Proton Pump Inhibitors Relieve and Prevent Symptoms Related to Gastric Acidity after Esophagectomy

Postoperative Outcomes and Quality of Life After Left Thoracoabdominal Esophagogastrectomy: Contrasting Esophagogastrostomy with Esophagojejunostomy

BACKGROUND

Following left thoracoabdominal (LTA) esophagogastrectomy, gastrointestinal continuity can be re-established via esophagogastrostomy or esophagojejunostomy. We explored how the method of reconstruction impacted postoperative outcomes and quality of life (QoL).

METHODS

From January 2007 to January 2022, patients undergoing LTA were identified from a single center's prospectively maintained database. Following esophagogastrectomy or extended total gastrectomy, an esophagogastrostomy (GAS) or Roux-en-Y esophagojejunostomy (R-Y) was fashioned. Postoperative outcomes were compared according to the method of reconstruction. The Functional Assessment of Cancer Therapy-Esophagus (FACT-E) questionnaire compared QoL.

RESULTS

Of the 147 LTA patients identified, 135 (92%) were included-97 GAS (72%) and 38 R-Y patients (28%). R-Y patients had more ypT3/4 lesions (97% vs. 61%, p ≤ 0.001) and a similar incidence of ypN+/M+ disease. Anastomotic leaks were more common among GAS patients (17% vs. 3%, p = 0.023), however grade 3/4 complications (26.6% vs. 19.4%, p = 0.498), reoperation, intensive care admission, hospital representation and readmission were similar. FACT-E data were available for 68/97 (70%) GAS patients and 22/38 (58%) R-Y patients, with scores for 80/21/24/18/23/24 patients at baseline/preoperatively/1 month/3-6 months/1-3 years/3+ years postoperatively, respectively. Comparing between the groups, the scores were similar at each timepoint. FACT-E improved between baseline and preoperatively (79, 34-124 vs. 102, 81-123, p = 0.027). Only at 3+ years were postoperative scores equivalent to preoperative values. GAS patients had more reflux and esophagitis >6 months postoperatively (54% vs. 13%, p = 0.048; 62% vs. 0%, p ≤ 0.001).

CONCLUSION

While the type of reconstruction did not affect QoL, it did affect the postoperative course.

Efficacy of Vonoprazan for Refractory Reflux Esophagitis after Esophagectomy

BACKGROUND

Refractory reflux esophagitis (RRE), unresponsive to conventional proton-pump inhibitors (PPIs), is a complication in esophagectomy with gastric pull-up. Vonoprazan (VPZ), a novel potassium-competitive acid blocker, has been available in Japan since 2015. Here, we investigated the efficacy of VPZ on PPI-resistant RRE after esophagectomy with gastric pull-up.

METHODS

This was a single-center retrospective study. We used the revised Los Angeles (r-LA) classification based on the Los Angeles classification and the modified Los Angeles classification to evaluate abnormal forms of mucosal breaks such as lateral spreading consistently. Patients who underwent esophagectomy with gastric pull-up and had RRE grade B-D as per the r-LA classification, despite using standard-dose PPIs or double dose of rabeprazole, were included. Sixteen patients who switched to VPZ (20 mg/day) and 14 patients who continued PPIs were assigned to the VPZ and PPI groups, respectively. Endoscopic observations were reviewed by 3 endoscopists using the r-LA classification to ensure consistent diagnosis, while the treatment arm and patient information were blinded to evaluators. We defined mucosal breaks that improved by at least one grade after treatment as improved mucosa and recovery to grade M or N as mucosal healing.

RESULTS

The percentage of patients with improved mucosa in the VPZ and PPI groups was 81.3 and 14.3%, respectively (p < 0.001). The rate of mucosal healing was 68.8 and 7.1%, respectively (p = 0.001).

CONCLUSION

VPZ significantly improved PPI-resistant RRE after esophagectomy with gastric pull-up.

Comparison of the incidences of anastomotic leakage when PDSII or LACLON are used in esophago-gastric conduit handsewn anastomosis after esophagectomy

The incidence of anastomotic leakage after esophagectomy remains around 10%. It was previously reported that PDSII rapidly loses tensile strength at pH 1.0 and pH 8.5. By contrast, LACLON degradation is reportedly insensitive to pH. We therefore compared LACLON with PDSII for esophago-gastric conduit, layer-to-layer, handsewn anastomosis. Between January 2016 and January 2020, 90 patients who received posterior mediastinal gastric conduit reconstruction with layer-to-layer handsewn anastomosis (51 using PDSII and 39 using LACLON) at Akita University Hospital were enrolled. The incidence of anastomotic leakage was significantly lower in the LACLON (2.6%, 1/39 patients) than PDSII group (15.7%, 8/51 patients) (p = 0.0268). Multivariable logistic analysis showed the risk of anastomotic leakage was significantly greater with PDSII than LACLON (odds ratio 11.01; 95% CI 1.326–277.64; p = 0.024). The percentages of time the pH was higher than 8 on the gastric conduit side of the anastomosis were 3.1%, 5.7%, 20.9% and 80.5%, respectively, in the four most recent patients. The present study showed that pH at the anastomosis soon after esophagectomy tends to be alkaline rather than acidic, which raises the possibility that this alkalinity facilitates the deterioration of surgical sutures including PDSII.

Reflux Following Esophagectomy for Esophageal Cancer

Gastroesophageal reflux is a common problem after gastroesophageal resection and reconstruction, despite the routine prescription of proton pump inhibitors (PPIs). Resection of the lower esophageal sphincter and excision of the vagus nerve are generally thought to be the main factors that interfere with gastric motor function. However, physiological studies of reflux symptoms after esophagectomy are still lacking. Gastroesophageal reflux occurs frequently after esophagectomy, but there is no known effective method to prevent it. Therefore, in order to manage gastroesophageal reflux after esophagectomy, strict lifestyle modifications and gastric acid suppression treatment such as PPIs are needed, and further clinical studies are required.

Predictors of Patient-Reported Reflux After Esophagectomy

BACKGROUND

Patient-reported reflux is among the most common symptoms after esophagectomy. This study aimed to determine predictors of patient-reported reflux and to ascertain whether a preserved pylorus would protect patients from symptomatic reflux.

METHODS

A prospective clinical study recorded patient-reported reflux after esophagectomy from August 2015 to July 2018. Eligible patients were at least 6 months from creation of a traditional posterior mediastinal gastric conduit, had completed at least 1 reflux questionnaire, and had the pylorus treated either temporarily (≥100 IU Botox [onabotulinumtoxinA]) or permanently (pyloromyotomy or pyloroplasty).

RESULTS

Of the 110 patients meeting inclusion criteria, the median age was 65 years, and 88 of the 110 (80%) were male. Botox was used in 15 (14%) patients, pyloromyotomy in 88 (80%), and pyloroplasty in 7 (6%). A thoracic anastomosis was performed in 78 (71%) patients, and a cervical anastomosis was performed in 32 (29%). Esophagectomy was performed for malignant disease in 105 of 110 (95%), and 78 of 110 (71%) patients were treated with perioperative chemoradiation. Multivariable linear regression analysis revealed that patient-reported reflux was significantly worse in patients with shorter gastric conduit lengths (P = .02) and in patients who did not undergo perioperative chemoradiation (P = .01). No significant difference was found between patients treated with pyloric drainage and those treated with Botox.

CONCLUSIONS

The absence of perioperative chemoradiation therapy and a shorter gastric conduit were predictors of patient-reported reflux after esophagectomy. Although few patients had Botox, preservation of the pylorus did not appear to affect patient-reported reflux. Further objective studies are needed to confirm these findings.

Risk factors for loss of bone mineral density after curative esophagectomy

Micronutrient and fat malabsorption and altered enteroendocrine signaling occur after esophagectomy for cancer; however, the impact of malnutrition on bone health in this cohort has not been previously investigated. In this study, the prevalence of osteoporosis increased after curative surgery, associated with disease-specific, treatment-related, and population risk factors.

PURPOSE

Improved oncologic outcomes in esophageal cancer (EC) have resulted in increased survivorship and a focus on long-term quality of life. Malnutrition and micronutrient malabsorption are common among patients with EC, but the effect on bone metabolism is not known. The aim of this study was to characterize changes in bone mineral density (BMD) following curative esophagectomy.

METHODS

Consecutive disease-free patients who underwent esophagectomy with gastric conduit for pathologically node-negative disease from 2000 to 2014 were included. BMD was assessed at vertebral levels T12-L5 by computed tomography using a simple trabecular region-of-interest attenuation technique, and serum markers of nutritional status and bone metabolism were examined. Independent risk factors for osteoporosis were identified by multivariable logistic regression.

RESULTS

Seventy-five consecutive patients were studied. Osteoporosis was present in 25% at diagnosis. BMD declined at 1 and 2 years postoperatively (144.3 ± 45.8 versus 128.6 ± 46.2 and 122.7 ± 43.5 Hounsfield Units (HU), P < 0.0001), with increased osteoporosis prevalence to 38% and 44% (P = 0.049), respectively. No significant postoperative change in vitamin D, calcium, or phosphate was observed, but alkaline phosphatase increased significantly (P < 0.001). While female sex (P = 0.004) and ASA grade (P = 0.043) were independently associated with osteoporosis at diagnosis, age (P = 0.050), female sex (P = 0.023), smoking (P = 0.024), and pathologic T stage (P = 0.023) were independently predictive of osteoporosis at 1 year postoperatively.

CONCLUSIONS

Osteoporosis is prevalent among disease-free patients post-esophagectomy for EC, associated with disease-specific, treatment-related, and population risk factors. Strategies which minimize BMD decline should be considered to avoid fragility fractures in this cohort.

Influence of esophagectomy on the gastroesophageal reflux in patients with esophageal cancer

This study aims to assess the influence of esophagectomy with gastric transposition on the gastroesophageal reflux (GER) and gastric acidity in patients with esophageal cancer. Data on 53 esophageal cancer patients who underwent 24-hour impedance-pH monitoring after esophagectomy were retrospectively analyzed. We used a solid-state esophageal pH probe in which the esophageal pH sensor is placed 1.5 cm distal to the upper esophageal sphincter and the gastric pH sensor is located 15 cm distal to the esophageal pH channel. 24-hour impedance-pH monitoring data and other clinical data including anastomosis site stricture and incidence of pneumonia were collected. We defined pathologic reflux with reference to known normative data. Stricture was defined when an intervention such as bougienage or balloon dilatation was required to relieve dysphagia. The esophageal and gastric mean pH were 5.47 ± 1.51 and 3.33 ± 1.64, respectively. The percent time of acidic pH (<4) was 6.66 ± 12.49% in the esophagus and 70.53 ± 32.19% in the stomach. Esophageal pathologic acid reflux was noticed in 32.1%, 20.8%, and 35.8% during total, upright, and recumbent time, respectively. Esophageal pathologic bolus reflux was noted in 83.0%, 77.4%, and 64.2% during total, upright, and recumbent time, respectively. Gastric acidity increased with time after esophagectomy. Esophageal acid exposure time correlated with intragastric pH. However, esophageal pathologic acid reflux was not associated with anastomosis site stricture or pneumonia. In conclusion, GER frequently occurs after esophagectomy. Thus, strict lifestyle modifications and acid suppression would be necessary in patients following esophagectomy.

Esophagectomy with gastroplasty in advanced megaesophagus: late results of omeprazole use

Objective: To analyze the late results of advanced Chagasic megaesophagus treatment by esophagectomy associated with the use of proton pump inhibitor (omeprazole) as for the incidence of esophagitis and Barrett's esophagus in the remaining stump. Methods : We studied patients with advanced megaesophagus undergoing esophagectomy and transmediastinal esophagogastroplasty. Patients were divided into three groups: A (20) with esophageal replacement by full stomach, without the use of omeprazole; B (20) with esophageal replacement by full stomach, with omeprazole 40 mg/day introduced after the first postoperative endoscopy and maintained for six years; and C (30) with esophageal replacement by gastric tube with use of omeprazole. Dysphagia, weight loss and BMI were clinical parameters we analyzed. Upper gastrointestinal endoscopy was performed in all patients, and determined the height of the anastomosis, the aspect of the mucosa, with special attention to possible injuries arising from gastroesophageal reflux, and the patency of the esophagogastric anastomosis. Results : We studied 50 patients, 28 males (56%) and 22 (44%) females. All underwent endoscopy every year. In the first endoscopy, erosive esophagitis was present in nine patients (18%) and Barrett's esophagus, in four (8%); in the last endoscopy, erosive esophagitis was present in five patients (8%) and Barrett's esophagus in one (2%). When comparing groups B and C, there was no evidence that the manufacturing of a gastric tube reduced esophagitis and Barrett's esophagus. However, when comparing groups A and C, omeprazole use was correlated with reduction of reflux complications such as esophagitis and Barrett's esophagus (p <0.005). Conclusion : The use of omeprazole (40 mg/day) reduced the onset of erosive esophagitis and Barrett's esophagus during the late postoperative period.

Columnar metaplasia in the esophageal remnant after esophagectomy: a systematic review

Barrett's metaplasia is a well-recognized risk factor for esophageal adenocarcinoma. It is believed to develop in response to the injurious effects of gastroesophageal reflux. Following subtotal esophagectomy and reconstruction with a gastric conduit, many patients experience profound reflux into the remnant esophagus. Barrett's-like epithelium has been described in these patients, and they have been identified as a potential human model in which to study the early events in the development of metaplasia. This phenomenon also raises clinical concerns about the long-term fate of the esophageal remnant following surgery and the potential for further malignant change. This systematic review summarizes the literature on the prevalence and timing of Barrett's metaplasia occurring after esophagectomy, reviews the evidence regarding risk factors and malignant progression in such patients, and considers the implications for clinical practice.

Evaluation of anatomical and functional changes esophageal stump of patients with advanced megaesophagus submitted to subtotal laparoscopic esophagectomy

PURPOSE

Evaluate anatomical and functional changes of the esophageal stump and gastric fundus of patients with advanced megaesophagus, submitted to laparoscopic subtotal esophagectomy.

METHODS

Twenty patients with advanced megaesophagus, previously submitted to a videolaparoscopic subtotal esophagectomy, were evaluated. Were conducted: radiological evaluation of the stump esophagus with transposed stomach, electromanometric, endoscopic examination and histopathology of the esophageal stump and gastric fundus, without making gastric tube or pyloroplasty.

RESULTS

It was observed that the average height and pressure of the anastomosis, in the electromanometric evaluation, were 23.45cm (±1.84cm) and 7.55mmHg (±5.65mmHg). In patients with megaesophagus III, the pressure of the anastomosis was 10.91mmHg (±6.33mmHg), and pressure from the UES, 31.89mmHg (±14.64mm Hg), were significantly higher than those in grade IV. The pathological evaluation detected mild esophagitis in 35% of patients, moderate in 20% and acanthosis glicogenica in 45%. The examination of the gastric fundus showed that 50% of patients were infected with Helicobacter pylori. Chronic gastritis occurred in 95% of the patients.

CONCLUSIONS

The laparoscopic esophagectomy shown to be effective in the treatment of advanced achalasia. The cervical level anastomosis protects the esophageal stump from the aggression resulted from gastric reflux after the esophagectomy.

Gastric motor activity in gastric pull-up esophagectomized patients with and without reflux symptoms

BACKGROUND

Patients frequently experience reflux symptoms of heartburn and regurgitation after a gastric pull-up esophagectomy. The pathogenesis of reflux symptoms is not fully understood. The gastrointestinal tract exhibits a temporally coordinated cyclic motor pattern, termed interdigestive migrating motor contraction, during the interdigestive state. Phase III of interdigestive migrating motor contraction is important in cleaning indigestible solids and basal secretions. Impairment of phase III may result in reflux symptoms of heartburn and regurgitation. The present study evaluated whether gastropyloroduodenal motility after gastric pull-up esophagectomy influences the pathogenesis of reflux symptoms.

METHODS

Gastropyloroduodenal motility was recorded by manometry in 20 patients after a gastric pull-up esophagectomy. Esophagectomized patients were questioned about the presence of heartburn or regurgitation, or both.

RESULTS

Of 20 patients, 8 (40%) were considered the symptomatic group. Phase III, in which contractions originating from the antrum migrate to the pylorus and then move to the duodenum, was observed in only 1 of 8 patients. In the asymptomatic group, phase III was observed in 8 of 12 patients. A significant correlation was found between the presence of reflux symptoms and the paucity of phase III activity (p=0.02).

CONCLUSIONS

The presence of reflux symptoms after gastric pull-up esophagectomy is significantly associated with the paucity of gastric phase III. Gastric motor activity is important in the occurrence of reflux symptoms.

Influence of CYP2C19 and ABCB1 polymorphisms on plasma concentrations of lansoprazole enantiomers after enteral administration

An intraoral annihilation enteric-coated preparation of lansoprazole is often administered via intestinal fistula. The purpose of this study was to determine the plasma concentrations of lansoprazole enantiomers after enteral administration in subjects with cytochrome P4502C19 (CYP2C19) and ABCB1 C3435T genotypes. Fifty-one patients who underwent a curative oesophagectomy for oesophageal cancer were enrolled in this study. After a single enteral dose of racemic lansoprazole (30 mg), plasma concentrations of lansoprazole enantiomers were measured 4 h post-dose (C(4h)). There were significant differences in the C(4h) of (R)- and (S)-lansoprazole and the R/S-enantiomer ratio for three CYP2C19 genotype groups (*1/*1, *1/*2 ± *1/*3, and *2/*2 ± *2/*3 ± *3/*3 (poor metabolizers (PMs)), but not the ABCB1 C3435T genotypes. In a stepwise forward selection multiple regression analysis, the C(4h) of (R)- and (S)-lansoprazole were associated with CYP2C19 PMs (p = 0.0005 and < 0.0001 respectively) and age (p = 0.0040 and 0.0121 respectively), while the R/S-enantiomer ratio was associated with CYP2C19*1/*1 (p = 0.0191) and CYP2C19 PMs (p = 0.0426). Direct administration to the jejunum is unaffected by residence time in the stomach and the gastric emptying rate. With enteral administration, CYP2C19 phenotyping of patients using the lansoprazole R/S enantiomer index at C(4h) could be possible.

Risk factors of reflux esophagitis in the cervical remnant following esophagectomy with gastric tube reconstruction

BACKGROUND

The risk factors and suitable treatment of reflux esophagitis (RE) of the cervical remnant in patients undergoing radical esophagectomy remain unclear. The aim of this study was to evaluate the risk factors in patients with RE in the cervical remnant.

METHODS

We retrospectively examined 141 consecutive patients who underwent esophagectomy and reconstruction with gastric tubing. RE was diagnosed by upper gastrointestinal endoscopy and graded according to the Los Angeles Classification. Statistically, 11 potential risk factors of RE were evaluated. The postoperative follow-up time ranged from 18 to 204 months (median 60 months).

RESULTS

Among a total of 141 patients, 48 (34%) had RE in the cervical remnant, with 14 (29%) cases categorized as grade B, nine (19%) as grade C, and 25 (52%) as grade D. The cumulative incidence of RE in the cervical remnant was 24% at 5 years after surgery and 60% at 10 years, respectively. Pyloroplasty and bile reflux were identified as independent risk factors of RE in the cervical remnant by univariate and multivariate analyses.

CONCLUSIONS

The results of this study show a high incidence and high grade of RE in the cervical remnant after esophagectomy. Routine endoscopic examination and suitable medication is required for the control of RE in the cervical remnant together with surgical procedures to avoid bile reflux.

The esophageal remnant after gastric interposition

Gastric interposition is usually considered the reconstruction of choice following esophageal resection. However, a number of reports show that esophagectomy followed by a gastric transplant is associated with poor quality of life and significant reflux esophagitis in the esophageal remnant. The aim of this work is to review the factors affecting the mucosa of the esophageal remnant when using the stomach. A Medline was conducted. Additional references and search pathways were sourced from the references of reviewed articles. Reflux disease is considered an unavoidable consequence of esophageal resection followed by gastric interposition. Mucosal damage from acid and bile exposure in the esophageal remnant affects approximatively 50% of these patients. There is usually no correlation between symptoms and the presence of mucosal damage in the remaining esophagus. Endoscopy and endoscopic biopsies are the only reliable methods to document the status of the mucosa. When present, reflux esophagitis shows a progression from inflammation to erosions and to the development of columnar lined metaplasia. Esophageal and gastric function, gastric drainage operation, level of the anastomosis, route of reconstruction, and patients' position after the operation have all been shown to influence the severity and extent of damage in the esophageal remnant. Prevention and treatment of esophagitis in the remaining esophagus are discussed. When the stomach is used as a substitute to reconstruct the esophagus whether for malignant or benign conditions, an in vivo model of reflux diseases is created. Studies using this model may help clarify molecular and cellular events that lead to irreversible insult on the esophageal mucosa. Improvement to the reconstruction itself must be sought to favor better results with the gastric transplant.