Postoperative Esophagram Research Articles

Evaluation of postoperative esophagram following peroral endoscopic myotomy (POEM).

The routine use of post-operative esophogram has come under evaluation for multiple upper GI surgeries such as with bariatric surgery and gastric resections. A major complication following Per Oral Endoscopic Myotomy (POEM) is a leak from the myotomy site. A post-operative contrast esophogram is often utilized to evaluate the presence of a leak, however it is not a standardized care practice for all patients. Presently it is selectively performed depending on physician assessment intra-operatively. This project will evaluate the necessity of post-operative contrast esophogram following POEM. We retrospectively reviewed 277 patients diagnosed with achalasia who underwent POEM by two surgeons from 2011 to 2022. 173 patients met the inclusion criteria. A post-operative esophogram was used for the evaluation of a leak. Post-operative esophagram were selectively performed on day 1 following surgery using a water-soluble material. Data was evaluated using Stata. There were 3 detected leaks in the group that underwent esophagrams compared to the non-esophagram group in the early post-operative period. The overall complication rate was 5.5% in the non-esophagram versus 7.9% in the esophagram group. Length of stay was 1.48days in the non-UGI vs 1.76days in the esophagram group. Readmission rate was 10.9% in non-esophagram versus 8.7% in esophagram group. There was no statistically significant difference in outcomes in patients undergoing POEM who received post-operative esophagram verses patients who did not receive post-operative esophagram. The routine use of a contrast esophogram to detect a leak following POEM may not be justified. This study suggests that esophagrams should be performed depending on the clinical signs/symptoms post-operatively that would warrant imaging and intervention.

Safe implementation of transoral incisionless fundoplication as a new technique in a tertiary care center

Background/AimsTransoral incisionless fundoplication (TIF) is an accepted anatomic treatment for gastroesophageal reflux disease in selected patients. In this report, we analyze our institution’s programmatic allocation of resources during the safe implementation of TIF as a new procedure. MethodsA retrospective analysis of all patients who underwent TIF from January 2020 to February 2021 at our institution was performed. The process of initially allocating the operating room (OR) with overnight admission and postoperative esophagram for added safety, and subsequently transitioning TIF to the endoscopy suite (ES) as an outpatient procedure was described. Patient safety and outcomes were evaluated during transition. ResultsThirty patients who underwent TIF were identified. The mean age was 51.2±16.0 years. TIF was performed in an OR in nine patients (30%) and 21 (70%) in the ES. All the OR patients were admitted overnight and had routine esophagogram. In contrast, four (19%) from the ES group required clinically-indicated admission and three (14.2%) required esophagram. The mean procedure duration was significantly lower in the ES group (65.7 min vs. 84 min, p=0.02). ConclusionsA stepwise, resource-efficient process was described that allowed safe initiation of TIF as a new technique and its effective transition to a fully outpatient procedure.

Half of Anastomotic Leaks After Esophagectomy Are Undetected on Initial Postoperative Esophagram

BackgroundThe sensitivity of fluoroscopic esophagography with oral administration of contrast material to exclude anastomotic leak after esophagectomy is not well documented, and the consequences of missing a leak in this setting have not been previously described. MethodsWe performed a retrospective cohort study of a prospectively maintained institutional database of patients undergoing esophagectomy with esophagogastric anastomosis from 2008 to 2020. Relevant details of leaks, management, and outcomes were obtained from the database and formal chart review. Statistical analysis was performed to compare patients with and without leaks and those with false-negative vs positive esophagrams. ResultsThere were 384 patients who underwent esophagectomy with gastric reconstruction; the majority were Ivor-Lewis (82%), and 51% were wholly or partially minimally invasive. By use of a broad definition of leak, 55 patients (16.7%) developed an anastomotic leak. Of the 55 patients, 27 (49%) who ultimately were found to have a leak initially had a normal esophagram result (performed on average on postoperative day 6). Those with a normal initial esophagram result were more likely to have an uncontained leak (81% vs 29%; P < .01), to require unplanned readmission (70% vs 39%; P = .02), and to undergo reoperation (44% vs 11%; P < .01). ConclusionsEarly postoperative esophagrams intended to evaluate anastomotic integrity have a low sensitivity of 51%, and leaks missed on the initial esophagram have greater clinical consequences than those identified on the initial esophagram. These findings suggest that a high index of suspicion must be maintained even after a normal esophagram result and call into question the common practice of using this test to triage patients for diet advancement.

657 ROUTINE ESOPHAGRAMS FOLLOWING HIATUS HERNIA REPAIR MINIMISES REOPERATIVE MORBIDITY: A MULTICENTER COMPARATIVE COHORT STUDY

Abstract Hiatus hernia repairs are common. Early complications such as re-herniation, esophageal obstruction and perforation, although infrequent, incur significant morbidity. Here, we determine whether routine postoperative esophagrams following hiatus hernia repair may expedite the surgical management of these complications, reduce reoperative morbidity, and improve functional outcomes. Methods Analysis of a prospectively-maintained database of 1829 hiatus hernia repairs undertaken in 14 hospitals from 1 January 2000 to 30 September 2020. 1571 (85.9%) patients underwent a postoperative esophagram which was reviewed. An early (&amp;lt;14 days) reoperation was performed in 44 (2.4%) patients. Results Compared to those without an esophagram, patients who received one prior to reoperation (n = 37) had a shorter time to diagnosis (2.4 vs. 3.9 days, p = 0.041) and treatment (2.4 vs. 4.3 days, p = 0.037) of their complications. This was associated with decreased open surgery (10.8% vs. 42.9%, p = 0.034), gastric resection (0.0% vs. 28.6%, p = 0.022), postoperative morbidity (13.5% vs. 85.7%, p &amp;lt; 0.001), ICU admission (16.2% vs. 85.7%, p &amp;lt; 0.001), and length-of-stay (7.3 vs. 18.3 days, p = 0.009). Furthermore, patients who underwent early reoperations for asymptomatic re-herniation had less complications and superior functional outcomes at one-year follow-up than those who needed surgery for symptomatic recurrences later on. Conclusion Postoperative esophagrams decreases the morbidity associated with early and late reoperations following hiatus hernia repair, and should be considered for routine use.

379 Safety and Efficacy of Peroral Endoscopic Myotomy (POEM) in Patients ≥ 65 Years at a Single Academic Tertiary Care Center

INTRODUCTION: Peroral endoscopic myotomy (POEM) has been proven to be effective for treating esophageal dysmotility disorders. Herein is a report of the safety and efficacy of POEM in patients aged ≥65 years at an academic US tertiary care center. METHODS: Medical charts of all patients aged ≥65 years that underwent POEM between December 2014 and October 2018 were retrospectively reviewed. Demographic data, clinical data and treatment outcomes were obtained. POEMs were performed by multidisciplinary teams each including 1 of 2 endoscopists (HG, RE) and 1 of 3 surgeons (KP, PN, JK). Clinical success was defined as Eckardt score ≤ 3 and improvement of symptoms. RESULTS: During the study period, 62 patients were included. The mean age of patients was 72.3 ± 5.7 years (range 65-89 years; 42% women). Mean BMI was 29.8 kg/m2. Indications for POEM included Achalasia 88.7%, diffuse esophageal spasm (DES) 6.5%, Jackhammer esophagus 3.2% and esophagogastric junction outflow obstruction (EGJOO) 1.6%. There were 2 intraoperative complications documented (pneumothorax and anaphylaxis to medication). Mean pretreatment IRP was 24.1. Pretreatment Eckardt score was 6.98 ± 2.2 compared with posttreatment Eckardt score of 1.25 ± 2 (P &lt; 0.05). Clinical success (Eckardt score ≤3) was achieved in 88.7% of patients. Mean myotomy length 13.8 cm (posterior orientation of myotomy 75.8%). Median hospitalization duration was 1.9 days. Postoperative complications included 1 patient with esophageal leak on postoperative esophagram, 1 patient with esophageal stricture, and 1 patient with both stricture and leak. No deaths occurred. Six patients with persistent symptoms post POEM required through-the-scope dilation to achieve improvement in symptoms. CONCLUSION: POEM can be safely carried out in symptomatic elderly patients ≥ with esophageal dysmotility disorders. An excellent clinical response (88.7%) was noted in this patient cohort.

1821 Post-Fundoplication Esophageal Bezoar Resolved With Endoscopic Instillation and Oral Ingestion of Cola

INTRODUCTION: We present a difficult bezoar-like esophageal food impaction which occurred 6 months after repair of a giant Type IV hiatal hernia. CASE DESCRIPTION/METHODS: The patient is an active 90-year-old female who had a giant Type IV paraoesophageal hernia containing stomach and colon for many years. She underwent repair with mesh and a loose Nissen fundoplication (58 Fr). Pre-operative esophageal manometry was not performed. Post-operative esophagram showed intact wrap, with “3 mm minimum diameter central luminal channel through the fundoplication.” Preserved esophageal motility was also noted. Recovery was uneventful. Six months later, she presented to the ED complaining of sensation of food stuck in her throat. She was tolerating secretions and tiny sips of water. Barium esophagram revealed “dilated distal esophagus, with contrast pooling above retained material at the GE junction”. EGD was performed under general anesthesia. The distal esophagus was completely obstructed with food. Despite use of multiple tools including net, rat-tooth forceps and pronged graspers, it could not be cleared. Using small instillations of cola through a 60 cc syringe, we were able to “tunnel” through the impaction and create a lumen into the stomach. Retroflexion showed a small hiatal hernia. After more than 2 hours, there was still a significant amount of food adherent to the walls of the esophagus. The patient was extubated and admitted to the hospital. She was instructed to drink small sips of cola and ice chips upright in bed. She ingested 2 L of cola over the next 8 hours without difficulty. EGD the next day noted complete passage of food. There was no frank ring or stricture. Fundoplication was intact with a small(2 cm) hiatal hernia. She was discharged the same day on soft diet. At follow up with thoracic surgery she had no further dysphagia episodes. She was instructed to drink cola once a day for maintenance. DISCUSSION: Although the patient had a loose wrap and no known dysmotility, post-op diameter of the esophageal lumen was fairly small (3 mm). If patient was not adhering to post-fundoplication diet, this likely precipitated “packing” of food into the distal esophagus and remnant small hernia. Removal of esophageal food impaction is most commonly done by pushing food into the stomach, or removing it mechanically. The use of proteolytic enzymes e.g. papain is not recommended due to perforation risk. One can consider adding cola to the arsenal of tools for safely treating difficult esophageal food impactions.

Rare Complications of Portal Hypertension in a Patient With Underlying Focal Nodular Hyperplasia

Introduction: Esophageal variceal ligation (EVL) and sclerotherapy are both considered standards of care in management of esophageal variceal hemorrhage. Minor complications are not uncommon but occasionally, severe and potentially life-threatening sequelae may develop. Case presentation: Patient is a 30-year-old female with history of variceal bleeding due to portal hypertension secondary to noncirrhotic focal nodular hyperplasia (FNH) and resultant portal vein thrombosis that began at age 13 until she underwent banding at age 20. She was also treated with a splenorenal shunt as well as a superior mesenteric vein to inferior vena cava shunt to help reduce portal venous pressure. Evaluation for anemia with esophagogastroduodenoscopy (EGD) revealed an extremely large esophageal varix in the distal esophagus with active bleeding, which initially improved with sclerotherapy. Ten days after, she vomited blood and fainted. Methods: Repeat EGD noted profuse variceal bleeding, requiring intubation for airway protection. Attempts to band the varices were unsuccessful, requiring repeat sclerotherapy. 27 mL of sodium tetradecyl was injected throughout the esophagus. Post-procedure chest X-ray revealed a large left-sided pneumothorax, requiring a chest tube, and esophageal perforation. Portal venous shunt was attempted; however, the anastomosis was thrombosed, so the cryopreserved vein was ligated. Post-operative esophagram showed no obvious leak. CT chest/abdomen/pelvis showed bilateral pleural effusions. Left pigtail catheter was placed and drained 150 mL and grew E. faecalis as well as Candida kefyr; patient was placed on zosyn and fluconazole. Results: Patient was transferred to medical ICU intubated on CPAP, hemodynamically stable. Patient recovered with all catheters removed following prolonged antimicrobial support. She was stable on discharge and placed on beta blocker therapy without further incident. Conclusion: This case is unusual for many reasons. Firstly, the etiology of portal hypertension secondary to FNH; secondly, the continuous complications of portal hypertension despite previous shunting; and thirdly, her development of a massive upper gastrointestinal bleed a week after successful EVL. Although sclerotherapy is still occasionally used after unsuccessful EVL, we must be cognizant of rare but potentially devastating complications. For this patient, prompt recognition followed by appropriate and aggressive management fortunately resulted in a successful outcome with long-term survival.

The Plication Technique to Enhance the Endoscopic Approach to Zenker's Diverticulum.

Endoscopic stapler approaches to Zenker's diverticulum often yield a persistent diverticulum and recurrent dysphagia up to 20%. A novel technique to reduce the postoperative diverticulum is described. Eight consecutive patients with Zenker's diverticulum who underwent endoscopic stapler diverticulotomy had adjunctive endoscopic plication of the diverticulum wall to functionally reduce the residual diverticulum size. On postoperative esophagram, there was no visible diverticulum in 4 of 7 patients (57%). The remaining 3 patients had a reduction in common wall of 76%, 50%, and 40% with a mean postoperative size of 1.0 cm. All patients had resolution or significant improvement in dysphagia. There were no complications or recurrences at a mean follow-up of 6.3 months. As an adjunct to endoscopic treatment of Zenker's diverticulum, the plication technique can reduce diverticulum size. Further studies will determine if the plication technique affects long-term recurrence of endoscopic stapler approaches.

Challenging surgical dogma in the management of proximal esophageal atresia with distal tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium

PurposePerioperative management of infants with esophageal atresia and tracheoesophageal fistula (EA/TEF) is frequently based on surgeon experience and dogma rather than evidence-based guidelines. This study examines whether commonly perceived important aspects of practice affect outcome in a contemporary multi-institutional cohort of patients undergoing primary repair for the most common type of esophageal atresia anomaly, proximal EA with distal TEF. MethodsThe Midwest Pediatric Surgery Consortium conducted a multicenter, retrospective study examining selected outcomes on infants diagnosed with proximal EA with distal TEF who underwent primary repair over a 5-year period (2009–2014), with a minimum 1-year follow up, across 11 centers. Results292 patients with proximal EA and distal TEF who underwent primary repair were reviewed. The overall mortality was 6% and was significantly associated with the presence of congenital heart disease (OR 4.82, p=0.005). Postoperative complications occurred in 181 (62%) infants, including: anastomotic stricture requiring intervention (n=127; 43%); anastomotic leak (n=54; 18%); recurrent fistula (n=15; 5%); vocal cord paralysis/paresis (n=14; 5%); and esophageal dehiscence (n=5; 2%). Placement of a transanastomotic tube was associated with an increase in esophageal stricture formation (OR 2.2, p=0.01). Acid suppression was not associated with altered rates of stricture, leak or pneumonia (all p>0.1). Placement of interposing prosthetic material between the esophageal and tracheal suture lines was associated with an increased leak rate (OR 4.7, p<0.001), but no difference in the incidence of recurrent fistula (p=0.3). Empiric postoperative antibiotics for >24h were used in 193 patients (66%) with no difference in rates of infection, shock or death when compared to antibiotic use ≤24h (all p>0.3). Hospital volume was not associated with postoperative complication rates (p>0.08). Routine postoperative esophagram obtained on day 5 resulted in no delayed/missed anastomotic leaks or a difference in anastomotic leak rate as compared to esophagrams obtained on day 7. ConclusionMorbidity after primary repair of proximal EA and distal TEF patients is substantial, and many common practices do not appear to reduce complications. Specifically, this large retrospective series does not support the use of prophylactic antibiotics beyond 24h and empiric acid suppression may not prevent complications. Use of a transanastomotic tube was associated with higher rates of stricture, and interposition of prosthetic material was associated with higher leak rates. Routine postoperative esophagram can be safely obtained on day 5 resulting in earlier initiation of oral feeds. Study typeTreatment study. Level of evidenceIII.

Routine post-operative esophagram Is not necessary after repair of esophageal atresia

IntroductionEsophagrams are routinely performed following repair of esophageal atresia (EA) with or without tracheoesophageal fistula (TEF); however, its utility has not been validated. MethodsEA/TEF repair performed from 2003 to 2014 at a single pediatric hospital and from 2004 to 2014 in the Pediatric Health Information System (PHIS) database were retrospectively reviewed to determine utility of esophagrams. ResultsEsophagram was performed in 99% of patients at our institution (N = 105). Clinical signs were seen prior to esophagram in patients whose leak changed clinical management. Esophagram on post-operative day ≤15 was performed in 66% of PHIS database patients (N = 3255). Esophagram did not change the incidence of chest tube placement, reoperation, or dilation. Patients who required a reoperation were less likely to have an esophagram than patients who did not require a reoperation (40.7% versus 65.7%, p < 0.001). ConclusionOur data suggest that routine esophagram is not necessary in asymptomatic patients.

Contemporary Management of Achalasia by Pediatric Surgeons: A Survey of the International Pediatric Endosurgical Group.

Achalasia is a rare neurodegenerative disorder of the esophagus. Surgical repair consists of esophagomyotomy, often in conjunction with an antireflux procedure. We sought to determine practice patterns in surgical treatment of pediatric achalasia. Data regarding preferences were collected as part of a comprehensive online-based survey sent to members of the International Pediatric Endosurgery Group (IPEG) completed by 191 surgeons of which 141 performed esophagomyotomies for achalasia. Procedures performed per surgeon were 1-2 (n = 21, 15%); 3-5 (n = 49, 34%); 6-10 (n = 39, 28%); 11-20 (n = 21, 15%); >20 (n = 11, 8%). Most approached the operation laparoscopically (n = 127, 90%). Workup before esophageal myotomy consisted of a diagnostic esophagram (n = 133, 94%) or manometry (n = 102, 73%). Only 60% of surgeons (n = 84) required an EGD. No preference observed in division location of the phrenoesophageal ligament for mobilization of the esophagus. There was a predominant preference for hook cautery (n = 82, 58%) over harmonic shears (n = 30, 21%), heated sealing device LigaSure™ (n = 18, 13%), and other devices (n = 11, 8%) for muscle division. Intraoperatively, 57% (n = 80) had endoscopy and 50% (n = 71) had postoperative esophagram before initiation of enteral feeding. For antireflux procedure, Thal/Dor approach was performed most frequently (n = 111, 79%) followed by the Toupet (n = 18, 13%) and Nissen (n = 4, 3%) and none (n = 7, 5%). Diet restrictions were provided in 76% (n = 107) of postoperative patients. Given the infrequency of achalasia in children, there are a range of treatment plans among pediatric surgeons. We have identified current practices as a first step in developing more standard treatment pathways.

Preservation of native esophagus in infants with pure esophageal atresia has good long-term outcomes despite significant postoperative morbidity.

To evaluate long-term outcomes of pure esophageal atresia (EA) repair with preservation of native esophagus. Infants with pure EA treated at our institution (2000-2010) and with minimum 5-year follow-up were reviewed (REB:1000046653). Data analysed included demographics, management and outcomes and are reported as mean±SD/median (range). Of 185 infants with EA, 12 (7%) had pure EA (gestational age: 36±2.4weeks, birth weight: 2353±675g). Ten had associated anomalies, including trisomy-21 (n=2) and duodenal atresia (n=1). 1 patient (short gap) underwent primary thoracoscopic anastomosis, 11 had gastrostomy (Stamm, n=5; image-guided, n=6) as initial procedure. At definitive repair (age: 128±91days; weight 5.5±2.3kg): ten had primary anastomosis and 1 had Collis gastroplasty. No patient had esophageal replacement surgery. three patients had gastrostomy dehiscence requiring re-operation. At post-operative esophagram, seven had anastomotic leak successfully treated conservatively. Seven patients developed strictures requiring balloon dilatations (median two dilatations, range 1-10), six received antireflux surgery. At 7-year follow-up (range 5-15years), all patients had the gastrostomy closed and were on full oral feeds. The management of pure EA continues to be challenging. The preservation of native esophagus is possible with significant morbidity. The long-term outcomes are favourable.

The Esophageal Anastomotic Stricture Index (EASI) for the management of esophageal atresia

BackgroundAnastomotic stricture is the most common complication following repair of esophageal atresia. An Esophageal Anastomotic Stricture Index (EASI) based on the postoperative esophagram may identify patients at high risk of stricture formation. MethodsDigital images of early postoperative esophagrams of patients undergoing EA repair from 2005 to 2013 were assessed. Demographics and outcomes including dilations were prospectively collected. Upper (U-EASI) and lower (L-EASI) pouch ratios were generated using stricture diameter divided by maximal respective pouch diameter. Score performances were evaluated with area under the receiver operator curves (AUC) and the Fisher's exact test for single and multiple (>3) dilatations. Interrater agreement was evaluated using the intraclass correlation coefficient (ICC). ResultsForty-five patients had esophagrams analyzed; 28 (62%) required dilatation and 19 received >3 (42%). U-EASI and L-EASI ratios ranged from 0.17 to 0.70, with L-EASI outperforming the U-EASI as follows: L-EASI AUC: 0.66 for a single dilatation, 0.65 for >3 dilatations; U-EASI AUC: 0.56 for a single dilatation, 0.67 for >3 dilatations. All patients with an L-EASI ratio of ≤0.30 (n=8) required multiple esophageal dilatations, p=0.0006. The interrater ICC was 0.87. ConclusionThe EASI is a simple, reproducible tool to predict the development and severity of anastomotic stricture after esophageal atresia repair and can direct postoperative surveillance.

A gentle reminder

As we have all come to appreciate, there are many reasonsfor reading a journal article. For many, it is a way of learningaboutatopic,andyetforothers,itisawayofconfirmingwhatis already known by the reader. I, on occasion, use journalarticles to see what my contemporaries, colleagues, andfriendsarewriting about—whatputsthe“windintheirsails.”Earning continuing education credits, formulating researchideas, and learning from different writing styles are allbenefits that come from reading an original article, review,pictorial essay, or case report. Yet the one for me that trumpsthem all is the “gentle reminder,” namely the article thatreminds me of an important concept I once knew, still tuckedin the back of my memory, but one I do not see often enoughto have at the ready. In other words, it’s the one I might misswithout the “gentle reminder.”The article titled “Congenital esophageal stenosis asso-ciated with esophageal atresia/tracheoesophageal fistula:clinical and radiologic features,” by Yoo and colleagues [1],falls easily into this last category. I am sure that some ofyou have had a case of congenital esophageal stenosis(CES) with esophageal atresia/tracheoesophageal fistula(EA/TEF)in whichyou sawthe finding,dida literaturesearchor showed a colleague, and followed up with the pediatricsurgeon to see what the lesion turned out to be. I clearlyremember a case from my fellowship, with the subsequentnoon conference discussion about complete cartilaginousrings/tracheobronchial remnants as one cause of the distalstenosis. And I recall another case 10 years later, where CESwas at first called a reflux stricture in a 2-year-old afterneonatal repair of EA/TEF, with unsuccessful balloon dilata-tion and subsequent esophageal perforation after bougienage,where in retrospect the limited postoperative esophagram atday7oflifesuggestedadistalesophagealstricture(usuallytooyoung to have already developed a reflux stricture). Then4 years after that, there was a child with a congenitalesophageal stenosis suggested by postoperative esophagramwho we are currently following as there are no clinicalsymptoms (mild distal esophageal narrowing by routinescreeningesophagramlookingforpost-anastamoticstricture).Now we are presented with the “gentle reminder”—thatcongenital esophageal stenosis is associated with EA/TEF(12% of patients in the current article), and that CES isfrequently symptomatic (45% of the CES cases in this series)and often fails balloon dilatation, the standard of care forreflux strictures. Mostly, for me, this article reminds me thatone has an invaluable opportunity to study the distalesophagus in patients with EA/TEF at the first postoperativeesophagram. We are so focused on looking for anastamoticleaks and recurrent/residual tracheoesophageal fistulae thatwemaylosesightofthefactthattherecanbeanomaliesoftheremaining distal esophagus. Even in patients who are toundergo delayed repair, with either temporizing proximalesophageal pouch decompression by an enteric tube orcervical esophagostomy, fistula takedown and gastrostomytube insertion, evaluation of the distal esophagus can be per-formed safely and effectively. By performing a gastrostomytube study, one may be able to reflux the distal esophagus tolookforCES.Theopportunityisthere,ifweremembertotakeit. Our patients will be the true beneficiaries. To Dr. Yoo andcolleagues, thank you for the “gentle reminder.”Reference

Objective outcomes after laparoscopic giant hiatal hernia repair: Minimization of hernia recurrence

Abstract Introduction: Laparoscopic giant hiatal hernia (GHH) (> 50% of stomach above the diaphragm) repair is associated with a 12–40% early recurrence rate. We applied specialized laparoscopic maneuvers to address this potential technical compromise. Methods: 43 patients underwent GHH laparoscopic repair (34 virgin, 9 reoperative) with esophageal lengthening. Specific emphasis was placed on meticulous preservation of crural integrity, complete sac excision, routine gastroesophageal fat-pad dissection, and Collis gastroplasty. A totally intraabdominal wedge Collis gastroplasty (using simplified EndoGIA stapler techniques) combined with Nissen fundoplication was performed. A validated questionnaire assessed functional outcomes at a 7.8 month median (range, 2–42). Postoperative esophagram objectively evaluated for possible hiatal hernia recurrence at a 7.5 month median (range, 1–26). Results: Operating time averaged 299 ± 108 minutes; wedge gastroplasty added only 10 minutes (mean). Median hospital stay was 4 days (range, 1–43). Perioperative complications occurred in 9% (4/43) of patients: 1 esophageal leak, 1 respiratory failure, 1 gastric-bloat readmission, and 1 pneumothorax. Complete postoperative data were available for 74% (32/43). There was 1 (3%) miniscule, asymptomatic radiographic recurrence. Most patients reported on questionnaire, excellent results in each of 9 symptoms (e.g., heartburn resolved in 94% [30/32]). GERD-related medications were discontinued in 78% (25/32). The mean postoperative GERD Quality-of-Life score was 1.2 ± 3.2 (scale 0–45; 0=asymptomatic). Overall, 97% (31/32) were satisfied with their surgical outcome. Conclusions: Consistent application of specialized techniques in minimally-invasive GHH repair yields a very low rate of early recurrence. Functional results are excellent in most patients, translating to high levels of satisfaction with the procedure.

Clinical characteristics of congenital esophageal stenosis distal to associated esophageal atresia

Background. Congenital esophageal stenosis (CES) has been reported to be a rare association in patients with esophageal atresia or tracheoesophageal fistula, or both (EA-TEF). This study investigates the clinical characteristics of this association with special reference to its treatment. Methods. A retrospective review of medical and radiographic records of 81 patients who underwent primary repair of EA-TEF was performed. An association of CES was diagnosed when they showed histologic evidence or persistent radiographic images of esophageal narrowing since the neonatal period. Results. Eleven of 81 EA-TEF patients (14%) were identified with CES. Their symptoms were difficulty in swallowing solid food, food impaction, emesis, stridor, repeated respiratory infection, and failure to thrive. Two patients had a recurrence of TEF. Three patients were diagnosed with CES in the neonatal period—2 at the time of primary repair of EA-TEF and 1 on the initial postoperative esophagram. The remaining 8 patients were diagnosed between the ages of 2 months and 3 years. Although esophageal dilatation was attempted in 9 patients, its effectiveness was temporary in all except 2 patients and esophageal laceration occurred in 4 patients. Surgical repair including myotomy and resection of the narrow segment was performed in 7 patients, in 6 of whom Nissen/Collis-Nissen fundoplication was added. A histologic examination was performed in 5 patients, revealing that their CES was due to fibro-muscular hypertrophy (2) or tracheobronchial remnants (3). The long-term outcome was satisfactory in all patients except one who showed wrap herniation. Conclusions. The association between CES and EA-TEF is not rare. Esophageal dilatation was not universally effective and carried with it a considerable incidence of esophageal leakage. An antireflux operation concomitant with repair of CES may be useful to prevent postoperative gastroesophageal reflux in patients with a narrowing close to the esophagogastric junction. (Surgery 2001;129:29-38.)

Gastric emptying procedures decrease the risk of postoperative recurrent reflux in children with delayed gastric emptying

Purpose: Although several centers often perform gastric emptying procedures (GEP) together with fundoplication for gastroesophageal reflux (GER) and delayed gastric emptying (DGE), the benefit of GEP is controversial. The present study addresses the question of whether adding a GEP in children with preoperatively diagnosed GER and DGE affects the recurrence rate of GER after Nissen fundoplication (NF). Methods: A retrospective chart review was performed on all children under the age of 16 years, operated on for GER from 1980 to 1997, who had a preoperative diagnosis of DGE, and at least 6 months of follow-up. Gastric retention of more than 50% of a radiolabeled meal at 90 minutes was considered DGE. Recurrent reflux was defined as reappearance of GER symptoms, confirmed by postoperative esophagram or 24 hours of pH monitoring. Results: Of the 183 patients with DGE, 92 were available for long-term follow-up. Of these, 20 had no gastric emptying procedure performed (no-GEP group) and 72 had a GEP performed together with an NF (GEP group). Groups were comparable as to age at operation, mean follow-up time, male to female ratio and prevalence of associated anomalies. A higher prevalence of neurological impairment (NI) was present in the GEP group (48.6% v 20.0%). Mean preoperative gastric retention was significantly higher in the GEP group (69.9 ± 1.3%) than in the no-GEP group (61.4 ± 2.2%). No complications resulted from the GEP. Recurrent reflux rate was 18.1% in the GEP group (13 of 72) versus 35.0% (7 of 20) in the no-GEP group. Actuarial analysis disclosed a marginally significant difference in the rate of recurrent reflux between the groups ( P = .057) and estimation of the relative risk showed a 1.94 increase of recurrent reflux risk in the no-GEP (0.89 < RR < 4.20). Conclusions: Children with DGE, who did not have GEP, had twice the frequency of recurrent reflux as those who had a GEP. Preoperative screening for DGE, as well as operative correction of DGE at the time of fundoplication, is therefore recommended.

Laparoscopic redo Nissen fundoplication.

Nine patients underwent redo laparoscopic Nissen fundoplication because of failed primary laparoscopic antireflux procedure. Symptoms prior to reoperation included heartburn (n = 5), dysphagia (n = 2), dysphagia and heartburn (n = 1), and early satiety and epigastric pain (n = 1). Endoscopic and radiologic findings prior to reoperation included esophagitis (n = 6), reflux (n = 6), stenosis (n = 2), and hiatal hernia (n = 1). Findings at reoperation included fundoplication positioned on the stomach (n = 5); a disrupted cruroplasty (n = 1); gastric volvulus (n = 1); and an excessively tight wrap (n = 1) or cruroplasty (n = 1). Reconstruction of the fundoplication was performed according to accepted principles for this procedure. All patients were discharged within 2 days after the redo procedure. Follow-up time is 4-14 months. Preoperative symptoms were relieved in all patients and all antireflux medication have been discontinued. Routine postoperative esophagram and endoscopy demonstrated intact repair and without gastroesophageal reflux or stenosis. Reoperative laparoscopic Nissen fundoplication is feasible and effective.

The postcricoid impression masquerading as an esophageal tumor.

A case has been reported of a 57-year-old man who underwent negative neck exploration for an apparent mass, supposedly lying between the esophagus and trachea, which was seen elsewhere on an esophagram and at bronchoscopy. A postoperative esophagram performed at Stanford demonstrated a typical postcricoid impression. This impression forms on the anterior esophageal wall, immediately below the slight impression which the cricoid cartilage's posterior lamina sometimes produces. It can assume seven different shapes. Unlike a tumor, it is transient and varies in size and shape.