Pneumatic Dilation Research Articles

Comprehensive Approaches to the Treatment of Esophageal Achalasia

Introduction and purpose Achalasia is the most prevalent primary esophageal motility disorder, marked by improper relaxation of the lower esophageal sphincter (LES), increased resting pressure in the LES, and a lack of peristalsis in the esophagus. Symptoms include difficulty swallowing (dysphagia), regurgitation, chest pain, and weight loss. Due to the nonspecific nature of these symptoms, diagnosis can be delayed by several years. Since the underlying cause of achalasia is still unknown, treatment options focus on alleviating symptoms by targeting the lower esophageal sphincter. Materials and methods This paper is based on a literature review sourced from PubMed, using the following keywords: achalasia, POEM, laparoscopic cardiomyotomy, pneumatic dilation, and botulinum toxin injection. Results Various treatment options are available for achalasia, each offering unique features and results. The main approaches include Peroral Endoscopic Myotomy (POEM), Laparoscopic Myotomy (LM), Botulinum Toxin Injection, and Pneumatic Dilation (PD). Conclusion Each treatment differs in its level of invasiveness, duration of symptom relief, risk of complications, and the likelihood of requiring additional interventions. The selection of the most suitable option is influenced by individual patient factors, such as the type and severity of achalasia, overall health, and personal preference

Sex/Gender Differences in Esophageal Motility Disorders

Esophageal motility disorders are relatively rare and are attributed to an imbalance between the excitatory and inhibitory nerves that innervate the esophagus. These disorders include achalasia, distal esophageal spasms, and jackhammer esophagus. The prevalence of achalasia is equal in men and women; however, lower esophageal hypermotility disorders are slightly more common in women. Women with achalasia experience chest pain more frequently, whereas men tend to have high lower esophageal sphincter pressure. Additionally, women with achalasia respond better to pneumatic balloon dilatation than men. However, research on sex and gender differences in the outcomes of peroral endoscopic myotomy remains insufficient. Future studies should investigate the differences in outcomes, complications, and long-term effects to ensure optimal treatment in men and women with esophageal motility disorders. This research will be useful to develop sex-tailored treatments for esophageal motility disorders.

Elevated preoperative lower esophageal sphincter pressure predicts improved clinical outcomes after per oral endoscopic myotomy (POEM).

Although per oral endoscopic myotomy (POEM) has shown to be beneficial forthe treatment ofachalasia, it can be difficult to predict who will have a robust and long-lasting response. Historically, it hasbeen shownthat higher lower esophageal sphincter pressures havebeen associatedwith poorer responses to alternative endoscopic therapies such as Botox therapy and pneumatic dilation. This studywas designedto evaluate if modern preoperative manometric data could similarly predict response totherapyafter POEM. This was a retrospective study of 237 patients who underwent POEM at a single institution over a period of 13years (2011-2023) and who had a high-resolution manometry performed preoperativelyandan Eckardt symptom score performed both preoperative and postoperatively. The achalasia type and integrated relaxation pressures (IRP) were tested for potential correlation with the need for any further achalasia interventions postoperativelyaswell asthe degree of Eckardt score reduction using a linear regression model. The Achalasia type on preoperative manometry was not predictive for further interventions or degree of Eckardt score reduction (p = 0.76 and 0.43, respectively). A higher IRP was not predictive of the need forfurtherinterventions, however, it was predictive of agreaterreduction in postoperative Eckardt scores (p = 0.03)asshown by the non-zero regression slope. In this study, achalasia type was not a predictive factor in the need for further interventions or the degree of symptom relief.Although IRPwas not predictive ofthe need for further interventions, a higher IRPdid predictbetter symptomatic relief postoperatively.This result is opposite that of other endoscopic treatment modalities (Botox and pneumatic dilation). Therefore, patients with higher IRP on preoperative high-resolution manometry would likely benefit from POEMwhichprovides significant symptomatic relief postoperatively.

ThP3.5 - A systematic review of comparing the outcomes of per-oral endoscopic myotomy vs pneumatic dilation in patients diagnosed with achalasia

Abstract Objective The objective of this meta-analysis is to compare the success rate of per-oral endoscopic myotomy (POEM) versus pneumatic dilation (PD) for patients with achalasia. Methods Studies reporting success rates and symptoms in patients undergoing POEM versus PD were selected from medical electronic databases and meta-analysis was conducted by following the guidelines of the Cochrane Collaboration using statistical software RevMan version 5. Results Four studies on 319 patients reporting success rates and Eckardt scores were included. In the random effect model analysis, the success rate [odds ratio (OR) 6.22, 95%, CI (3.23, 11.97), Z = 5.47, p = 0.00001] favoured the PD and there was no heterogeneity (Tau2 = 0; Chi2 = 1.29, df = 2 (P = 0.53; I2 = 0 %) among included studies. Eckardt scores [mean difference -0.36, 95%, CI (-0.76, 0.03), Z = 1.79, p = 0.07] suggesting the achalasia symptoms severity was also similar in both interventions. There was moderate heterogeneity (Tau2 = 0.10; Chi2 = 7.47, df = 3 (P = 0.06; I2 = 60 %) among the included studies. Conclusion The POEM seems to be more successful when compared to the PD for patients with achalasia. On comparison of Eckardt score, there was no statistical difference seen between the two groups.

SP4.11 - Retrospective review of achalasia management in a tertiary UGI centre

Abstract Introduction Achalasia is a rare disorder significantly impacting quality of life (QoL). Medical management includes calcium channel blockers (CCB), Pneumatic dilatation (PD) and Peroral endoscopic myotomy (POEM). Surgical management includes laparoscopic Heller’s myotomy (HM) or more recently robotic assisted Heller’s Myotomy. Aim This is a retrospective study of management of patients with achalasia in a tertiary Upper GI centre. Material and method Data was collected retrospectively between 2013-2023 (10 years) and analysed using Prism 10. In this period, 193patients with suspected achalasia were analysed and only 89patients with confirmed diagnosis were included. Results Of these 89 patients, 46 were female (48%) and 43 were male (52%). The median age was 61years (range 21-94years). 64 patients (72%) were local referrals and 25 patients (28%) were referred via the network. 3 patients (3%) were acute admissions. 45 patients (50%) received medical therapy initiated by gastroenterologists. 6 patients (6.7%) received CCB, 17 patients (19%) received endoscopic Botox and 22 patients (25%) underwent PD. 6 patients (27%) developed perforation post PD; of these, 3 patients underwent surgical repair and had a prolonged hospital stay. Of the 66 patients (74%) who underwent surgery, 55 patients (61%) had laparoscopic HM, 8 patients (9%) underwent robotic assisted HM and 1 patient (1%) had open HM. Average Length of stay was 5.8 days for laparoscopic HM and 3.9 days for robotic HM. In the laparoscopic HM group 3 patients (5%) had iatrogenic oesophageal injury repaired perioperatively and a further 5 patients (8%) needed oesophageal dilation for residual dysphagia. No complication was noted in the robotic HM group. Conclusion Surgery remains the treatment of choice for achalasia. Early outcomes of robotic surgery look promising, with lesser complication rates thus improving quality of life.

Dysphagia, dyspnoea, dizziness, and ‘inverted D’: Abnormal LV eccentricity secondary to extrinsic compression by oesophageal achalasia

AbstractExtrinsic compression of the left atrium (LA) due to oesophageal achalasia though uncommon has been reported in literature. This case report describes a middle‐aged man who presented with sudden onset dyspnoea and atrial fibrillation, but was later diagnosed to have achalasia cardia and megaoesophagus, resulting in extrinsic compression of the LA as well as posterobasal wall of the left ventricle (LV). The patient's early complaints of dysphagia and weight loss prompted a thorough study, with echocardiography helping to identify extrinsic compression of heart chambers caused by the dilated oesophagus. The left ventricular eccentricity index was increased secondary to compression by volume‐loaded megaoesophagus, which was one of the most notable findings. Through this case, we describe probably the first case of LV compression by achalasia cardia, in addition to LA and we want to highlight the fact that D‐shaped LV can also occur secondary to extrinsic etiologies particularly compression from posterior mediastinal structures.

498. LATROGENIC ESOPHAGEAL DISEASE POST OBESITY TREATMENT: SEVERE ESOPHAGEAL DILATATION RELATED TO ADJUSTABLE GASTRIC BANDING (AGB)

Abstract Iatrogenic Esophageal Disease post obesity treatment: severe esophageal dilatation related to adjustable gastric banding (AGB) Introduction Obesity is considered one of the biggest epidemics of the 21st century, which pushes us as health professionals to seek for solutions to this pathology. Within the medical-surgical approach, the most used techniques are gastric bypass, vertical gastrectomy and adjustable gastric banding (AGB). Even though they are frequently used, they are not free of complications. In this communication based on a case we would like to comment on the main complications of the use of the gastric band. These side effects has being between 0.5-5% to 20%: stoma stenosis, band slippage, intraluminal erosion, gastric volvulus and perforation. Clinical Case 54-year-old woman underwent surgery 20 years ago for obesity using a restrictive technique with adjustable gastric banding. The patient began 18 years later with retrosternal pain, epigastric pain, vomiting and dysphagia. Endoscopic tests revealed esophageal dilation with retention of food remains, tortuous and macerated mucosa; said achalasia was caused by a gastroesophageal stenosis. Among the diagnostic tests, an esophageal-gastric-duodenal barium transit was performed, showing a decrease in peristalsis with diffuse esophageal dilation of up to 7cm in diameter. Stenosis was observed in the lower esophageal third at the level of the esophagogastric junction of approximately 16 x 11 mm in longitudinal and transverse diameters. Evolution Surgical removal of the device is decided by a multidisciplinary team. Laparoscopic release of the gastric band was performed with electrocautery following adhesions around the device. Complete withdrawal upon release. Intraoperative endoscopy was performed, showing significant esophageal dilation with retained fermented food remains, mucous membrane affected by esophageal candidiasis. After the esophagogastric junction, a gastric fibrous ring was evidenced at the place of location of the gastric band, with good passage without evidence of gastric or esophageal lesions. Favorable postoperative evolution, being discharged 24 hours after surgery. After the case we observed the failure of the safety mechanism of the gastric band that regulates the internal diameter of the device due to the formation of a fibrotic constriction ring. Removal of the device improves the symptoms without requiring, in this case, section of the constriction ring. Currently, the patient shows improvement in her symptoms 6 months after the bariatric revision surgery.

378. LAPAROSCOPIC PRIMARY CLOSURE OF ESOPHAGEAL RUPTURE CAUSED BY BALLOON DILATATION FOR ACHALASIA AND HELLER'S MYOTOMY WITH DOR FUNDOPLICATION

Abstract Background Achalasia is a Primary motor disorder of the esophagus cased by Insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. Major clinical presentations are Dysphagia, regurgitation, and occasional chest pain with or without weight loss. One of most commonly performed conservative treatment is pneumatic dilatation and its most serious complication is esophageal perforation. In this presentation we will introduce a case of esophageal perforation caused by pneumatic dilatation for esophageal achalasia treated with laparoscopic primary closure of perforation and simultaneous Heller’s myotomy with Dor Fundoplication. Methods Esophageal perforation occurred during endoscopic pneumatic dilatation occurred in 61-year-old female patient with achalasia. Initially endoscopic clipping was performed but the patient showed leukocytosis, tachycardia and decreased oxygen saturation with dyspnea. Chest CT showed intraabdominal and mediastinal free air and defect in distal esophagus. Then the patient was referred for surgery. During laparoscopic exploration, 3cm mucosal and 6cm muscle tearing at distal esophagus 2cm proximal to the esophagogastric junction at 3 o’clock direction. After removal of endoscopic clips, primary closure of esophageal rupture in 2-layed method and simultaneous Heller’s Myotomy with Dor fundoplication at 12 o’clock direction was performed. Results The patient showed rapid recovery from septic condition. Nasogastric tube was removed 4 days after surgery. Upper GI series checked with gastrografin 5 days after surgery showed no leakage and no delayed passage in distal esophagus. Chest tube and abdominal drain were removed and the patient was discharged 10 days after surgery. There was no dysphagia and reflux during follow-up afterwards. Conclusion Primary closure for esophageal rupture occurred during balloon dilatation for achalasia and simultaneous Heller’s myotomy with Dor fundoplication by approaching the esophagus from a different direction were successfully performed reducing not only the risk of fulminant sepsis but also the burden of the surgery for achalasia that would be needed to be performed later.

506. CLINICAL OUTCOMES OF A NEW SURGICAL TREATMENT FOR GASTROESOPHAGEAL REFLUX DISEASE: RETROSPECTIVE CHART REVIEW OF 28 PATIENTS FROM GERMANY

Abstract Background Gastroesophageal reflux disease (GERD) is a troublesome gastrointestinal ailment with significant prevalence worldwide. First-line treatment is attempted with proton pump inhibitor (PPI) therapy, but about 40% of patients experience irresponsiveness. Inadequate response, intolerance, or aversion to long-term therapy are indications for anti-reflux surgery. Fundoplication techniques, magnetic sphincter augmentation, and endoscopic techniques are existing surgical options, but are often associated with postoperative complications like dysphagia. The RefluxStop implant is an emerging technology that has demonstrated effectiveness in managing patients with chronic GERD. This report summarizes the clinical outcomes of 28 patients managed with RefluxStop at a German institution. Methods The RefluxStop procedure was performed on 28 patients with chronic GERD in a German center between July 2021 and November 2023. Data was obtained from a retrospective chart review to present the clinical outcomes following RefluxStop surgery, including GERD Health-Related Quality of Life (GERD-HRQL), PPI use, symptom resolution, patient satisfaction, and perioperative adverse events (AEs). Results Twenty-eight patients were followed for 14.1±4.7 months. Baseline patient characteristics are shown in Table 1. Median GERD-HRQL score decreased by 90% from a baseline of 40 (IQR 17) to 4 (IQR 5) at follow-up. PPI use decreased from 96.4% at baseline to 7.1% at follow-up. Almost 93% of reflux symptoms were eliminated. Only one patient (3.6%) was not satisfied with treatment. All patients with dysphagia at baseline (42.9%) experienced complete resolution. No reoperations or esophageal dilations were required. Seven patients experienced minor intraoperative AEs (e.g., neck emphysema) but none were procedure- or device-related. Conclusion This cohort of GERD patients in Germany demonstrated the safety and effectiveness of the RefluxStop procedure. Significant improvements in quality of life, PPI use, and reflux-related symptoms were observed without consequential safety concerns for over one year. Furthermore, this study corroborates the existing evidence of favorable postoperative safety outcomes associated with RefluxStop. Additional study is necessary to continue validation of this promising new treatment option.

253. CLINICAL USEFULNESS OF ENDOSCOPY, BARIUM FLUOROSCOPY, AND CHEST COMPUTED TOMOGRAPHY FOR THE CORRECT DIAGNOSIS OF ACHALASIA

Abstract Background The definite diagnosis of esophageal achalasia is established using manometry, which is per- formed in patients with suspected achalasia based on the findings of screening examinations, such as upper gastrointestinal endoscopy, chest computed tomography (CT), or a barium swallow test. However, the exact values of test characteristics in these supportive diagnostic examinations remain unclear. Methods We estimated the sensitivity and specificity of characteristic findings in the supportive diagnostic examinations for achalasia by comparing the data of a large number of achalasia patients and others with digestive symptoms. Patients Achalasia patients (n=119) and non-achalasia patients with suspected achalasia and repeated feelings of chest discomfort (n=37) who were treated in a single university hospital. Results Characteristic findings on chest CT (i.e. dilated esophagus, air-fluid level formation) and barium swallow tests were observed in more than 80% of achalasia patients but in less than 10% of non-achalasia patients. In contrast, conventional characteristic findings of upper gastrointestinal endoscopy (i.e. intra- esophageal food debris, feeling of resistance at the esophagogastric junction) were seen in only 40%-70% of achalasia patients. In particular, the feeling of resistance at the esophagogastric junction was observed by the examiner in only 30%-50% of patients. Conclusion Intra-esophageal food debris or resistance at the esophagogastric junction on upper gastrointestinal endoscopy will be positive in only about half of patients with achalasia. Other supportive diagnostic examinations, such as chest CT or barium fluoroscopy, should therefore be included in order to avoid overlooking the disease.

Does preoperative symptom duration affect outcomes following per oral endoscopic myotomy (POEM)?

Per oral endoscopic myotomy (POEM) is a safe therapy for the treatment of achalasia. Long-term effects of untreated achalasia include worsening dysmotility and disruptions in esophageal anatomy, i.e., tortuosity and dilation. We hypothesize that long-standing achalasia prior to intervention will have worse outcomes following POEM than in patients with symptoms for shorter duration. We retrospectively analyzed achalasia patients who underwent POEM at our institution from 2011 to 2023, categorizing them into symptom duration cohorts (< 1year, 1-3years, 4-10years, > 10years). Inclusion criteria comprised patients with documented achalasia diagnosis who received POEM treatment at our facility. Exclusion criteria encompassed individuals lacking data pertaining to achalasia diagnosis, the time frame before intervention, or those missing pre and postoperative Eckardt scores. POEM failure was defined as symptom recurrence, necessity for repeat intervention, or high postoperative Eckardt score. We compared demographic, preoperative, and postoperative outcomes across these cohorts, and employed multivariable logistic regression to explore the link between symptom duration and POEM response. During the study period, in our increased cohort 234 patients met inclusion criteria. 75 patients had symptoms for < 1year, 78 patients had symptoms from 1 to 3years, 47 patients had symptoms from 4 to 10years, and 34 patients had symptoms > 10years. Patient demographics such as age, sex, BMI, Charleson-Deyo-Comorbidity-Index, and diabetes did not differ amongst cohorts. High-resolution manometry data, including achalasia type, Median IRP, LES residual pressure, and Basal LES pressure did not differ between groups. Preoperative Eckardt scores ranged from 4 to 5 across groups (p 0.24). Patients endorsed an average of three total preoperative symptoms across groups (p 0.13). Patients with symptoms greater than 4years had significantly more endoscopic interventions prior to POEM (37% vs, 68% p .001). There was no significant difference in post-procedure mean Eckardt scores between cohorts. All cohorts experienced the same number of post-POEM symptoms. Post-POEM manometric measurements remained consistent across cohorts. Similarly, there were no significant differences in terms of symptom recurrence, requirement for repeat interventions, or repeat POEM among the cohorts. Multivariable logistic regression analysis determined achalasia symptoms greater than a decade did not result in increased odds of having a higher postoperative Eckardt score, worse dysphagia, regurgitation, or weight loss. In this increased cohort, this data once again suggests that longer symptom duration is not associated with increased rates of POEM failure.

630. ENDOSCOPIC MANAGEMENT OF DELAYED-GASTRIC-EMPTYING AFTER ESOPHAGECTOMY IN A TERTIARY REFERRAL CENTER: COMPARISON BETWEEN DIFFERENT ENDOSCOPIC PROCEDURES

Abstract Background Delayed Gastric Emptying (DGE) after Esophagectomy with a gastric conduit is a complication that occurs in 15-39% of patients. It is associated with short and long-term complications and with a poor quality of life. Intra-Pyloric Injection of Botulinum Toxin (BT), Pyloric Pneumatic Dilation (PD), and combination of these two techniques (BTPD) in the same session, represent the main endoscopic procedures, but comparative data are currently unavailable. Methods We retrospectively analyzed prospectively collected data on all consecutive patients with DGE after esophagectomy endoscopically treated from December 2018 to November 2023. DGE was classified based on the onset time (early/late), and the Gastric Outlet Obstruction Score (GOOS) was used for clinical staging. All BT patients received 200UI of toxin, while those PD patients have been dilated up to 20mm. Technical success (TS) was defined as the completion of the procedure, clinical success (CS) as achieving a GOOS of ≥2, and recurrence as the need for endoscopic/surgical treatment in patients who achieved CS. Adverse events (AEs) were classified using the AGREE classification. Results 34 patients (82.4% male, 94.1% Ivor-Lewis, divided as follow: 13 (38.2%)BTPD-group, 12 (35.3%)BT-group and 9(26.5%)PD-group. Median follow-up was of 170 days (IQR 67-604), with no differences between the three groups. No statistically significant differences were found in the baseline characteristics among the three groups (e.g.surgical pyloromyotomy, neoadjuvant treatments). Despite identical TS (100%), BT-group exhibited a higher rate of clinical failure (25%) compared to the other groups (p=0.03). No difference in the recurrence rate was observed between the three groups (p=0.47). Dysfunction analysis showed that BTPD-group was characterized by a significatively shorter median time to refeeding of 1 day (IQR 1) compared to the other two groups (log-rank test p=0.0051). No AEs procedures related were recorded. Conclusions Our study reveals that BT is associated with a considerable rate of clinical failure, and that the combined BTPD treatment may offer a more rapid clinical success, maintaining an equivalent safety profile. Further prospective studies are needed to validate these findings.

578. DUPILUMAB EFFICACY IN EOSINOPHILIC OESOPHAGITIS PATIENTS TREATED WITH PRIOR THERAPY AND INADEQUATE RESPONSE, INTOLERANCE, OR CONTRAINDICATION TO SWALLOWED TOPICAL CORTICOSTEROIDS

Abstract Background Improvements in histologic, symptomatic, and endoscopic aspects of eosinophilic oesophagitis (EoE) were observed in patients treated with dupilumab weekly (qw) enrolled in the 3-part, phase 3 LIBERTY EoE TREET study (NCT03633617), regardless of prior inadequate response, intolerance, and/or contraindication to swallowed topical corticosteroids (STC). Here we assess the efficacy of dupilumab qw versus placebo in this STC non-responsive/intolerant subgroup, stratifying further by those with/without history of food elimination diets, proton pump inhibitor (PPI) use at randomisation, or history of oesophageal dilation. Methods This analysis includes patients who received dupilumab 300 mg qw or placebo for 24 weeks in Part B and an additional 28 weeks dupilumab in Part C. Co-primary endpoints (Weeks 24 and 52) include: proportions of patients achieving peak eosinophil count (PEC) ≤6 eosinophils/high-power field (eos/hpf) and absolute change in Dysphagia Symptom Questionnaire (DSQ) score. Secondary endpoints assessed included proportions of patients achieving PEC ≤1 eos/hpf, &amp;lt;15 eos/hpf, % change in PEC, and absolute change in Endoscopic Reference Score, and EoE-Histologic Scoring System grade/stage scores. Results Dupilumab 300 mg qw improved proportions of patients achieving co-primary endpoints, ≤6 eos/hpf and absolute change in DSQ score, and secondary endpoints, ≤1 eos/hpf and &amp;lt;15 eos/hpf at Week 24 versus placebo, regardless of history of food elimination diets, PPI use at randomisation, or history of dilation (Table). Improvements were maintained or continued to improve at Week 52. A similar trend was observed for other secondary endpoints assessed. Placebo-treated patients who switched to dupilumab in Part C demonstrated similar efficacy to patients treated with dupilumab in Part B. Dupilumab safety was consistent with the known dupilumab safety profile. Conclusion Dupilumab qw demonstrated sustained improvements in histologic and symptomatic aspects of EoE up to 52 weeks in adults and adolescents with an inadequate response, intolerance, and/or contraindication to STC, regardless of history of food elimination diets, PPI use, or history of oesophageal dilation. Improvements in endoscopic aspects of EoE up to 52 weeks were also observed.

Prenatal diagnosis of tracheo-oesophageal fistula/oesophageal atresia: is MRI helpful?

Oesophageal atresia (OA) with or without tracheo-oesophageal fistula (TOF) affects 2.75 per 10,000 births within the UK. It is most frequently suspected on antenatal imaging when the stomach is absent or appears small. Studies have shown fetal magnetic resonance imaging (MRI) has greater diagnostic accuracy than ultrasound; however, there remains uncertainty over what size constitutes a small stomach and how frequently this correlates with a diagnosis of TOF/OA. A retrospective study of patients referred for fetal MRI due to suspicions of TOF/OA on antenatal ultrasound from 2011 to 2022. We also included patients with a fetal MRI suspecting TOF/OA who had been referred for other reasons. The indication, MRI findings and postnatal outcome were compared to assess diagnostic accuracy. For each case, the size of the stomach bubble was measured on MRI, and stomach volumes in a control group were measured for comparison. The positive predictive value for USS was 45.5% and 51.7% for fetal MRI. Fetal MRI had a negative predictive value and sensitivity of 100% (p = 0.027). The control group showed a strong positive correlation between stomach size and increasing gestational age (R2 = 0.69, p < 0.001), but this correlation was less positive in the TOF/OA group (R2 = 0.26, p = 0.03), and the stomach volumes in TOF/OA were consistently lower than the control group. The receiver operating characteristic curve illustrates that an absent stomach or unmeasurably small stomach is more diagnostic of TOF/OA as volumes ≤0.06 ml had 90% sensitivity. Fetal MRI can accurately exclude TOF/OA but only has marginally improved positive predictive value over ultrasound. Research with larger numbers is required to further aid the development of a cut-off value for what can be considered a pathologically small stomach. There are several features on imaging that raise the suspicion of TOF/OA. Fetal MRI has some improved diagnostic accuracy compared with antenatal ultrasound alone; however, it is only marginally better. Absence of stomach bubble and presence of oesophageal dilatation combined on fetal MRI are more diagnostic of TOF/OA.

Treating acid reflux without compressing the food passageway: 4-year safety and clinical outcomes with the RefluxStop device in a prospective multicenter study

IntroductionRefluxStop is an implantable device for laparoscopic surgical treatment of gastroesophageal reflux disease (GERD) to restore and maintain lower esophageal sphincter and angle of His anatomy without encircling and putting pressure on the food passageway, thereby avoiding side effects such as dysphagia and bloating seen with traditional fundoplication. This study reports the clinical outcomes with RefluxStop at 4 years following implantation of the device.MethodsA prospective, single arm, multicenter clinical investigation analyzing safety and effectiveness of the RefluxStop device in 50 patients with chronic GERD.ResultsAvailable data are presented for 44 patients at 4 years with the addition of three patients at 3 years carried forward. At 4 years, median GERD-HRQL score was 90% reduced compared to baseline. Two patients (2/44) used regular daily proton pump inhibitors (PPIs) despite subsequent 24-h pH monitoring off PPI therapy yielding normal results. There were no device-related adverse events (AEs), esophageal dilations, migrations, or explants during the entire study period. AEs reported between 1 and 4 years were as follows: one subject with heartburn and a pathologic pH result with device positioned too low at surgery; one subject with dysphagia, thus, 46/47 patients reported no dysphagia-related AEs between years 1 and 4. Two patients (2/47) were dissatisfied with treatment despite normal 24-h pH monitoring, of whom one had manometry-verified dysmotility at 6 months, indicating dissatisfaction for reasons other than acid reflux.ConclusionThese results confirm the excellent and already published 1-year results as stable in the long-term, supporting the safety and effectiveness of the RefluxStop device in treating GERD for over 4 years. GERD-HRQL score, pH testing, and PPI usage indicate treatment success without dysphagia or gas-bloating and only minimal incidence of other AEs. This favorably low rate of AEs is likely attributable to RefluxStop’s dynamic physiologic interaction and non-encircling nature.

Gender medicine in diseases of the upper gastrointestinal tract

Benign and malignant diseases of the upper gastrointestinal tract show gender-specific differences. The frequent gastroesophageal reflux disease is aprime example: men have an erosive reflux disease more often than women and are also younger at the time of onset. The rate of progression to a metaplastic Barrett's esophagus is also higher in men. In the case of achalasia, there are indications that surgical treatment by laparoscopic Heller's myotomy and semifundoplication 180° according to Dor leads to amarkedly better improvement in the symptoms in women compared to men, although they showed amore pronounced dilation of the tubular esophagus. The female hormone status influences the localization and histopathology of adenocarcinoma of the esophagogastric junction and gastric carcinoma. Premenopausal and postmenopausal carcinomas differ significantly in women. In addition, high microsatellite instability (MSI high) is more frequent in women and is associated with agenerally significantly better prognosis. The MSI high gastric carcinomas of women show better survival than MSI high carcinomas of men. The future inclusion of gender-specific aspects in studies of the upper gastrointestinal tract is desirable in order to generate adequate data and to enable differentiated treatment stratification in the future.

Efficacy and safety of peroral endoscopic myotomy for pediatric achalasia: A nationwide study.

Achalasia, a rare esophageal motility disorder characterized by the inability of the lower esophageal sphincter to relax and loss of esophageal peristalsis, significantly impacts pediatric patient quality of life through symptoms like dysphagia, chest pain, and weight loss. This nationwide retrospective cohort study evaluates the efficacy and safety of peroral endoscopic myotomy (POEM) for pediatric achalasia in Mongolia, contributing to the limited global data on this minimally invasive treatment in children. Conducted between February 2020 and March 2022 at 2 tertiary centers, the study included symptomatic achalasia patients, treatment-naive or those with unsatisfactory outcomes from previous esophageal dilations. The POEM procedure was assessed for its impact on esophageal structure and function, symptom severity via the Eckardt score, and procedure-related safety, with outcomes measured at baseline, 3 days, and 12 months post-procedure. The study demonstrated notable post-procedure improvements across all measured outcomes: abnormal contraction length and esophageal width significantly reduced, underscoring the procedure's effectiveness. More precisely, the integrated relaxation pressure showed a significant improvement from a mean of 26.8 mm Hg (standard deviation [SD], 5.4 mm Hg) pre-procedure to 10.8 mm Hg (SD, 1.1 mm Hg) 12 months (P < .001). Similarly, Eckardt scores, which assess symptom severity, improved significantly from a pre-procedure mean of 7.0 (SD, 1.0) to a substantially lower score post-procedure (P < .001), reflecting enhanced patient quality of life and symptom alleviation. This study underscores POEM's role as an effective, minimally invasive option for pediatric achalasia management within the Mongolian population, offering significant symptomatic relief and improved esophageal function.

Endoscopic management of a massive esophageal perforation following pneumatic dilation

Endoscopic management of a massive esophageal perforation following pneumatic dilation

68-year-old patient with chronic dysphagia, dilated and lumen-filled esophagus

68-year-old patient with chronic dysphagia, dilated and lumen-filled esophagus

Safety of a Novel Upper Esophageal Sphincter Balloon Dilator.

The shape of esophageal dilators has not changed in over 350 years. Clinical and animal research suggests that the upper esophageal sphincter (UES) is not round but approximates a kidney shape and that cylindrical dilators may be suboptimal. The Infinity UES Dilation System has been developed specifically for the anatomic configuration of the UES. This study evaluates the safety of the UES-specific Infinity Dilation System. All patients undergoing dilation of the UES between January 1, 2022 and September 1, 2023 were included. Demographics, procedure indication, dilator type, minor adverse events, and major complications were abstracted. Minor adverse events, complications, and maximum dilation dimension (mm) were compared between groups. A total of 477 patients were included. Eight hundred and seventy-three total UES dilations were performed. The primary indications for UES dilation were cricopharyngeus muscle dysfunction (43%) and stenosis from radiation toxicity (40%). Twenty-three percent (202/873) of dilations were performed with an Infinity balloon, 31% (270/873) were performed using two conventional balloons placed side by side, and 46% (401/873) were performed with one singleton conventional balloon. The average maximum dilation dimension was 33 (±4.7) mm for Infinity balloons, 32 (±3.8) mm for two side-by-side balloons, and 18 (±3.4) mm for singleton balloons. There were three major complications with conventional balloons and none with Infinity balloons. There were no significant differences in minor adverse events between groups. A UES-specific esophageal dilator provides a greater maximum dilation dimension and appears to be at least as safe as dilation with a single cylindrical balloon designed to dilate the esophagus. Level 3 Laryngoscope, 2024.