Pneumatic Dilation Research Articles

Anesthetic management of a patient with achalasia, a disease with a considerable risk for aspiration under anesthesia

BackgroundAchalasia is a rare condition characterized by dysfunction of esophageal motility and impaired relaxation of the lower esophageal sphincter. Anesthetic management of these patients is challenging due to the elevated risk of regurgitation and aspiration.Case presentationA 53-year-old man diagnosed with achalasia was scheduled for renal cancer surgery before esophageal myotomy. Since his severe dysphagia suggested the possibility of vomiting and aspiration under anesthesia, a stomach tube was inserted before induction of general anesthesia. After preoxygenation, rapid sequence induction was performed and an antiemetic was administered to prevent postoperative vomiting. Although anesthetic management was uneventful, the inserted stomach tube coiled up in the dilated esophagus and substantial residue was aspirated via the tube even after a prolonged fasting period.ConclusionAnesthesiologists should be familiar with achalasia even though it is an uncommon disease, since affected patients are at risk of regurgitation and aspiration under anesthesia.

Extrathoracic esophageal elongation with Foker technique in patients with Type-A esophageal atresia. A case series

Background: Long-gap esophageal atresia (EA) is not amenable to primary anastomosis though the goal of surgical treatment is to restore the patency in the native esophagus; the Foker technique is one of the methods that can accomplish it. Case Presentation: This case series consists of three patients who presented with a type-A long-gap EA. Extrathoracic esophageal elongation was achieved using the Foker technique. During the first stage, we utilized pledgeted sutures reinforced with titanium clips for elongation that began five days after the surgery. As the elongation progressed, and the gap between esophageal pouches decreased, we restored the continuity of the esophagus. On follow-up, all patients needed pneumatic dilatation of the esophagus. Conclusion: The Foker technique successfully restored the esophageal continuity using the native esophagus in our patients with esophageal atresia.

Examining Disparities in Pediatric Eosinophilic Esophagitis.

Little is known regarding the impact of race, ethnicity, and socioeconomic status on the health outcomes of children with eosinophilic esophagitis (EoE). To (1) identify demographic characteristics of children diagnosed with EoE in a large tertiary care center, and (2) determine associations between a patient's demographics and depth of evaluation or treatment choices. This retrospective cohort study included children 0 to 18 years old seen in Children's Hospital Colorado between January 1, 2009, and December 31, 2020. Demographics were extracted from the electronic medical record. Rural-Urban Commuting Area taxonomy codes were used to classify urbanization. Area Deprivation Index (ADI) scores were used to categorize neighborhood advantage/disadvantage. Data were analyzed using descriptive statistics and regression analysis. The study included 2,117 children with EoE. Children with higher state ADI scores (greater neighborhood disadvantage) had less radiographic evaluation of their disease (odds ratio [95% CI] per unit increase in state ADI= 0.93 [0.89-0.97]; P= .0002) and had esophageal dilations at younger ages (r= -0.24; P= .007). Black children compared with White children were younger at diagnosis (8.3 y vs 10.0 y; P= .002). Children from rural areas were seen less by feeding therapy (3.9% vs 9.9%; P= .02), but were younger at their visits (2.3 y vs 4.3 y; P < .001). In this study of children with EoE cared for in a large tertiary care center, we found differences in presentation and care depending on race, urbanization, and socioeconomic status.

Efficacy and safety of dupilumab up to 52 weeks in adults and adolescents with eosinophilic oesophagitis (LIBERTY EoE TREET study): a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial

Efficacy and safety of dupilumab up to 52 weeks in adults and adolescents with eosinophilic oesophagitis (LIBERTY EoE TREET study): a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial

423. DYSPHAGIA AND RE-INTERVENTION AFTER MYOTOMY FOR ACHALASIA: A MATTER OF TECHNIQUE, OR A MATTER OF TIME?

Abstract Background Achalasia is an incurable neurodegenerative disease of the esophagus. Palliative treatment includes disruption of the lower esophageal sphincter via multiple techniques, including open Heller myotomy (OHM), laparoscopic Heller myotomy (LHM), and per-oral esophageal myotomy (POEM). There is a paucity of data comparing long-term outcomes between OHM, LHM, and POEM. We sought to evaluate the relationship of these methods with clinical outcome parameters using our institution’s experience. Methods Patients greater than 3 years removed from myotomy for achalasia were studied. Post-operative Eckardt Symptom (ES) score and daily proton pump inhibitor (PPI) usage was recorded. Patients underwent timed barium esophagram (TBE) as clinically indicated. Retention was defined as a persistent column &amp;gt;5 cm at 5 minutes. Post-operative interventions included Savary dilation, Botox injection, pneumatic dilation, surgical myotomy, and esophagectomy. Groups were stratified by surgery type (OHM, LHM, POEM) and by time since surgery (3–6 years, 6–10 years, &amp;gt;10 years). A logistic regression analysis was performed examining the relationship of surgery type, time, symptomatic/objective outcomes, and post-operative interventions. Results 172 patients had long-term data available. Mean follow up was 7.8 years (3.1–19.5 years). Nearly one-third of patients had a post-operative intervention (31%, 53/172). On regression analysis, OHM was associated with a higher risk of intervention (OR 9.4, p &amp;lt; 0.05). Barium retention was significantly associated with LHM (OR 15.9, p &amp;lt; 0.05) and the 3–6 year post-operative period (OR 11.1, p &amp;lt; 0.05). PPI usage was not associated with surgery type, but was associated with the 3–6 year post-operative period (OR 3.2, p &amp;lt; 0.05). There was no significant association of dysphagia with surgery type or time. Conclusion Post-operative barium retention and interventions are associated with specific myotomy techniques, but not time. PPI usage is associated with the early post-operative period, but not technique. Neither myotomy technique nor time alone are sufficient to predict risk of abnormal ES or dysphagia.

431. RARE CASE OF CONTAINED ESOPHAGEAL PERFORATION IN LONG STANDING ACHALASIA CARDIA AND ITS SUCCESSFUL MANAGEMENT

Abstract Background Esophageal perforation is the most feared complication after any intervention in achalasia cardia, especially after pneumatic dilation. We present a case of contained perforation after manometry in a long-standing case of achalasia cardia and its successful management. Methods A 64-year-old lady, known case of long-standing Rheumatoid arthritis on steroids and methotrexate, presented to us with complains of dysphagia to solids and liquids and 15 kgs weight loss in the past 3 years. On evaluation, she was dehydrated and cachexic. Upper GI endoscopy showed lot of food residue with erosions in body of esophagus and tight LES. Barium swallow showed sigmoid esophagus with typical bird beak appearance. Patient was admitted for hydration and nutritional optimization was done with nasojejunal feeding. She was further subjected to manometry to characterize the achalasia, which couldn’t be completed despite multiple forceful attempts. After 5 days, she was admitted for elective surgery. A CT scan of chest was done to evaluate the anatomy thoroughly before surgery, which showed contained mucosal perforation in lower esophagus on right side with minimal right pleural effusion. We planned for surgery next day. Results Laparoscopic Heller’s cardiomyotomy with Dor’s fundoplication was done with thoracoscopic lavage. Intra-operatively, upper GI endoscopy with minimal insufflation was done to confirm adequate cardiomyotomy and to look for the site of perforation. The perforation was not found. Hence, right thoracoscopy was done, which showed reactive pleural effusion without any food contents. Lavage was given and ICD was placed. Feeding jejunostomy was done laparoscopically. Patient was kept NBM for 7 days and JT feeds were started on POD 1 and gradually increased. ICD removed on POD 7. Oral gastrograffin contrast study was done on POD 8, which showed delayed passage at 5 minutes and no extravasation. Oral liquids were started and escalated gradually. Supplemental high protein nutrition was given through JT feeding. Patient was discharged on POD 15. At 1 month follow up, patient had 2 kgs weight gain and tolerated semisoft diet adequately. Conclusion Successful management of contained perforation in long standing achalasia cardia was achieved by targeting the source pathology in an already immunocompromised patient.

403. END-STAGE ACHALASIA: FEASIBILITY OF CARDIOMYOTOMY WITH ANTERIOR 90-DEGREE FUNDOPLICATION AS TREATMENT

Abstract Achalasia is a primary motor disorder of the oesophagus. End-stage achalasia is characterised by a grossly dilated sigmoid-shaped oesophagus with food stasis leading to chronic inflammation. Despite treatment, approximately 5% of patients progress to this late stage, needing oesophagectomy. Current guidelines recommend oesophagectomy as the last resort after failure of first-line endoscopic treatment or cardiomyotomy. We review a case of a 70 years old female with end-stage achalasia who successfully underwent cardiomyotomy but required a looser wrap for oesophageal emptying. Patient first presented in her 50s with dysphagia and Oesophago-Gastro-Duodenoscopy (OGD) showed a dilated oesophagus with food stasis and no contractions. Barium swallow confirmed the diagnosis of achalasia. She underwent pneumatic dilatations with minimal symptom improvement and eventually defaulted follow-up. Several years later she presented with haematemesis due to severe oesophagitis and Eckardt score of 7. Both OGD and CT scans showed a grossly dilated megaoesophagus. High-resolution manometry confirmed Type I achalasia with IRP (integrated relaxation pressure) 25.8 and complete absence of peristalsis. She was initiated on nasogastric feeding and was also diagnosed with pulmonary embolism (PE). In view of PE and patient’s comorbidities, she was not fit for oesophagectomy. Peroral endoscopic myotomy (POEM) was also deemed challenging in the presence of severe, chronic oesophagitis and patient’s need for anticoagulation with potential difficulty in endoscopic haemostasis. She underwent laparoscopic cardiomyotomy with anterior 180-degree fundoplication. However, post-operation contrast swallow showed hold up of contrast despite intraoperative OGD showing smooth passage of scope through LES. Decision was made for revision of fundoplication to anterior 90-degree to further promote oesophageal emptying. Post-operation contrast swallow showed satisfactory drainage into stomach and patient tolerated post-fundoplication diet regime. This case illustrates the role of cardiomyotomy as first-line in patients with end-stage achalasia who are not fit for oesophagectomy. However, an anterior 180-degree fundoplication may not allow adequate drainage from a megaoesophagus and a less tight wrap should be considered in such cases. Post-operation, reported Eckardt score of our patient was 1 with no reflux symptoms, indicating marked alleviation of symptoms. Thus, cardiomyotomy with a lesser 90-degree fundoplication is feasible as first-line treatment in end-stage achalasia.

457. WHEN LAPAROSCOPIC MYOTOMY FAILS, COMPLEMENTARY PNEUMATIC DILATIONS REPRESENT AN EFFECTIVE AND SAFE OPTION

Abstract Background In the last 3 decades, laparoscopic Heller myotomy (LHM) has represented the treatment of choice for esophageal achalasia (EA), solving symptoms in most patients. Little is known about the fate of patients who relapsed after LHM, or about their most appropriate treatment. In this study we aimed at evaluating the results of complementary pneumatic dilations (CPD) after ineffective LHM. Methods We evaluated the patients with EA who underwent LHM plus Dor fundoplication (LHD) from 1992 to 2021 and were submitted to CPD for persistent or recurrent symptoms. The patients were followed clinically and with manometry, barium swallow and endoscopy when necessary. An Eckardt score (ES) &amp;gt; 3 was used as threshold for failure both after LHD and after LHD + CPD. Results Out of 1420 patients undergoing LHD in the study period, 115 (8.1%) were considered failures and were offered CPD. Ten patients refused further treatment, in 5 CPD was not indicated for severe reflux esophagitis, 1 patient had surgery for a misshaped fundoplication and 1 last patient developed a cancer 2 years after LHD; that leaves 103 patients who underwent a median 2 CPD (IQR:1–3), at a median of 16 (IQR:8–36) months after surgery, with 3.0 to 4.0 cm Rigiflex dilator. No perforations were recorded. Only 6 patients were lost to follow up. The remaining 97 were followed for a median of 37 months (IQR:6–112) after the last CPD: 70 saw their symptoms healed, whereas 27 still complained of symptoms (ES &amp;gt; 3). The only differences between the 2 groups were the ES before CPD, that was 3 (IQR:3–4) in the former and 4 (IQR:4–5) in the latter (p &amp;lt; 0.05), and the number of required CPD, that was 2 (IQR:1–2) and 3 (IQR:1–3), respectively (p &amp;lt; 0.05). All other parameters were similar between the 2 groups. Of the un-responding patients, 17 still require repeated CPD, 7 underwent re-myotomy, 1 POEM and 1 esophagectomy for end-stage disease. Conclusion CPD represent an effective and safe option to treat patients after a failed LHD: when the post-surgery ES consistently remains high, and the number of CPD exceeds 3, this may suggest the need for further invasive treatments.

Surgical Options for End-Stage Achalasia.

Achalasia is one of the most commonly described primary esophageal motility disorders worldwide, but there is significant controversy regarding ideal management of end-stage disease. This article reviews the definition of end-stage achalasia and summarizes past and present surgical treatment. Myotomy of the lower esophageal sphincter remains the mainstay of treatment of achalasia, even in advanced disease. Esophagectomy may have benefit as a primary treatment modality in end-stage achalasia with sigmoid esophagus, but international guidelines recommend consideration of laparoscopic or endoscopic approaches initially in most patients. Novel peroral esophageal plication techniques may provide alternative treatment options in patients with significant esophageal dilation that fail myotomy or esophagectomy. End-stage achalasia is characterized by progressive tortuosity and dilation of the esophagus as a failure of primary peristalsis. Up to 20% of patients with achalasia will progress to end-stage disease. In most cases, laparoscopic or endoscopic myotomy is recommended as initial approach to surgical management.

264. A RETROSPECTIVE CHART REVIEW OF 85 PATIENTS UNDERGOING THE REFLUXSTOP PROCEDURE TO MANAGE GASTROESOPHAGEAL REFLUX DISEASE: SAFETY AND EFFICACY

Abstract Background RefluxStop is a novel surgical device that manages gastroesophageal reflux disease (GERD) by restoring the normal structure of the antireflux barrier. This is accomplished by reinstating the acute angle of His and anchoring the gastroesophageal sphincter adequately in the intraabdominal cavity. This study reports the safety and efficacy of 79 patients in the postoperative period. Methods A retrospective chart review was performed on 79 patients that underwent the RefluxStop procedure at a single institution between July 2021 and November 2022 to manage GERD symptoms after informed consent was obtained. Measures were evaluated to assess the feasibility, safety, and clinical outcomes during the follow-up period. Results 79 patients (age 49.8 ± 14 years), 46 of which were male, had a mean BMI of 25.8 ± 4.5. Associated conditions noted included esophagitis (45.6%), Barrett’s esophagus (17.7%), and hiatal hernia (57%). Hiatal hernias were large in 35% of cases, with an overall average size of 2.9 cm. Baseline symptoms included general GERD symptoms (35.4%), heartburn (29.1%), cough (13.9%), regurgitation (11.4%), retrosternal burning (10.1%), hoarseness (5.1%), abdominal pain or pressure (3.8%), nausea (2.5%), and others. Baseline GERD health-related quality of life (GERD-HRQL) score was 21.5 ± 5.2 and patients were receiving proton pump inhibitors (PPIs) for a mean of 4.7 ± 6.8 years. After surgery (10.7 ± 3.1 months), all subjects experienced significant improvement in GERD-related symptoms including dysphagia. Only 2.5% of patients required use of PPIs and no subjects required postoperative esophageal dilatation or reoperation. Additionally, there were no severe perioperative complications. Postoperatively, the mean GERD-HRQL score was significantly reduced to 1.6 ± 3.2 (92.6% improvement). Conclusion This study adds to a growing body of evidence that the RefluxStop procedure is safe and effective in management of GERD patients. Notably, a considerable improvement in PPI usage and health-related quality of life parameters were appreciated. Additional studies are required to further validate the role of this procedure in disease management.

Developing balloon dilatation sizing guidance for anastomotic stricture dilatation following oesophageal atresia repair.

To develop guidance for the selection of balloon catheter size when performing an oesophageal dilatation for a stricture post oesophageal atresia repair. This was a single centre retrospective study at a paediatric tertiary centre. Dilatations were performed between 2015 and 2020. All dilatations were performed under general anaesthesia using balloon catheters under fluoroscopic guidance. Outliers were excluded using ROUT method and descriptive analysis was calculated to 1SD or IQR depending on the normality of data distribution. 97 patients underwent 341 dilatations. Median age was 19 months (37 weeks corrected gestation-17 years), median weight was 10.7 kg (2.6-72 kg). Balloon catheter sizes ranged from 6-8 mm to 18-20 mm. There was strong correlation between weight and balloon size (r = 0.8, p < 0.0001). There were 2 perforations (0.6%), both diagnosed intra-operatively and treated conservatively. From the results, weight recommendations were created for each balloon size. Fluoroscopic balloon dilatation is a safe and effective method to treat anastomotic stricture following oesophageal atresia repair. Previous studies have shown correlation between patient weight and oesophageal diameter. We propose guidance for using an appropriate balloon size based on patient's weight with the aim to reduce complication.

Management of Leakage after Gastroesophageal Anastomosis

Abstract Background Esophagectomy is needed for a variety of esophageal disorders, the most common indication is cancer esophagus, however, it is needed in benign disorders as postcorrosive strictures &amp; endstage achalasia with esophageal dilatation. Anastomotic leakage is one of the most severe complications leading to significant morbidity and increased risk of mortality. Objective To evaluate different approaches in management of leakage after gastroesophageal anastomosis in Upper GIT surgery unit in Ain Shams University Hospitals. Patients and Methods This study was conducted at General surgery department, Ain Shams University Hospitals. Approval of the Ethical Committee was obtained. The study was conducted over patients with postoperative gastroesophageal leakage during the period from 3/2019 to 3/2021. Results Patients managed after cervical anastomosis leakage needed less time to start oral intake&amp; had shorter hospital stay in comparison to those managed after thoracic leakage. There was a higher perioperative morbidity and mortality in patients who underwent surgical intervention as compared with patients who underwent conservative treatment. Conclusion Anastomotic leak after surgery for esophageal diseases can vary in location, onset time, size, and extent. For local management, personalized treatment should be decided based on patient’s particular situations. Cervical anastomosis leakage has less morbidity &amp; mortality compared to thoracic anastomosis. Conservative treatment is safe and successful in many cases, in cervical leakage conservative management is effective in most cases. Stent implantation is an effective method with other emerging endoscopic techniques. Resurgery should be considered carefully and reserved to uncontrolled leakage or patients with failed conservative management.

Role of Mesh in the Reinforcement of the Primary Repair of Large Hiatal Hernia

Abstract Background The incidence of hiatal hernias increases with age. Approximately 55%-60% of individuals over the age of 50 have a hiatal hernia. However, only about 9% have symptoms, and it depends on the type and competency of the lower esophageal sphincter. Aim of the Work In our study, an objective observational study was made regarding post operative short term mesh related complications possible to develop in patients underwent hiatal repair of large hiatal hernia with mesh rienforcement. Patients and Methods An observational cohort (retrospective and prospective) study regarding the post operative mesh related complications in patients who underwent Large diaphragmatic hernia repair with mesh application. The study was conducted at Ain Shams University Hospitals, Al-Demerdash, Department of General surgery. Approval of the research ethics Committee of medicine and general surgery department at faculty of medicine, Ain Shams University as well as a written informed consent from all participants was obtained. The study was conducted on 15 patients over a period of six months, starting from date of approval of the protocol by the faculty and the university committee at 10/7/2021. Results Five patients (33.3%) complained about dysphagia postoperatively. In one case, the symptoms declined spontaneously within 6 months was grade 1. Another patient successfully underwent esophageal dilatation of a stenosis 2 months postoperatively was grade 2. Up to this date, two patients (13.3%) still report mild dysphagia but maintain normal body weight were grade 3. Three cases report persistent intraabdominal discomfort without weight loss described as bloating. Two patients experienced heartburn, while another patient reported respiratory compromise in the form dyspnea due to already huge hiatal defect with lung collapse present preoperatively. Conclusion Laparoscopic large hiatal/paraesophageal hernia repair with prosthetic meshes as well as laparoscopic antireflux surgery with prosthetic hiatal closure are safe and effective procedures to prevent hiatal hernia recurrence and/or postoperative intrathoracic wrap migration, with low complication rates and mesh fixation is indicated in patients with large hiatal hernial defect &amp;gt; 5 cm.

Effect of peroral endoscopic myotomy on growth and esophageal motility for pediatric esophageal achalasia

Peroral endoscopic myotomy (POEM), a novel minimally invasive treatment for esophageal achalasia, has been shown to be effective and safe for both adult and pediatric patients. However, studies on its application in children in Taiwan and its impact on growth and esophageal motility are lacking. We conducted a retrospective study on consecutive pediatric patients who were diagnosed with esophageal achalasia at National Taiwan University Hospital and underwent POEM during 2015-2022. Disease characteristics and treatment outcomes were analyzed. Ten patients (age 16.9±3.1 years), nine newly diagnosed and one previously treated with pneumatic dilatation, underwent POEM for achalasia (type I/II/III: 3/7/0). Average symptom duration before diagnosis was 19.4±19.9 months, mean POEM procedure time was 83.6±30.7min, and clinical success (Eckardt score ≤3) was achieved in all patients. Eight patients experienced mild adverse events during POEM, but none required further endoscopic or surgical intervention. Over a mean follow-up period of 3.7±1.6 years, mean Eckardt score decreased significantly from 5.7±2.4 to 1.1±0.7 (p=0.0001). The BMI z-score also increased significantly after POEM (p=0.023). Five patients received follow-up high-resolution impedance manometry (HRIM), and all had improved lower esophageal sphincter resting pressures (p=0.011), body contractility, and bolus transit (p=0.019). POEM is an effective and safe treatment for pediatric achalasia in Taiwan. Early diagnosis and treatment with POEM may help to restore esophageal function and nutrition status in children.

Per-oral endoscopic myotomy in cases with prior Heller's myotomy: Outcomes at a median follow-up of 5years.

Per-oral endoscopic myotomy (POEM) is an established treatment for achalasia cardia. However, data on the long-term efficacy of POEM in patients with failed Heller's myotomy (HM) are limited. The purpose of this study was to evaluate the long-term outcomes of POEM in patients with persistent or recurrent symptoms following HM. Data of patients with recurrence of symptoms after HM who underwent POEM (September 2013 to December 2022) were analyzed, retrospectively. Primary outcome was clinical success [Eckardt score (ES)≤3]. Secondary outcomes included improvement of manometry parameters, barium emptying at 5min and gastroesophageal reflux (esophagitis and increased esophageal acid exposure) after POEM. Seventy-two cases (45.9±13.4years, 43 men) with history of HM were included in the study. The subtypes of achalasia were type 1 (40.3%), type 2 (37.5%), and unknown (19.4%). Prior treatment included HM in 48 (66.7%), HM plus pneumatic dilatation in 20 (27.8%), and HM plus pneumatic dilatation and Botox in 4 (5.5%). Technical success was achieved in all cases. Mean length of myotomy was 10.7±3.3cm, and mean procedure duration was 59.2±25.9min. There was significant improvement in ES (pre-POEM 6.5±1.8 vs post-POEM 0.7±0.7), lower esophageal sphincter pressure pressures (31.7±12.5 vs 13.3±5.7mmHg) and barium emptying (14.2±4.2 vs 2.4±3.1cm) after POEM. At a median follow-up of 63months (IQR 40-95), clinical success (ES≤3) was documented in 58 (80.6%) patients. Reflux esophagitis and increased esophageal acid exposure were recorded in 28 of 49 (57.1%) and 11 of 20 (55%) patients, respectively. POEM is a durable treatment modality in cases with relapse of symptoms after HM.

Extramural hematoma after esophageal stricture dilatation in mixed connective tissue disease.

Extramural hematoma after esophageal stricture dilatation in mixed connective tissue disease.

Esophageal Dilation: Pearls and Pitfalls

Esophageal dilation is an important part of endoscopic practice. Proper preparation and technique can optimize outcomes. Techniques include wire guided per oral dilation, blind bougienage and balloon dilation. Fluoroscopy and steroid injections may also be part of endoscopic practice. Diseases that are often and addressed with esophageal dilation include peptic strictures, lower esophageal rings, eosinophilic esophagitis, achalasia and other motility disorders, postoperative dysphagia, radiation induced strictures and malignant strictures. The techniques and approach to all of these disorders will be discussed in this review.

Predictors of Underlying Esophageal Motility Disorders in Patients Presenting with Esophageal Candidiasis.

Esophageal motility disorders (EMDs) are a known risk factor for esophageal candidiasis (EC), but this relation has not been described particularly well. We sought to evaluate the predictors of underlying EMDs in patients presenting with EC. Cases of EC at a single medical center between 2010 and 2021 were identified retrospectively based on the International Classification of Diseases, Ninth Revision code. Demographic, clinical, endoscopic, and manometric data were reviewed. The diagnosis of EC was based on typical endoscopic appearance. In total, 130 EC patients were identified (mean age 69.5 ± 14.6; 66.2% male). Of these, 12 (9.2%) had an underlying EMD (11 cases of achalasia; 1 case of esophagogastric junction outflow obstruction). Five (41.7%) of these patients had previously been diagnosed as having an EMD, whereas 7 were newly diagnosed only after their presentation with EC. No significant differences were noted between those with or without EMDs in terms of demographics, medical comorbidities, or medication use. Patients with an EMD, however, were more likely to complain of dysphagia (91.7% vs 30.5%, P < 0.001), and on endoscopy, they were more likely to have residual food in the esophagus, residual fluid in the esophagus, a dilated esophagus, and resistance to traversing the esophagogastric junction (all P < 0.001). Sixty-one (46.9%) patients with EC died during follow-up (mean 58 months). EMDs are present in approximately 10% of patients presenting with EC, with half being diagnosed only after presenting with EC. Similar to non-EC patients, patients with EC with dysphagia and the typical endoscopic findings of achalasia are more likely to have an EMD and warrant prompt manometric evaluation.

Elimination Diet or Swallowed Topical Steroid Treatment of Pediatric Eosinophilic Esophagitis: Five-Year Outcomes.

Eosinophilic esophagitis (EoE) is a chronic, antigen-mediated disease of the esophagus commonly treated with swallowed topical steroids (STS) or elimination diets (EDs). Evidence of a long-term response to EDs in pediatric patients is sparse. Our study sought to understand the natural history of pediatric EoE treated exclusively with EDs and to examine a similar population of STS-treated EoE subjects. We hypothesized that long-term adherence to an effective ED would result in ongoing EoE disease remission. We conducted a retrospective study of pediatric EoE subjects who had at least 2 visits to a multidisciplinary clinic. Subjects were identified who had (1) a new referral with a suspected diagnosis of EoE; (2) received either EDs or STS alone, and (3) completed both a diagnostic and a posttreatment endoscopy. Concomitant proton-pump inhibitor use was allowed. We collected demographics, clinical features, treatment plans, and associated side effects on each subject. Remission was defined as fewer than 15 eosinophils/high-powered field. We screened the electronic medical record from 2015 to 2016 for subjects cared for in the Gastrointestinal Eosinophilic Diseases Program who fit criteria for inclusion in this analysis. One hundred ninety-nine subjects were identified, 16 who received exclusive EDs and 15 who were treated with STS. Treatment of these subjects was documented for 4.8 and 5.2 years, respectively (P= .51). Significant differences between the groups were observed in average age at EoE diagnosis (3.5 y ED vs 7.8 y STS; P= .002) and in number of endoscopies (6.6 in ED vs 4.5 in STS; P= .03). Fifteen of 16 subjects treated with ED attained histological remission. The initial effective ED removed a mean of 7.7 foods and the final ED removed a mean of 4 foods. No food impactions or esophageal dilations occurred in the ED group. The STS group required an average of 3.7 dose/formulation changes, 4 subjects required 1 or more dilations, 1 subject had 2 food impactions, and 2 were diagnosed with adrenal insufficiency. Treatment with either ED or STS can lead to long-term remission of EoE. In this study, fewer side effects developed in the ED group than the STS group, but the validity of this conclusion is limited by the small sample size and reinforces the need for prospective study to explore these initial findings.

Pre-operative endoscopic balloon dilatation and its impact on outcome of laparoscopic Heller cardiomyotomy for patients with achalasia: does the frequency and interval matter?

Many surgeons believe that pre-operative balloon dilatation makes laparoscopic myotomy more difficult in achalasia patients. Herein, we wanted to see if prior pneumatic balloon dilatation led to worse outcomes after laparoscopic myotomy. We also assessed if the frequency of dilatations and the time interval between the last one and the surgical myotomy could affect these outcomes. The data of 460 patients was reviewed. They were divided into two groups: the balloon dilation (BD) group (102 patients) and the non-balloon dilatation (non-BD) group (358 patients). Although pre-operative parameters and surgical experience were comparable between the two groups, the incidence of mucosal perforation, operative time, and intraoperative blood loss significantly increased in the BD group. The same group also showed a significant delay in oral intake and an increased hospitalization period. At a median follow-up of 4 years, the incidence of post-operative reflux increased in the BD group, while patient satisfaction decreased. Patients with multiple previous dilatations showed a significant increase in operative time, blood loss, perforation incidence, hospitalization period, delayed oral intake, and reflux esophogitis compared to single-dilatation patients. When compared to long-interval cases, patients with short intervals had a higher incidence of mucosal perforation and a longer hospitalization period. Pre-operative balloon dilatation has a significant negative impact on laparoscopic myotomy short and long term outcomes. It is associated with a significant increase in operative time, blood loss, mucosal injury, hospitalization period, and incidence of reflux symptoms. More poor outcomes are encountered in patients with multiple previous dilatations and who have a short time interval between the last dilatation and the myotomy.