Management Of Esophageal Disease Research Articles

Measuring and improving quality in esophageal care and swallowing disorders.

Evaluating clinical care through quality-related metrics is increasingly common. There are now numerous quality statements and indicators related to the medical management of benign and pre-malignant esophageal diseases. Expert consensus leveraging evidence-based recommendations from published society guidelines has been the most frequently used basis for developing esophageal quality statements. While surgical care of patients with esophageal malignancies, including squamous cell carcinoma, has also been developed, those related to benign esophageal disease now include domains of diagnosis, treatment, and monitoring for gastroesophageal reflux disease, eosinophilic esophagitis (EoE), achalasia, and Barrett's esophagus (BE). Several recent studies evaluating adherence to quality metrics affirm substantial variation in practice patterns with opportunities for improvement in care across esophageal diseases. In particular, patient education regarding treatment options in achalasia, frequency of esophageal biopsies among patients with dysphagia to evaluate for EoE, and endoscopic evaluation within a BE segment are areas identified to have need for improvement. As the management of esophageal diseases becomes more complex and interdisciplinary, adherence to quality metrics may be a source of standardization and improvement in delivery and ultimately patient outcomes. Indeed, the development of national quality databases has resulted in a significant growth in the use of these metrics for quality improvement activities and may form the basis for future inclusion in quality reporting and payment programs.

Relationship Between Esophageal Disease and Pulmonary Fibrosis

Esophageal disorders are prevalent among patients with chronic lung diseases, including idiopathic pulmonary fibrosis (IPF). Gastroesophageal reflux disease (GERD) has been associated with IPF prevalence, severity, and respiratory decline. The pathophysiologic relationship between GERD and IPF is likely bidirectional, with aspiration of refluxate leading to lung inflammation and fibrosis, while the restrictive pulmonary physiology may contribute to altered transdiaphragmatic pressure gradient and increased reflux. Esophageal symptoms are frequently absent and do not predict esophageal dysfunction or pathologic reflux in patients with IPF, and objective diagnostic tools including upper endoscopy, ambulatory reflux monitoring, and high-resolution manometry are often needed. Impedance-based testing that identifies both weakly/non-acidic and acid reflux may provide important additional diagnostic value beyond pH-based acid testing alone. Novel metrics and maneuvers, including advanced impedance measures on impedance-pH study and provocative testing on HRM, may hold promise to future diagnostic advancements. The main treatment options include medical therapy with acid suppressants and anti-reflux surgery, although their potential benefits in pulmonary outcomes of IPF require further validations. Future directions of research include identifying phenotypes of IPF patients who may benefit from esophageal testing and treatment, determining the optimal testing strategy and protocol, and prospectively assessing the value of different esophageal therapies to improve outcomes while minimizing risks. This review will discuss the pathophysiology, evaluation, and management of esophageal diseases, particularly GERD, in patients with IPF, as informed by the most recent publications in the field, in hopes of identifying targets for future study and research.

S1503 Barriers and Facilitators to Shared Decision-Making Implementation in the Management of Esophageal Diseases: A Mixed Methods Study

S1503 Barriers and Facilitators to Shared Decision-Making Implementation in the Management of Esophageal Diseases: A Mixed Methods Study

Demystifying Esophageal Lichen Planus: A Comprehensive Review of a Rare Disease You Will See in Practice.

Lichen planus (LP) is a chronic inflammatory disorder that often affects the skin, hair, nails, and mucus membranes. Although esophageal involvement has traditionally been felt to be rare, recent reports suggest that it is often unrecognized or misdiagnosed. The diagnoses of esophageal lichen planus can be challenging and is suspected based on patients' endoscopic and histologic findings and in the context of their clinical history and physical examination. Physicians must have an index of suspicion, particularly in older white women and in those patients with an atypical esophagitis or stricturing disease, which do not respond to traditional treatment. Currently, there are limited data on esophageal lichen planus patients, and no formal management guidelines for this disease, which all gastroenterologists will see in practice. This article reviews the etiology and histopathology of LP and provides a comprehensive discussion of the clinical features, diagnosis, and management of esophageal disease from the gastroenterologist's perspective. Finally, we address the esophageal complications of LP.

Expanding Role of Third Space Endoscopy in the Management of Esophageal Diseases.

OPINION STATEMENT: "Third space" endoscopy, also commonly referred as submucosal endoscopy, is founded on the principle that the deeper layers of the gastrointestinal (GI) tract can be accessed by tunneling in the submucosal space without compromising the integrity of the overlying mucosa. Peroral endoscopic myotomy (POEM), endoscopic submucosal dissection (ESD), and submucosal tunneling endoscopic resection (STER) are innovative techniques within the field of third space endoscopy in the management of esophageal disorders. POEM has become an accepted minimally invasive therapy for achalasia and related motility disorders with excellent short-term results, with early studies yielding similar efficacy to surgical myotomy and increased durability when compared to pneumatic balloon dilation (PBD). Data are needed to establish long-term outcomes with POEM, with particular interest on the incidence of gastroesophageal reflux, which appears to be higher than initially anticipated. ESD, a mature endoscopic resection technique in Asia, has recently gained traction in the West as a viable option for the management of early Barrett's esophagus (BE) neoplasia. Compared to standard endoscopic mucosal resection (EMR), ESD allows the en bloc resection of lesions irrespective of size, which may facilitate histological interpretation and reduce recurrence rates. Large prospective randomized controlled trials are needed to validate the efficacy and safety of this technique and to further define its role in the endoscopic armamentarium in early BE neoplasia. STER is an attractive technique that theoretically permits the resection of subepithelial esophageal tumors (SETs) arising from the deeper GI layers. Initial studies from highly experienced endoscopic centers support its technical feasibility and safety, although these results should be interpreted with caution due to variability arising from small numbers and heterogeneity among studies. Overall, third space endoscopy is an expanding field within endoscopic therapeutics for the treatment of esophageal diseases. While initial results have been very promising, large prospective studies, long-term data, and structured training programs with the establishment of competency parameters are needed before third space endoscopy can be advocated outside of highly specialized centers.

Can We Use Diet to Effectively Treat Esophageal Disease? A Review of the Current Literature.

Esophageal diseases represent a wide variety of conditions affecting esophageal anatomy, physiology, and motility. Therapy focuses on pharmacotherapy and endoscopic or surgical management. Dietary therapy can be considered in management algorithms for specific esophageal diseases. This review focuses on outlining the literature related to dietary therapy in gastroesophageal reflux disease, eosinophilic esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. Currently, data are strongest for dietary manipulation in eosinophilic esophagitis, specifically the six-food elimination diet. Dietary effects on gastroesophageal reflux disease are less clear, though newer research indicates that increased fiber with reduction in simple sugar intake may improve symptoms. In terms of Barrett's esophagus and esophageal adenocarcinoma, antioxidant intake may affect carcinogenesis, though to an unknown degree. Outcomes data regarding dietary manipulation for the management of esophageal diseases is heterogeneous. Given the rising interest in non-pharmacological treatment options for these patients, continued research is warranted.

Application of the Functional Lumen Imaging Probe to Esophageal Disorders.

The functional luminal imaging probe (FLIP) provides a novel method to evaluate esophageal physiology and function in both health and disease. FLIP enables assessment of a previously underexplored component of esophageal function, distensibility, by utilizing high-resolution impedance planimetry to evaluate the relationship of the esophageal luminal geometry with pressure during controlled volumetric distension. Recent studies have described the potential utility of FLIP to evaluate the severity and effectiveness of therapy for esophageal diseases including achalasia, gastroesophageal reflux disease, and eosinophilic esophagitis. This review summarizes these emerging clinical applications of FLIP in the evaluation and management of esophageal diseases.

Novel insights into esophageal diagnostic procedures.

The 21st century offers new advances in diagnostic procedures and protocols in the management of esophageal diseases. This review highlights the most recent advances in esophageal diagnostic technologies, including clinical applications of novel endoscopic devices, such as ultrathin endoscopy and confocal laser endomicroscopy for diagnosis and management of Barrett's esophagus; novel parameters and protocols in high-resolution esophageal manometry for the identification and better classification of motility abnormalities; innovative connections between esophageal motility disorder diagnosis and detection of gastroesophageal reflux disease (GERD); impedance-pH testing for detecting the various GERD phenotypes; performance of distensibility testing for better pathophysiological knowledge of the esophagus and other gastrointestinal abnormalities; and a modern view of positron emission tomography scanning in metastatic disease detection in the era of accountability as a model for examining other new technologies. We now have better tools than ever for the detection of esophageal diseases and disorders, and emerging data are helping to define how well these tools change management and provide value to clinicians. This review features novel insights from multidisciplinary perspectives, including both surgical and medical perspectives, into these new tools, and it offers guidance on the use of novel technologies in clinical practice and future directions for research.

Should a Thoracic Surgeon Transfer a Complicated Case to a Competing Medical Center Against the Hospital’s Order?

Robert M. Sade, MD The Patient Protection and Affordable Care Act was signed into law several years ago, but the future of the emerging health care system remains unclear. The law is not popular and the political outlook for many of its key components is in doubt. Certain aspects of health care can be predicted with considerable confidence, however: an increasing role for bureaucracies and decreasing power of physicians. These trends pose dilemmas for surgeons, particularly when a conflict of loyalties is created when hospital administrators demand that physicians place the interests of the medical center before the interests of patients. The question of how to respond to such conflicts of loyalties was debated at the 61st Annual Meeting of the Southern Thoracic Surgical Association. The session focused on the case of a surgeon faced with a complex clinical situation that would require operative management, either in her own hospital, as demanded by an administrator, or in a competing hospital after referral to a surgeon more experienced in handling such cases. A Case of Divided Loyalties Dr. Elizabeth Black, a young cardiothoracic surgeon in a 400 bed community hospital, receives a call from the emergency department regarding a patient with a confirmed diagnosis of perforated esophagus, which occurred more than 24 hours ago. The patient is stable, but has early sepsis and multiple co-morbidities, including alcohol abuse. The hospital where the surgeon works has 2 groups of cardiothoracic surgeons in competition with one another, all of whom do cardiac surgery and most of whom also do some general thoracic surgery. None of the surgeons has special expertise with esophageal surgery — they generally refer elective esophageal cases to a large university hospital 50 miles away, which has an international reputation in the management of esophageal disease. Dr. Black feels it would be in the patient's best interest to be transferred to the university hospital instead of caring for him locally. When arrangements for transfer are begun, the hospital administrator informs the surgeon that she must accept the patient and care for him. The hospital is in the same market catchment area as the university and does not wish to lose patients to its competitor, especially a patient who has already been seen in its emergency department. Dr. Black feels uncomfortable in accepting this patient, and does not feel confident in her ability to optimize his chances of survival. Nonetheless, financial arrangements and competition with the other group of surgeons make it very difficult to refuse the hospital's demand – she is board-certified and through her education and training, she knows the correct care of the patient, and has done similar cases as a resident. The patient's social situation (no apparent family members) and current medical condition do not allow him to make an informed decision about his locus of care. In case of a bad outcome, legal repercussion are highly unlikely. Dr. Black asks two of her out-of-state surgical colleagues to advise her on what she should do.

Evolution in the treatment of esophageal disease at a single institution: 2004-2013.

96 Background: The aim of this study was to analyze the evolution in the surgical management of esophageal disease at an academic medical center during the last decade. Methods: We reviewed a retrospective cohort of patients who underwent esophagectomy between 2004 and 2013 for benign and malignant esophageal disease. Patient, institutional and postoperative variables were abstracted and reviewed across the study period. Results: 317 patients were analyzed. The median age was 63.5 years and 80% were male. Malignancy accounted for 88% of esophagectomy patients in 2004 and 97% in 2013. Operations for high grade dysplasia (HGD) decreased 75% in the same period (p=0.008). In 2004, an Ivor Lewis esophagectomy was the most common surgical technique but the 3-Field technique has become the operation of choice in 2013 (54% vs.71%, p<0.001). Likewise, a laparoscopic approach was used in 19% of cases in 2004 and 100% of cases in 2013 (p<0.001). Median lymph node harvest increased from 7 to 18 nodes (p=0.001). Atrial fibrillation was the most common perioperative complication (24%) and anastomotic leaks ranged between 3 to 14% (p=0.18), occurring in 3% of patients in 2013. Hospital stay decreased from 15 to 8 days over the study period (p=0.001). In 2013, 89% of patients were discharge to home compared to 73% in 2004 (p=0.04). The average mortality rate for our cohort was 3.5%. Conclusions: Over the last decade, our treatment of esophageal disease has evolved from a predominant open Ivor Lewis to a laparoscopic 3-Field approach. Operations for malignancy have also increased dramatically. Postoperative complications and mortality has been consistently low during the latter years of the study.

Experience with rigid esophagoscopy in Jos, north-central Nigeria.

Esophagoscopy which may be done for either a therapeutic or diagnostic reason has remained useful in the management of esophageal diseases. This study evaluates our experience with rigid esophagoscopy with special emphasis on esophageal foreign bodies in our unit. This is a six-year (January 2000-December 2005) retrospective review of cases of rigid esophagoscopy in the Ear, Nose and Throat Unit of our center. Fifty-seven patients with ages ranging from 10 months 75 years were studied. There were 35 (61.4%) males and 22 (38.6%) females. Fifty-three of the patients (93%) had varying foreign bodies in the esophagus, 3 (5.2%) patients had carcinoma of the esophagus while 1 (1.8%) had pharyngeal pouch. The 0-10 year age group had the highest prevalence of esophageal foreign bodies (66.0%) with the middle third of the esophagus been the commonest site of impaction (58.5%). There was no fatality recorded. Rigid esophagoscopy is a relatively safe procedure in trained hands and ideal environment with the necessary facilities in place.

The Use of Self-Expanding Silicone Stents in Esophagectomy Strictures: Less Cost and More Efficiency

Benign and postoperative anastomotic esophageal strictures remain a common problem in the management of esophageal diseases and cancer. Repeated dilation remains the most common treatment algorithm. Esophageal stenting with a removable plastic stent is another option. This study evaluated the dysphagia effects and cost of removable silicone stents in the management of benign and postoperative anastomotic strictures compared with standard repeat dilation. A matched case-control study was done of benign esophageal stricture treatments from July 2004 to August 2006 in all patients treated for benign esophageal strictures identified in a prospectively maintained esophageal database. Eighteen patients had a retrievable silicone-covered stent placed, and 24 were treated with standard repeated dilations without stents. Early esophageal stenting vs repeated dilation in esophagectomy strictures and other benign strictures was compared. The median number of dilatations was two (range, 1 to 3) for the 18 stent patients, with all stents placed for 3 months' duration, and four dilations (range, 2 to 12) in 24 patients treated solely with dilatation. An evaluation of median, high, and low total charges, net revenue, and direct margin demonstrated that the use of a removable stent after one failed dilation was more cost-efficient than repeated dilations. In patients who do not respond to initial dilation, placement of removable esophageal stent at the second dilation leads to improved quality of life and dysphagia relief. Early use of a removable esophageal stent is significantly more cost-efficient when two or more esophageal dilations are avoided.

The Use of Self-Expanding Silicone Stents in Esophageal Strictures: Less Cost and More Efficiency

Background. Benign and postoperative anastomotic esophageal strictures remain a common problem in the management of esophageal diseases and cancer. Repeated dilation remains the most common treatment algorithm. Esophageal stenting with a removable plastic stent is another option. This study evaluated the dysphagia effects and cost of removable silicone stents in the management of benign and postoperative anastomotic strictures compared with standard repeat dilation. Methods. A matched case-control study was done of benign esophageal stricture treatments from July 2004 to August 2006 in all patients treated for benign esophageal strictures identified in a prospectively maintained esophageal database. Eighteen patients had a retrievable siliconecovered stent placed, and 24 were treated with standard repeated dilations without stents. Early esophageal stenting vs repeated dilation in esophagectomy strictures and other benign strictures was compared. Results. The median number of dilatations was two (range, 1 to 3) for the 18 stent patients, with all stents placed for 3 months’ duration, and four dilations (range, 2 to 12) in 24 patients treated solely with dilatation. An evaluation of median, high, and low total charges, net revenue, and direct margin demonstrated that the use of a removable stent after one failed dilation was more cost-efficient than repeated dilations. Conclusions. In patients who do not respond to initial dilation, placement of removable esophageal stent at the second dilation leads to improved quality of life and dysphagia relief. Early use of a removable esophageal stent is significantly more cost-efficient when two or more esophageal dilations are avoided.

The nutritional management of gastrointestinal tract disorders in companion animals

Dietary protein, carbohydrates, fats and fibre have marked influences on gastrointestinal tract function and dysfunction. This article reviews the nutritional management of common gastrointestinal disorders in companion animals and introduces some of the current areas of research including probiotics, prebiotics, protein-hydrolysate diets, immunonutrition and dietary fibre. Nutritional management of oesophageal disease revolves around varying the consistency of the diet and feeding the animal from an elevated container. Provision of bowel rest remains the mainstay of the management of acute gastroenteritis but food-based oral rehydration solutions are a useful adjunct. The recommended diet for chronic small bowel diarrhoea is a highly digestible, hypoallergenic, gluten-free, low-lactose and low-fat diet with modest amounts of fermentable fibre. The use of probiotics in the management of diarrhoea in companion animals has not yet been shown to be beneficial. It is likely that prebiotics will prove more effective than probiotics in the prevention of enteropathogenic infections. Approximately 50% of cats in New Zealand that suffer from chronic idiopathic vomiting or diarrhoea will respond to a novel-protein-elimination diet and approximately 30% meet the diagnostic criteria for food sensitivity. Growing evidence supports the use of protein-hydrolysate diets in the management of inflammatory bowel disease and further advances in immunonutrition are expected. The dietary management of colitis should include a hypoallergenic diet with a fermentable fibre source. Manipulation of the diet provides clinicians a powerful therapeutic strategy to be used alone or concurrently with drug therapy in the management of gastrointestinal disorders.

Photodynamic Therapy for Esophageal Diseases: A Clinical Update

Photodynamic therapy (PDT) is a "drug and device" therapy that combines the use of a photosensitizing agent and a photosensitizer (a drug that selectively accumulates and is preferentially retained in dysplastic or neoplastic cells). When activated by light of a specific wavelength in the presence of oxygen, the photoactive compound produces rapid cell death in the target tissue. While studied in nearly every area of medicine, PDT has been applied most extensively in the treatment of Barrett's mucosa, dysplasia, and early and advanced cancer of the esophagus. This article represents an extensive survey of literature to review the experience gained with PDT and to assess its clinical value in the management of esophageal diseases.

Management of Oesophageal Disease in the Elderly

Oesophageal disease becomes increasingly common with age and is therefore prevalent in the elderly (<70 yr). Oesophageal disease may present with symptoms related to the oesophagus‐dysphagia, odynophagia or chest pain‐and presents a number of management challenges related to the presence of comorbidities in this group. With the exception of infections and the occasional malignancy, diseases affecting the oesophagus are generally chronic, progressive and not amenable to curative therapy.Oesophageal diseases affecting the elderly may be grouped into gastrooesophageal reflux disease, motility disorders, malignancy, infection and drug‐induced oesophageal disease.This article reviews the use of drugs and their place in the overall management of these disorders.

Practical Management of Oesophageal Disease

Practical Management of Oesophageal Disease

Diagnosis and management of esophageal disease in the acquired immunodeficiency syndrome.

Esophageal disorders are common complications of human immunodeficiency virus (HIV)-infected patients. In a significant number of patients, the esophagus may be the site of the first acquired immunodeficiency syndrome (AIDS)-defining opportunistic illness. We reviewed pertinent articles, obtained from a MEDLINE search, on the diagnosis and treatment of esophageal diseases in HIV disease. Infections are the most common cause of esophageal disease, and opportunistic disorders such as cytomegalovirus and idiopathic esophageal ulceration rarely present until the CD4 lymphocyte count falls below 100/mm3. Endoscopy is the most valuable tool for evaluating esophageal complaints in AIDS. Almost all esophageal infections in patients with AIDS are treatable; therefore, a thorough work-up is indicated. With the widespread use of more effective antiretroviral therapy including the protease inhibitors, there is a general consensus that the incidence of many opportunistic diseases appears to be decreasing.

Short-segment intestinal interposition of the distal esophagus

Esophageal replacement remains a challenge. Colon and jejunum provide alternative conduits to replace the lower esophagus when stomach is not suitable. Between 1971 and 1991, 41 patients underwent short-segment interposition of the esophagus with jejunum or colon. Indications were failed antireflux procedures (n = 21), nondilatable stricture (n = 9), achalasia (n = 2), moniliasis (n = 2), Barrett's esophagus with carcinoma in situ (n = 2), hemorrhagic esophagitis after esophagogastrectomy (n = 1), motility disorder (n = 1), instrumental perforation (n = 1), carcinoma (n = 1), and leiomyosarcoma (n = 1). Thirty-one patients (75.6%) had prior surgical procedures. Interposition with colon was performed in 22 patients and with jejunum in 19. Major complications occurred in 45% after colon interposition (10/22) and hospital mortality was 4.5% (1/22). Major complications after jejunal interposition occurred in 31% (6/19) and hospital mortality was 10.5% (2/19). A contained anastomotic leak occurred in 1 patient, perforation of a colon segment in 1, and jejunal graft necrosis in a third. Late functional results in 34 patients with a mean follow-up of 87 months were excellent or good in 26, fair in 5, and poor in 1. Colon interposition failed to improve symptoms in 2 patients with gastrointestinal motility disorders. Six patients underwent manometry and barium food provocation study. Two colon segments and 3 jejunal interpositions were hypoperistaltic or aperistaltic according to manometry. There was 1 case of aperistaltic jejunum with a distended afferent loop. When stomach is not available, successful palliation of swallowing can be accomplished with either jejunum or colon. Surgeons involved in the management of esophageal disease should be familiar with the technical details of both procedures.

Management of Esophageal Disease

This book on esophageal disease represents a comprehensive and monumental review by two surgeons of great experience in esophageal problems. The book is almost entirely authored by Drs Skinner and Belsey, except for 4 of the 57 chapters contributed by other members of the departments of anesthesiology, gastroenterology, radiology, and psychiatry at the University of Chicago (Ill). The book begins with a section on the normal esophagus, including embryology, anatomy, and physiology, and then goes on to the investigation of esophageal disease, including radiological studies, endoscopy, and esophageal function tests. The next sections deal with medical therapy and esophageal manifestations of psychiatric disease and with principles and techniques of surgical treatment. A section on congenital problems of the esophagus is included, followed by a section on neuromuscular functional disorders, a long section (12 chapters) on hiatal hernia and reflux esophagitis, a section on benign strictures, sections dealing with neoplasms of