Food Stasis Research Articles

Duodenal-Jejunal Stenosis as a Manifestation of Eosinophilic Gastroenteritis: A Case Report

Introduction: Eosinophilic gastroenteritis (EGE) is a rare disorder characterized by eosinophilic infiltration of the stomach and small intestine. Its clinical manifestations depend on the extent, location, and depth of the inflammatory infiltrate. The pathogenesis remains unclear, but it may be related to food allergy or other hypersensitivity reactions in some patients. Untreated cases can cause intestinal stricture or perforation, making timely diagnosis and intervention essential. Clinical case: A 13-year-old male adolescent was hospitalized due to symptoms suggesting intestinal obstruction or alterations in intestinal motility. Medical imaging revealed significant gastric distension and delayed gastric emptying. An endoscopic study showed a “snake-skin” pattern, duodenitis due to food stasis, a 2 cm ulcer, and stenosis in the duodenum. The biopsy confirmed EGE with significant irregular eosinophilic infiltration of the lamina propria. A panendoscopy was performed after steroid treatment without being able to assess the site of stenosis and perform pneumatic dilation. After completing the immunomodulatory management, a contrast-enhanced abdominal tomography was performed showed a significant decrease in the intestinal lumen, therefore an exploratory laparotomy with a lateral to lateral jejune-jejunal anastomosis was performed. Discussion: EGE is a rare inflammatory disorder characterized by eosinophilic infiltration of the stomach and small intestine. Symptoms are based on the affected gastrointestinal tract segment. In this case, our patient presented intestinal obstruction symptoms with endoscopic biopsies and a histopathological study confirmed eosinophil infiltration. Treatment typically involves identifying potential triggers and corticosteroids to reduce inflammation and symptoms. However, in this case, a decrease in the intestinal lumen was observed, therefore an elective surgical resection was performed. Conclusion: Eosinophilic gastroenteritis is a rare disorder that requires strong clinical suspicion to be diagnosed, which is why its knowledge is important. In this case, gastrointestinal symptoms, radiological and endoscopic images, in addition to the histopathological report, were key tools for integrating the diagnosis. Although management with steroids and immunomodulators was not successful, surgical management became an appropriate option as definitive treatment.

An extreme megaesophagus causing lung collapse.

An 83-year-old male with long-term dysphagia and weight loss was admitted due to an acute ST-elevation myocardial infarction. During hospitalization he developed hematemesis requiring several red blood cell transfusions. An upper endoscopy was attempted being interrupted due to esophageal high-volume stasis. Despite remaining fasting for several days and naso-esophageal tube drainage, three additional upper endoscopies still revealed non-removable solid food stasis in a markedly dilated esophagus and bleeding from severe underlying esophagitis. A thoracic CT confirmed an aberrant and massive esophageal dilation with 110x100mm and large food impaction leading to almost complete right lung atelectasis and respiratory failure. A narrow esophagogastric junction and no apparent associated obstructive lesions were also observed on CT scan. Based on clinical symptoms and radiologic findings a presumptive diagnosis of achalasia was considered although it could not be confirmed through esophageal manometry. Parenteral nutrition was started. Nevertheless, the patient died a few days later from aspiration pneumonia.

Severe esophageal candidiasis in a megaesophagus patient: a rare case

Megaesophagus is a largely dilated esophagus, an uncommon condition that could be the end-stage of preceding esophageal achalasia. Chronic food stasis such as in achalasia and megaesophagus could cause fungi infection in the esophagus. This report aimed to raise awareness of these rare cases. A 68-year-old male with two decades of swallowing difficulty was referred to Sardjito Hospital. Computed tomography esophagography showed megaesophagus and bird beak sign suggesting achalasia. Both esophagoscopy and esophageal tissue biopsy showed consistent results of severe esophageal candidiasis (EC). The patient was also suspected to have a mass at the distal part of the esophagus and gastric cardia, which could also contribute to the esophageal obstruction. We consulted the gastroenterologist for gastrostomy feeding and exploration of the suspected tumor. EC is known mainly in patients with immunodeficiency, while food stasis is a lesser-known cause. End-stage achalasia not only could lead to megaesophagus, but chronic food stasis is the perfect environment for fungi growth. Other causes of food stasis such as distal esophageal and gastric cardia tumors could also be the predisposition of EC. We reported a rare case of a patient with EC as a complication of megaesophagus and esophageal achalasia.

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.

Esophageal Dysbiosis in Achalasia and Cancer Development: A Critical Review.

Microorganisms provide various benefits to their human hosts, including assisting with digestion, synthesizing certain vitamins, developing the gastrointestinal and immune systems, regulating metabolism, and protecting against some pathogens. However, microbial imbalances can cause tissue damage and contribute to inflammatory disorders and cancers. Microbial dysbiosis refers to an imbalance or disruption in the normal composition and function of the microbial communities that inhabit various body parts, including the gut, oral cavity, skin, and reproductive tract. Emerging research suggests that microbial dysbiosis plays a significant role in cancer development and progression. This issue is particularly relevant in achalasia, in which food stasis, changes in endoluminal pH, and poor esophageal clearance might contribute to esophageal microbial dysbiosis. This study aimed to evaluate the association between dysbiosis and esophageal cancer development, focused on esophageal dysmotility disorders. This study is a critical review, gathering the current evidence for the association between dysbiosis and the development of esophageal cancer. Studies have shown that microbiota play a role in cancer development, although the mechanisms for how they do so are not yet fully understood. One possible explanation is that microbiota alterations can lead to chronic inflammation, promoting cancer cell growth. Additionally, some bacteria produce toxins that can damage DNA and cause genomic instability, and certain bacterial products can promote tumor growth. Despite the close relationship between dysbiosis and cancer development in esophageal dysmotility disorders, further investigations are still needed to elucidate the precise mechanisms by which dysbiosis contributes to cancer development and to identify potential therapeutic interventions targeting the microbiota to prevent or treat cancer.

Characteristics of the esophageal microbiome in patients with achalasia and its changes before and after peroral endoscopic myotomy: A pilot study.

Achalasia often presents with chronic food stasis and fermentation in the esophageal lumen, which may lead to alterations of the esophageal microbiome, with associated mucosal inflammation and dysplastic changes. The study aims to evaluate the characteristics of the esophageal microbiome in achalasia and changes of the esophageal microbiome before and after peroral endoscopic myotomy (POEM). This is a prospective case-control study. This study enrolled patients with achalasia and asymptomatic subjects as control group. Endoscopic brushing for esophageal microbiome collection was performed in all subjects, with additional follow-up endoscopy and brushing 3months after POEM in achalasia patients. The composition of the esophageal microbiome was determined and compared between (1) achalasia patients and asymptomatic controls and (2) achalasia patients before and after POEM. Thirty-one achalasia patients (mean age 53.5±16.2years; male 45.2%) and 15 controls were analyzed. We observed a distinct esophageal microbial community structure in achalasia patients, with increased Firmicutes and decreased Proteobacteria when compared with the control group at the phylum level. The discriminating enriched genera in achalasia patients were Lactobacillus, followed by Megasphaera and Bacteroides, and the amount of Lactobacillus was associated with the severity of achalasia. Twenty patients were re-examined after POEM, and a high prevalence of erosive esophagitis (55%) was noted, alongside an increase in genus Neisseria and decrease in Lactobacillus and Bacteroides. The altered esophageal microenvironment in achalasia leads to dysbiosis with a high abundance of genus Lactobacillus. Increased Neisseria and decreased Lactobacillus were observed after POEM. The long-term effect of microbial changes warrants further study.

Comparison of 2 Hours Fasting with Conventional 8 Hours Fasting Before Undergoing Upper Gastrointestinal Endoscopy

Endoscopy is performed in routine to diagnose gastrointestinal diseases. Usually, a patient has fast for 8 hours fast before undergoing endoscopy. But it has also been observed that 2 hours fast can have equal efficacy in clearing upper gastrointestinal tract for diagnosis of gastrointestinal disease and equivalent comfort for endoscopy. Objective: To compare the outcome of upper gastrointestinal endoscopy with 2 hours fasting versus 8 hours fasting (conventional method). Methods: Ninety cases (45 in each group) were enrolled and divided in two groups. Patients randomized to group A were asked to fast for 2 hours before undergoing endoscopy. In group B, patients underwent endoscopy after 8 hours fast. Just before procedure, patients were inquired if they felt hunger, thirst, weakness, anxiety, nausea or discomfort. The gastroenterologist also observed the patient for nausea or regurgitation at intubation, liquid or food stasis, and risk of aspiration during procedure. The quality of endoscopy was noted as gastric mucosa visibility and overall endoscopy quality rate was noted to. An overall endoscopy quality score >5 was deemed as good quality. Results: In the 2 hours fast group, no patient had hunger, thirst, or weakness before undergoing procedure while 27 (60.0%) patients had anxiety, 13 (28.9%) patients had nausea and 5 (11.1%) patients felt discomfort. In the 8 hours fast group, 5 (11.1%) patients had hunger, but no patient had thirst or weakness before undergoing procedure while 18 (40.0%) patients had anxiety, 13 (28.9%) patients had nausea and 9 (20.0%) patients were feeling discomfort. In 2 hours, fast group, all (100%) patients had comfort with endoscopy. Similarly, in 8 hours fast group, all (100%) patients had comfort with endoscopy. In the 2 hours fast group, gastroenterologist observed nausea in 32 (71.1%) patients, and liquid stasis in 13 (28.9%) patients, while regurgitation at intubation, food stasis, and risk of aspiration were not observed during endoscopy. In the 8 hours fast group, the gastroenterologist observed nausea in 45 (100%) patients, while liquid stasis, regurgitation at intubation, food stasis, and risk of aspiration were not observed during endoscopy. The difference in both groups was highly significant (p<0.05). The overall endoscopy quality rate was 7.47±0.51 in 2 hours fast group and 7.78±0.60 in 8 hours fast group (p<0.05). In both groups, all patients had score 7 or above and hence, a good quality of endoscopy. Conclusion: 2 hours fast prior to endoscopy achieved results equivalent to those achieved after 8 hours fasting. So, as a day case procedure, endoscopy can be performed within same day after 2 hours fast, instead of waiting for 8 prolonged hours.

Swallowing Problems after Thyroidectomy.

Introduction Thyroidectomy is a common procedure. Certain swallowing problems could happen after this surgery and affect the quality of life of the patient. Objective To evaluate swallowing after thyroidectomy in the early and late postoperative periods and to correlate subjective and objective parameters. Methods A prospective study with100 patients who underwent total thyroidectomy at our institution from April 2018 to September 2019. Each patient was assessed by the Arabic version of the Eating Assessment Tool (EAT-10) questionnaire and the fiberoptic endoscopic evaluation of swallowing (FEES) preoperatively, and in the early postoperative (EPO) and late postoperative (LPO) periods. Results The rate of dysphagia was of 82% in the EPO period, and of 36% in the LPO period. Two groups were compared regarding vocal fold mobility using the FEES. Group I included 89 patients with normal vocal fold mobility, 42% of whom had early dysphagia, and only 22% had late dysphagia. Regarding swallowing, we found that in the EPO period, the rates of delayed triggering, aspiration, penetration and residue were of 12.4%, 0%, 0%, and 42.7% respectively. Group II (unilateral immobile vocal fold) included 11 patients in the EPO evaluation, and all of them had early dysphagia. Conclusion Swallowing problems can occur in patients after thyroidectomy regardless of alterations in larynx mobility, and they are characterized by delayed triggering and stasis of food, which are also noticed in the LPO period, though more frequently in the EPO period. Moreover, there is a highly significant correlation between the subjective and objective parameters of swallowing in both EPO and LPO periods.

Swallowing Problems after Thyroidectomy

Abstract Background Dysphagia is the medical term that is used to describe the difficulty of swallowing and the feeling of difficulty in passage of solids or semisolids or liquids from the mouth to the stomach. Objectives The aim of this work is to evaluate swallowing after different types of thyroidectomy operations. Subjects and Methods This study is a prospective, randomized trial on evaluation of swallowing after different types of thyroidectomy operations. This thesis study was conducted on 100 patients underwent different types of thyroidectomy operations, recruited from otorhinolaryngology and general surgery outpatient clinic Ain Shams university hospital from April 2018 to September 2019. An informed consent was obtained from each patient or their legal guardians before enrolment in the study. Each patient assessed by A EAT-10 Questionnaire and FEES(functional endoscopic evaluation of swallowing) both (pre-operative, early post-operative(EPO) and late postoperative(LPO). Results The study include 100 patient and mean age of study cases was 37.4 ±10.1; females represented 94% of cases. Total thyroidectomy was performed in 94% of cases. Among our cases, we found that Dysphagia was scored 0% at pre-operative questionnaire, 82% at early post-operative questionnaire and 36% at late post-operative questionnaire. Two groups were compared by FEES: Group I with normal vocal fold mobility(NVFM) and Group II with abnormal vocal fold mobility(AVFM) (unilateral fixed vocal fold). Group I included 89 patients, Forty two percent of them had early Dysphagia, while only 22% of them had late dysphagia. As regard swallowing; we found that early post-operative delayed triggering, early post-operative aspiration; early postoperative penetration and early postoperative residue were 12.4%, 0%, 0% and 42.7% respectively. While late postoperative examination revealed that there was improvement of 6 patients and the number of patients of this group became 95 who had normal vocal fold mobility. And the swallowing evaluation revealed that as regard late post-operative delayed triggering, late post-operative aspiration; late post-operative penetration and late post-operative residue were 11.6%, 0%, 0% and 6.3% had respectively. Group II included 11patients at the early postoperative evaluation, all of them had early Dysphagia (100%). As regard the swallowing evaluation, we found that early post-operative delayed triggering, early post-operative aspiration early postoperative penetration and early postoperative residue were 100%, 54.5%, 100% and 45.5% respectively. But the late post-operative evaluation showed that 45% only of the cases of this group (5 cases) still had abnormal vocal fold mobility (unilateral fixed vocal fold). And as regard swallowing; we found late postoperative delayed triggering, late postoperative aspiration, late post-operative penetration and late post-residue were 100%, 100%, 80% and 0% respectively. Conclusion Dysphagia occurs in patients after thyroidectomy operations (regardless of larynx mobility alteration) and characterized by delayed triggering and stasis of food in the oro and hypopharynx, which is also noticed in LPO, though more frequently in EPO.

Esophageal Thermal Injury after Catheter Ablation for Atrial Fibrillation with High-Power (50 Watts) Radiofrequency Energy.

Background and ObjectivesData regarding the safety of atrial fibrillation (AF) ablation using high-power (50 W) radiofrequency (RF) energy in Asian populations are limited. This study was conducted to evaluate the incidence and pattern of esophageal injury after high-power AF ablation in an Asian cohort.MethodsWe searched the prospective AF ablation registry to identify patients who underwent AF ablation with 50 W RF energy using the smart touch surround flow catheter (Biosense Webster, Diamond Bar, CA, USA). Visitag™ (Biosense Webster) was used for lesion annotation with predefined settings of catheter stability (3 mm for 5 seconds) and minimum contact force (50% of time >5 g). All patients underwent upper gastrointestinal endoscopy at 1 or 3 days after the ablation.ResultsA total of 159 patients (mean age: 63±9 years, male: 69%, paroxysmal AF: 45.3%, persistent AF: 27.7%, long-standing persistent AF: 27.0%) were analyzed. Initially, 26 patients underwent pulmonary vein isolation with 50 W for 5 seconds at each point. The remaining 133 patients underwent prolonged RF duration (anterior 10 seconds and posterior 6 seconds). The incidence rates of esophageal erythema/erosion and superficial ulceration were 1.3% for each type of the lesion. Food stasis, a suggestive finding of gastroparesis, was observed in 25 (15.7%) patients. There were no cases of cardiac tamponade, stroke, or death.ConclusionsIn Asian patients, AF ablations using 50 W resulted in very low rates of mild esophageal complications.

DISTÚRBIO DE DEGLUTIÇÃO EM CRIANÇA COM COMPLEXO DE DOENÇAS PULMONARES INTERSTICIAIS: AVALIAÇÃO E PROPOSTA TERAPÊUTICA

Case report of a 7 month old baby with the disease studied, in which the evaluation and therapeutic proposal of the swallowing disorder was performed in home care. In the speech-language evaluation hypotonia of the musculature of the stomatognathic system was identified, and bite and GAG reflexes were present. It presented little tolerance to the intra-oral touch, with signs of stress during evaluation. A direct evaluation of swallowing was performed, offering 5ml of food in a homogeneous pasty consistency in which we observed respiratory incoordination and slow oral transit time, with food stasis in the oral cavity. Patient presented respiratory discomfort, crying, and irritability, with the presence of regurgitation of mucoid secretion and the refusal to a new attempt of supply. Patient with speech-language diagnosis of oropharyngeal dysphagia, with signs of eating difficulties. Speech-language intervention, global sensory stimulation, guidelines for those responsible and the nursing techniques team on posture, and therapeutic and stimulation activities were conducted. Patient presents a rare complex of pulmonary diseases and speech-language pathology is innovative in patients with this pathology.

Histopathological Analysis of Esophageal Mucosa in Patients with Achalasia.

Background/AimsAchalasia is an esophageal motor disorder that leads to functional esophageal obstruction. Food stasis and bacterial fermentation can predispose an individual to esophageal mucosal inflammation, causing multifocal dysplasia and increasing the risk of developing esophageal squamous cell carcinoma. We aimed to evaluate esophageal mucosal alterations in achalasia patients and determine clinical factors associated with the histopathological findings.MethodsFrom 2009 to 2013, we obtained endoscopic biopsies from the lower and middle esophagus of 22 patients with achalasia and 17 controls. Patients’ clinical data and histological severity of esophagitis were retrospectively analyzed. Additionally, immunohistochemical staining for CD3, CD20, Ki-67, and p53 was conducted.ResultsThe median age of achalasia patients was 49.5 years (range, 27 to 82 years), and there were nine males (40.9%). The median symptom duration was 5.8 years (range, 1 to 33.5 years), and 10 patients (45%) underwent previous treatment (nine, balloon dilation; one, botulinum toxin injection). Achalasia patients had significantly more severe esophagitis than did controls (p=0.001, lower esophagus; p=0.008, middle esophagus), and the number of CD3-positive lymphocytes exceeded that of CD20-positive lymphocytes (p<0.001). Achalasia patients also had a higher esophageal Ki-67 proliferation index (p=0.048). Although statistically nonsignificant, p53 expression was only observed in achalasia patients. There was no association between the histological severity of esophagitis and other clinicopathological findings.ConclusionsAchalasia patients showed significantly severe histological esophagitis and a high Ki-67 proliferation index, indicating an increased risk of neoplastic progression. Therefore, careful endoscopic inspection is necessary for the early detection of superficial neoplasia in these patients. (Gut Liver 2021;15-722)

Initial experience of single-incision plus one port left-side approach totally laparoscopic distal gastrectomy with uncut Roux-en-Y reconstruction.

BACKGROUNDSingle incision plus one port left-side approach (SILS+1/L) totally laparoscopic distal gastrectomy (TLDG) is an emerging technique for the treatment of gastric cancer. Reduced port laparoscopic gastrectomy has a number of potential advantages for patients compared with conventional laparoscopic gastrectomy: relieving postoperative pain, shortening hospital stay and offering a better cosmetic outcome. Nevertheless, there are no previous reports on the use of SILS+1/L TLDG with uncut Roux-en-Y (uncut R-Y) reconstruction.AIMTo investigate the initial feasibility of SILS+1/L TLDG with uncut Roux-en-Y digestive tract reconstruction (uncut R-Y reconstruction) to treat distal gastric cancer.METHODSA total of 21 patients who underwent SILS+1/L TLDG with uncut R-Y reconstruction for gastric cancer were enrolled. All patients were treated at The Second Hospital of Shandong University. Reconstructions were performed intracorporeally with 60 mm endoscopic linear stapler and 45 mm no-knife stapler. The clinicopathological characteristics, surgical details, postoperative short-term outcomes, postoperative follow-up upper gastrointestinal radiography findings and endoscopy results were analyzed retrospectively.RESULTSAll SILS+1/L operations were performed by SILS+1/L TLDG successfully. The patient population included 13 men and 8 women with a mean age of 48.2 years (ranged from 40 years to 70 years) and median body mass index of 22.8 kg/m2. There were no conversions to open laparotomy, and no other port was placed. The mean operation time was 146 min (ranged 130-180 min), and the estimated mean blood loss was 54 mL (ranged 20-110 mL). The mean duration to flatus and discharge was 2.3 (ranged 1-3.5) and 7.3 (ranged 6-9) d, respectively. The mean number of retrieved lymph nodes was 42 (ranged 30-47). Two patients experienced mild postoperative complications, including surgical site infection (wound at the navel incision) and mild postoperative pancreatic fistula (grade A). Follow-up upper gastrointestinal radiography and endoscopy were carried out at 3 mo postoperatively. No patients experienced moderate or severe food stasis, alkaline gastritis or bile reflux during the follow-up period. No recanalization of the biliopancreatic limb was found.CONCLUSIONSILS+1/L TLDG with uncut R-Y reconstruction could be safely performed as a reduced port surgery.

Comparison of the Clinical Outcomes Between Isoperistaltic and Antiperistaltic Anastomoses After Laparoscopic Distal Gastrectomy for Patients With Gastric Cancer.

Background: No consensus exists regarding the superiority of either of the two types of gastrointestinal anastomosis, which are isoperistaltic and antiperistaltic. This study aimed to compare the clinical outcomes between isoperistaltic and antiperistaltic anastomoses after total laparoscopic distal gastrectomy (TLDG) in patients with gastric cancer.Methods: We retrospectively reviewed the medical records of patients with gastric cancer who underwent TLDG with Billroth II anastomosis between January 2014 and December 2018. The patients were divided into two groups according to the peristaltic direction of gastrointestinal anastomosis after TLDG. One group underwent isoperistaltic anastomosis (Iso group), and the other underwent antiperistaltic anastomosis (Anti group). Clinical outcomes were compared between the groups.Results: Of the 148 patients who underwent TLDG with Billroth II anastomosis, 124 were included in the Iso group and 24 were included in the Anti group. The Anti and Iso groups showed no significant difference with regard to the incidence of internal hernia (0.0 vs. 6.5%, respectively; p = 0.355). The incidence of bile reflux was more frequent in the Iso group than in the Anti group (p = 0.010), but food stasis was more common in the Anti group than in the Iso group (p = 0.006).Conclusion: In gastric cancer patients who underwent TLDG in which postoperative adhesion was minimized, antiperistaltic anastomosis may have created a physiologic barrier in gastrointestinal continuity. However, a large-scale study is necessary to validate the relationship between the digestive stream and the peristaltic direction.

Immediate effect of neuromuscular electrical stimulation on swallowing function in individuals after oral and oropharyngeal cancer therapy.

Objective:To analyze the immediate effect of sensory and motor neuromuscular electrical stimulation, in oral and pharyngeal stages of swallowing, in individuals after oral and oropharyngeal cancer therapy.Methods:The study was conducted on 10 individuals (mean age of 58 years) submitted to oral and oropharyngeal cancer therapy. The individuals were submitted to videofluoroscopy, during which they were randomly asked to swallow 5 mL of liquid, honey, and pudding, in three conditions: without stimulation, with sensory neuromuscular electrical stimulation, and with motor neuromuscular electrical stimulation. The degree of swallowing dysfunction was scored (Dysphagia Outcome and Severity Scale), as well as the presence of food stasis (Eisenhuber scale), and measurement of the oral and pharyngeal transit time. The results were statistically analyzed by the Friedman test or analysis of variance for repeated measures.Results:The Dysphagia Outcome and Severity Scale revealed improvement for one individual with both sensory and motor stimuli, and worsening in two individuals, being one with motor and one with sensory stimulus. In the Eisenhuber scale, the neuromuscular electrical stimulation changed the presence of residues to variable extents. Concerning the oral and pharyngeal transit time, no difference was observed between the different stimulation levels for the consistencies tested (p > 0.05).Conclusion:Both sensory and motor neuromuscular electrical stimulations presented a varied immediate impact on the oral and pharyngeal stages of swallowing in individuals after oral and oropharyngeal cancer therapy. Thus, the results of the immediate effect suggest that the technique is not indicated, evidencing the need of caution in the use of neuromuscular electrical stimulation for the rehabilitation of dysphagia, after HNC treatment.

MYOFIBRILLAR AND DISTAL MYOPATHIES: P.253Severe intestinal pseudo-obstruction in a p.R405W desmin knock-in model: a new phenotype lead to light smooth muscle involvement in myofibrillar myopathies

The intermediate filament desmin, specifically expressed in striated and smooth muscle cells, forms a filament network which provides maintenance of cellular integrity, resistance to mechanical stress, force transmission and mechanochemical signaling. Abnormal expression or lack of desmin leads to a progressive disruption of the contractile machinery, which can be observed in the muscles from patients affected by myofibrillar myopathies (MFM) due to mutations of the desmin gene DES (DES-MFM). To clarify the pathophysiology of DES-MFM, we generated a mouse KI model expressing the R405W DES mutation, homologous to human R406W. This mutation is associated with a severe and relatively early clinical phenotype in patients, which develop muscular weakness, cardiopathy and respiratory failure from the third decade of life. Molecular studies showed that p.Arg406Trp desmin has a reduced ability to support longitudinal annealing as well as radial compaction, two essential steps required for the formation of the desmin network. Heterogygous DesWT/R405W as well as homozygous DesR405W/R405W KI mice showed abnormal accumulation of desmin at the subsarcolemmal membrane in striated muscles. Homozygous animals died early (at 3.4 ± 1.2 months) and developed severe dilatation of the intestinal tract associated with food stasis in the lumen around 3 months. Echographic and histological studies showed a thickening of the colon and desmin aggregates in all muscle segments of the digestive tract. Functional studies revealed reduced spontaneous contraction and strength generation of the homozygous duodenum, suggesting an alteration of the mechanical properties of smooth muscle cells. Intestinal malapsorption and pseudo-obstruction have been reported in very rare DES-MFM patients. Our model brings to light the importance of desmin for intestinal smooth muscles, and suggests that smooth muscle involvement may have been underestimated in patients suffering from MFMs.

Achalasia and esophageal cancer: risks and links.

Esophageal cancer affects more than 4,50,000 persons worldwide, and its incidence has increased in recent years. It is the eighth most common cancer across the globe. The main histologic types are esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EA), and their associated risk factors are well known. Achalasia, an idiopathic esophageal disorder that conditions aperistalsis and the absence of lower esophageal sphincter relaxation, stands out among them. The prevalence of ESCC in subjects with esophageal achalasia is 26 in every 1,000 cases, whereas the prevalence of EA is 4 in every 1,000. Patients with achalasia have a 50 times higher risk of presenting with ESCC than the general population, and the disease manifests 20–25 years after achalasia symptom onset. Multiple mechanisms are related to the development of ESCC in achalasia, and they include bacterial overgrowth, food stasis, genetic alterations, and chronic inflammation. Regarding the risk of EA in achalasia patients, most cases are associated with Barrett’s esophagus, due to uncontrolled chronic acid reflux. Given that achalasia is a well-established factor for ESCC/EA, clinicians must be aware of said associations to enable the development of programs for the prevention and opportune detection of these cancers in patients with achalasia.

Three-Port Right-Side Approach-Duet Totally Laparoscopic Distal Gastrectomy for Uncut Roux-en-Y Reconstruction.

This study presents the initial feasibility of three-port right-side approach-duet totally laparoscopic distal gastrectomy (R-duet TLDG) with uncut Roux-en-Y (R-Y) reconstruction for the treatment of lower- or middle-third gastric cancer. A total of 30 patients who underwent R-duet TLDG with uncut R-Y reconstruction for gastric cancer were enrolled. All patients were treated at the Catholic Medical Center. Reconstructions were performed intracorporeally without special instruments. The clinicopathological characteristics, operative details, postoperative short-term outcomes, and postoperative follow-up endoscopy results were analyzed retrospectively. All operations were performed by three-port R-duet TLDG. There were no conversions to an open approach, and no additional ports were placed. The mean operating time was 170 minutes, and the mean number of retrieved lymph nodes was 44. Three patients experienced mild postoperative complications, including small bowel ileus and pneumonia. Follow-up endoscopy was carried out at 3 months. No patients had experienced moderate-or-severe food stasis, alkaline gastritis, or bile reflux during the follow-up period. Recanalization of the biliopancreatic limb was not observed. R-duet TLDG with uncut R-Y reconstruction could be safely performed as a reduced port surgery without special instruments.

Roux Stasis Syndrome and Gastric Food Stasis After Laparoscopic Distal Gastrectomy with Uncut Roux-en-Y Reconstruction in Gastric Cancer Patients: A Propensity Score Matching Analysis.

Uncut Roux-en-Y gastrojejunostomy (uRYGJ) was developed to prevent slow peristalsis in the Roux limb after Roux-en-Y gastrojejunostomy (RYGJ). This study compared the incidence of Roux stasis syndrome (RSS) and severe gastric food stasis in gastric cancer patients who underwent RYGJ or uRYGJ after laparoscopic curative distal gastrectomy. Between January 2006 and June 2012, 319 patients underwent RYGJ or uRYGJ. After covariates were adjusted by propensity score matching, 39 patients in the RYGJ group and 65 patients in the uRYGJ group were included in the final analysis. RSS was defined as the presence of symptoms, such as nausea, vomiting, and abdominal fullness, requiring refasting without ileus or obstruction within 30days post-surgery. Gastric food stasis was measured endoscopically at 1 and 3 years after gastrectomy. Operative outcomes and morbidities were similar between the two groups, whereas the incidence of RSS was higher in the RYGJ group than in the uRYGJ group, although the difference was not significant (7.7 vs. 0%; odds ratio (OR) 0.157; 95% confidence interval (CI) 0-1.059, p = 0.111). Comparison of endoscopic findings revealed that severe gastric stasis 1 year after surgery was significantly less frequent in the uRYGJ group (46.2 vs. 13.8%; OR 0.247; 95% CI 0.102-0.599, p = 0.002). The same result was reproduced 3 years after surgery (39.4 vs. 15.5%; OR 0.279; 95% CI 0.088-0.882, p = 0.030). Compared with RYGJ, uRYGJ after laparoscopic distal gastrectomy is a safe and effective procedure for preventing severe postoperative gastric food stasis.

Esophageal Achalasia: Pathophysiology, Clinical Presentation, and Diagnostic Evaluation

Esophageal achalasia is a primary esophageal motility disorder characterized by the absence of esophageal peristalsis and failure of the lower esophageal sphincter to relax in response to swallowing. These abnormalities lead to impaired emptying of food from the esophagus into the stomach with resulting food stasis. Most patients experience severe dysphagia, and regurgitation can lead to aspiration and respiratory problems. Consequently, the quality of life of patients affected by achalasia is severely impacted. A thorough evaluation with upper endoscopy, barium swallow, and esophageal manometry is mandatory to establish the diagnosis and plan the optimal treatment. In selected patients, an ambulatory pH monitoring is recommended to distinguish between gastroesophageal reflux disease and achalasia.