Pilot studies have indicated that peroral endoscopic myotomy (POEM) might be a safe and effective treatment for achalasia. We performed a prospective, international, multicenter study to determine ...the outcomes of 70 patients who underwent POEM at 5 centers in Europe and North America. Three months after POEM, 97% of patients were in symptom remission (95% confidence interval, 89%–99%); symptom scores were reduced from 7 to 1 ( P < .001) and lower esophageal sphincter pressures were reduced from 28 to 9 mm Hg ( P < .001). The percentage of patients in symptom remission at 6 and 12 months was 89% and 82%, respectively. POEM was found to be an effective treatment for achalasia after a mean follow-up period of 10 months. Clinical Trials Gov Registration number: NCT01405417.
Introduction
Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are commonly performed bariatric procedures in obesity management. Gastroesophageal reflux disease ...(GERD) in this population has reported rates of 23–100%. GERD after LSG has been noted with recent studies demonstrating de novo reflux or symptom exacerbation despite weight loss. Fundoplication is not an option, and medically refractory GERD after LSG is usually treated with conversion to RYGB. GERD post-RYGB is a unique entity, and management poses a clinical and technical challenge. We evaluate safety and effectiveness of magnetic sphincter augmentation after bariatric surgery.
Materials and methods
A retrospective review of a prospectively maintained database was performed identifying patients that underwent LINX placement for refractory GERD after LSG, LRYGB, or duodenal switch across three institutions. Outcomes included complications, length of stay, PPI use, GERD-HRQL scores, and patient overall satisfaction.
Results
From March 2014 through June 2018, 13 identified patients underwent LINX placement after bariatric surgery: 8 LSG, 4 LRYGB, and 1 duodenal switch. The patients were 77% female, with mean age 43 and average BMI 30.1. Average pre-operative DeMeester score was 24.8. Pre-operatively, 5 patients were on daily PPI, 6 on BID PPI, and 1 on PPI + H2 blocker. We noted decreased medication usage post-operatively, with 4 patients taking daily PPI, and 9 off medication completely. A GERD-HRQL score was obtained pre- and post-operatively in 6 patients with average reduction from 25 to 8.5 (
p
value 0.002). Two patients experienced complications requiring endoscopic dilation after LINX placement. 100% of patients reported overall satisfaction post procedure.
Conclusion
LINX placement is a safe, effective treatment option for surgical management of refractory GERD after bariatric surgery. It can relieve symptoms and obviate the requirement of high-dose medical management. Magnetic lower esophageal sphincter augmentation should be another tool in the surgeon’s toolbox for managing reflux after bariatric surgery in select patients.
Endoscopic balloon dilatation and laparoscopic myotomy are established treatments for achalasia. Recently, a new endoscopic technique for complete myotomy was described. Herein, we report the results ...of the first prospective trial of peroral endoscopic myotomy (POEM) in Europe.
POEM was performed under general anesthesia in 16 patients (male:female (12:4), mean age 45 years, range 26-76). The primary outcome was symptom relief at 3 months, defined as an Eckhard score ≤3. Secondary outcomes were procedure-related adverse events, lower esophageal sphincter (LES) pressure on manometry, reflux symptoms, and medication use before and after POEM.
A 3-month follow-up was completed for all patients. Treatment success (Eckhard score ≤3) was achieved in 94% of cases (mean score pre- vs. post-treatment (8.8 vs. 1.4); P<0.001). Mean LES pressure was 27.2 mm Hg pre-treatment and 11.8 mm Hg post-treatment (P<0.001). No patient developed symptoms of gastro-esophageal reflux after treatment, but one patient was found to have an erosive lesion (LA grade A) on follow-up esophagogastroduodenoscopy. No patient required medication with proton pump inhibitors or antacids after POEM.
POEM is a promising new treatment for achalasia resulting in short-term symptom relief in >90% of cases. Studies evaluating long-term efficacy and comparing POEM with established treatments have been initiated.
Historical data indicate that surgical resection may benefit select patients with metastatic gastric and gastroesophageal junction cancer. However, randomized clinical trials are lacking. The current ...RENAISSANCE trial addresses the potential benefits of surgical intervention in gastric and gastroesophageal junction cancer with limited metastases.
This is a prospective, multicenter, randomized, investigator-initiated phase III trial. Previously untreated patients with limited metastatic stage (retroperitoneal lymph node metastases only or a maximum of one incurable organ site that is potentially resectable or locally controllable with or without retroperitoneal lymph nodes) receive 4 cycles of FLOT chemotherapy alone or with trastuzumab if Her2+. Patients without disease progression after 4 cycles are randomized 1:1 to receive additional chemotherapy cycles or surgical resection of primary and metastases followed by subsequent chemotherapy. 271 patients are to be allocated to the trial, of which at least 176 patients will proceed to randomization. The primary endpoint is overall survival; main secondary endpoints are quality of life assessed by EORTC-QLQ-C30 questionnaire, progression free survival and surgical morbidity and mortality. Recruitment has already started; currently (Feb 2017) 22 patients have been enrolled.
If the RENAISSANCE concept proves to be effective, this could potentially lead to a new standard of therapy. On the contrary, if the outcome is negative, patients with gastric or GEJ cancer and metastases will no longer be considered candidates for surgical intervention.
The article reports of a health care intervention on human participants and is registered on October 12, 2015 under ClinicalTrials.gov Identifier: NCT02578368 ; EudraCT: 2014-002665-30.
Introduction
The advent of peroral endoscopic myotomy (POEM) shed some light on the role of the current standards in the treatment of idiopathic achalasia, namely endoscopic pneumatic dilatation (PD) ...and laparoscopic Heller myotomy (LHM). We analyzed the quality of the current evidence comparing LHM and PD.
Methods
A systematic literature search was performed in Pubmed/Medline, Web of Science, Google Scholar and Cochrane for meta-analyses/systematic reviews comparing PD and LHM or open surgery, limited to English language full-text articles. After a detailed review of these meta-analyses, all studies included were analyzed further in depth with respect to treatment protocol, assessment of success, complications and sequelae such as gastroesophageal reflux (GER), as well as follow-up details.
Results
Six randomized controlled trials (RCT), 5 with LHM and 1 with open surgery, were found, published in 10 papers. In contrast to a rather homogeneous LHM technique, PD regimens as well as the clinical dysphagia scores were different in every RCT; most RCTs also showed methodological limitations. There were nine meta-analyses which included a variable number of these RCTs or other cohort studies. Meta-analyses between 2009 and 2013 favored surgery, while the 4 most recent ones reached divergent conclusions. The main difference might have been whether repeated dilatation was regarded as part of the PD protocol or as failure.
Conclusions
The variability in PD techniques and in definition of clinical success utilized in the achalasia RCTs on PD versus LHM render the conclusions of meta-analyses unreliable. Further randomized studies should be based on uniform criteria; in the meantime, publication of even more meta-analyses should be avoided.
Background
Transanal hybrid rectal and colon resection have been introduced in recent years at dedicated surgical centers. The anus is used as a natural orifice for large size access. The use of ...transanal hybrid colectomy techniques is still in its infancy with outcomes and unique complications being identified. The purpose of this work is the evaluation of outcomes for transanal hybrid colon resections (ta-CR), including intra operative and postoperative complications, results, and advantages.
Methods
A prospectively maintained database was analyzed. Inclusion criteria were any patient who underwent ta-CR for rectal prolapse, slow transit, obstructive defaecation, and chronic sigmoid diverticulitis. Patients were excluded from ta-CR if BMI > 30, major previous abdominal surgery, or presence of a large inflammatory mass in diverticulitis. Transanal access was used for all operative steps requiring access of more than 5 mm, such as staplers, large graspers, and specimen retrieval. Data acquisition and analysis was performed for operative time, complications, and postoperative quality of life.
Results
From 2012 to 2017, 82 patients underwent ta-CR 33 males, 49 females, median age 58 (24–80). Transanal-subtotal colectomy and ta-CR for constipation was performed in 12 patients; ta-CR and rectopexy in 31, and ta-CR for diverticulitis was performed in 39 patients. Conversion to traditional approach was required in 3 cases (3.6%). Intraoperative complication included 1 rectal tear requiring intervention. Post-op complications included 3 leaks requiring laparoscopic and 1 open revision, the latter developed wound infection and an incisional hernia. Gastrointestinal Quality of Life Index (GIQLI) improved significantly from preoperative 89 to postoperative 119 (
p
< 0.001). No patients with ta-CR without open revision developed a hernia post-op with median 18 months follow-up.
Conclusions
ta-CR is a safe and effective NOTES Hybrid technique for colorectal procedures in selected patients with benign colon disorders. GIQLI shows improvement and this technique can have the potential in preventing wound and hernia complications.
Zur Behandlung der gastroösophagealen Refluxkrankheit (GERD) stehen sehr effektive, lang bewährte Medikamente und konservative Maßnahmen sowie eine Reihe guter chirurgischer Therapiemöglichkeiten zur ...Verfügung. Doch welche Strategien gibt es bei der konservativen Behandlung? Wieviel Diagnostik ist sinnvoll oder gar notwendig vor einer differenzierten Therapieentscheidung? Wann ist die chirurgische Behandlung indiziert und welches Verfahren sollte wann gewählt werden? Dieses Buch bietet gezielt Hilfestellung für eine umfassende Diagnostik, ein differenziertes Vorgehen bei der Indikationsstellung, die Verfahrenswahl und das adäquate operative Vorgehen. Neben der detaillierten Darstellung der operativen Standardtherapie (laparoskopische Fundoplikatio) bietet das Buch eine kritische Auseinandersetzung zu den Fragen: Voll- oder Teilmanschette? Netz - ja oder nein? LINX- oder Endostim-Implantat? Wann ist eine Revision nötig und mit welchem Verfahren? Abgerundet wird das Buch durch Kapitel zur Pathophysiologie und Definition der Erkrankung, zur konservativen und medikamentösen Therapie und zur Diagnostik der Krankheit und einer differenzierten Analyse der assoziierten Symptomatik und überlagernden Entitäten.
Introduction
Chronic anemia is a common, coinciding or presenting diagnosis in patients with paraesophageal hernia (PEH). Presence of endoscopically identified ulcerations frequently prompts surgical ...consultation in the otherwise asymptomatic patient with anemia. Rates of anemia resolution following paraesophageal hernia repair (PEHR) often exceed the prevalence of such lesions in the study population. A defined algorithm remains elusive. This study aims to characterize resolution of anemia after PEHR with respect to endoscopic diagnosis.
Materials and methods
Retrospective review of a prospectively maintained database of patients with PEH and anemia undergoing PEHR from 2007 to 2018 was performed. Anemia was determined by preoperative labs: Hgb < 12 mg/dl in females, Hgb < 13 mg/dl in males, or patients with ongoing iron supplementation. Improvement of post-operative anemia was assessed by post-operative hemoglobin values and continued necessity of iron supplementation.
Results
Among 56 identified patients, 45 were female (80.4%). Forty patients (71.4%) were anemic by hemoglobin value, 16 patients (28.6%) required iron supplementation. Mean age was 65.1 years, with mean BMI of 27.7 kg/m
2
. One case was a Type IV PEH and the rest Type III. 32 (64.0%) had potential source of anemia: 16 (32.0%) Cameron lesions, 6 (12.0%) gastric ulcers, 12 (24.0%) gastritis. 10 (20.0%) had esophagitis and 4 (8%) Barrett’s esophagus. 18 (36%) PEH patients had normal preoperative EGD. Median follow-up was 160 days. Anemia resolution occurred in 46.4% of patients. Of the 16 patients with pre-procedure Cameron lesions, 10 (63%) had resolution of anemia. Patients with esophagitis did not achieve resolution. 72.2% (13/18) of patients with no lesions on EGD had anemia resolution (
p
= 0.03).
Conclusion
Patients with PEH and identifiable ulcerations showed 50% resolution of anemia after hernia repair. Patients without identifiable lesions on endoscopy demonstrated statistically significant resolution of anemia in 72.2% of cases. Anemia associated with PEH adds an indication for surgical repair with curative intent.
Introduction: Advanced endoscopic therapy techniques have been developed and have created alternative treatment options to surgical therapy for several gastrointestinal diseases. This work will focus ...on new endoscopic tools for special indications of advanced endoscopic resections (ER), especially endoscopic submucosal dissection (ESD), which were developed in our institution. This paper aims to analyze these specialized instruments and identify their status. Methods: Initially, the technical process of ESD was analyzed, and the following limitations of the different endoscopic steps and the necessary manipulations were determined: the problem of traction–countertraction, the grasping force needed to pull on tissue, the instrument tip maneuverability, the limited angulation/triangulation, and the mobility of the scope and instruments. Five instruments developed by our team were used: the Endo-dissector, additional working channel system, external independent next-to-the-scope grasper, 3D overtube working station, and over-the-scope grasper. The instruments were used and applied according to their special functions in dry lab, experimental in vivo, and clinical conditions by the members of our team. Results: The Endo-dissector has a two-fold function: (1) grasping submucosal tissue with enough precision and strength to pull it off the surrounding mucosa and muscle, avoiding damage during energy application and (2) effectively dividing tissue using monopolar energy. The AWC system quickly fulfills the lack of a second working channel as needed to complete the endoscopic task on demand. The EINTS grasper can deliver a serious grasping force, which may be necessary for a traction–countertraction situation during endoscopic resection for lifting a larger specimen. The 3D overtube multifunctional platform provides surgical-like work with bimanual-operated instruments at the tip of the scope, which allows for a coordinated approach during lesion treatment. The OTSG is a grasping tool with very special features for cleaning cavities with debris. Conclusions: The research and development of instruments with special features can solve unmet needs in advanced endoscopic procedures. The latter may help to increase indications for the endoscopic resections of gut lesions in the future.
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