Background A circular muscle myotomy preserving the longitudinal outer esophageal muscular layer is often recommended during peroral endoscopic myotomy (POEM) for achalasia. However, because the ...longitudinal muscle fibers of the esophagus are extremely thin and fragile, and completeness of myotomy is the basis for the excellent results of conventional surgical myotomy, this modification needs to be further debated. Here, we retrospectively analyzed our prospectively maintained POEM database to compare the outcomes of endoscopic full-thickness and circular muscle myotomy. Study Design According to the myotomy depth, 103 patients with full-thickness myotomy were assigned to group A, while 131 patients with circular muscle myotomy were assigned to group B. Symptom relief, procedure-related parameters and adverse events, manometry outcomes, and reflux complications were compared between groups. Results The mean operation times were significantly shorter in group A compared with group B (p = 0.02). There was no increase in any procedure-related adverse event after full-thickness myotomy (all p < 0.05). During follow-up, treatment success (Eckardt score ≤ 3) persisted for 96.0% (95 of 99) of patients in group A and for 95.0% (115 of 121) of patients in group B (p = 0.75). There were no statistically significant differences in pre- and post-treatment D-value of symptom scores and lower esophageal sphincter pressures between groups (both p > 0.05). The overall clinical reflux complication rates were also similar (21.2% vs 16.5%, p = 0.38). Conclusions Short-term symptom relief and manometry outcomes of each method were comparable. Full-thickness myotomy significantly reduced the procedure time but did not increase the procedure-related adverse events or clinical reflux complications.
Background Given the high morbidity and mortality rates for surgery and the diminishment of quality of life caused by operative resection of the gastric cardia, a minor invasive treatment without ...loss of curability is desirable for submucosal tumors (SMTs) of the esophagogastric junction (EGJ). Endoscopic submucosal dissection (ESD) has been used successfully for the removal of esophageal or gastric SMTs; however, the EGJ has been regarded as a difficult location for ESD because of its narrow lumen and sharp angle. Objective To evaluate the clinical impact of ESD for SMTs of the EGJ arising from the muscularis propria layer. Design Single-center, prospective study. Setting Academic medical center. Patients 143 patients with 143 SMTs of the EGJ originating from the muscularis propria layer. Interventions ESD. Main Outcome Measurements Complications, en bloc resection rate, local recurrence, and distant metastases. Results The average maximum diameter of the lesions was 17.6 mm (range 5 - 50 mm). The en bloc resection rate was 94.4% (135/143). All en bloc resection lesions showed both lateral and deep tumor-free margins, including 20 GI stromal tumors. Perforations occurred in 6 patients (4.2%, 6/143), and metal clips were used to occlude the defect. Four pneumoperitoneum and 2 pneumothorax caused by perforations were resolved with nonsurgical treatment. Local recurrence and distant metastasis have not occurred during a 2-year follow-up. Limitations Single-center, short follow-up. Conclusions ESD appears to be a safe, feasible, and effective procedure for providing accurate histopathologic evaluations, as well as curative treatments for SMTs of the EGJ originating from the muscularis propria layer.
Background Peroral endoscopic myotomy (POEM) has been developed to provide a less-invasive myotomy for achalasia in adults but seldom has been used in pediatric patients. Objective To evaluate the ...feasibility, safety, and efficacy of POEM for pediatric patients with achalasia. Design Single-center, prospective study. Setting Academic medical center. Patients A total of 27 pediatric patients (mean age 13.8 years, range 6-17 years) with achalasia. Interventions POEM. Main Outcome Measurements The primary outcome was symptom relief during follow-up, defined as an Eckardt score of ≤3. Secondary outcomes were procedure-related adverse events, clinical reflux adverse events, and lower esophageal sphincter (LES) pressure on manometry before and after POEM. Results A total of 26 cases (96.3%) underwent successful POEM. A submucosal tunnelling attempt failed in 1 case because of serious inflammation and adhesion. No serious adverse events related to POEM were encountered. During a mean follow-up period of 24.6 months (range 15-38 months), treatment success was achieved in all patients (mean score before vs after treatment 8.3 vs 0.7; P < .001). Mean LES pressure also decreased from a mean of 31.6 mm Hg to 12.9 mm Hg after POEM ( P < .001). Five patients developed clinical reflux adverse events (19.2%). Limitations Single center and lack of some objective evaluations. Conclusion This relatively long-term follow-up study adds to the evidence that POEM seems to be a promising new treatment for pediatric patients with achalasia, resulting in long-term symptom relief in all cases and without serious adverse events.
Purpose The vascularized free fibula flap has become the most popular reconstruction method after mandibular resection because of adequate bone graft length and acceptance of dental implants. ...However, using 1 fibula bone may produce a height discrepancy between the native mandible and the grafted fibula that results in subsequent difficulty in wearing conventional dentures or osseointegrated implants. Several options can be used to resolve this problem such as delayed onlay bone graft, iliac bone reconstruction, fibula distraction, and double-barrel fibula flap graft. This article describes the reconstruction of segmental mandible defects with the double-barrel fibula flap and denture rehabilitation. Materials and Methods This procedure was used in 7 patients. A donor site fibula corresponding to at least twice the length of the mandibular defect was harvested. Double-barrel free fibula grafting was performed in 6 patients for primary reconstruction and 1 patient for secondary reconstruction, including 3 cases of osteocutaneous flap with skin islands in the reconstruction of a composite defect from a malignant tumor. Prosthodontic treatment was completed in all 7 patients. Four patients received secondary implant-supported dental reconstruction, and 3 patients who received radiation (6,000 cGy) after graft surgery had conventional removable partial dentures. Results Microvascular fibula transfers were completely successful, and all skin paddles survived without necrosis. The original mandibular contour was maintained by a reconstruction plate; the reconstruction mandibular length was 6.5 to 10 cm, the reconstruction height of the double-barrel fibula was 3.0 to 3.8 cm, and all patients were satisfied with the postoperative facial esthetics and chewing function from the implant-supported denture and removable partial prostheses. Conclusions Mandibular segmental defects can be esthetically and functionally reconstructed by a double-barrel vascularized fibula flap that not only matches the height of the native mandible but also allows osteointegrated dental implantation for dental rehabilitation.
Introduction
We aim to explore the risk factors for in-hospital mortality and to derive a prognostic model for patients with APE in China.
Materials and methods
Inpatients with APE were enrolled from ...West China Hospital between January 2016 and December 2019. Logistic regression analyses were used to explore risk factors for in-hospital mortality and develop a prognostic model.
Results
A total of 813 subjects with APE were included in this study, of whom 542 were in the training set and 271 were in the test set. Multivariable regression analyses indicated that age, male, heart rate, systolic blood pressure, elevated NT-proBNP or troponin T, malignancy, chronic renal insufficiency, and respiratory failure were independent risk factors for in-hospital mortality. For the training set, the area under the curve (AUC) of the ROC curve was 0.899, with a sensitivity and specificity of 89.7% and 77.7%, respectively. The model had higher prediction accuracy than the PESI and sPESI.
Conclusions
The prediction model has proven excellent discrimination and calibration, which may be a useful tool to help physicians make decisions regarding the best treatment strategy.
Objective Our aim was to test whether a unidirectional valve patch would provide benefit to early and long-term survival for patients with ventricular septal defect and severe pulmonary artery ...hypertension. Methods Eight hundred seventy-six cases of ventricular septal defect with severe pulmonary artery hypertension were closed with or without a unidirectional valve patch and were classified as the unidirectional valve patch (UVP) group (n = 195) and nonvalve patch (NVP) group (n = 681), respectively. Propensity scores of inclusion into the UVP group were used to match 138 pairs between the 2 groups. Kaplan–Meier survival curves were constructed to compare early and long-term survival. Results For the 138 propensity-matched pairs, there were 7 and 9 early deaths (in-hospital deaths) in the UVP and NVP groups, respectively. The difference in early mortality between the 2 groups did not reach statistical significance (χ2 = 0.265, P = .6064). With a mean of 9.2 ± 4.92 years' and 2511 patient-years' follow-up, there were 6 late deaths in the UVP group and 7 late deaths in the NVP group. The difference in actuarial survival at 5, 10, 15, and 18 years between the 2 groups was not significant (log-rank test, χ2 = 0.565, P = .331). The difference in the late mortality between the groups with or without a patent patch at the time of discharge did not reach statistical significance (χ2 = 1.140, P = .2856). There was no difference between the 2 groups in the 6-minute walk distance assessed at the last follow-up (525.9 ± 88.0 meters for the UVP group and 536.5 ± 95.8 meters for the NVP group, F = 1.550, P = .214). Conclusion A unidirectional valve patch provides no benefits to early and long-term survival when it is used to deal with ventricular septal defect and severe pulmonary artery hypertension.
Background During the last few years, prone thoracoscopic esophagectomy has been increasingly adopted for thoracolaparoscopic esophagectomy (TLE). However, evidence for the prone position (PP) over ...the decubitus position (DP) during TLE is currently not strong enough to reach conclusions. Study Design From May 2009 to December 2010, we conducted thoracoscopic esophagectomies in the DP and then PP on consecutive patients admitted to our institution. TLE in DP was conducted from May 2009 to February 2010 and in PP from March 2010 to December 2010. Clinical features and operation characteristics of all patients were collected and compared to determine differences between the 2 groups. Results A total of 93 consecutive esophageal cancer patients were enrolled; Forty-one had their operations in DP and 52 in PP. There was no significant difference found between the 2 groups in age, sex, body mass index, tumor location, histological type, and TNM stage. When compared with DP, thoracoscopic esophagectomy in PP had a shorter operation duration (67 vs 77 minutes; p = 0.013), horter overall hospital stay (17.4 vs 11.4 days; p = 0.011), and yielded a larger number of lymph nodes (11.6 ± 4.0 vs 8.9 ± 4.9 on average; p = 0.005). Complication rates were similar between the 2 groups, with anastomotic leak developing in a significantly smaller number of patients in PP (7.7% vs 22.0%; p = 0.049). Conclusions TLE in the PP is a feasible and safe alternative to DP and is potentially associated with fewer complications. Additional randomized studies are required to discuss the long-term prognostic value of this procedure.
Hypothesis The biomechanical effects of placing a portal through the subscapularis tendon have not been studied. Our hypothesis is that placing a portal through the subscapularis tendon will affect ...the strain properties of the tendon. Materials and methods Eight shoulders from deceased donors were dissected to expose the subscapularis musculotendinous unit. The subscapularis muscle was isolated, the arm was locked at neutral (0° abduction, 0° flexion/extension, 0° external rotation/internal rotation), and 3 cables were sutured to the subscapularis musculotendinous junction. Each cable was connected to a static weight. Three differential variable reluctance transducers (DVRTs) from Microstrain were sutured into the subscapularis tendon—superior, inferior, and in line with the proposed 5 o’clock portal. The musculotendinous unit was loaded along its line of action with 3, 9, and then 15 kg. Strain at each DVRT was measured in the native subscapularis tendon at each load level. The same strain measurement was taken after placing and removing a 5-mm suture anchor through the 5 o’clock portal and in the tendon after placing and removing an 8-mm cannula. Results Penetrating the subscapularis tendon with either a 5-mm suture anchor or an 8-mm cannula does not produce any statistically significant change in strain compared with the native tendon. Conclusion Placing an anchor, or even an 8-mm cannulated portal, does not significantly alter the strain properties of the subscapularis tendon. This lack of effect on the strain characteristics of the subscapularis does not preclude the possibility of clinical effects.
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