Abstract
Up to 30% of patients with gastroesophageal reflux disease (GERD) suffer from laryngopharyngeal reflux (LPR) with symptoms, as chronic cough, laryngitis, or asthma. Besides life-style ...modifications and medical acid suppression, laparoscopic fundoplication is an established treatment option. Treatment-related side effects after laparoscopic fundoplication have to be weighted against LPR symptom control in 30–85% of patients after surgery. Magnetic sphincter augmentation (MSA) is described as an effective alternative to fundoplication for surgical treatment of GERD. However, evidence on the efficacy of MSA in patients with LPR is very limited. Preliminary data on the results of MSA treating LPR symptoms in patients with acid and weakly acid reflux are promising; showing comparable results to laparoscopic fundoplication by providing the potential of decrease side effects.
The aim of this study was to determine the clinical role of the systemic immune-inflammation index in patients with resectable adenocarcinoma of the gastroesophageal junction treated with or without ...neoadjuvant therapy.
Adenocarcinoma of the gastroesophageal junction is an aggressive disease, with less than 20% of overall patients surviving more than 5 years after diagnosis, while currently available clinical staging for esophageal cancer is lacking necessary accuracy. The systemic immune-inflammation index (SII) based on peripheral neutrophil, lymphocyte, and platelet counts has shown a prognostic impact in various malignancies.
Data of consecutive patients undergoing esophagectomy (n = 320, 1992 to 2016) were abstracted. The cut point for high and low SII before neoadjuvant treatment and before surgery was calculated for illustration of the Kaplan-Meier curves. SII was used for the correlation with patients' clinicopathological characteristics as a continuous variable. Survival was analyzed with Cox proportional hazards models using clinical or pathological staging, adjusting for other known survival predictors.
In both neoadjuvantly treated and primarily resected patients, high SII was significantly associated with diminished overall hazard ratio (HR) 1.3, 95% confidence interval (95% CI) 1.2-1.4; HR 1.2, 95% CI 1.2-1.3, respectively and disease-free survival (HR 1.3, 95% CI 1.2-1.3; HR 1.2, 95% CI 1.2-1.3, respectively). In multivariable survival analysis, SII remained an independent prognostic factor for overall survival (HR 1.3, 95% CI 1.2-1.4; HR 1.2, 95% CI 1.2-1.3, respectively) and disease-free survival (HR 1.3, 95% CI 1.2-1.3; HR 1.2, 95% CI 1.2-1.3, respectively) in primarily resected and neoadjuvantly treated patients.
Elevated SII is an independent adverse prognostic factor in patients with resectable gastroesophageal adenocarcinomas with and without neoadjuvant treatment.
Objectives
To assess the impact of sarcopenia and alterations in body composition parameters (BCPs) on survival after surgery for oesophageal and gastro-oesophageal junction cancer (OC).
Methods
200 ...consecutive patients who underwent resection for OC between 2006 and 2013 were selected. Preoperative CTs were used to assess markers of sarcopenia and body composition (total muscle area TMA, fat-free mass index FFMi, fat mass index FMi, subcutaneous, visceral and retrorenal fat RRF, muscle attenuation). Cox regression was used to assess the primary outcome parameter of overall survival (OS) after surgery.
Results
130 patients (65 %) had sarcopenia based on preoperative CT examinations. Sarcopenic patients showed impaired survival compared to non-sarcopenic individuals (hazard ratio HR 1.87, 95 % confidence interval CI 1.15–3.03, p = 0.011). Furthermore, low skeletal muscle attenuation (HR 1.91, 95 % CI 1.12–3.28, p = 0.019) and increased FMi (HR 3.47, 95 % CI 1.27–9.50, p = 0.016) were associated with impaired outcome. In the multivariate analysis, including a composite score (CSS) of those three parameters and clinical variables, only CSS, T-stage and surgical resection margin remained significant predictors of OS.
Conclusion
Patients who show signs of sarcopenia and alterations in BCPs on preoperative CT images have impaired long-term outcome after surgery for OC.
Key Points
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Sarcopenia is associated with impaired OS after surgery for oesophageal cancer
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Other body composition parameters are also associated with impaired survival
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This influence on survival is independent of established clinical parameters
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Sarcopenia provides a better estimation of cachexia than BMI
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Sarcopenia assessment could be considered in risk
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benefit stratification before oesophagectomy
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Gastroesophageal reflux disease (GERD), a prevalent problem among obese individuals, is strongly associated with obesity and weight loss. Hence, bariatric surgery effectively improves GERD for many ...patients. Depending on the type of bariatric procedure, however, surgery can also worsen or even cause a new onset of GERD. As a consequence, GERD remains a relevant problem for many bariatric patients, and especially those who have undergone sleeve gastrectomy (SG). Affected patients report not only a decrease in physical functioning but also suffer from mental and emotional problems, resulting in poorer social functioning. The pathomechanism of GERD after SG is most likely multifactorial and triggered by the interaction of anatomical, physiological, and physical factors. Contributing factors include the shape of the sleeve, the extent of injury to the lower esophageal sphincter, and the presence of hiatal hernia. In order to successfully treat post‐sleeve gastrectomy GERD, the cause of the problem must first be identified. Therapeutic approaches include lifestyle changes, medication, interventional treatment, and/or revisional surgery.
Gastroesophageal reflux disease (GERD) is a prevalent problem among obese individuals. For many of these patients, bariatric surgery effectively improves GERD, but it can also worsen or even cause a new onset of GERD, especially for those who have undergone sleeve gastrectomy (SG). In our narrative review, possible pathomechanisms of GERD after SG are discussed, and available strategies for preventing and treating GERD after SG are elucidated.
Magnetic sphincter augmentation (MSA) has been designed as a less disruptive and more standardized laparoscopic surgical procedure than fundoplication for patients with early stage gastroesophageal ...reflux disease (GERD). We analyzed the more recent literature in search of updates regarding indications, technique, perioperative management, and long-term outcomes.
Over the years, the procedure of MSA has evolved to including full hiatus repair rather than relying on the preservation of the phreno-esophageal ligament. Restoring the mechanical synergy between the lower esophageal sphincter and the crural diaphragm has the potential to further enhance the antireflux barrier. The adoption of this approach has led to expand the indications from early stage disease to different scenarios including patients with high esophageal acid exposure, atypical symptoms, large hiatal hernias, Barrett's esophagus, postbariatric surgery, and previously failed fundoplication.
MSA has a favorable side-effect profile and is highly effective in reducing typical reflux symptoms, medication dependency, and esophageal acid exposure. Excellent outcomes have been confirmed over a 12-year follow-up, indicating that the operation has the potential to prevent GERD progression. Further studies are needed to confirm the cost-effectiveness of this procedure in patients with more advanced disease-stage and prior gastric surgery. A randomized control trial comparing MSA with fundoplication could raise the level of evidence and the strength of recommendation.
Background
Magnetic sphincter augmentation (MSA) is a surgical intervention for gastroesophageal reflux disease (GERD) which has been evaluated in numerous studies and has shown beneficial effects. ...Long-term effectiveness data for MSA as well as laparoscopic fundoplication (LF) in patients with GERD are needed.
Objective
The objective of this study was to evaluate the 3-year outcomes for MSA and LF in patients with GERD.
Methods
This prospective, multi-center, observational registry study evaluated MSA and LF in clinical practice over 3 years (ClinicalTrials.gov identifier: NCT01624506). Data collection included baseline characteristics, reflux symptoms, medication use, satisfaction and complications. Post-surgical evaluations were collected at yearly intervals.
Results
Between December 2009 and December 2014, 631 patients (465 MSA and 166 LF) were enrolled in the registry. Both MSA and LF resulted in improvements in total GERD-HRQL score (mean reduction in GERD-HRQL from baseline to 3 years post-surgery: MSA 22.0 to 4.6 and LF 23.6 to 4.9) and in satisfaction (GERD-HRQL satisfaction increase from baseline to 3 years: MSA 4.6% to 78.2% and LF 3.7% to 76.5%). Most patients were able to belch as needed with both therapies (MSA 97.6% and LF 91.7% at 3 years). MSA allowed a higher percentage of patients the ability to vomit as needed (MSA 91.2% and LF 68.0% at 3 years). PPI usage declined from baseline to 3 years for both groups after surgery (MSA 97.8% to 24.2% and LF 95.8% to 19.5%). The mean procedure time was shorter for MSA than for LF. Intraoperative and procedure-related complication rates (≤ 2%) were low for both therapies.
Conclusions
This 3-year prospective observational registry study contributes to the mounting evidence for the effectiveness of MSA and LF. Despite the more severe nature of GERD in the LF group, the clinical outcomes for MSA and LF were favorable from an effectiveness and safety standpoint.
Patient satisfaction when treated with acid-suppressing medication for chronic GERD disease is less than 70%. Surgical standardisation, centralisation, improved awareness of patient selection and new ...surgical methods have stimulated interest in surgical reflux therapy in recent years. Magnetic sphincter augmentation (MSA) seems to be a safe alternative to laparoscopic fundoplication, with reported complication rates of 0.1% and reoperation rates of 3.4% and is also effective (GERD-HRQL improvement from 19.9 to 4.1, p = 0.001 as well PPI cessation and pH normalisation in 79 and 89% of patients, respectively). Electric sphincter augmentation shows promising short-term results in small patient cohorts (92% symptomatic improvement). However, randomised controlled studies comparing these new techniques to the "gold standard" of laparoscopic fundoplication are still missing.
Abstract AF1q associates with tumor progression and metastases upon WNT signaling. The downstream WNT target CD44 has demonstrated prognostic significance in gastric cancer (GC). This study evaluates ...the impact of AF1q on tumor stage and survival in GC patients. Immunohistochemical marker expression was analyzed and data were processed to correlation and survival analysis. Out of 182 GC samples, 178 (97.8%) showed moderate to high AF1q expression ( p < 0.001), these samples correlated with positive lymph node stage ( p = 0.036). In a subgroup analysis of patients with nodal-positive GC (n = 129, 70.9%), enhanced tumoral AF1q expression resulted in impaired recurrence-free survival (RFS, p = 0.030). Enhanced tumoral CD44 expression resulted in impaired disease-specific survival (DSS) in the subgroup of patients with nodal-positive GC ( p = 0.031) as well as in the overall GC group ( p = 0.005). AF1q demonstrated as an independent prognostic marker for RFS ( p = 0.035) and CD44 for DSS ( p = 0.036). AF1q has shown potential for prognostication of RFS in GC patients and is predominantly expressed in nodal-positive GC. Testing AF1q provides a possibility of identifying patients with locoregional (and advanced) disease, particularly at risk for disease recurrence. Implementing AF1q into the diagnostic process may facilitate screening, prognosis estimation as well as consideration of preoperative multimodal treatment in patients qualifying for elective upfront surgery.
Tumor budding is a prognostic factor in biopsies of different tumor entities. Recent evidence suggests that this also applies to esophageal squamous cell carcinomas. Since esophageal cancer is ...diagnosed by biopsy, the aim of this study was to investigate whether tumor budding in pretherapeutic biopsies of a mixed tumor population of the esophagus and gastroesophageal junction might predict survival.
In this retrospective analysis, samples of 78 patients were analyzed (55 adenocarcinomas, 17 squamous cell carcinomas, 5 adenosquamous carcinomas, 1 carcinosarcoma). In addition to preoperative biopsies, budding foci in corresponding resection specimens were assessed and related to overall and relapse-free survival.
The main finding was that the number of budding foci in preoperative biopsies predicted overall survival independent of the patient's age and disease stage in a grade-specific (P = .009) manner. In patients with grade 2 tumors, each additional budding focus was associated with an increased chance of death by a factor of 1.28 (hazard ratio 95% confidence interval 1.06-1.55, P = .011). There was no significant association between survival and the number of budding foci in patients with grade 3 tumors, and no budding was observed in grade 1 tumors. Budding foci in resection specimens also showed a certain association with survival, but to a lesser degree.
Budding foci in preoperative biopsies might serve to improve prognostic accuracy in esophageal carcinomas.
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