 43 years) underwent a laparoscopic Heller-Dor operation for achalasia: 203 underwent primary surgery (group A), 19 had been previously treated with pneumatic dilations (group B), and 26 had BT injections (alone [22] or with dilations [4] (group C)). Median duration of the operation and rate of intraoperative mucosal lesions were not different in the three groups. Median follow-up was 41 months. The 5-year actuarial of control of dysphagia was similar in groups A (86%) and B (94%), whereas only 75% of group C patients were symptom free at 5 years (P = 0.02). On logistic regression analysis, prior treatment with two BT injections or BT combined with dilation was associated with poor outcome of surgery. Further, dilations for surgical failure patients were effective in 80% of group A but in only 33% of group B or C patients. Heller-Dor surgery is safe and effective as a primary or a second-line treatment (after pneumatic dilations or BT injections) for achalasia. However, long-term results seem less satisfactory in patients previously treated with BT.

The role of botulinum toxin injection and upper esophageal sphincter myotomy in treating oropharyngeal dysphagia.

The aims of this study were to assess the efficacy and safety of botulinum toxin (BoTox) injection in the cricopharyngeus muscle (CP) and CP myotomy in patients with oropharyngeal dysphagia (OPD) and to identify factors predicting the outcome of these treatments. The study involved patients with persistent OPD despite 2-6 months of rehabilitation, who all underwent clinical evaluation, esophageal manometry, upper gastrointestinal endoscopy, and videofluoroscopy (VFS). Patients received 5-10 BoTox units injections in the CP, identified by electromyography. Surgical myotomy of the upper esophageal sphincter was performed when dysphagia persisted after two BoTox injections. After treatment, patients were reevaluated with clinical interviews and VFS. The study population included 21 patients (15 mean and 6 women; median age, 68 years), classified into three groups, based on the etiology of their OPD: eight (38%) had central nervous system abnormalities, five (24%) had peripheral nerve disease, and eight (38%) were classified as idiopathic. The median time since the onset of dysphagia was 18 months. Thirteen of 21 patients (62%) needed supplemental/total gastrostomy feeding, and 5 of 21 (24%) had tracheostomy. One patient died, on posttreatment day 7, due to massive aspiration. No other BoTox-related complications were observed. After BoTox injection, dysphagia improved in 9 of 21 (43%) patients. Severely altered VFS findings and CP incoordination or low activity predicted BoTox failure at multivariate analysis. Dysphagia improved in 8 of 11 (72.7%) patients who failed to respond to BoTox and underwent myotomy. A mild impairment of VFS findings and a higher pressure of pharyngeal contractions best predicted response to BoTox with or without myotomy. BoTox injection can be used as the first therapeutic option in patients with OPD: it is safe and simple and relieves dysphagia in 43% of cases. If BoTox fails, CP myotomy can be offered to patients with preserved oral and tongue activity at VFS and an intact bolus propulsion ability on manometry.

Oesophageal diverticula.

Oesophageal diverticula are rare. They are most commonly seen at the pharyngo-oesophageal junction (Zenker's diverticula) or at the distal oesophagus (epiphrenic diverticula). In both cases they are caused by altered motility which results in abnormal intraluminal pressure and the pushing of the oesophageal mucosa through focal weaknesses of the muscular wall (pulsion diverticula). The established surgical treatment for these diverticula therefore consists of eliminating the functional obstruction causing the disease (myotomy), associated with resection of the diverticulum (diverticulectomy) or its suspension (diverticulopexy). Recently, the spread of minimally invasive surgery has also led the application of such techniques to the treatment of oesophageal diverticula. Endoscopic diverticulostomy with stapler, laser or coagulation, through a rigid or flexible endoscope, has been demonstrated to be a valid treatment for Zenker's diverticula-as an alternative to surgery-especially in high-risk patients. On the other hand, laparoscopic treatment of epiphrenic diverticula has recently been introduced with encouraging results. However, because the disease is rare, more experience is required in order to allow definitive conclusions.

Acalasia: estrategias terapéuticas / Achalasia: estrategias terapéuticas

La acalasia es debida a la destrucción irreversible de las neuronas del plexo mientérico del esófago, que causa aperistalsis y falta de relajación del esfínter esofágico inferior (EEI). La consecuencia de ello es la parada del bolo alimentario en el cardias y la aparición de disfagia. Actualmente, el tratamiento de la acalasia es paliativa y se basa en la parálisis o destrucción (química, farmacología o física) de las fibras musculares del esfínter esofágico inferior. Dada la rareza de la acalasia, existen pocos estudios clínicos aleatorizados sobre los que basar un esquema terapéutico: la terapia farmacológica y la inyección de toxina botulínica desempeñan un papel marginal, como puente de espera a un tratamiento más eficaz. Las 2 terapias más eficaces continúan siendo la miotomía quirúrgica y la dilatación neumática: existe únicamente un estudio clínico aleatorizado realizado hace 13 años que confronta ambos tratamientos. El estudio demostró que la cirugía era más eficaz (un 95 por ciento de éxito a los 5 años frente al 51 por ciento de la dilatación; p < 0,01), pero la invasividad del método, el coste más elevado y los defectos metodológicos del estudio citado favorecieron la dilatación neumática en la práctica clínica. La introducción de la miotomía laparoscópica ha reducido significativamente la invasividad del procedimiento y ha reducido el coste, por lo que se ha convertido en muchos centros en la opción terapéutica de elección. Es el momento en que, de forma común, los gastroenterólogos y los cirujanos planifiquen un nuevo estudio clínico aleatorizado que confronte los dos métodos más usados en la actualidad en el tratamiento de la acalasia (dilatación y miotomía laparoscópica) para conocer la mejor opción terapéutica basada en argumentos científicos (AU)